Practical Musculoskeletal Ultrasound

PRACTICAL
MUSCULOSKELETAL
ULTRASOUND
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Second Edition
PRACTICAL
MUSCULOSKELETAL
ULTRASOUND
Eugene G. McNally FRCR FRCPI
Consultant Musculoskeletal Radiologist, Nuffield Orthopaedic Centre and
John Radcliffe Hospital, University of Oxford, Oxford, UK
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© 2014, Elsevier Limited. All rights reserved.
First edition 2005

Second Edition 2014
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Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
ISBN: 978-0-7020-3477-0
e-book ISBN: 978-1-4557-7404-3
Printed in China
Contents
Video Contents vii

PART 4 FINGER
Preface xi
14 Finger Anatomy and Techniques 143
List of Contributors xiii
15 Disorders of the Fingers and Hand 150
Abbreviations/Contractions xv
PART 1 SHOULDER PART 5 HIP

1 Shoulder: Anatomy and Techniques 3 16 Hip Joint and Thigh: Anatomy and
Techniques 167
2 Shoulder 1: Supraspinatus Tendon 16
17 Disorders of the Groin and Hip:
3 Shoulder 2: The SASD Bursa, Rotator Groin Pain 177
Interval and Other Rotator Cuff Tendons 33
4 Shoulder 3: Beyond the Rotator Cuff 48 Anterior 193

PART 2 ELBOW Lateral and Posterior 207

5 Arm and Elbow Joint: Anatomy and
Paediatric Hip 216
Techniques 57
6 Disorders of the Elbow: Lateral 70
7 Disorders of the Elbow: Medial 78 PART 6 KNEE

8 Disorders of the Elbow: Anterior 87 21 Knee Joint and Calf: Anatomy and
Techniques 229
9 Disorders of the Elbow: Posterior 91
22 Knee Pathology 239
PART 3 WRIST
10 Forearm and Wrist Joint: Anatomy and
PART 7 ANKLE
Techniques 99
23 Ankle Joint and Forefoot: Anatomy and
11 Disorders of the Wrist: Radial 113 Techniques 253
12 Disorders of the Wrist: Ulnar Side 122 24 Disorders of the Ankle and Foot: Posterior 269
13 Disorders of the Wrist: Miscellaneous 129 25 Disorders of the Ankle and Foot: Anterior 285
v
vi Contents
26 Disorders of the Ankle and Foot: Lateral 295

PART 9 GENERAL
27 Disorders of the Ankle and Foot: Medial 301
31 Ultrasound of Soft Tissue Masses 387
28 Disorders of the Ankle and Foot: Forefoot 315
32 Ultrasound Imaging of Joint Disease 407
PART 8 INTERVENTION
PART 10 TRAUMA
29 Musculoskeletal Intervention:
General Principles 331 33 Ultrasound of Muscle Injury 421
30 Specific Intervention Techniques 346 Index 433

Video Contents
PART 1 SHOULDER PART 2 ELBOW

Subacromial-subdeltoid bursal fluid: Partial tear Distal biceps rupture
supraspinatus
Distal biceps rupture
Hemorrhage in glenohumeral joint
Common extensor origin enthesopathy
Full thickness supraspinatus tendon tear
Full thickness leading edge tear filled with bursitis
Common extensor origin enthesopathy and tear
Bural fluid in most dependent area of bursa
Acromioclavicular joint cyst
Common flexor origin enthesopathy
Biceps tenosynovitis axial image
Biceps tendinopathy with some fluid in sheath
Biceps tenosynovitis Dilated ulnar nerve above cubital tunnel
Bursal bunching and small click on abduction Distal biceps rupture with retraction
Bursal fluid over biceps tendon Distal biceps rupture
Bursal thickening at free edge Elbow loose bodies
Subacromial-subdeltoid bursa with doppler Common extensor origin enthesopathy and small
lamellar tear
Fluid in biceps sheath
Fluid in both subacromial-subdeltoid bursa and
biceps tendon sheath Common flexor origin enthesopathy
Free edge full thickness tear supraspinatus Osteochondritis capitellum
Large hill sachs deformity Subluxing ulnar nerve
Medially subluxed biceps tendon
Mid substance supraspinatus tendon tear axial PART 3 WRIST

Mid substance supraspinatus tendon tear axial Finger flexor tenosynovitis
Rim rent partial tear Finger flexor tenosynovitis axial
Subscapularis tendon full thickness tear Extensor compartment four tenosynovitis
vii
viii Video Contents
Footballers ankle
PART 4 FINGER
Insertional Achilles tendinopathy
Metacarpophalangeal joint synovitis
Peroneal tenosynovitis
Plantar fasciitis
PART 5 HIP
Plantar fibroma
Hamstring enthesopathy
Plantaris tear
Iliopsoas partial tear
Posteromedial impingement
Iliopsoas snap
Pre Achilles bursa: Haglund’s deformity
Labral cyst
Pre Achilles bursa
Rectus femoris muscle tear
Spring ligament tear
Snapping iliotibial band
Tibialis anterior tear
Sub gluteus medius bursa with doppler
Tibialis posterior split tear
Tibialis posterior tendinopathy
PART 6 KNEE
Osteomyelitis with fluid visible in medulla through PART 8 POSTERIOR ANKLE
a cloaca
Achilles tendinopathy
Focal patellar tendinopathy with doppler
Complete Achilles tendon tear
Gastrocnemius hematoma
Complete Achilles tendon tear
Jumpers knee sagittal with intense doppler activity
Partial Achilles tendon tear
Meniscal cyst
Recurrence of complete Achilles tendon tear
Myositis ossificans
Haglund’s disease
Osgood schlatter’s disease
Subcutaneous bursitis
Osgood schlatter’s disease
Partial tear of plantaris tendon
Focal patellar tendinopathy with doppler
Popliteal cyst with synovitis
PART 9 LATERAL ANKLE
PART 7 ANKLE Retro-malleolar peroneus brevis tendon tear

Infra-malleolar peroneusbrevis tendon tear
Achilles focal tendinopathy
Small intra-tendinous peroneus brevis tendon tear
Achilles paratenonopathy
Dynamic test for examination of the superior
Achilles re rupture peroneal retinaculum
Aspirating tarsal ganglion Intern snapping of the left peroneal tendons
Calcific Achilles tendinopathy Anterior talo-fibular ligament injury
Calcific tenosynovitis Normal calcaneo-fibular ligament
Diabetic plantar fasciopathy Ruptured calcaneo-fibular ligament
Video Contents ix
Cannulatingsubacromial subdeltoid bursa

PART 10 FOOT and injection
Double Mulder’s click Cuff tear visualised during injection
Inflamed intermetatarsal bursa in rheumatoid arthritis Hip joint injection
Injecting Morton’s neuomai Forceps on FB prior to retrieval
Mortons intermetatarsal neuroma/bursitis complex Out of view approach to small joint: needle tip
in joint
Mortons intermetatarsal neuroma/bursitis complex
Pre Achilles injection
Plantar fibroma
Pulsating eggshell is supraspinatus tendon following
Small Morton’s calcium aspiration
Stress fracture second mettarsal neck Posterior approach to glenohumeral joint
Tendon sheath injection
PART 11 INTERVENTION
Fenestrating supraspinatus calcium deposit
Soft tissue biopsy

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Preface
In the last decade musculoskeletal ultrasound has progres gained. Throughout the book the authors display an aware
sively gained widespread popularity in the diagnosis and ness of what does and what doesn’t work, what is or isn’t
assessment of the musculoskeletal system. This is mainly due useful, and an appreciation of the role of ultrasound in
to advances in ultrasound technology (new generation of relation to other imaging techniques.
digital equipment and transducers, color/power doppler) The second edition is totally re-written, re-structured and
which has refined the clinician’s ability to visualise superfi revised. The previous edition had 16 chapters, this has 33
cial soft tissue structures to an extent that in some areas chapters. There is expanded coverage of the shoulder,
rivals the diagnostic capability of MR. Intrinsic musculo elbow, wrist, hand, hip, knee, foot and ankle, and interven
skeletal ultrasound advantages include easy accessibility, tional techniques. There are hundreds of new illustrations
time and cost-effectiveness, and the ability to perform a real (line drawings and ultrasound scans) help illustrate relevant
time, dynamic examination during the clinical examination. anatomy and pathology and provide the user with a com
Although the quality and consistency of the diagnostic exam prehensive visual guide to accurate interpretation and diag
is heavily dependent on the examiner’s expertise, musculo nosis. The addition of real time videos that complement the
skeletal ultrasound has become an attractive and effective images in the book and better illustrate the pathology. There
modality to image the musculoskeletal system and for some are differential diagnosis summary tables to quickly direct
conditions has established itself the first-line examination the user to the most likely clinical problem being assessed.
technique. The book is also available on the Expert Consult platform
This book provides a practical guide for those wishing to with online access to text, images and video clips. As before,
obtain an understanding of ultrasound techniques, their I am very grateful to all the contributors who once again
major applications and their role in patient diagnosis and have given their expertise and insights so willingly.
management. It offers essential guidance on how to conduct
an ultrasound examination, how best to obtain optimal Eugene G McNally
images, and on how best to interpret the information Oxford 2013
xi
List of Contributors
Hifz-ur-Rahman Aniq MBBS FRCR Philip J. O’Connor MRCP FRCR

Consultant Musculoskeletal Radiologist, Royal Liverpool Consultant Musculoskeletal Radiologist, Department of
and Broadgreen Hospitals, Honorary Lecturer, Radiology, Leeds General Infirmary, Leeds, UK
University of Liverpool, Liverpool, UK
Simon J. Ostlere FRCP FRCR
Robert Campbell MBChB DMRD FRCR Consultant Musculoskeletal Radiologist, Nuffield
Consultant Musculoskeletal Radiologist, Royal Liverpool Orthopaedic Centre and John Radcliffe Hospital,
and Broadgreen University Hospital, Liverpool, UK University of Oxford, Oxford, UK
Michel Court-Payen MD PhD Karen J. Partington MRCS FRCR

Consultant in Radiology, Department of Diagnostic Clinical Fellow, Musculoskeletal Radiology, Nuffield
Imaging, GildhÃ¸j Private Hospital, University of Orthopaedic Centre, Oxford, UK
Copenhagen, Denmark
Philip Robinson MRCP FRCR
Andrew J. Grainger MRCP FRCR Consultant Musculoskeletal Radiologist; Honorary Senior
Consultant Musculoskeletal Radiologist, Department of Lecturer, St James’s University Hospital, Leeds, UK
Radiology, Leeds General Infirmary, Leeds, UK
Emma L. Rowbotham BSc Hons MB BChir FRCR
Catherine L. McCarthy MBChB FRCR Consultant Musculoskeletal Radiologist, Radiology
Consultant Musculoskeletal Radiologist, Nuffield Department, Royal United Hospital Bath NHS Trust,
Orthopaedic Centre and John Radcliffe Hospital, Bath, UK
University of Oxford, Oxford, UK
James L. Teh MBBS BSc FRCP FRCR
Eugene G. McNally FRCR FRCPI Consultant Musculoskeletal Radiologist, Nuffield
Consultant Musculoskeletal Radiologist, Nuffield Orthopaedic Centre and John Radcliffe Hospital,
Orthopaedic Centre and John Radcliffe Hospital, University of Oxford, Oxford, UK
University of Oxford, Oxford, UK
xiii
Abbreviations/Contractions
A acetabulum/acetabular component EDT extensor digitorum tendons

AB adductor brevis Ef effusion
Acc Col Lig accessory collateral ligament EHB extensor halluces brevis
ACJ acromioclavicular joint EHL extensor halluces
ACL anterior cruciate ligament EI extensor indicis
Add adductor EO external oblique
ADM abductor digiti minimi EPB extensor pollicis brevis
AH abductor hallucis EPL extensor pollicis longus
AHB abductor hallucis brevis EPL extensor pollicis longus
AHL abductor hallucis longus ESR erythrocyte sedimentation rate
AIN anterior interosseous nerve ET extensor tendon
AL adductor longus ExP Br expollicis brevis
AM adductor magnus Ext hood extensor hood
AP abductor pollicis
APB abductor pollicis brevis FA femoral artery
APL abductor pollicis longus FCL fibular collateral ligament
APL abductor pollicis longus FCR flexor carpi radialis
ASIS anterior superior iliac spine FCU flexor carpi ulnaris
ATaFL anterior talofibular ligament FD flexor digitorum
ATFL anterior tibiofibular ligament FDB flexor digitorum brevis
AVN avascular necrosis FDL flexor digitorum longus
FDM flexor digiti minimi
CAL coracoacromial ligament FDP flexor digitorum profundus
CCL calcaneocuboid ligament FDS flexor digitorum superficialis
CEO common extensor origin Fem femoral
CFA common femoral artery FH flexor hallucis
CFL calcaneofibular FHB flexor hallucis brevis
CFO common flexor origin FHL flexor hallucis longus
CHL coracohumeral ligament FNAC fine needle aspiration cytology
CID concealed interstitial delamination FP flexor pollicis
CMCJ carpometacarpal joint FPB flexor pollicis brevis
Col Lig collateral ligament FPL flexor pollicis longus
CPN common peroneal nerve FT flexor tendon
CPPD calcium pyrophosphate deposition disease FV femoral vein
CTS carpal tunnel syndrome
G ganglion
DI dorsal interosseii GCTTS giant cell tumour of the tendon sheath
DIPJ distal interphalangeal joint GHJ glenohumeral joint
Dist P distal phalanx GL Md gluteus medius
DN digital nerve Gl Mn gluteus minimus
DRUJ distal radioulnar joint GL Mx gluteus maximus
Gr gracilis
EC extensor compartment
ECR extensor carpi radialis IEA internal epigastric artery
ECRB extensor carpi radialis brevis IEV inferior epigastric vessel
ECRL extensor carpi radialis longus INF inferior
ECU extensor carpi ulnaris INR international normalized ratio
ED extensor digitorum IO internal oblique
EDB extensor digitorum brevis IP iliopsoas
EDL extensor digitorum longus IPJ interphalangeal joint
EDM extensor digiti minimi IST infraspinatus tendon
xv
xvi Abbreviations/Contractions
L/R length/radius PIPJ proximal interphalangeal joint

L/T longitudinal/transverse Prox P proximal phalanx
Lat H lateral head Ps psoas
LCL lateral collateral ligament PB Pubic bone
LGH lateral head of gastrocnemius Pu pubis
LH long head PRF pulse repetition frequency
LM lateral malleolus
LPL lateral patellofemoral ligament Quad fem quadratus femorus
LT Lister’s tubercle QP quadratus plantae
LUCL lateral ulnar collateral ligament
RA radial artery
MC metacarpal RCL radial collateral ligament
MCJ midcarpal joint RN radial nerve
MCL medial collateral ligament RCJ radiocarpal joint
MCP metacarpophalangeal RLT radiolunotriquetral
MCPJ metacarpophalangeal joint RSL radioscapholunate
MCT N musculocutaneous nerve Rec fem rectus femoris
Med PIN medial planter nerve
Med Triceps medial triceps Sart sartorious
MG medial head of gastrocnemius Sc scaphoid
MH medial head SLAC scapholunate advanced collapse
MHG medial head of gastrocnemius SLL scapholunate ligament
Mid P middle phalanx STT scapho-trapezio-trapezoid
MN median nerve Sttj scaphotrapezium-trapezoid joint
MO myositis ossificans ScN sciatic nerve
MOM metal-on-metal SH small head
MPL medial patellofemoral ligament SASD subacromial subdeltoid
MRI magnetic resonance imaging Sub GI M B subgluteus medius bursa
MT metatarsal sct subscapularis
MTJ myotendinous junction SUP superior
MTPJ metatarsophalangeal joint SSM supraspinatus muscle
SST supraspinatus tendon
N nerve SP symphysis pubis
O oblique TT tibial tuberosity

OE obturator externis TMTJ tarsometatarsal joint
OI obturator internis TFL tensor fascia lata
ON obturator nerve TM teres minor
OP opponens pollicis TN tibial nerve
OCD osteochondritis dessecans TPT tibialis posterior tendon
TA transverse abdominis
PI palmar inteross Trap trapezius muscle
PASTA Partial Articular Supraspinatous Tendon TFCC triangular fibrocartilage complex
Avulsion
Pect pectineus UA ulnar artery
PNST peripheral nerve sheath tumour UCL ulnar collateral ligament
Per Tub peroneal tubercle UCLt ulnar collateral ligament of the thumb
PVNS pigmented villonodular synovitis UN ulnar nerve
PN plantar nerve Ulna ulnar styloid
PRP platelet-rich plasma US ultrasound
Pos position
PIN posterior interosseous nerve V vessels
PD power Doppler
PART 1
SHOULDER
1
Shoulder: Anatomy 1
and Techniques
Eugene McNally
CHAPTER OUTLINE
OVERVIEW Standard Position 6: Supraspinatus Muscle

Patient Position and Acromioclavicular Joint
Standard Position 1: Biceps Tendon DYNAMIC SHOULDER ASSESSMENT
Standard Position 2: Rotator Interval Dynamic Assessment for Cuff Tears
Standard Position 3: Subscapularis Tendon DYNAMIC ASSESSMENT OF BURSAL
Standard Position 4: Supraspinatus Tendon IMPINGEMENT
Standard Position 5: Infraspinatus and Teres JOINT SUBLUXATION
Minor Tendon
cause. Impingement is a clinical diagnosis, whereby pain

OVERVIEW occurs during arm abduction, as the supraspinatus tendon
and subacromial subdeltoid bursa are compressed between
The important bony landmarks in the evaluation of the the humeral head and the coracoacromial arch. This clini
supraspinatus tendon are the humeral head, the coracoid, cal scenario is also called painful arc syndrome, as pain is
the clavicle and acromium, joined at the acromioclavicular maximal in an arc of abduction between 30° and 60°. Inter
joint. The glenohumeral joint is an inherently unstable joint estingly, patients frequently complain of pain on the lateral
and depends on the surrounding soft tissues for stabilization. deltoid rather than in the region of the acromion.
Soft tissue stabilizers are divided into intrinsic and extrinsic. A complete ultrasound examination involves evaluating
The most important extrinsic soft tissues are the supraspina the four major tendons of the rotator cuff (biceps, subscapu
tus tendon superiorly, infraspinatus posteriorly and subscap laris, supraspinatus and infraspinatus), the subacromial sub
ularis anteriorly (Fig. 1.1). The important intrinsic soft tissue deltoid bursa and the acromioclavicular joint.
stabilizers are the glenohumeral joint and capsule.
The supraspinatus and infraspinatus are difficult to sepa
PATIENT POSITION
rate close to their insertions and share what is almost a
conjoined tendon. Some of the fibres crisscross each other, The easiest position in which to examine the shoulder is
making the two tendons difficult to separate. Anteriorly the with the patient seated. A stool with either no back or a low
subscapularis tendon is separated from the supraspinatus back and arms is ideal. This will allow for full access and
tendon by a gap, the rotator interval, which allows passage permit the shoulder to be moved into a range of positions.
of the long head of biceps out of the joint and into its groove It is a matter of personal preference whether the examiner
in the upper arm. The long head of biceps originates from carries out the examination standing or sitting, behind or
the superior glenoid margin. The coracohumeral ligament in front of the patient. There are minor advantages and
helps keep the long head of biceps in position within the disadvantages to each of these, but none is particularly
upper groove, by forming a sling mechanism in conjunction important and the choice is a matter of personal preference.
with the superior glenohumeral ligament. These ligaments Some variations in position are required for patients in
pass from the coracoid and glenoid respectively, and insert wheelchairs and for patients who must remain recumbent
into the humeral head on either side of the biceps tendon, whether because of illness, surgery or fear of fainting. Many
securing it in place. Another important ligament, the cora wheelchairs allow the sidearm to be removed, facilitating
coacromial ligament (CAL). Links the coracoid to the acro arm movement. If the patient is also able to sit a little
mium and forms the coracoacromial arch along with the forward in the chair then generally all of the important
bony acromium. positions can be achieved without too much difficulty.
Shoulder pain is a common complaint in the general It is important to take a history directly from the patient
population and impingement is a common underlying before the examination begins as this can often provide
3
4 PART 1 — SHOULDER
The cuff tendons, particularly supraspinatus, should be

Supraspinatus
examined both statically and dynamically. The static exami
nation is divided into six standard positions with specific
imaging goals in each position. The dynamic examination
has many components, but primarily seeks to evaluate the
behaviour of the subacromial subdeltoid bursa as it abuts
the coracoacromial arch on arm abduction.
Biceps tendon
STANDARD POSITION 1: BICEPS TENDON
IMAGING GOALS
Infraspinatus 1. Confirm that biceps tendon lies within groove.
and Teres
2. Identify abnormal fluid in the sheath and bursa.
Subscapularis 3. Identify normal internal tendon structure.
TECHNIQUE
The patient sits and places their hand on their knee palm
upwards. This induces a little external rotation sufficient to
bring the bicipital groove to an anterior position (Fig. 1.3).
The groove is easily located by placing the probe in an axial
plane on the anterior aspect of the humeral head. The
probe is then moved superiorly and inferiorly, tracing the
biceps tendon from the upper part of the groove to below
its upper musculotendinous junction. The normal tendon
has a bright speckled appearance in the axial plane, made
up of the poorly reflective tendon fibre bundles and the
hyperechoic connective tissue matrix. Care must be taken
to ensure that the probe is always held at 90° to the tendon
to remove the effects of anisotropy. Anisotropy is an artefact
whereby areas of reduced reflectivity simulating tendinopa
thy occur as a result of incident echoes arriving at angles
other than perpendicular and being reflected away from the
tendon, rather than bouncing back to the probe to help
form an image.
At its upper part, the biceps tendon sheath surrounds the
tendon. As is well known, this is an extension of the gleno
Figure 1.1 The glenohumeral joint is stabilized by a combination of
the joint capsule with its condensations, the glenohumeral ligaments
humeral joint and a small quantity of fluid is often identified
and the rotator cuff tendons. The coracoacromial arch overlies the within it. Also in its upper part, the anterior portion of the
supraspinatus comprising the coracoid, acromial and CAL. subacromial subdeltoid bursa can be seen deep to the
deltoid muscle and anterior to the biceps sheath. The ante
rior limb of the circumflex humeral artery is frequently
useful diagnostic information. The examination itself begins visible around the tendon. Distally, the relationship of the
with a brief inspection of the shoulder, useful to detect musculotendinous junction with the traversing pectoralis
muscle wasting. As with most ultrasound examinations the tendon should be noted. A number of tendon variations
probe should be held lightly with sufficient, but not exces may be identified. There are often a number of slips that
sive, contact with the skin. Holding the probe between the pass from the upper humerus to the tendon. Occasionally
thumb and adjacent fingers while resting the little finger a duplex tendon is encountered.
on the patient’s skin is an ideal way of obtaining excellent The probe is then rotated 90° so that the tendon can
contact with minimal pressure. be examined in its long axis (Fig. 1.4). Maintaining the
The cuff is examined from biceps anteriorly to teres tendon in view during this manoeuvre takes a little practice;
minor posteriorly and from the acromioclavicular joint however, if the probe falls off the tendon it is very easy to
superiorly to deltoid insertion inferiorly. The examination move a little medial or lateral to find it again, noting where
is concentrated on the four major tendons, but it is impor the reflective humeral shaft drops away as the probe crosses
tant to have a routine to ensure that none of the other the groove. In most individuals, the tendon travels deeper
important structures is overlooked. My preference is to as it passes distally. This introduces an element of anisot
begin with the biceps tendon and rotator interval anteriorly, ropy, which can be easily corrected by some gentle pressure
then move sequentially through subscapularis, supraspina at the distal end of the probe. This manoeuvre is called
tus and infraspinatus and teres in that order (Fig. 1.2). The ‘heel toeing’ and is used in several locations in musculo
examination concludes with an assessment of the posterior skeletal ultrasound. The long-axis image of the tendon is
glenohumeral joint, infraglenoid notch, supraspinatus very useful for confirming integrity; however, as with most
muscle and the acromioclavicular joint, before sweeping tendons, the internal structure is best evaluated in the axial
down to the deltoid insertion. plane.
CHAPTER 1 — Shoulder: Anatomy and Techniques 5
a b c
d e f
g h
i j
Figure 1.2 Standard ultrasound examination positions. (A, B) Dorsum of hand on patient’s knee with some shoulder extension: used to
visualise biceps tendon in short and long axis. (C, D) Shoulder extended, hand by side position for subscapularis (external rotation can also
be used). (E, F) Hand on back pocket: used for supraspinatus short and long axis. (G, H, I, J) Arm across anterior chest for teres minor long
and short axis, supraspinatus muscle belly and acromioclavicular joint.
Deltoid
CHL
Humeral head A
Short head Subscapularis
ML
b P c
Figure 1.3 Position 1: the biceps lies centrally within its groove.
A
S I
b P c
Figure 1.4 Position 2: long axis of biceps with the subacromial subdeltoid bursa just visible anterior to the superior part of the tendon.
When assessment of the long head of biceps is complete, be covered in a later section. The probe is then returned to
the probe is moved medially to locate the short head of the upper biceps to review the rotator interval.
biceps. The bony margin of the coracoid process provides a
very useful landmark. The short head arises from its inferior STANDARD POSITION 2: ROTATOR INTERVAL
margin superficial to the insertion of the pectoralis minor
and coracobrachialis tendons. The tendon of pectoralis IMAGING GOALS
major can be identified as a long, thin slip passing over the 1. Identify ligamentous sling around biceps.
biceps tendon around the level of the proximal musculoten 2. Confirm ligaments are intact.
dinous junction. The more detailed anatomy of the arm will 3. Evaluate Doppler signal.
STANDARD POSITION 3: SUBSCAPULARIS

TENDON
IMAGING GOALS
1. Identify tendon in long axis.
2. Identify tendon in short axis.
3. Note relationship of tendon with rotator interval.
TECHNIQUE
a
Subscapularis arises, as the name suggests, from the under
surface of the scapula and is an internal rotator of the
shoulder. It is a multipennate muscle forming several
Deltoid tendons that insert as a conjoined unit on the medial border
Supraspinatus of the bicipital groove. The tendon measures approximately
8 cm from superior to inferior. Its upper margin is adjacent
Biceps
to the anterior interval. The tendon must be examined in
CHL
A both its long and short axis, as, because of the width of the
Humeral head tendon, significant tears may be present in one location, yet
SCT ML
b P other areas of the tendon will appear completely normal.
Following a successful examination of the biceps tendon
Figure 1.5 Rotator interval image. The coracohumeral ligament re-
inforced by the superior glenohumeral ligament separates supraspi-
and rotator interval, the patient is asked to move their elbow
natus from infraspinatus. posteriorly, then, keeping the elbow firmly by their side, the
shoulder is externally rotated by asking the patient to move
their hand as far as possible laterally. This draws the sub
scapularis out from beneath the coracoid, making it easier
TECHNIQUE to examine in its full extent (Fig. 1.6). Patients with adhesive
As has already been mentioned, the rotator interval is the capsulitis will find it difficult to externally rotate the shoul
name given to the space between the subscapularis and the der, an important initial clue to this diagnosis. Take care to
supraspinatus tendons through which the long head of ensure the patient doesn’t lift their arm to try and simulate
biceps passes as it exits the glenohumeral joint. Because the external rotation.
tendon undergoes a 90° turn as it enters the bicipital groove, In the axial plane, the normal bright reflective tendon
it must be supported to ensure that it does not displace should be followed from musculotendinous junction to
medially. Two ligaments in particular combine to create insertion. In some normal patients, and patients with
this support, which is also referred to as the rotator pulley chronic tendinopathy, the tendon may be very thin and dif
(Fig. 1.5). The two ligaments are the coracohumeral and ficult to separate from the surrounding bursa. If there is any
the superior glenohumeral ligaments. The pulley is also doubt as to its integrity, moving the tendon by internal/
reinforced by fibres of the subscapularis tendon passing external rotation easily separates it from surrounding struc
superficially to the coracohumeral ligament and inserting tures and isolates what is tendon and what is surrounding
on the lateral aspect of the groove. These fibres are some bursa.
times erroneously referred to as the transverse ligament. Once the axial view is completed, the probe is rotated 90°
The patient position is the same as for the biceps tendon. to assess the tendon in its short or sagittal axis. The examiner
The rotator interval is best evaluated with the probe in the should be careful not to displace the probe too far laterally
axial plane, positioned just above the upper part of the beyond the subscapularis insertion and into the supraspina
biceps groove. In this position, a rim of tissue is seen around tus tendon. In the short axis, the subscapularis tendon is
the biceps tendon, between the subscapularis medially and recognized by its multifascicular pattern (Fig. 1.7). It should
the supraspinatus laterally. This ‘rim’ represents the con be examined from upper to lower border. If the upper
joined coracohumeral and superior glenohumeral liga border cannot be clearly defined, it is brought more inferi
ments and the bridging subscapularis fibres. The margins orly by further posterior movement of the elbow. Sharp
of the coracohumeral ligament can usually be identified definition of the upper border is important, as many injuries
with good-quality equipment. It measures approximately begin at the upper border of the tendon. The normal upper
1.5 mm in thickness and should have the striated, predomi border should have a nice rounded margin and the biceps
nantly reflective appearance typical of ligaments elsewhere. tendon should lie just above and lateral to it. The relation
It should have little or no Doppler activity within it. ship of the upper border of the tendon and the rotator
On the medial aspect of the interval, particularly at its interval is also easier to appreciate in this position.
uppermost extent, the contribution from the superior gle In addition to examining the tendon, the underlying
nohumeral ligament can be identified. This is seen as a humeral head should be scrutinized; that said, it is not
nodule of tissue often inserting itself just underneath the uncommon to identify asymptomatic surface defects. The
biceps tendon and blending with the coracohumeral liga anterior compartment of the glenohumeral joint lies deep
ment, from which it is often difficult to separate. Note to the subscapularis, although visualization of the anterior
should be made of thickening or abnormal Doppler activity labrum is insufficient for reliable diagnosis. Capsular con
in and around the coracohumeral ligament, before moving densations representing the middle glenohumeral ligament
the probe medially to assess subscapularis. may be seen. Anteriorly, the subacromial subdeltoid bursa
Deltoid
ursa
SASD B
Short head
ris
ula
c ap A
bs Humeral
Su head M L
P
b c
Figure 1.6 External rotation draws the subscapularis tendon laterally out from under the coracoid. This image is obtained just below the tip
of the coracoid, demonstrating the proximal portions of short head of biceps and coracobrachialis muscle.
Bursa
SASD Subscapularis Deltoid
BT
A Humeral head
S I
b P c
Figure 1.7 In short axis, subscapularis muscle is multipennate, forming an elongated tendon that inserts in a slight depression on to the neck
of the humerus.
lies between subscapularis and deltoid, and fluid frequently

gravitates in this position. TECHNIQUE
As with tendons elsewhere, supraspinatus is examined in
STANDARD POSITION 4: SUPRASPINATUS both planes. In order to best visualize the tendon, the
TENDON patient is asked to abduct and internally rotate their shoul
der. This is best achieved by placing the palm of their hand
IMAGING GOALS on their ‘back pocket’. Alternatively, the patient can be
1. Identify the tendon in short axis. asked to put their arm in an ‘armlock’ position. These posi
2. Note the relationship with biceps tendon. tions bring supraspinatus forward and out from under the
3. Identify the tendon and long axis. cover of the coracoacromial arch (Fig. 1.8). Although
b c
Figure 1.8 Extending and internally rotating the shoulder draws the supraspinatus forward and laterally from under the coracoacromial arch.
The biceps tendon provides a key landmark identifying the rotator interval with subscapularis medially and supraspinatus laterally.
similar, the two positions do not result in an identical con

figuration of the tendon and bursa. As such, moving between
them can be very useful to create changes in tension, which
can be useful diagnostically.
Just as patients with adhesive capsulitis (frozen shoulder)
may find it difficult to adopt the best position for visualiz
ing subscapularis, patients with impingement may struggle
to achieve the positions described above. In these instances,
asking the patient to let their arm hang by their side a
and internally rotate as much as they are able may be
sufficient.
Once a comfortable position is achieved, begin with the White
short axis examination. This is usually referred to as the
axial view, but in practice, the image is achieved with Supraspinatus
the probe held in a slightly tilted axial position (see Fig.
In
1.5). The biceps tendon is the key landmark. In some fr
as
patients who internally rotate particularly well, the biceps A
pi
na
Humeral head
may be very medial and out of the field of examination. ML tu
s
Gentle manipulation of the patient’s position can usually b P
bring it into better view.
Figure 1.9 The orientation of the fibres of infraspinatus is slightly
Once the biceps tendon is located, it is easy to identify different from supraspinatus. The resulting anisotropy renders the
the leading edge of supraspinatus which lies adjacent to infraspinatus fibre slightly darker than supraspinatus.
biceps on the lateral side. The supraspinatus tendon is an
oval-shape structure with a smooth round anterior border.
Occasionally this can appear particularly reflective and
mimic the appearance of the biceps tendon itself: the false tendon should be predominantly a bright, reflective, stri
biceps sign. The area of supraspinatus adjacent to the biceps ated structure until the junctional area between the supra
is also referred to as the leading edge or the free edge. It spinatus and the infraspinatus is reached. At this point,
usually lies very close to the biceps, occasionally overlapping low-reflective striations become visible. This is the anterior
them. Any significant increase in the distance between the part of infraspinatus. The fibres run in a different plane to
biceps tendon and the free edge of the supraspinatus should supraspinatus and therefore appear anisotropic and dark in
be regarded as suspicious for a free edge tear. comparison to supraspinatus.
The probe is then moved laterally, keeping it in the tilted The probe is then rotated 90° to view supraspinatus in its
axial plane, to view the midportion of the supraspinatus long axis. This is the classic image of supraspinatus, and is
(Fig. 1.9). The internal structure of the supraspinatus usually referred to as the coronal plane because the
Deltoid
Ten Supraspinatus
don
foo
tpri Art
nt icu
lar
S Car
Humeral head tila
LM ge
b I c
Figure 1.10 A slight ridge is noted between the articular surface of the humeral head and the supraspinatus footprint. Note the low-reflective
articular cartilage ending just proximal to the medial point of the insertion of supraspinatus.
ultrasound image mimics the coronal image seen on MRI The articular cartilage of the humeral head will be seen
(Fig. 1.10). It will be noted that the probe is actually held deep and medial. The cartilage is hyporeflective, though
in a tilted rather than true coronal plane, and even quite with high-resolution equipment will be noted to have a thin
sagittal in some patients, depending on the degree of shoul bright reflective surface. Deeper again, the highly reflective
der internal rotation. If there is uncertainty, the biceps surface of the humeral head is noted. The subacromial
tendon can be located anteriorly and the probe gently subdeltoid bursa lies superficially, and overlying this is the
rotated until the best longitudinal view of biceps is achieved. deltoid muscle.
The same angle is then used to examine supraspinatus in There is a modification of Position 4 whereby the forearm
the coronal plane. under examination is held further across the back in the
In the coronal position, supraspinatus has a very charac so-called armlock position. In some patients the ‘hand on
teristic appearance. Its upper border is convex with a bright pocket’ is better than the armlock for visualizing pathology
margin representing the subacromial subdeltoid bursa. The and vice versa in others. In all patients, both arm positions
tendon fibres can be seen arching towards its insertion onto should be used and the tendon should be observed under
the greater tuberosity and should have a predominantly movement as the hand passes between the two. Patients
bright, reflective, striated appearance. Two distinct layers of quickly become familiar with the names of the two positions
the tendon are frequently observed in this position. The and easily understand when movement between the two
more medial fibres have to turn more acutely than the positions is needed. The examiner can then concentrate on
lateral fibres to insert and so reflectivity at the insertion is observing the tendon during this movement. More exten
variable, usually ranging from dark medially to brighter and sive dynamic movements are also helpful to depict pathol
more normal laterally, depending on the orientation of the ogy (these will be described in a later section).
probe. This is a form of anisotropy, which can be problem Although the majority of supraspinatus fibres are orien
atic at many tendon insertions. Dynamic probe manipula tated in the coronal plane, there are some that have
tion with heel toeing, beam steering and lateral movement more transverse orientation. These are referred to as the
are combined with slight movement of the patient’s shoul rotator cable and are said to have an important role in
der and can help to overcome this problem. determining both the location and rate of propagation of
The insertion of supraspinatus in this position is called rotator cuff tears.
the footprint. It measures approximately 2 cm medial to The subacromial subdeltoid bursa overlies the supraspi
lateral. It should be examined carefully, anterior to poste natus tendon in the coronal plane. It is a low-reflective
rior, to ensure that the entire footprint has been visualized. structure itself but it is surrounded by reflective fat and con
Particular attention should be paid to the medial margin of nective tissue. The bursa should be traced laterally by
the joint surface where tears may begin. These tears are moving the probe around the greater tuberosity and into
sometimes referred to as ‘rim-rent’ tears. The coronal image the upper arm. In the seated patient, small quantities of
is best for examining the lateral margin of supraspinatus fluid gravitate in these dependent areas. Care must be taken
insertion but poor at demonstrating the leading edge. The not to apply too much pressure with the transducer and
axial image works in the opposite way. underestimate the size or presence of bursal fluid. The
Deltoid
Figure 1.11 The low-signal subacromial subdeltoid bursa is
assessed adjacent to the coracoacromial ligament. The thickness is
noted at rest and in arm abduction. Bursal bunching may be demon-
atus
strated in patients with impingement, although this is not always Infraspin
associated with symptoms. The schematic diagram demonstrates the
location and appearance of bursal bunching with thickening of the
bursa lateral and thinning inferior and medial to the coracoacromial Humeral head P
ligament. ML
A
b
bursa should also be traced medially to the lateral margin

of the acromium (posteriorly) or to the CAL (anteriorly).
In the coronal image, the ligament will be visualized in cross
section as a 1–2 mm bright, oval shaped reflective structure.
If there is difficulty in identifying it, what sometimes helps
is to locate it in long axis first and then rotate the probe to
see it in its short axis. To locate it longitudinally, place the
medial end of the probe over the reflective surface of the
coracoid and hold the probe in the axial plane. Then rotate
the lateral end of the probe upwards, keeping the medial
end still. As the lateral end reaches the acromium, a thin
linear, highly reflective, striated structure representing the
CAL comes into view. Keeping the ligament in the centre of
the image and rotating the probe brings up the ligament in c
cross section. Once the appearance in this plane has been
recognized a few times it will be more easily picked up on Figure 1.12 With the arm abducted and internally rotated, the
the conventional coronal image without having to go tendon of the infraspinatus extends quite far laterally. It has a similar
through this localization process. This is the point where appearance to the supraspinatus tendon, though is generally thinner.
bursal bunching will be sought as the patient abducts their
arm. This is discussed in more detail in the section on
dynamic shoulder examination (Fig. 1.11). of the greater tuberosity posterior to the insertion for supra
spinatus. To examine it in long axis, the patient is asked to
STANDARD POSITION 5: INFRASPINATUS AND place their arm across the front of their chest, internally
TERES MINOR TENDON rotating the humeral head and elongating infraspinatus.
The probe is placed in the axial plane with its medial border
IMAGING GOALS a little lower than lateral to align itself along the tendon.
1. Identify tendon in long access from musculotendinous The appearance of the tendon is very similar to supraspina
junction. tus, although generally smaller (anterior to posterior) (Fig.
2. Note underlying posterior labrum and glenohumeral 1.12). Its relationships are similar with the humeral head
joint. deep and deltoid muscle superficial. The tendon should
3. Find the spinoglenoid notch and neurovascular bundle. be traced medially where it becomes the central tendon
of infraspinatus muscle. The musculotendinous junction
TECHNIQUE should be carefully scrutinized as injuries may occur at this
Infraspinatus, as the name suggests, rises from the dorsal location rather than at the insertion. The tendon also passes
aspect of the scapula below its spine, and inserts on a facet over the dorsal aspect of the glenohumeral joint, where the
a a
Deltoid
Deltoid
IST
IST
TM
Triceps
P
P
ML
A S I
b b A
Figure 1.13 The spinoglenoid notch is located on the posterosupe-
rior aspect of the scapula. It is located by moving the probe a little
medially and superiorly from the position used to locate the infraspi-
natus tendon. The glenohumeral joint and glenoid labrum (postero-
superior part) are identified.
posterior labrum can be readily identified in thin patients.

The posterior recess of the joint is also visible and this is a
good location to detect joint effusion (Fig. 1.13). Cartilage
damage and marginal osteophytes should be sought here.
The spinoglenoid notch lies medial to the posterior labrum
and glenoid margin. This is a bony depression with a well
rounded margin that contains reflective fat and the supra
c
scapular neurovascular bundle. The commonest pathology
identified in this location is a ganglion cyst arising from the Figure 1.14 In short axis, the teres minor muscle is identified on the
posterior labrum which may expand within the fossa, com inferior aspect of the infraspinatus tendon, although sometimes can
press the nerve and also cause infraspinatus muscle atrophy. be difficult to differentiate from it. It has a slightly rounder contour
Increased echotexture of the muscle belly is a sign of infra than the infraspinatus.
spinatus muscle atrophy, which is more often a complication
of throwing sports. musculotendinous junction occurs at a similar location or
Keeping it in the axial plane, the probe is moved inferi perhaps slightly more laterally than infraspinatus.
orly to overlie the teres minor tendon. This tendon has a The quadrilateral space can be identified just below the
similar appearance to infraspinatus and in some patients teres minor tendon. The circumflex humeral artery is prom
can be difficult to separate from it. One feature that can inent in this location and can be used as a marker for the
assist is that the deep relation of teres minor is bone whereas axillary nerve. The probe is then rotated 90° to demonstrate
the structure deep to infraspinatus is articular cartilage. The infraspinatus and teres minor in short axis (Fig. 1.14).
STANDARD POSITION 6: SUPRASPINATUS

MUSCLE AND ACROMIOCLAVICULAR JOINT
IMAGING GOALS
1. Identify supraspinatus muscle belly.
2. Compare echotexture with trapezius.
3. Examine acromioclavicular joint for structure and
tenderness.
TECHNIQUE
The final examination position is also posterior. Having
completed the examination of teres minor in the sagittal
plane, the probe is once again rotated into the axial plane
and moved superiorly, passing above the spine of the scapula
into the area of the supraspinatus muscle belly. This is par
ticularly important in patients with rotator cuff tears, as
associated muscle atrophy can be detected here (Fig. 1.15).
a
The bulk and reflectivity of the muscle are compared with
the overlying trapezius muscle. The ease and clarity with
which the central tendon is visualized is also useful; increas
ing fatty atrophy absorbs the ultrasound beam and blurs the
margins of the central tendon, making it appear larger than Trapezius
normal. The margins of the muscle also be come less clear.
Having assessed the muscle in both long and short axes
(Fig. 1.16), the probe is moved laterally to overlie the acro
mioclavicular joint. It is easy to locate the joint by passing
the probe along the clavicle until the joint is encountered SSM
(Fig. 1.17). The normal joint margins are smooth, although
the capsule will frequently bulge a little upwards. The
margins of the joint are assessed for osteophytes and ero
sions and the joint cavity itself should be reviewed to detect
effusion and synovitis. More important than abnormal joint
morphology, gentle compression with the ultrasound probe S
over the joint may reproduce symptoms, if they arise, from ML
the joint. The acromioclavicular joint is also examined I
b
dynamically. The patient is asked to move their arm from its
position across the chest to the ipsilateral knee, then back
to the contralateral shoulder. This cycle is repeated and
note is made of the relative movement of the lateral aspect
of the clavicle with respect to the acromium. Under normal
circumstances the two bones will approximate slightly,
though some superior/inferior movement may be observed.
When subluxation is present, the lateral end of the clavicle
deviates upwards and there will be abnormal movement of
the capsule and synovial contents.
DYNAMIC SHOULDER ASSESSMENT
Dynamic assessment of the shoulder is most often used

c
to detect subacromial subdeltoid bursal impingement;
however, there are a number of other useful dynamic tech Figure 1.15 The conspicuity of the central tendon of supraspinatus
niques that can be applied to detect cuff tears, including within the supraspinatus muscle belly is used to assess for supraspi-
patient movement, probe movement, fluid movement and natus atrophy. Loss of definition or increased reflectivity around the
the use of bursography as well as dynamic manoeuvres to tendon representing a fatty replacement is an indication of atrophy.
assess glenohumeral instability.
can be observed during this movement. Changes in tissue

DYNAMIC ASSESSMENT FOR CUFF TEARS
tension with separation of fibres can all help with the diag
During the routine examination, supraspinatus should be nosis of cuff tears, and particularly the movement of tissue
examined in a number of different positions, as has previ interfaces. If an abnormality in the region of this interface
ously been outlined. With prompting, the patient can move is detected, its behaviour under movement can help with
efficiently between the optimal positions and the tendon differential diagnosis. Changes in bursal dimension may be
Clavicle Acromium
a
S
ML
b I
Trapezius
SSM
S
P A
I c
b
Figure 1.17 The acromioclavicular joint is located in long axis on
Figure 1.16 The bulk in reflectivity of supraspinatus muscle can also
the superior aspect of the shoulder. The superior coracoclavicular
be assessed in short axis. The muscle generally should fill the arch
ligament overlies, demarcating the upper aspect of the joint space.
between the spine and upper border of the body of the scapula.
The deltoid ligament attaches to the lateral aspect of the acromion.
observed and movement between the planes of supraspina If fluid is present in the bursa it can be used dynamically
tus and the subacromial subdeltoid bursa is particularly to assist in the differentiation of cuff tears. Bursal fluid
useful at differentiating bursal surface partial tears from located in the dependent position can be massaged into a
areas of bursal thickening. If the abnormal tissue moves more useful location on the superior aspect of the tendon
synchronously with the supraspinatus tendon, it is a partial with lateral compression on the outer aspect of the patient’s
tear. If the tendon moves independently of the tissue then shoulder. The patient can even be positioned in a prone
the abnormality is likely to represent an area of bursal recumbent position, although this is rarely necessary. Fluid
thickening. movement, combined with sonopalpation and patient move
In addition to using patient movement, the compress ment, may either fill a previously unrecognized tear or dem
ibility of the underlying tissue can be assessed using sono onstrate that an apparent partial tear is in fact complete, by
palpation. Sonopalpation refers to the cyclical compression showing a fluid connection between the bursa and joint.
and release of probe pressure, while observing the behaviour In addition to fluid that is already present within the
of the underlying tissue. Normal and minimally diseased bursa, if the patient undergoes diagnostic or therapeutic
tissue is poorly compressible. The fibres will respond syn bursal injection, the fluid introduced can be used to identify
chronously and continuity is preserved. With more advanced more subtle pathology, especially of the bursal surface. It is
stages of tendinopathy, the tendon becomes increasingly helpful to re-examine the biceps tendon sheath when par
compressible and the behaviour of the underlying fibre is ticulate corticosteroids are injected into the bursa. If the
more abnormal. Structural integrity is poorly preserved reflective steroid is identified in the glenohumeral joint or
during compression. the biceps tendon sheath, a full-thickness tear is confirmed.
in the same position as is used to assess infraspinatus. The

DYNAMIC ASSESSMENT OF BURSAL posterior recess of the joint is identified deep to this and
IMPINGEMENT the relationship of the round humeral head and posterior
margin of the glenoid noted. The patient is asked to draw
As has been described above, the thickness of the subacro back the arm into the late cocking position. As the humeral
mial subdeltoid bursa can be assessed as it overlies the supra head externally rotates, its effect on the posterosuperior
spinatus and other tendons. The method for locating the labrum is reviewed as posterosuperior impingement may
CAL has also already been described. Once these principal be identified. The manoeuvre is completed by asking the
structures have been located, the patient’s arm can be gently patient to simulate a forward throwing action. Any loss of
abducted, with the elbow flexed and level with the wrist, and congruity between the humeral head and the glenoid
any changes in the configuration of the bursa as it abuts the should be noted. As with any other dynamic manoeuvre, it
CAL noted. Typical findings include increased thickness of is useful to undergo several practice cycles with the patient,
the bursa as it tries to pass beneath the CAL. Occasionally, as some movement of the probe is required to keep the
thickening is sufficient to prevent further abduction, or, relevant structures in view. It is difficult, under physiological
after initial resistance, the bursa may pass under the liga conditions, to maintain visualization of the glenohumeral
ment with an audible and palpable click. The most impor joint, and the power and range of movement of the simu
tant finding during these manoeuvres is the patient’s lated throwing manoeuvre is only a fraction of a normal
response. Bursal bunching without pain is of doubtful sig dynamic throw. Consequently, it is likely that this technique
nificance but pain without bunching is an important clinical carries a significant false negative.
finding. Despite this nonspecificity, the manoeuvre can be Acromioclavicular joint subluxation is more easily
a useful adjunct to the routine examination, especially when assessed. The patient begins with their hand on the ipsilat
equivocal symptoms are present. The same findings may eral knee, then moves it to the contralateral shoulder and
also occur with the bursa impinging against the bony acro back. Under normal conditions, there is some approxima
mium; however, impingement against the CAL is more tion of the acromium at the lateral end of the clavicle. Sig
usually assessed. nificant inferior–superior movement is not detected unless
there is ligamentous laxity. As the joint moves, synovial tissue
and fluid may be extruded. In some patients with a large
JOINT SUBLUXATION quantity of fluid in the subacromial subdeltoid bursa, often
in association with a massive rotator cuff tear, a communica
Glenohumeral joint subluxation is difficult to assess with tion can exist between the bursa and the joint. Under these
ultrasound, but a number of techniques have been described. circumstances, significant quantities of fluid may pass
The examination is generally carried out from a posterior through the joint to emerge on its superior aspect, filling
approach. The probe is initially placed in the transverse a large synovial cyst. This is referred to as the geyser
plane with the arm across the anterior aspect of the chest phenomenon.
2 Shoulder 1:
Supraspinatus Tendon
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION A TEAR IS DETECTED: REPORTING SIZE,

THE AETIOLOGY OF SHOULDER LOCATION AND MUSCLE ATROPHY
IMPINGEMENT NO FULL-THICKNESS TEAR DETECTED.
Bony Impingement WHAT NEXT?
SICK Scapula Other Technique Tips and Tricks:
Other Theories Associated Signs
The Rotator Cable SUPRASPINATUS TENDINOPATHY
SUPRASPINATUS TEAR NOMENCLATURE Aetiology
Partial Versus Full Thickness Clinical Features
Full-Thickness Tear Patterns, Location Image Findings
and Shape CALCIFIC TENDINOPATHY
A STEPWISE APPROACH TO THE DIAGNOSIS
OF SUPRASPINATUS TEARS: FIVE SIMPLE
STEPS
Patients with external impingement syndrome, painful

INTRODUCTION arc or, as it is more usually referred to: impingement syn
drome, typically present with insidious onset shoulder pain
Shoulder pain is one of the commonest orthopaedic pre and limitation of movement. Pain occurs in a variety of clas
sentations in the general population and subacromial sical arm positions, including working with the arm above
impingement is a common underlying cause. The glenohu the head, trying to put on a shirt or undo a bra strap or
meral joint is an intrinsically unstable joint and the tendons reaching to the backseat of a car. In the early stages, these
of the rotator cuff play an important role in stabilizing it movements induce pain that settles, but in time becomes
(Fig. 2.1). The supraspinatus tendon (SST), the most impor more persistent with repeated insult. The patient begins to
tant component of the rotator cuff, lies along the superior wake at night when they turn onto the affected shoulder,
aspect of the humeral head passing beneath the coracoac sleep is disturbed and ultimately pain becomes continuous.
romial arch. The arch is made up of a bony component Classically, the patients point to the lateral aspect of the
posteriorly, the acromion, and a soft tissue component ante deltoid as the location of symptoms. Weakness may be
riorly, the coracoacromial ligament. The other tendons of present and related to muscle disuse or tendon tears.
the rotator cuff are subscapularis, anteriorly, and infraspina The principal pathology is SASD bursitis with or without
tus and teres minor, posteriorly. supraspinatus tendinopathy or tear.
The other important anatomical structure involved in
shoulder impingement is the subacromial subdeltoid
(SASD) bursa. This is a large bursa that also passes under Key Point
neath the coracoacromial arch separating it from the rotator
cuff below. It also separates the cuff from the deltoid muscle The bursal wall becomes thickened and pain and limitation
laterally and a component extends medial to the arch of movement occur as the inflamed bursa and SST pass
between the supraspinatus muscle belly and trapezius above. under the coracoacromial arch on shoulder abduction.
Although large, the bursa is quite thin, containing only a
small quantity of fluid under normal circumstances. Its func
tion is to facilitate movement of the SST beneath the acro Put simply, the bursa and tendon become trapped within
mion and the coracoacromial ligament. this space, leading to further soft tissue swelling and further
16
CHAPTER 2 — Shoulder 1: Supraspinatus Tendon 17
it must be appreciated that not all rotator cuff tears are

Supraspinatus
symptomatic and many patients function, even at a very high
level, with torn tendons. Even when symptoms are present,
these may be due to impingement/bursitis rather than from
a tear in the tendon itself. Repair of the tendon is not always
necessary to relieve pain, and treatment of the bursitis or
surgical management of the subacromial space alone may
Biceps tendon
be adequate and less invasive. As in many other areas of
musculoskeletal ultrasound, a good understanding of local
practices, shared terminology and frequent discussion with
surgical colleagues are most important.
Infraspinatus External impingement must be distinguished from inter
and Teres
nal impingement syndromes, which generally refer to dis
Subscapularis orders of the glenoid labrum such as superior labral tear
from anterior to posterior (SLAP) tears and posterosupe
rior impingement. Pain due to sternoclavicular arthropathy
is sometimes referred to as tertiary impingement. Ultra
sound has a minimal role in the former but is useful in
detecting and treating the latter.
THE AETIOLOGY OF SHOULDER

IMPINGEMENT
As with tendinopathy elsewhere in the body, a combination

of extrinsic and intrinsic factors, coupled with misuse and
combined with a genetic predisposition, lead to tendinopa
thy and rotator cuff tears. Extrinsic factors include external
impingement on the tendon from the surrounding bony or
soft tissue components of the arch.
BONY IMPINGEMENT
Multiple factors have been implicated in the aetiology of
impingement and rotator cuff disease. Attention is fre
quently drawn to the shape of the acromion, although it is
Figure 2.1 Sagittal diagram of rotator cuff tendons. The tendons of
subscapularis, supraspinatus and infraspinatus merge together to
now generally accepted that, apart from extremes, changes
form the cuff. There is an anterior opening to allow egress of the long in the acromion are secondary to impingement rather than
head of biceps. This is called the anterior interval. a primary cause. Bony irregularity on the undersurface of
the acromion can arise as a result of enthesopathy at the
coracoacromial ligament attachment. In extreme cases,
a distinct bony spur may be present, leading to further nar
impingement. A variety of clinical tests have been described rowing of the subacromial space. Entheseal changes may
to detect impingement. These are fairly reliable in detecting also occur at the humeral insertion of the involved tendons.
a problem beneath the arch, but less reliable at determining Bony upgrowth from the humeral head combines with bony
the full extent of the problem. This then becomes the downgrowth from the acromion leading to further diminu
most important goal for imaging, differentiating patients tion in the subacromial space, increased bursal impinge
with simple bursitis from those who have progress towards ment and progressive supraspinatus tendinopathy (Fig.
tendinopathy or, more importantly, rotator cuff tears. If a 2.2). Although bony and entheseal factors have been shown
tear is present, secondary goals include determining whether to narrow the subacromial space, it is probable that they are
it is partial or full thickness, the size and full extent of the not the most important.
tear and the presence of chronic features such as muscle
atrophy and arthropathy. The importance of these second
SICK SCAPULA
ary features depends on other factors such as the age of the
patient, their activity, the acute nature of any underlying
injury and local surgical preferences. This is particularly Key Point
variable with partial thickness tears. In some countries these
are managed surgically, particularly if they involve more Two factors that are almost certainly more important than
than 50% of attending thickness, whilst in other countries acromial shape and enthesopathy in the aetiology of rotator
they are managed the same way as focal tendinopathy. cuff disease are genetic factors and scapulothoracic
Indeed, in some descriptions, the meaning of partial thick dyskinesia.
ness tear and focal tendinopathy is the same. Furthermore,
diseased tendons in the body, prominent increased vascular

ity is present. Notable examples include the Achilles and
patellar tendons. Neovascularity or angioneogenesis is not
a prominent feature in supraspinatus tendinopathy. The
underlying cause for the differences between these tendons
is unclear.
THE ROTATOR CABLE

It has been suggested that central or ‘crescent’ supraspinatus
tears are more common in older individuals as a degenerate
phenomenon. It has also been suggested that they are more
likely to occur when there is a prominent condensation of
fibres traversing the supraspinatus, called the rotator cable.
The rotator cable has not been extensively studied, but it
appears to be a condensation of tendon fibres that are ori
entated in a different plane from the remainder of the
tendon. Together they form a band of tissue that extends as
an arch from the anterior leading edge into the tendon
Figure 2.2 A down sloping acromion and/or a spur/enthesopathy
substance to the posterior margin of the tendon close to its
on the undersurface of the acromion may impinge on the bursal
space. In addition, bony enthesopathy may impinge on the undersur- insertion. The cable reinforces the anterior and posterior
face of the SST. An important factor is shoulder dyskinesia, where parts of the tendon in the same manner as a cable links the
scapular rotation and upward migration of the humeral head further struts of a suspension bridge. Between the cables, a weak
impinge on the subacromial space. area is created in the central substance of the tendon, sec
ondary to stress shielding. This area becomes more prone to
degeneration leading to a tear. The terms central, midsub
Scapulothoracic dyskinesia refers to the narrowing of the stance or cresent have all been applied to this tear pattern.
subacromial space that arises as a result of abnormal scapu It has also been suggested that the presence of a strong rota
lar motion. The term SICK scapula syndrome comprises: tor cable may explain why not all tears are symptomatic.
Scapular malposition, Inferomedial prominence, Coracoid
pain and scapular dysKinesis. The muscular imbalance
SUPRASPINATUS TEAR NOMENCLATURE
between the thoracic and cuff musculature leads to eleva
tion of the humeral head and impingement of the subacro
PARTIAL VERSUS FULL THICKNESS
mial space beneath the coracoacromial arch. Abnormal
shoulder biomechanics, termed microinstability, with or One of the issues that frequently causes confusion is the
without joint laxity, may also contribute. The aetiology of nomenclature of cuff tears, particularly the definition of
the SICK scapula is incompletely understood, but maladap partial versus full thickness versus massive rotator cuff tears.
tive postural biomechanics, possibly due to habitual poor This can be more easily understood when it is appreciated
posture or other causes, leads to the abnormal relationship that the SST is a sheet-like tendon, unlike, say, the tendons
between the scapula, thorax and humerus. The contribu of the wrist that are more tubular or string-like. As such, the
tion that scapular dyskinesia makes to impingement is supraspinatus has both thickness and width. It has a supe
important and underlines the importance of physical rior surface facing the subacromial bursa and an inferior
therapy as part of the patient’s management. surface facing the glenohumeral joint. An intact SST pre
vents communication between these two compartments. Its
anterior edge abuts the biceps/rotator interval and its pos
OTHER THEORIES
terior margin blends with the infraspinatus tendon into
An important intrinsic mechanism leading to tendon degen which tears may extend.
eration and tear is apoptosis: the intrinsic degeneration of
collagen, largely influenced by genetic factors. Like the
stress factors of bone, the state of a tendon at any one time Key Point
is a balance between damage and repair. If apoptosis is
accelerated beyond the intrinsic repair mechanism’s ability If a tear is detected, its description should include a
to heal, tears occur. A watershed area has been defined in comment on its thickness, width and location.
an area of the tendon close to, but not at the bony attach
ment, where an area of decreased vascularity may pre
dispose to cuff tear. This area is often referred to as the The thickness of a tear is described as partial or full; the
‘critical zone’. Anatomical studies, however, have not always width of a tear is described either by its dimensions
demonstrated an area of decreased vascularity, nor is it (anterior/posterior × medial/lateral) or by how much
obvious that the majority of tendon tears occur in this area. intact tendon tissue remains (standard descriptive terms are
Decreased vascularity has not been consistently demon described below).
strated and, when it is seen, it is not clear that this is not A partial thickness tear is one that involves either the joint
an effect rather than the cause of tendinopathy. In many or bursal surface alone and does not allow communication
Figure 2.3 Schematic diagram of joint surface partial tear. There is Figure 2.5 Schematic diagram of full-thickness tear where the joint
no communication between the joint space and the SASD bursa. and bursa now communicate.
supraspinatus remaining intact or as involving the midpor

tion with 1 cm of supraspinatus intact anteriorly and 1 cm
of infraspinatus intact posteriorly, and so forth.
FULL-THICKNESS TEAR PATTERNS, LOCATION

AND SHAPE
Supraspinatus is divided into an anterior portion, some
times called the leading or free edge, and a posterior
portion, also called the crescent, midsubstance or footprint.
Occasionally a posterior portion is described, representing
the area abutting the infraspinatus tendon. The supraspina
tus and infraspinatus are intimately related and share many
crossing fibres. Differentiation between them is less clear-
cut than previously thought.
Leading-edge tears are those that reach and involve the
portion of supraspinatus that lies adjacent to the biceps
tendon/rotator interval. If there is intact tendon tissue
between the biceps tendon and the tear, a midsubstance/
Figure 2.4 Schematic diagram of a bursal surface partial tear. There
is no communication between the joint and SASD bursal spaces.
crescent/footprint tear is diagnosed. What determines why
a tear occurs in these different locations is not completely
understood; however, the rotator cables described above
may play a role.
between the two compartments (Figs 2.3 to 2.5). If contrast Tears are occasionally further divided according to their
is injected into the glenohumeral joint, it will fill a joint shape, although this tends to be used more arthroscopically
surface partial tear but will not pass into the SASD bursa. If than with imaging. The simplest shape is linear. This is a
contrast is injected into the bursa, it will fill a bursal surface separation from the humeral attachment, perpendicular to
partial tear but will not pass into the joint. The most common the normal direction of supraspinatus fibres. Linear tears
tear pattern is said to be a joint surface partial tear, although may involve the anterior edge or midsubstance (Figs 2.6 and
some authors say that this is due to underdiagnosis of bursal 2.7). On ultrasound, these are much larger in one plane
surface lesions. A full-thickness tear is present when both than the other. Extension in two tendon planes leads to the
surfaces are involved and the tear results in communication formation of L-shaped or tongue shaped tears (Figs 2.8 and
between the joint and the bursal compartments. Once this 2.9). When retraction occurs, the tears are described as V
communication is present, a full-thickness tear is diagnosed or U shaped (Fig. 2.10).
regardless of the width of the communicating channel. If both the leading edge and midsubstance areas are torn,
Some full-thickness tears are of large width, measuring the tendon is markedly damaged and retraction becomes
greater than 3 cm in diameter, others are little more than inevitable. Tendon retraction increases as the size of the tear
pinholes. A full-thickness tear might also be described as increases, particularly if the rotator cables are disrupted. As
extending from the anterior leading edge with 1 cm of the tendon retracts it ceases to function and muscle atrophy
Infraspinatus Supraspinatus Subscapularis
Lesser
tubercle
Long head
of biceps
brachii
tendon
Figure 2.8 Leading-edge tear with retraction. Difficult to see on

Head of Tear Greater coronal images.
humerus tubercle
Figure 2.6 Schematic diagram of a linear supraspinatus tear involv-

ing the midportion/crescent/footprint. Difficult to see on axial images.
Figure 2.9 Crescent tear with retraction.
Figure 2.7 A linear L-shaped tear involving the leading edge extend-
ing into the midportion. massive tears, the humeral head is free to sublux superiorly,
impacting against the undersurface of the acromion. Ulti
mately glenohumeral arthritis develops, the so-called cuff
arthropathy.
follows. The constellation of a large tear, retraction and There are also different terms used to describe subtypes
atrophy is sometimes referred to as a massive tear and these of partial tear. A joint surface partial tear that involves the
are frequently not reparable. As supraspinatus tears extend, medial aspect of the footprint is sometimes referred to as a
they may involve the other tendons of the rotator cuff. Pos rim-rent tear or PASTA lesion (partial articular supraspina
terior extension into infraspinatus is relatively common with tus tendon avulsion) (Figs 2.11 and 2.12). A particularly
large tears. Chronic enthesopathy leads to bony changes difficult partial tear type is the intrasubstance tear, or con
around the bicipital groove, where friction of the biceps cealed interstitial delamination (CID). In these cases, a cleft
tendon leads to attrition, biceps tendinopathy and ulti is present within the substance of the tendon itself but it
mately rupture. Anteriorly, the tear may extend into the does not reach either the joint or the bursal surfaces. These
subscapularis, involving its upper border initially. With are difficult tears for the radiologist to diagnose and for the
Figure 2.10 Large U- or V-shaped tear with retraction.
Deltoid
arthroscopist to see as they only become visible if the tendon

is incised. On rare occasions, a rim-rent tear may link with
Tear
an intrasubstance tear to form a J-shaped tear that can
delaminate medially along the tendon back to the mus
SST
culotendinous junction (Fig. 2.13). It may then exit the
tendon and form a ganglion cyst at the musculotendinous
junction. This uncommon lesion is referred to as a sentinel
ganglion.
S
Humeral head
ULTRASOUND IMAGING GOALS ML
I
The majority of shoulder problems can be categorized into b
a relatively small number of conditions based on the patient’s Figure 2.11 Free-edge supraspinatus tear. Note the gap between
presenting complaint and initial physical examination. The the biceps tendon medially and supraspinatus laterally. Some fluid
different clinical scenarios include arthritis, impingement, fills the tendon space, but there is still flattening of the overlying SASD
instability/recurrence dislocation, frozen shoulder, nerve bursa.
compression syndromes and, more rarely, avascular necrosis,
tumour or infection. As has been outlined above, impinge
ment is further subdivided into external and internal
impingement. Internal impingement refers to injuries to the between these two diagnoses and, more particularly, their
glenoid labrum and anterior interval. External impinge management implication is not completely clear-cut. It is
ment includes SASD bursitis/rotator cuff tendinopathy likely that in many cases the two terms are used interchange
complex, calcific tendinopathy and impingement due to an ably or at least inconsistently. Some arthroscopists may refer
abnormal acromioclavicular joint, sometimes referred to as to an area of tendon fibrillation as a partial tear whereas
high arc impingement. Ultrasound is mostly used for patients others will call this tendinopathy. What is more important
with suspected external impingement and frozen shoulder. to appreciate is whether there are management implications
It has little role in recurrent dislocation and internal impinge to making the differentiation.
ment where, if imaging is needed, MRI plays the leading If a partial tear is detected, its size and location should be
role. For ease of discussion, the term ‘impingement’ should described. In many centres partial thickness tears are not
be considered synonymous with external impingement. treated surgically. Many factors impact on this decision,
The primary goal of the ultrasound examination in including the age of the patient, the degree of disability and
patients with impingement is to differentiate those with the size of the partial tear. Some authors regard partial
early disease from those with more advanced forms that thickness tears greater than 50% of the cross section of the
have progressed to full-thickness tendon tears. If a tear is tendon as reparable whereas those that are less than 50%
detected, its width and location should be described along are treated conservatively. A third goal is to differentiate the
with an assessment of the state of the tendon margins and normal tendon from tendinopathy. This is where the great
the degree of associated supraspinatus muscle belly atrophy. est inter- and intraobserver variation occurs, but also where
A secondary goal is to determine whether a partial thickness failure to make this differentiation accurately has the least
tear or tendinopathy is present. The precise difference impact on the patient’s management.
Key Point
An important landmark is the biceps tendon just proximal to

where it enters the bicipital groove in the region of the
anterior interval. The leading edge of supraspinatus is the
smooth convex anterior margin of the tendon that lies close
to the biceps tendon on the lateral side.
It will either be in close contact with the biceps/anterior

interval or be separated by a small distance.
Step Two: Is there a Gap between the Leading
Edge of Supraspinatus and Biceps?
Figure 2.12 Schematic diagram of a PASTA lesion, also referred to Practice Tip
as a rim-rent tear. This is a joint surface partial tear that extends from
the medial aspect of the supraspinatus footprint. The proportion of Under normal circumstances, at most only a small gap is
the supraspinatus footprint that is involved can also be described. present between the biceps and the leading edge of
supraspinatus, containing the coracohumeral ligament and
some fluid. The SST edge should be smoothly rounded and
of normal reflectivity.
If the size of the gap increases and/or the leading edge

becomes ill defined and loses its normal reflectivity, an ante
rior leading-edge tear is diagnosed (Fig. 2.14). Fluid-filled
tears are generally easier to recognize than more chronic
tears, where the only sign may be an alteration of the con
figuration of the SASD bursa. In the presence of a more
chronic tear, the bursa sags into the defect created by the
tear (Fig. 2.15). The size of the tear is measured by the
distance from biceps to where normal tissue is found. If a
tear is identified, it should be confirmed in the coronal
plane. This can be difficult for larger tears (Fig. 2.16). If the
distance between the biceps tendon and the supraspinatus
is normal, the examination proceeds to step three.
Figure 2.13 J-shaped tear. This likely begins as a rim-rent tear that Step Three: Is there a Gap in the Midportion
then forms an extensive delamination along the long axis of supra- of Supraspinatus?
spinatus. The tear may extend over a significant distance medially,
where it may then breach the surface of the tendon, forming a sentinel Keeping it in the axial plane, the probe is moved laterally
ganglion. 2–3 cm to examine the mid and posterior portions of supra
spinatus. A substantial layer of tendon of roughly uniform
thickness should be present between the overlying deltoid
muscle and the underlying humeral head. Loss of tendon
thickness, and particularly the appearance of a gap between
A STEPWISE APPROACH TO THE the anterior and posterior portions of the tendon, is indica
DIAGNOSIS OF SUPRASPINATUS TEARS: tive of a midsubstance tear (Fig. 2.17). These are also called
FIVE SIMPLE STEPS crescent or footprint tears. Like the leading-edge tear, the
presence of fluid makes the tear easier to detect. A chronic
As most supraspinatus tears involve either the leading edge lesion without associated fluid is more difficult to diagnose.
or the midsubstance of the tendon, a structured approach In these cases, the configuration of the SASD bursa should
to identifying and assessing these areas is used. be carefully scrutinized to look for a depression, where the
bursa has fallen into the gap created by the tear (Fig. 2.17).
Step One: Locate the Supraspinatus Leading Edge In the same position, the probe also needs to be moved
in the Axial Plane superiorly and inferiorly so that the full (medial/lateral)
The method of acquiring a standard image of the leading extent of the midportion of the tendon is assessed. The two
edge of supraspinatus has already been described in the steps outlined above will detect the majority of moderate
previous section. As has been outlined, an ‘axial’ image is sized tears. Any tear detected should be confirmed in the
acquired by placing the probe on the anterior aspect of the coronal plane. Smaller tears close to the lateral insertion of
shoulder with a slight upward slant of the probe medial to the SST may be hard to see in the axial plane. To detect
lateral. these lesions, the probe is rotated into the coronal plane.
a a
Deltoid
Deltoid
SST
SST Tear
SASD
Tear
ps
ce
Bi
Biceps A
Humeral
Humeral head ML
head
P
A
LM
P
b b
Figure 2.14 Free-edge tear. There is a gap between the biceps and Figure 2.15 Free-edge tear. There is a gap between the biceps and
supraspinatus. Some free fluid and debris fills the gap. Note the supraspinatus. This is a more chronic tear with relatively little fluid in
sagging of the bursa and overlying deltoid into the gap created by the bursa. Note the sagging of the bursa/deltoid and overlying deltoid
the tear. into the gap created by the tear.
Step Four: Is there a Normal Convex Configuration the gap is filled with fluid, the tear is usually easy to detect
of the Tendon/Bursa on the Coronal Image? (Fig. 2.19). Where no fluid is present, the gap may be filled
If there is no gap in the tendon detected on the axial image, by the bursa sagging into the defect created by the tear.
the probe is rotated so that a long-axis ‘coronal’ view of the
tendon is obtained. This view is similar to the appearance
Practice Tip
of the tendon on coronal MRI images. If a tear has not been
detected by the previous two steps, it is likely to be small and An alteration in the contour of the SASD bursa may be the
involve the most distal (lateral) portion of the tendon only sign of a tear in the coronal plane (Fig. 2.20).
attachment (Fig. 2.18) or linear, with the coronal compo
nent larger than the transverse. Confirming a tear in the
coronal plane involves looking for a gap in the tendon The configuration of the bursa is normally convex upwards.
structure just as in the axial images, but also looking for an If it becomes flattened or convex downwards, a tear should
abnormal configuration to the SASD bursa. In cases where be suspected, although not all will be full thickness.
a a
Deltoid Deltoid
Tear
Biceps
SST
Biceps
SST
Humeral head
A
SCT ML A Humeral
P ML head
P
b b
Figure 2.16 Large free-edge tear and most likely extending into the Figure 2.17 Tear of the midportion of SST. Some residual tissue
midportion. No tendon is identified lateral to the biceps tendon. The remains adjacent to the biceps tendon, possibly reflecting an intact
tendon medially is subscapularis. There is a little fluid. Note the reflec- anterior rotator cable. A fluid-filled gap is then present within the
tive surface of the articular cartilage on the humeral head due to the tendon. Note increased reflectivity from the articular cartilage surface.
increased transmission of sound waves to the articular cartilage as
they are no longer absorbed by the overlying tendon.
Step Five: How Does the Tendon Behave on Patient movements can be simple, with movement of the
Dynamic Examination? arm position between the hand on pocket and the arm lock
If no gap is detected on any of the above manoeuvres, it is position, or more complex, where the examiner takes the
unlikely that a significantly sized full-thickness tear is pres patient’s arm and gently abducts it. Under both circum
ent; however, there are a number of pitfalls. Occasionally stances, the movement of the tendon should be observed in
reflective bursal tissue may fill a gap in the tendon, simulate relation to surrounding structures, particularly the bursa.
intact tendon tissue and make a tear difficult to appreciate
on a static examination. To overcome this, the SST should
Practice Tip
also be examined dynamically.
Intact tendon tissue moves synchronously throughout and is
Practice Tip noncompressible.
The dynamic examination involves both gentle movements of

the patient and compressing movements of the probe. The Tears in the tendon filled with bursal tissue show disorga
latter is called sonopalpation. nized or dyssynchronous movement and the abnormal
tissue can be more easily compressed.
a a
Deltoid
Deltoid
Tear
Tear
SST SASD
SASD
SST
Humeral head
Humeral
head
S S
LM ML
b I I
b
Figure 2.18 Small rotator cuff tear. Coronal (long axis) image of the
Figure 2.19 Moderate-sized midportion tear. Coronal image
SST. The tear lies close to the attachment. The clue is some flattening
showing the fluid-filled defect and slight retraction of the tendon.
of the overlying SASD bursa. These are amongst the most difficult
There is thickening of the acromial subdeltoid lining. There is bony
tears to identify.
enthesopathy at the insertion that provides a useful clue.
The probe position used to evaluate the suprapinatus

A TEAR IS DETECTED: REPORTING SIZE, muscle has been described in the techniques section. Several
LOCATION AND MUSCLE ATROPHY features are used to assess muscle atrophy. The normal
muscle should appear generally hyporeflective, with a well-
If a full-thickness tear is found, its size, location and configu demarcated central tendon and normal muscle striations
ration are reported. Most commonly the size of the tear is (starry sky appearance in cross section). The bulk and
reported in two planes: anterior to posterior and medial to reflectivity of the muscle can be compared with the overly
lateral. Tears are classified into small, medium and large. ing trapezius muscle.
Medium sized tears are considered to be between 1 and
3 cm. If there is significant retraction, the medial to lateral Key Point
extent of the tear may be difficult to measure precisely.
These tears are large, however, and it is not likely that the Fatty infiltration leads to an increase in overall reflectivity and
difference in measurement will have a substantial impact on loss of definition of the central tendon. Muscle atrophy leads
management. The size of the tear may also be described by to loss of muscle bulk and an increase in surrounding fat.
noting how much intact tendon tissue remains either ante
riorly (supraspinatus) or posteriorly (mostly infraspinatus). There is no generally accepted ultrasound classification for
If the tear is large, the degree of associated muscle atrophy muscle atrophy; however, the CT/MRI classification of
should also be evaluated. Goutallier can generally be applied. This divides fatty
a
Deltoid
SST Deltoid
SASD Tear
SASD
Humeral S Tear
head LM
I SST
b
Figure 2.20 Larger full-thickness SST tear with marked bony enthe-
sopathy. Coronal image; note again flattening of the SASD bursa.
atrophy into five grades, 0–4. Grade zero is normal muscle. Humeral
Grade 1: years old occasional fatty streaks, grade 2: fat less head
than 50% of muscle volume, grade 3: 50% fat and grade 4:
fat greater than 50% of muscle volume. It should be noted,
however, that not all authors agree that significant fatty S
atrophy precludes surgical repair and several studies have ML
shown functional improvement following cuff repair, despite I
higher grades of fatty atrophy.
b
Figure 2.21 Joint surface partial tear. This is a defect on the joint
NO FULL-THICKNESS TEAR DETECTED. surface that is triangular/pyramidal in shape with its apex extending
WHAT NEXT? towards, but not clearly breaching, the bursal surface. Coronal image
obtained following SASD bursal injection. Fluid can be identified
OTHER TECHNIQUE TIPS AND TRICKS: within the bursa.
ASSOCIATED SIGNS
Key Point Detecting partial thickness tears and tendinopathy is more

difficult and areas of decreased reflectivity within the tendon
Careful assessment of the leading edge and midportion of could represent either. If there is clear interruption of
the tendon, in both static and dynamic mode, will result in tendon structure, and particularly if fluid can be seen
the detection of the vast majority of full-thickness rotator cuff extending into the tendon from either the glenohumeral
tears in patients in whom there is reasonable visualization. joint or the bursa, the diagnosis of partial tear is easier
to make (Figs 2.21 and 2.22). If the tendon fibres show
a a
Deltoid
Deltoid
SASD
SASD
Tear
Tear SST
SST
S Humeral head
Humeral head S
LM
LM
I
b I b
Figure 2.22 Joint surface partial tear with a large base extending Figure 2.23 Extensive supraspinatus damage. Image obtained fol-
towards, but not breaching, the bursal surface of the tendon. Coronal lowing SASD bursal injection. A thin residual cuff of tissue remains
image. Mild bony enthesopathy is present. separating the bursa from the joint. Bursal injection is helpful in
depicting the nature of these lesions.
abnormal reflectivity but are not obviously interrupted, the area of decreased reflectivity. This area is unfortunately
diagnosis is likely to be tendinopathy. particularly prone to anisotropy (Fig. 2.24), and careful
In many practices, the important differentiation is technique is required to eliminate this. True focal tendi
between the patient with a full-thickness tear and those nopathy should be consistently visible, in both planes,
without. Further subdivision into patients with partial tear, regardless of probe position. Anisotropic artifact is not
tendinopathy and normal have little impact on manage constant. Lateral movement of the probe, using different
ment. The reason for this is that many patients with symp angles of insonation and gentle movement of the patient’s
toms of impingement who do not have a full-thickness shoulder, all help to remove artifact and show the under
rotator cuff tear will be managed by subacromial decom lying tendon to be normal. Artefact from septae within
pression regardless of the state of the underlying tendon. deltoid can also cast shadows over the tendon mimicking
In other practices, large partial thickness tears (Fig. 2.23) a tear.
are managed the same as full-thickness tears with a combina Diagnostic accuracy is improved by noting the presence
tion of tendon repair and subacromial decompression. It is of other findings that are frequently associated with rotator
important for the ultrasonologist to understand local prac cuff damage. The most useful associated sign is the presence
tices in order to be able to best help the patient. of bony enthesopathy (Fig. 2.25). Significant rotator cuff
Joint surface partial tears most commonly occur at the damage is less likely if the bony contour of the tendon foot
medial margin of the tendon insertion or footprint. These print is completely normal, although an exception is acute
so-called rim-rent or PASTA lesions are recognized as an traumatic cuff tears.
a a
Deltoid Deltoid
SASD
SASD
SST
SST
Humeral
head
S
S Humeral head
LM
LM I
I
b b
Figure 2.24 Spurious low signal is noted at the medial aspect of the Figure 2.25 Extensive enthesopathy with intact cuff. Coronal image
supraspinatus footprint. Anisotropy can mimic a PASTA/rim-rent demonstrating the bony irregularity and low-reflective signal change
lesion. Manipulation of the probe is necessary to demonstrate that involving the joint surface of the supraspinatus.
the low signal is not present in all positions and thus represents an
artifact. Note the normal bone contour.
Bursal surface partial tears are said to be less common Many diagnostic examinations are coupled with an
than joint surface partial tears, although this may reflect the ultrasound-guided injection of local anaesthetic and corti
greater difficulty in diagnosing them (Fig. 2.26). Partial costeroid into the bursa. Such injections serve a useful diag
tears of the bursal surface close to the tendon attachment nostic and therapeutic purpose. If the patient’s symptoms
are becoming increasingly recognized. Bursal surface tears are diminished following local anaesthetic injection, a posi
may also be more difficult to diagnose in the presence of tive impingement test, the diagnosis of SASD bursitis is
thickening of the SASD bursa. Dynamic assessment is useful supported.
and gentle movement of the arm and tendon will help to
separate moving tendon tissue from static bursal tissue.
Practice Tip
If fluid is present in the SASD bursa, it can be used to
assist with diagnosis. In the seated position, fluid most com Depending on the volume of the injectate, fluid that is
monly gravitates to the inferior recesses of the bursa, often introduced into the bursa under these circumstances can be
along its lateral aspect. Gentle compression with the exam used for diagnosis. It is well worthwhile making a further
iner’s free hand can manipulate the fluid into a more supe inspection of the bursal surface following injection to see
rior location, which may help to outline a defect in the whether the fluid introduced helps to outline a bursal surface
superior surface of the tendon. This manoeuvre can also be defect (Figs 2.27 and 2.28).
helpful in differentiating bursal surface partial tears.
Deltoid
Deltoid
SASD Tear
SST Tear
SASD
Humeral
head SST
Biceps
A
ML
P
Humeral
b head
Figure 2.26 Bursal surface partial tear. Fluid is present in the SASD
bursa depicting the tear. A few intact joint surface fibres remain.
S
LM
I
b
Areas of hyperreflectivity in the majority of cases will Figure 2.27 Large bursal surface partial tear. Fluid is being injected
represent tendon calcification, although tendon scarring into the bursa (note the needle in the upper right of the image). A
can look similar. Occasionally, short linear wisps of increased reverse triangle/pyramidal shaped tear is present with the apex point-
reflectivity are identified close to the tendon insertion in ing towards the joint surface. Bursal injection helps to confirm lack
asymptomatic individuals. These are orientated along the of communication with the underlying joint.
long axis of the tendon and are of no clinical significance.
Larger, rounder areas of increased reflectivity most com
monly represent calcium deposition. These can be of varying
sizes and densities. Some are well demarcated, more solid easy diagnosis but comparison with the overlying deltoid
and chalk-like, whereas others, although also dense, are can be helpful. Supraspinatus is normally generally brighter
more paste or liquid-like. Not all are associated with symp than the overlying muscle and if this differentiation is not
toms and symptoms, if present, may be due to either impinge apparent then tendinopathy should be suspected. Clinical
ment or from the irritant effect of the calcium deposit. correlation is important and occasionally comparison with
Diffuse tendinopathy is diagnosed when there is more the other side can be useful, unless the pathology is
uniform loss of reflectivity within the tendon. This is not an bilateral.
AETIOLOGY
The aetiology of tendinopathy is still incompletely under
stood. Disordered biomechanics combined with accelerated
apoptosis leads to tendon degeneration, microtears and the
initiation of a proinflammatory pathway. Although the use
of the term tendinitis to imply an inflammatory process is
spurned, this view is largely because of the absence of an
inflammatory cellular response. However many of the
chemical agents implicated in inflammation, including cyto
kines, prostaglandins, neuropeptides and growth factors,
are present in tendon disease and perhaps the concept
of an inflammatory process should not be completely
rejected. The biomechanical mechanisms for rotator cuff
tendinopathy are discussed on page 17. A reduction in the
space between the coracoacromial arch and humeral head,
from whatever cause, leads to mechanical impingement of
the tendon and surrounding bursa.
CLINICAL FEATURES
a
The clinical syndrome is well described. Patients classically
report pain in typical positions frequently involving elevat
ing the arm above the head or reaching posteriorly. Often
the patient indicates the location of pain along the lateral
margin of the deltoid muscle below the insertion of supra
Deltoid
spinatus, possibly reflecting the associated bursal involve
ment. Several clinical signs have been described, which in
combination with the patient’s symptoms lead to a reason
ably confident diagnosis. Though none are thought suffi
ciently sensitive or specific to allow a certain diagnosis, most
patients are managed clinically and in the majority of cases
symptoms will resolve with simple conservative treatment.
For those whose symptoms do not resolve, more intense
Tear treatment is often planned and it then becomes important
to have a clearer idea of where the patient is along the
SASD
SST disease spectrum. It is recognized that it is difficult to dif
ferentiate tendinopathy from rotator cuff tear clinically,
although the presence of weakness is an important sign sug
Humeral gestive of a tear. The role of imaging becomes important in
S head these patients.
LM
I
b IMAGE FINDINGS
Figure 2.28 Bursal surface partial tear extends towards, but does The imaging diagnosis of rotator cuff tendinopathy is not
not clearly breach, the joint surface where bony enthesopathy is straightforward. There is considerable variation in the
present.
appearance of the tendon and overlap between the appear
ances of the normal and diseased tendon. Consequently,
ultrasound findings will range from completely normal
imaging appearances to positive findings in the bursa,
Although the most common reason for carrying out tendon or both. This is also true of MRI.
shoulder ultrasound is to look for SST tears, other abnor Features that are suggestive of tendinopathy on ultra
malities within the supraspinatus or in the adjacent tendons sound include tendon enlargement and diffuse loss of
and ligaments can be important causes of shoulder pain. reflectivity (Fig. 2.29). The SST is generally slightly more
reflective than the overlying deltoid muscle. If this dif
ferentiation is lost, tendinopathy may be present. The
SUPRASPINATUS TENDINOPATHY appearance of one tendon can be compared with the con
tralateral side if asymptomatic and this may help support
The majority of younger patients presenting with impinge the diagnosis. Doppler signal changes, usually extremely
ment will not have supraspinatus tears. In many cases, symp helpful in the diagnosis of tendinopathy in other tendons,
toms will be due to SASD bursitis with or without associated are unfortunately lacking for the SST. The reasons for this
supraspinatus tendinopathy. are poorly understood. The absence of a tendon sheath
Figure 2.30 Extensive, ill-defined calcification almost completely

filling the SST. There is no acoustic shadowing, suggesting that the
calcific matrix is less dense.
anaesthetic injection into the bursa. Fortunately, as has been

previously outlined, differentiating between patients with
painful arc syndrome and a normal appearing tendon, and
patients with painful arc syndrome and imaging features of
tendinopathy has relatively little impact on management.
b In a few patients, a specific cause of tendinopathy may be
Figure 2.29 Coronal image of the supraspinatus insertion. The detected. Such diagnoses include calcific tendinopathy, sero
tendon is intact, but has a diffuse low signal with some increased positive and seronegative arthritis, gout, xanthoma and other
Doppler, particularly at the interface between tendon and the SASD depositional disorders. Drug induced tendinopathy might
bursa. The overall reflectivity of the tendon is less than, the overlying be suggested from the patient’s history. Other systemic dis
deltoid. The findings here are suggestive of supraspinatus tendinopa- eases that predispose include diabetes and renal failure.
thy; however, this diagnosis should be suggested with caution as the
variation in appearance of the tendon is quite wide.
CALCIFIC TENDINOPATHY
cannot be the explanation as the patellae and Achilles Calcification within the rotator cuff tendons may take
tendons also lack this anatomical structure, yet frequently a number of forms. In some cases multiple small flecks
demonstrate even markedly increased Doppler activity. of calcification are present (Fig. 2.30). These are most com
It will therefore be appreciated that, for both ultrasound monly encountered close to the tendon insertion where
and MRI, an imaging diagnosis of tendinopathy should they are not always associated with symptoms. In other cases
be made with caution. In the majority of patients, the com the calcium deposit forms a conglomerate within the
bination of a typical clinical presentation and absence of tendon, which can often be quite large (Fig. 2.31). Some
significant changes within the tendon is suggestive, and of these conglomerates comprise a peripheral dense shell
the diagnosis can be aided by a positive response to local with a more liquid or paste-like content. Chronic lesions
may become more solidly calcified and occasionally even

ossified.
Calcification within a tendon is not always symptomatic.
When symptoms are present, they may be due to the mass
effect within the tendon leading to impingement. The
classic presentation of acute calcific tendinopathy, with
rapid-onset severe pain and restriction of movement, associ
ated with redness and extreme local tenderness, is less
common. This latter presentation mimics septic arthritis, a
condition with which it is often confused. The cause of an
acute presentation is said to be due to crystals of calcium
pyrophosphate escaping from the tendon into the bursa or
joint and exciting a severe inflammatory reaction.
The ultrasound appearance of the calcium deposit will
depend on its make up. More solid lesions will have a bright
reflective leading edge and posterior acoustic shadowing. In
these cases visualization of the contents is difficult. Liquid
or paste-like lesions will also have a strong leading echo, but
acoustic shadowing is less prominent and the contents and
posterior wall of the lesion can be better defined. Differen
tiating solid from liquid lesions is important in planning
a
therapy; however, sometimes this is not completely apparent
until aspiration is attempted. Plain radiography can some
times be useful, particularly in identifying bony or more
solid conglomerates.
Patients with calcific tendinopathy may respond to a
simple SASD bursal injection. If this fails to give significant
relief, aspiration (barbotage) can be attempted. The tech
nique of ultrasound guided calcium aspiration is described
on page 350.
FURTHER READING
Almekinders L. Impingement syndrome. Clin Sports Med 2001;20(3):
491–504.
Burkhart SS, Esch JC, Jolson RS. The Rotator Crescent and Rotator
Cable: An Anatomic Description of the Shoulder’s ‘Suspension
Bridge’. YJARS 2011;26(2):256–7.
de Jesus JO, Parker L, Frangos AJ, et al. Accuracy of MRI, MR arthrog
raphy, and ultrasound in the diagnosis of rotator cuff tears: a meta-
analysis. AJR Am J Roentgenol 2009;192(6):1701–7.
Harvie P, Ostlere SJ, Teh J, et al. Genetic influences in the aetiology
of tears of the rotator cuff. J Bone Joint Surg Br 2004;86(5):
696–700.
Lintner D, Noonan T, Kibler W. Injury Patterns and Biomechanics of
the Athlete’s Shoulder. Clin Sports Med 2008.
Mehta S, Gimbel J, Soslowsky L. Etiologic and pathogenetic factors
b for rotator cuff tendinopathy. Clin Sports Med 2003;22(4):
791–812.
Figure 2.31 Calcium conglomerate within the SST. Only the reflec- Walton J, Murrell GAC. Clinical tests diagnostic for Rotator Cuff tear.
tive leading edge is visible. There is posterior acoustic shadowing. A Tech Shoulder Elbow Surg 2012;13(1):17.
needle has been positioned by a single puncture in the lateral aspect Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors
of the conglomerate. The tip of the needle is difficult to identify within of a rotator cuff tear in the general population. J Shoulder Elbow
the calcium. Surg 2010;19(1):116–20.
Shoulder 2: 3
The SASD Bursa, Rotator
Interval and Other Rotator
Cuff Tendons
Eugene McNally
CHAPTER OUTLINE
SUBACROMIAL SUBDELTOID BURSITIS Rotator Interval Tear

Anatomy and Clinical Adhesive Capsulitis (Frozen Shoulder)
Ultrasound Appearances SUBSCAPULARIS TENDON DISEASE
Bursal Fluid Tendinopathy and Subcoracoid
Bursal Thickening Impingement
Dynamic Assessment of Bursal Impingement OTHER TENDONDS AND MUSCLES
THE BICEPS TENDON Infraspinatus
Biceps Dislocation Teres Minor
Biceps Rupture Pectoralis Muscle
Biceps Tendinopathy Pectoralis Minor Injuries
THE ROTATOR INTERVAL Deltoid and Trapezius
Anatomy
SUBACROMIAL SUBDELTOID BURSITIS ULTRASOUND APPEARANCES

On ultrasound, SASD bursal disease may take two forms. In
ANATOMY AND CLINICAL
some cases the bursa becomes filled with fluid. In others,
The subacromial subdeltoid (SASD) bursa is one of the thickening of the bursal lining is more apparent and there
largest bursae in the body and plays an important role in may be little in the way of free fluid.
patients with subacromial impingement. It is likely that
much of the discomfort felt during arm abduction in patients BURSAL FLUID
with this clinical problem is due to inflammation within the The normal bursa is a thin, low-reflective line surrounded
bursa. Arm abduction, particularly between 30 and 60°, typi- by several layers of bright fat. It is generally no more than
cally reproduces pain that is often felt over the lateral aspect 1 mm in thickness but can occasionally be more. When fluid
of the deltoid rather than over the supraspinatus tendon is present, there is separation of the fat layers and low-
itself. Patients find themselves unable to lie on the affected reflective fluid is detected. It is important not to press too
shoulder and sleep is interrupted. A variety of clinical signs hard with the ultrasound transducer or small quantities of
assist in the diagnosis of impingement but do not clearly fluid may be compressed out of the field of view and over-
differentiate between bursitis and tendon tears. It can some- looked. If patients are examined in the seated position, it is
times be difficult to differentiate between impingement and important to look in the dependent area of the bursa to
neural compression originating from cervical spondylosis. detect these small quantities of fluid. The probe should be
Pain obliterated by injection of local anaesthetic into the passed around the margin of the deltoid so that the inferior
bursal space can be very helpful diagnostically. part of the recess can be seen (Fig. 3.1). Another useful
33
Deltoid a
SST
S
*
Deltoid
ML
I
b
Figure 3.1 Coronal image of supraspinatus. The probe has been

moved around the lateral margin of the greater tuberosity where a *
small quantity of fluid is demonstrated in the most dependent part of
the bursa (*). *
Biceps
A
place to find small quantities of bursal fluid is anterior to S I
the biceps tendon (Fig. 3.2). When fluid is detected around P
biceps, care needs to be taken to determine whether it lies b
within the biceps tendon sheath or within the SASD bursa.
Figure 3.2 Long-axis view of the biceps tendon. Fluid is evident
Fluid within the biceps tendon sheath extends more distally
superficial to the tendon (*), but note there is no fluid deep to it. This
and surrounds the biceps tendon (Fig. 3.3). Bursal fluid is configuration and the location of the fluid suggest that it lies in the
limited by the lower limit of the bursal space anteriorly and SASD bursa and not within the tendon sheath.
cannot surround the tendon.
The presence of bursal fluid usually implies that bursitis
is present, although a very tiny quantity could be considered
normal. It does not mean that a rotator cuff tear is present, the shoulder, particularly by elevating the arm, can force
though the presence of a large quantity of fluid in both the fluid into other areas of the bursa and outline abnormalities
bursa and joint is usually indicative of a full-thickness tear. of the bursal surface of the tendon that may not otherwise
Conversely, if there is a large quantity of fluid in the bursa have been apparent.
and little, if any, glenohumeral joint fluid, a full-thickness If particularly large amounts of fluid are present in the
rotator cuff tear is unlikely. Similarly, following a large SASD bursa, especially when this is associated with marked
volume bursal injection, if there is no increase in fluid in thickening of the bursal lining (Fig. 3.4), a cause other than
the glenohumeral joint or its extension into the biceps impingement should be considered. Potential diagnoses
tendon sheath, communication between the bursa and gle- include rheumatoid arthritis, crystal deposition disease,
nohumeral joint indicating a full-thickness tear can also be infection and haemorrhage. Crystal disease can be particu-
considered unlikely. larly painful and is suggested when multiple echogenic foci
Once fluid is detected, it is useful to try to make use of are identified within the thickened synovium and bursal
its presence to assess for supraspinatus tears. Fluid can be fluid. This condition may progress to frozen shoulder. Haem-
massaged by compression with the examiner’s free hand to orrhage within the bursa may also appear echogenic. This
the superior part of the bursa. Getting the patient to move can be due to trauma, haemophilia or synovial angiomatous
CHAPTER 3 — Shoulder 2: The SASD Bursa, Rotator Interval and Other Rotator Cuff Tendons 35
a a
A
S I
P
b b
Figure 3.3 Long-axis view of biceps tendon showing fluid within the Figure 3.4 Coronal image of the shoulder. There is marked thicken-
tendon sheath and SASD bursa. The bursal fluid is more proximal, ing of the SASD bursa with increased Doppler activity. This indicates
superficial and deep to the deltoid. The biceps sheath fluid is distal a bursitis; however, this pattern is more typical of an inflammatory
and surrounds the tendon. bursitis than a mechanical one. When this pattern is encountered, an
inflammatory arthropathy should be considered.
malformation. Less common causes include other synovial- but the common locations to detect it are over the biceps
based conditions, including infection, pigmented villo- tendon in long axis, around the anterior interval (Fig. 3.5)
nodular synovitis and synovial osteochondromatosis. and, most commonly, over the supraspinatus tendon in the
coronal plane (Fig. 3.6), where the bursa abuts the cora-
BURSAL THICKENING coacromial ligament.
The more common ultrasound finding in patients with The range of normal for bursal thickening is also quite
SASD bursitis is thickening of the synovial lining rather than large. In some it can be subtle and difficult to differentiate
the presence of large quantities of fluid. It should also be from normal. In others it is markedly thickened and may
appreciated that the bursa may appear normal in patients appear bunched up against the coracoacromial ligament.
with painful bursal disease. In such cases, arthroscopy dem- Just as some symptomatic patients have a normal or mini-
onstrates a heavily injected but thin bursal lining. In most mally enlarged bursa, some patients with obvious bursal
individuals, the normal bursa is represented by a thin, echo- thickening may be symptom-free. Focal bursal thickening or
poor line beneath brighter lines representing peribursal fat. side to side difference of >2 mm may be more significant.
Bursal thickening can be seen anywhere within the bursa, As with the dynamic assessment of impingement, the
Deltoid
Deltoid
*
*
SASD Bursa
BT *
SST
SCT
SST
A
ML
P
Figure 3.5 Axial image of the anterior shoulder. The probe is located
over the rotator interval. Note the separation of the coracohumeral
ligament from the deep fibres of the deltoid epimysium. The interven- b
ing tissue represents thickened SASD bursa (*).
Figure 3.6 Coronal image of the shoulder. There is thickening of the
SASD bursa that abuts the coracoacromial ligament (*). The position
of the ligament can be identified by a change in contour of the
bursa. As the arm abducts, the thickened bursa pushes against the
patient’s symptoms underpin the diagnosis of impingement,
ligament and may even pass suddenly beneath it with an audible/
and the diagnosis is unlikely in patients with full and pain- palpable pop.
free shoulder abduction, regardless of the degree of bursal
thickening.
DYNAMIC ASSESSMENT OF BURSAL shoulder so that the medial point overlies the bony cora-
coid. This bony landmark is easy to find with ultrasound,
IMPINGEMENT
but if necessary, it can also be palpated. From this position,
Detecting a minimally enlarged bursa is easier with arm the lateral end of the probe is rotated upwards without
movement. As has been described elsewhere, dynamic moving the medial point. As the acromion comes into view,
shoulder assessment is an important adjunct to the static a ligamentous structure with an ordered homogeneous
examination and is used to detect more subtle manifesta- fibrillary pattern typical of ligaments is visualized (Fig. 3.8).
tions of cuff and bursal disease. Changes in the configura- This is the coracoacromial ligament. The probe can then be
tion of the bursa should be sought during arm abduction rotated 90° keeping the ligament in view until it is seen in
as it impinges against either the lateral margin of the cross section. In short axis, the ligament is small, bright and
acromion or, more preferably, against the coracoacromial oval shaped. With experience, the transverse image of the
ligament (Fig. 3.7). coracoacromial ligament can be quickly located without
The coracoacromial ligament is found by placing the the need to find it in long axis. Just lateral to the ligament,
probe in the axial plane over the anterior aspect of the the low-signal bursa is identified. The patient’s arm is then
Deltoid
*
Bursa * *
* SST
Figure 3.8 Long-axis image of the coracoacromial ligament (*). One

Humeral Glenoid end of the probe is positioned over the coracoid and then the lateral
head margin is rotated upwards until the ligament comes into view. Deltoid
is superficial and supraspinatus is deep to the ligament.
S
LM
b I
Figure 3.7 Coronal ultrasound image showing some thickening of proximal humerus. The tendon should be located within
the bursa as it abuts the coracoacromial ligament (*). This degree the groove, usually surrounded by a small quantity of fluid.
of bursal thickening only occurs during arm abduction and is rela- If the tendon is not present, it is either dislocated or rup-
tively mild. tured. In such cases, the probe should be moved medially
to see whether a displaced tendon can be found (Fig. 3.9).
The short head of biceps should be identified to ensure
that this is not mistaken for a displaced long head. This dif-
abducted and the bursa observed for thickening or bunch- ferentiation is easy, as the short head tendon can be traced
ing as it passes underneath the ligament. In some cases proximally to its origin from the coracoid.
bursal bunching is quite dramatic and further abduction is Four patterns of medial biceps migration/subluxation
blocked as the bursa cannot pass deep to the ligament. In are described (Fig. 3.10). If a medially displaced biceps
others bursal bunching is more subtle and passage under tendon is identified, it should be noted whether it lies
the ligament is not obstructed. In a few patients, the bursa superficial to, deep to or within the subscapularis tendon.
may initially be obstructed, but then passes underneath the A superficial location implies an isolated tear of the coraco-
ligament with an audible and palpable click. It is important humeral ligament (CHL) with an intact subscapularis
not to press too heavily with the probe as this may impede tendon (Fig. 3.9). The biceps lying deep to subscapularis
the normal movement of the bursa or may prevent the bursa indicates that the subscapularis is also torn, at least in its
from clicking underneath the ligament. upper part (Fig. 3.11). Medial migration into the substance
of the subscapularis tendon may occur due to the severe
subscapularis tendinopathy. This is uncommon. Finally,
THE BICEPS TENDON
partial subluxation is also recognized, whereby the biceps is
located on the anteromedial aspect of the groove during
BICEPS DISLOCATION
external rotation, but relocates centrally with internal
Evaluation of the biceps and anterior interval begins with rotation (Fig. 3.12).
the probe in the axial plane overlying the bicipital groove: The long head of biceps is also prone to injury at its origin
an easy to locate depression on the anterior aspect of the from the superior glenoid margin. Injury to the biceps
a b
c d
Figure 3.10 Patterns of medial biceps subluxation. (A) Perched
biceps. (B) Isolated interval tear, intact subscapularis tendon. The
Deltoid
BT biceps lie superficial to subscapularis. (C) Combines interval and
subscapularis tear. The biceps lie superficial to the humeral head.
(D) Interval tear with intratendinous migration of the biceps.
SCT
junction is more obviously different from the adjacent intact

short head component of the muscle. The musculotendi-
nous junction of a ruptured long head tendon will also lie
A below the level of the pectoralis major tendon insertion;
ML
P usually it is located above this level. Finally, asking the
b patient to flex their forearm against resistance often results
in the long head muscle belly bunching up and becoming
Figure 3.9 Axial image of the anterior shoulder. The biceps tendon
has dislocated medially. Subscapularis lies between the biceps and
prominent in the case of biceps tendon rupture, the so-called
the underlying humerus. The bony surface is irregular, indicating Popeye sign. In some cases the diagnosis remains difficult,
enthesopathy. particularly if the previously diseased and now torn tendon
has become adherent to the walls of the bicipital grove, thus
limiting the degree of distal tendon retraction, and obscur-
ing many of the associated signs.
tendon within the joint is difficult to detect using ultra-

BICEPS TENDINOPATHY
sound; MRI and MR arthrography are better techniques for
demonstrating injuries to the biceps labral anchor. If the biceps tendon is correctly located in its upper groove,
it should be further reviewed for biceps tenosynovitis, ten-
dinopathy, partial tear and lesions of the CHL. Repeated
BICEPS RUPTURE
minor trauma results in tendinosis of the biceps tendon,
If the long head of biceps tendon is not found in the upper which becomes thickened, and more rounded in cross
part of its groove, nor appears to be displaced medially, it is section with heterogeneous and decreased echogenicity
most likely that it has ruptured. The torn end of the tendon (Fig. 3.13). Intrasubstance splits may develop with a longi-
should be sought in the groove distal to the rotator interval, tudinal orientation, though occasionally a split biceps
and in most cases a clear diagnosis of biceps tendon rupture tendon is noted as a normal variation (Fig. 3.14). When the
can be made. In some cases, particularly where the tendon split is pathological, there is frequently increased Doppler
is very degenerate or the groove is narrow and irregular, the signal within the tendon and surrounding tendon sheath.
torn tendon end may be difficult to visualize and the ultra- One of the earliest signs of tenosynovitis is increased fluid
sound findings are not as clear cut. The bicipital groove may around the tendon. This is most obvious in the lower part
also contain echogenic debris following a tear, which can of the tendon sheath where the sheath is free to expand
mimic the appearance of a thin but intact tendon. Several slightly as it exits from the more constrained bicipital
tricks can be used to confirm the diagnosis of suspected groove. It is, therefore, important to examine this area care-
biceps rupture. The first, and most useful, is to follow the fully. It should also be appreciated that the presence of fluid
long head biceps muscle belly from distal to proximal when does not necessarily indicate biceps tendon disease, as the
either the torn tendon or retracted musculotendinous fluid may be present within the sheath as a consequence of
Deltoid
Deltoid
BT
Short BT
head
Humeral
head
Figure 3.11 Axial image of the anterior shoulder. The biceps tendon
is attenuated and completely subluxed from its groove. There is no A
subscapularis tendon separating the biceps from the underlying ML
humerus. This indicates a combined subscapularis tendon and T
SC P
rotator interval rupture.
b
Figure 3.12 Perched biceps tendon. The tendon has migrated up

and over the medial wall of the groove (*), but is not completely dis-
a glenohumeral joint effusion. Detecting increased Doppler located. Note that there is a fluid collection just medial to it where
flow is helpful as, if this is present in the sheath and not the subscapularis should be, indicating subscapularis rupture.
elsewhere within the joint, local biceps disease is more likely
(Fig. 3.15). On occasion, it may be difficult to differentiate
synovitis within the sheath from complex synovial fluid con-
taining internal echoes. In general, synovial thickening is
THE ROTATOR INTERVAL
noncompressible, whilst synovial fluid can be compressed
away from the area under interrogation by sonopalpation.
ANATOMY
Synovial fluid tends to accumulate in the dependent areas
of the sheath, usually inferiorly. However, synovitis may also The anatomy of the rotator interval is described on page 7.
accumulate in this region; unlike synovial hypertrophy, fluid In brief, it is composed of the ligaments that serve to main-
will move away from this area if the limb is elevated. Because tain stability of the long head of biceps as it passes from its
of the communication with the adjacent joint, intraarticular intraarticular location to the upper part of the bicipital
bodies may become lodged in the bicipital tendon sheath groove. Without a stabilization mechanism, the biceps
and should not be confused with tendon calcification. would easily dislocate medially. The principal ligaments
a
Deltoid
Deltoid
Biceps
A
Humeral ML
head P
Figure 3.13 Axial image of biceps within the groove. Note the focus
of decreased reflectivity within the tendon indicating tendinopathy. A
There is a little fluid and some synovial thickening surrounding the ML
P Humeral
tendon within the tendon sheath. head
involved are the coracohumeral and superior glenohumeral Figure 3.14 Axial image of anterior humerus. A split is evident in the
ligaments. biceps tendon, but there are no other features of tendinopathy. This
could represent a variant of normal. Occasionally, small accessory
tendon slips may also be identified.
ROTATOR INTERVAL TEAR
The anterior interval normally holds the biceps, supraspina-
tus and subscapularis in close apposition. An abnormal rela-
tionship between these structures requires further analysis to the sign described in a leading-edge tear of supraspinatus
as it suggests that an injury is present. If the biceps tendon tendon and is the less common cause of such a gap. In this
is displaced medially and subscapularis tendon is intact, a case, the smooth rounded configuration to the leading edge
tear of the rotator interval is present (see Fig. 3.10). This of supraspinatus is preserved. A third differential diagnosis
most frequently involves the medial limb ligament, in com- of an abnormal gap between subscapularis and biceps is a
bination with the superior glenohumeral ligament. There is rupture of subscapularis involving its upper margin and an
approximation of the upper border of subscapularis and the intact rotator interval. Like the supraspinatus tear, a normal
biceps tendon (Fig. 3.16) and an increased gap between the configuration to the upper border of subscapularis helps
biceps and the leading edge of supraspinatus. This is similar with this diagnosis.
a a
Deltoid
Biceps
L SST
CH
BT
Humeral A
head ML
P
b b
Figure 3.15 Axial image of the bicep sheath showing fluid around Figure 3.16 Axial image over the rotator interval. There is a tear of
the tendon with associated increased Doppler signal in the synovial the rotator interval with separation between the biceps tendon and
sheath. The appearances indicate tenosynovitis. adjacent supraspinatus. The fibrillated ligament tear is just visible
overlying the biceps.
arthrographically by a reduction in the overall joint capacity

ADHESIVE CAPSULITIS (FROZEN SHOULDER)
and failure to fill normally connecting bursae such as the
The final step in the assessment of the biceps mechanism is subscapularis bursa.
to examine the CHL itself. Normal ligaments are generally Several ultrasound findings in adhesive capsulitis have
bright structures with a fibrillary internal architecture. The been described, although most are rather nonspecific. They
CHL is approximately 2 mm in thickness as it surrounds the include thickening and loss of reflectivity of the ligaments
biceps tendon. Adhesive capsulitis, or frozen shoulder as it involved, and an increase in Doppler activity, although this
is commonly called, presents with a painful stiff shoulder. may be limited to the early phase. In some cases, the liga-
An early predominantly painful phase gives way to a more ment changes occur more proximally, closer to the cora-
painless stiff shoulder with limitations of movement in all coid process. Although positive ultrasound findings in and
directions. External rotation is the first movement to be around the CHL have been described in a high percentage
limited and the last to recover. The block to movement of patients in the literature, clinical experience suggests
occurs both actively and passively and persists under general that these are not completely reliable. MR studies have also
anaesthesia, suggesting capsular restriction as the cause. It shown that the main manifestation of adhesive capsulitis in
is a self-limiting condition but may take 1–2 years to resolve. many patients is capsular thickening in the axillary recess
The underlying cause of the condition is unknown. It is without involvement of the anterior interval. In such cases
more common in patients with diabetes and following cere- ultrasound would not demonstrate abnormal findings in
brovascular accident. Adhesive capsulitis is characterized the anterior interval either.
a a
Deltoid
Deltoid
*
Humeral
head *
A SCT
S I
inser
tion *
face
P t
b b
Figure 3.17 Axial image of the anterior humerus. There is no sub- Figure 3.18 Sagittal image of anterior humerus. Note the slight
scapularis tendon visible between the deltoid and articular cartilage depression on the anterior aspect of the humerus where the sub-
of the humeral head. This indicates complete subscapularis rupture. scapularis tendon should insert. A little fluid only is present at the
insertion (*). The tendon is torn and retracted.
In most patients with frozen shoulder, the ultrasound rotator cuff disease. Isolated traumatic tears occur due to
examination is completely normal; however, the ultrasonol- forced external rotation on a background of tendon degen-
ogist will have noted reduced external rotation during the eration. A few are related to shoulder dislocation and sub-
examination of subscapularis, a useful feature suggesting coracoid impingement. In acute cases, patients complain of
the diagnosis. In some patients, assessment of the shoulder sudden onset of pain and weakness following forced hyper-
is made more difficult by the coexistence of several condi- extension or external rotation. Occasionally a bony avulsion
tions. Subacromial impingement may be associated with a occurs.
secondary frozen shoulder. The main ultrasound sign of complete subscapularis
Ultrasound can be used to guide hydrodilation as a thera- rupture is absence of tendon tissue between the anterior
peutic technique. This technique is described in detail in portion of the deltoid muscle and the humeral head (Fig.
Part 8, Intervention (see p. 350). A needle is introduced via 3.17). In the sagittal plane, the facet for the subscapularis
a posterior approach and 30–40 mL of a combination of insertion is either empty, or contains only fluid and a few
local anaesthetic, cortisone and normal saline is injected to tendon strands (Fig. 3.18). In acute cases, there is usually
distend the joint. considerable fluid present around the torn tendon, making
the diagnosis easier. In chronic cases, where the gap is filled
with bursal thickening, granulation tissue or where there is
SUBSCAPULARIS TENDON DISEASE no excess tissue or fluid, the ultrasound diagnosis can be
more difficult. The remaining tissue, predominantly the
Isolated subscapularis tendon rupture is relatively uncom- SASD bursa, can fill the space and even simulate a thin but
mon. Tears most often occur in conjunction with advanced intact tendon. In such cases, cyclical internal and external
a
Deltoid
Deltoid
SCT
Humeral
head A SCT
S I
P
b
Figure 3.19 Sagittal (short axis) image of subscapularis. The mid

and lower portions of the tendon are present, but thinned. The upper Humeral A
portion is absent (*) and fluid only separates the overlying deltoid from head S I
the humeral head. This indicates a full-thickness partial-width tear of P
the upper third of subscapularis. b
Figure 3.20 Short-axis view of the subscapularis tendon. There is

a partial-thickness tear of the mid-third of the tendon with associated
bony enthesopathy. These lesions may be identified in asymptomatic
rotation will help to distinguish what is intact tendon tissue individuals.
from surrounding bursa.
Because the subscapularis tendon contributes signifi-
cantly to the rotator interval, subscapularis tears are often
associated with loss of integrity of the rotator sling and dis- factor that may be important is the concept of subcoracoid
placement of the biceps tendon. The biceps tendon dis- impingement. Subcoracoid impingement is classified as one
places medially and may come to lie within the joint. of the anterior impingement syndromes along with diseases
Subscapularis is a sheet-like tendon and, akin to the of the rotator interval. The subscapularis tendon passes
supraspinatus and pectoralis tendons, full-thickness tears do between the coracoid and the humeral head and, if this
not necessarily involve the full width of the tendon. Partial space is narrow, the tendon may become impinged. Narrow-
width tears are thought to involve the upper border most ing is most often secondary to bony deformity of the cora-
commonly (Fig. 3.19); however, mid- (Fig. 3.20) and lower coid, which may be either the consequence of a congenital
portion tears are becoming increasingly recognized. Short- anomaly or previous trauma. It has been suggested that a
axis (sagittal) images are important to demonstrate which coracohumeral distance of less than 9 mm in the axial plane
component of the tendon is involved. Unlike supraspinatus, predisposes to impingement.
partial tears involving the posterior or anterior margins
alone are not frequently described, but when they occur
OTHER TENDONS AND MUSCLES
they more often involve the joint surface.
INFRASPINATUS
TENDINOPATHY AND SUBCORACOID
Tears of the infraspinatus tendon most commonly occur as
IMPINGEMENT
a result of extension from a supraspinatus tear. The supra-
Subscapularis tendinopathy and calcification have patterns spinatus tendon measures approximately 2.5 cm anterior to
similar to those of supraspinatus. The aetiology, ultrasound posterior. If the tear extends further than this, involvement
findings and treatment options are similar. One additional of the infraspinatus tendon can be assumed. The traditional
Deltoid a
Humeral
In
head
fr
Deltoid
as
pi
na
tu
s
Infraspinatus
b
Figure 3.21 Transverse image of the posterior shoulder. The deep

epimysium of the deltoid and the SASD bursa are flattened against * *
the posterior aspect of the humeral head. The infraspinatus tendon
is torn and has become retracted, allowing these two structures to
approximate. Glenoid
Figure 3.22 Axial image over the posterior shoulder. An elongated

cyst (*) extends from the posterosuperior labrum and passes medially
view is that supraspinatus and infraspinatus insert onto the to expand in the spinoglenoid notch. Note the diffuse increased
humeral head on different facets and that these facets can reflectivity within the infraspinatus muscle indicating atrophy second-
ary to compression of the suprascapular nerve.
be identified with the probe held in the axial plane. In
practice, the insertions do appear to overlap. Supraspinatus
attaches to the superior facet and the anterior portion of
the middle facet. Infraspinatus attaches to the middle facet,
meaning that those tendons attach to the anterior portion point but the musculotendinous junction can also be
of the middle facet. Tears of infraspinatus in association with involved. It is therefore important to follow the tendon
supraspinatus are therefore more common than hitherto medially into the muscle belly to detect such injuries. The
thought. Like supraspinatus, tears of the infraspinatus ultrasound findings are similar to supraspinatus tears
tendon can also be diagnosed by demonstrating a gap in the with signs that include fluid-filled defects, sagging bursa
tendon overlying the middle facet. Similar principles can be (Fig. 3.21), tendon retraction and secondary atrophy.
applied and the sagging bursa sign is also useful when it Infraspinatus atrophy can occur following a tear but is
occurs over the infraspinatus. more commonly seen as a consequence of denervation
Infraspinatus tears can also occur in isolation. The usual injury. The nerve involved is the suprascapular nerve that
mechanism is traction with the shoulder extended, and arises from C5 and C6, the upper trunk of the brachial
falling off a fast moving motorcycle with the arm extended plexus. Neural compression syndromes are discussed in
is a well-described cause. The tear may occur at the insertion Chapter 4, pp. 52-54 (Figs 3.22 and 4.6).
Figure 3.23 Pectoralis major is a large fan-shaped muscle with

clavicular, sternal and costal origins.
TERES MINOR
Isolated tears of the teres minor are distinctly uncommon.
The muscle is most often affected by atrophy secondary to
axillary nerve impingement. Quadrilateral space syndrome
is discussed in the next chapter.
Impingement of the axillary nerve within the quadrilat-
b
eral space leads to atrophy of either the deltoid or teres
minor muscle or both, depending on the location of the Figure 3.24 Schematic diagram of pectoralis muscle. The muscle
compression and the branch involved. Causes include infe- is made up of multiple divisions. The uppermost arises from the
rior dislocation of the humeral head, mass lesions, or, like clavicle. The remaining six or seven divisions arise from the sternum
infraspinatus atrophy, many patients have no obvious lesion and the costochondral cartilage. They converge together to form a
compressing the nerve. In such cases, chronic traction within bilaminate tendon.
the confined space is thought to underlie muscle atrophy.
Central causes include cervical cord injury and syrinx.
The bulky muscle combines to form a thin but strong
tendon that inserts onto the anteromedial aspect of the
PECTORALIS MUSCLE
humeral shaft, medial to the biceps tendon. The inferior
The pectoralis muscle is a large, fan-shaped muscle of the two or three bands of the muscle share a separate tendon.
anterior thorax. Anatomically it comprises a clavicular head The combined tendon therefore comprises anterior and
and sternal head. The sternal head is further divided into posterior layers or laminae (Fig. 3.24). The anterior lamina
seven or eight bands, some of which arise from the costal is formed from the upper portion of the muscle and the
cartilages of the lower ribs (Fig. 3.23). These are sometimes posterior lamina from the lower portion. These laminae can
referred to as a costal head. Functionally the muscle is be separated almost to their insertion, although they are
divided into a superior and inferior portion. The superior said to be fused inferiorly. Prior to its insertion, the pecto-
portion comprises the clavicular head and the upper three ralis major tendon passes anterior to the long and short
or four bands of the sternal head and the inferior portion heads of biceps. Deep to this lies the coracobrachialis with
is the remainder. the musculocutaneous nerve in between the two muscles.
Tear Pec
Maj Maj
Pec
Pec Min
Figure 3.26 Axial extended field of view image of pectoralis muscle.

There is a tear just medial to the musculotendinous junction. The
a tendon itself can be seen to insert normally into the humerus (H).
The commonest injuries are said to involve the tendon

insertion, with the myotendinous junction (MTJ) the second
most common location (Fig. 3.25); however, others have
found the MTJ injury to be the commonest (Fig. 3.26).
Tendon injuries are sometimes further divided into true
avulsions and midsubstance tendon tears. Partial tears of the
tendon are very much less common than complete rup-
tures. Partial tears may involve one or either lamina. They
are deemed partial thickness if one lamina is involved and
partial width if a part of the lamina is involved. A partial
thickness full-width tear is a complete rupture of one of the
laminae. Tears of the tendon and the tendon insertion are
treated surgically. Some tears of the musculotendinous junc-
tion are treated surgically and the remainder managed
conservatively.
b PECTORALIS MINOR INJURIES

Figure 3.25 Axial image of the pectoralis major. There is a tear of Injuries most commonly involve the sternal head and occur
the muscle belly close to the musculotendinous junction. This is a most frequently at the musculotendinous junction. In most
significant grade 2 injury with separation of the tendon ends. cases there is a history of acute injury, often during weight
training, and the bench press is particularly implicated.
DELTOID AND TRAPEZIUS

The relative length of the inferior portion of the muscle,
along with the sharper angle of pennation as it approaches Tears to the deltoid and trapezius muscles are relatively
the posterior lamina of the tendon, makes the inferior part uncommon and are most often seen following shoulder
of the tendon and muscle more susceptible to injury. Males surgery. During shoulder replacement, the deltoid muscle
significantly outnumber females and sports outnumber may be detached from the acromion and clavicle. Although
work related injuries. The bench press manoeuvre is one of they are reattached, this creates a potential weak area and
the commonest mechanisms of stretching these lower fibres, muscle avulsion may occur during over-vigorous rehabilita-
with the arms abducted and externally rotated. tion. Minor tears of the deltoid associated with supraspina-
Injuries to the muscle origin (grade I) comprise less tus tears are quite common but many are not clinically
than 5% of injuries in total. Injuries to the muscle belly significant. Steroid injections that have remained within the
(grade II) are also relatively uncommon. There are four muscle have also been implicated. Advanced cuff arthropa-
further injury classifications (grades III–VI) and these are thy leading to acromiohumeral impingement may eventu-
injuries to the musculotendinous junction, tendon itself, ally cause a secondary erosion of the deltoid attachment,
insertion and bony avulsion of the insertion respectively. leading to atrophy and detachment.
FURTHER READING resonance arthrography and CT arthrography. Eur J Radiol 2012;

81(5):934–9.
Arai R, Mochizuki T, Yamaguchi K, et al. Functional anatomy of the Gaskill TR, Braun S, Millett PJ. The rotator interval: pathology and
superior glenohumeral and coracohumeral ligaments and the sub- management. Arthroscopy 2011;27(4):556–67.
scapularis tendon in view of stabilization of the long head of the Hudson VJ. Evaluation, Diagnosis, and Treatment of Shoulder Injuries
biceps tendon. J Shoulder Elbow Surg 2010;19(1):58–64. in Athletes. Clin Sports Med 2010;29(1):19–32.
Arai R, Sugaya H, Mochizuki T, et al. Subscapularis Tendon Tear: An Hunt SA, Kwon YW, Zuckerman JD. The rotator interval: anatomy,
Anatomic and Clinical Investigation. Arthroscopy. Elsevier 2008; pathology, and strategies for treatment. J Am Acad Orthop Surg
24(9):997–1004. 2007;15(4):218–27.
Buck FM, Dietrich TJ, Resnick D, et al. Long Biceps Tendon: Normal Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendi-
Position, Shape, and Orientation in Its Groove in Neutral Position nopathy: diagnosis and management. J Am Acad Orthop Surg 2010;
and External and Internal Rotation. Radiology 2011;261(3):872–81. 18(11):645–56.
Christopher Patton W, McCluskey G. Biceps tendinitis and subluxation. Piatt BE, Hawkins RJ, Fritz RC, et al. Clinical evaluation and treatment
Clin Sports Med 2001;20(3):505–29. of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;
De Maeseneer M, Boulet C, Pouliart N, et al. Assessment of the 11(6):600–4.
long head of the biceps tendon of the shoulder with 3T magnetic
4 Shoulder 3:
Beyond the Rotator Cuff
Eugene McNally
CHAPTER OUTLINE
BONE DISEASE AROUND THE SHOULDER THE ACROMIOCLAVICULAR JOINT

Bony Irregularity in the Humeral Head Erosive Athropathy
Greater Tuberosity Fracture Subluxation/Dislocation
Supraspinatus Footprint Lesions High-Arc Impingement
Hill–Sachs Lesion Geyser Phenomenon
Posterosuperior Impingement THE STERNOCLAVICULAR JOINT
THE LABRUM AND GLENOHUMERAL NEURAL COMPRESSION AND SYNDROMES
LIGAMENTS The Brachial Plexus
The Labrum Long Thoracic and Thoracodorsal Nerves
The Glenohumeral Ligaments Suprascapular Nerve/Spinoglenoid Notch/
GLENOHUMERAL JOINT Infraspinatus Atrophy
Effusion Axillary Nerve/Quadrilateral Space
Subluxation Syndrome
GREATER TUBEROSITY FRACTURE

BONE DISEASE AROUND THE SHOULDER
Fractures of the greater tuberosity are more easily detected
by ultrasound than plain films (Fig. 4.1). They are a common
BONY IRREGULARITY IN THE HUMERAL HEAD
cause of persistent shoulder pain following a fall on the
Many bony abnormalities will be encountered whilst per- outstretched hand where plain films have been considered
forming rotator cuff ultrasound. Some of these are common to be normal. These avulsion fractures may involve the
traumatic lesions, including fractures of the greater tuberos- supraspinatus insertion on the greater tubersosity or, less
ity and Hill–Sachs lesions, others are less well understood. often, the subscapularis insertion on the lesser tuberosity.
The location of the lesion on the humeral head can some- Ultrasound demonstrates a cortical break associated with
times be a clue to the underlying cause. focal tenderness. The degree of displacement can be
A bone defect in the anterior aspect of the humeral head assessed with reasonable reliability, although not as accu-
could be due to a reverse Hill–Sachs lesion. These occur as rately as with a CT scan. This is usually between 1 and 8 mm
a result of impaction of the humeral head against the ante- displacement, with larger displacements more significant as
rior glenoid during a posterior dislocation. Bony irregular- they may precipitate or accentuate subacromial impinge-
ity may also be encountered in the humeral head deep to ment. It is also helpful to give an indication of the propor-
the subscapularis tendon. This is sometimes referred to as tion of the supraspinatus footprint that is attached to the
a Welch lesion. Although the cause is unknown, it is fre- fracture fragment.
quently found in asymptomatic individuals and, therefore,
it is generally not regarded as clinically significant. It is often
SUPRASPINATUS FOOTPRINT LESIONS
not located at the tendon insertion but medial to it.
More laterally, bony irregularity is commonly encoun- Bony irregularity is not infrequently identified at the supra-
tered around the biceps tendon groove. This is likely to be spinatus insertion. The cause is not known with certainty. It
the consequence of enthesopathy and is most commonly may begin with traction enthesopathy, but secondary fluid
seen in association with chronic rotator cuff disease. In ingress may enlarge the bony defect that can become quite
some cases the degree of bony abnormality can be so marked large in some patients. The presence of bony regularity does
as to narrow the groove itself and constrict the biceps not always indicate a supraspinatus tear; however, apart
tendon, leading to biceps tendinopathy and rupture. from acute tears, it is unusual to encounter a significant
48
CHAPTER 4 — Shoulder 3: Beyond the Rotator Cuff 49
Deltoid
b
*
Figure 4.1 Coronal image of the shoulder showing a small step in
the cortex of the greater tuberosity consistent with fracture. Ultra-
sound (A) is more sensitive than plain radiography (B) CT confirms
the diagnosis of greater tuberosity fracture.
supraspinatus lesion where the underlying bone is com-

pletely normal. Humeral head
HILL–SACHS LESION b
Bony abnormalities on the posterior aspect of the humeral Figure 4.2 Axial image over the posterior shoulder. A large Hill–
head could be due to previous anterior dislocation. The Sachs defect is present in the humeral head (*). Dynamic assessment
typical Hill–Sachs lesion is due to an impaction of the pos- should follow detection of this lesion to see whether the defect
terolateral aspect of the humeral head against the anterior engages with the posterior glenoid. The dimensions of the lesion can
glenoid margin (Fig. 4.2). In addition to detection, the size also be reported to assist with surgical decisions.
of the defect should be assessed and particularly whether
there is any likelihood of it becoming locked against the
posterior glenoid margin during external rotation. Large The rotator cuff should also be assessed in patients who
lesions may influence surgical decisions. Measurement of have had shoulder dislocations as up to one-third may have
the distance between the bony margins and the depths of associated cuff tears. The incidence of tears in patients with
the lesion can be provided with ease during a routine ultra- a first dislocation is higher than that for recurrent disloca-
sound examination. It is also helpful to assess the position tions. Women appear to rupture the rotator cuff more often
of the Hill–Sachs lesion with respect to the posterior glenoid than men following dislocation.
margin during external rotation, though patients with
recurrent dislocation may be apprehensive during the
POSTEROSUPERIOR IMPINGEMENT
manoeuvre. This is to determine whether there is the poten-
tial to reengage at physiological external rotation angles. In A less common cause of a posterolateral bony injury is pos-
large lesions and lesions where there is the potential to terosuperior impingement. This is where the posterosupe-
engage, additional anterior capsule tightening may be rior aspect of the humeral head may impinge against the
carried out at surgery. posterosuperior labrum. This is most commonly seen in
throwing sports but can also occur in tennis during the to the biceps tendon as it enters the groove. It can be torn
serve. There is some role for using ultrasound in patients as part of a rotator interval tear or become inflamed in
with posterosuperior impingement, though it is recognized patients with adhesive capsulitis (frozen shoulder). The
that a complete evaluation of the glenoid labrum is not pos- middle and inferior glenohumeral ligaments may be injured
sible in many patients. The position of the humeral head in patients with anterior dislocation. The anterior limb of
and glenoid margin can be assessed during a simulated the inferior glenohumeral ligament is the most important
throwing manoeuvre. Bony irregularity of the humeral head as it attaches to the anteroinferior glenoid. This area can be
that comes into contact with the glenoid during the cocking examined by ultrasound; however, it is generally regarded
phase is suggestive of posterosuperior impingement. Vascu- as a less effective means of assessing the anteroinferior
lar channels may also cause bony irregularities and these are labrum than MRI or MR arthrography. The posterior limb
generally quite small and in a different location. Injuries to of the inferior glenohumeral ligament is important in
the labrum are discussed in the next section. patients with internal instability. Capsulitis in this area leads
to reduced internal rotation (GIRD phenomenon), which
THE LABRUM AND GLENOHUMERAL leads to abnormal glenohumeral contact which in turn,
predisposes to tears of the superior and the posterosuperior
LIGAMENTS
labrum. Consistent ultrasound findings in capsulitis of the
posterior limb of the inferior glenohumeral ligament have
THE LABRUM
not been described.
Many parts of the glenoid labrum are amenable to ultra-
sound investigation; however, some of the most important, GLENOHUMERAL JOINT
namely the superior labrum, are not. Some progress has
been made in the ultrasound diagnosis of anteroinferior EFFUSION
labral disease and in posterosuperior impingement. In thin
patients the posterior and posterosuperior glenoid labrum The glenohumeral joint (GHJ) space is assessed in several
can be moderately well seen. It is a triangular shaped, bright separate areas. The best view of the GHJ is obtained poste-
structure with an appearance typical of fibrocartilage. In riorly with the probe in an axial position. The margins of
larger patients, it is more difficult to reliably assess the pos- the joint, the humeral head, glenoid and posterior capsule
terior labrum and, as with the knee meniscus and the can be identified, with the posterior labrum within. Effusion
acetabular labrum, it is difficult to firmly exclude tears. manifests as a bulge in the posterior capsule. As with other
Compared with arthroscopy, ultrasound performs well in joints, an assessment should be made as to whether a simple
differentiating normal from abnormal labra (tear or degen- effusion or complex effusion is present (Fig. 4.3). A complex
eration) in this location; however, its true clinical value has
yet to be established.
The glenoid labrum is prone to paralabral cyst formation
akin to the knee meniscus and acetabular labrum. The cysts
are characteristically fluid filled, largely anechoic with scat-
tered bright foci. The most recognized site is an origin from
the posterosuperior labrum, but other locations, including
between the deltoid muscle and the subscapularis tendon,
between the deltoid muscle and the biceps tendon and
below the coracoacromial ligament, are also described.
Cysts arising from the posterosuperior labrum most com-
monly track medially along the dorsal lip of the glenoid into
the spinoglenoid notch. Here they expand and may com-
press the suprascapular nerve within the notch, leading to
atrophy predominantly of the infraspinatus and occasionally
the supraspinatus muscles. Patients complain of pain and
weakness that may improve following aspiration of the cyst.
The most common cause of infraspinatus atrophy is chronic
nerve traction in the absence of a cyst.
THE GLENOHUMERAL LIGAMENTS

The capsule of the shoulder joint is reinforced in several
locations anteriorly by condensations that form the gleno-
humeral ligaments. When the joint is distended the gleno-
humeral ligaments may be recognized as areas where the
capsule remains undisplaced by effusion, as the fluid pref-
erentially extends between them. The glenohumeral liga-
ments become important in several clinical situations. The Figure 4.3 Axial image over the posterior shoulder. Note the reflec-
superior glenohumeral ligament can be visualized as part of tions within the effusion. Most commonly this indicates haemorrhage
the rotator interval forming its inferomedial margin, deep or septic arthritis.
infusion is suggestive of infection or haemorrhage. The

EROSIVE ATHROPATHY
presence of Doppler signal indicates associated synovitis.
Anteriorly the biceps tendon sheath represents an ante- The acromioclavicular joint is not an uncommon site of
rior extension of the joint compartment. Fluid in this loca- involvement in rheumatoid arthritis, psoriatic arthropathy
tion can indicate either local biceps tenosynovitis or a more and other inflammatory arthropathies as well as septic
generalized disorder of the joint itself. Comparison of the arthritis. In all of these conditions synovitis with active
biceps tendon sheath and other areas where the GHJ can Doppler and erosion should be sought. These features also
be visualized is helpful with this differentiation. Marked occur with joint infection, where aspiration under ultra-
Doppler activity within the sheath, without active synovitis sound guidance may improve diagnostic yield.
in other locations where the GHJ can be viewed, is more
likely to reflect local biceps disease. Another area is the axil-
SUBLUXATION/DISLOCATION
lary pouch, which is located by tracing the medial aspect of
the humeral shaft proximally until the joint capsule is Acromioclavicular subluxation is due to rupture of the
encountered. The capsule can be traced to its glenoid superficial and deep acromioclavicular ligaments. The
attachment and fluid with synovial thickening in the axillary degree of subluxation and its grade depend on the extent
recess can be assessed. This part of the joint is most easily of involvement of the coracoclavicular ligaments. If these
visualized with the arm elevated; however, this position may ligaments are also torn, frank dislocation occurs. The cora-
compress the contents of the axillary pouch. coclavicular ligaments can be difficult to visualize in their
The anterior aspect of the joint is most difficult to visual- entirety as they pass deep to their insertion with a plane that
ize due to its deep location; however, the subscapularis is oblique to the probe. The described technique is to first
recess is located between the neck of the scapula and the locate the bony prominence of the coracoid process medial
subscapularis tendon. This communicates with the GHJ. to the humeral head in the transverse plane. The probe is
Care should be taken not be misdiagnose fluid and synovial then rotated into the sagittal plane so that the rounded
thickening in this area as an abnormality of the subacromial bony surface of the coracoid (below) and clavicle (above)
subdeltoid bursa. is visible. In this plane the coracoclavicular ligament can be
seen as an echogenic vertical or oblique band.
In acromioclavicular subluxations and dislocation there
SUBLUXATION
is widening of the distance between distal end of clavicle
In addition to noting the presence of joint effusion, the and acromion. Comparison with the uninjured contralat-
alignment of the GHJ can also be evaluated. The relative eral side helps to assess the degree of subluxation, which
position of the posterior margin of the humeral head can be classified according to Tossy. Tossy 1 injuries may
and the posterior margin of the glenoid can be used to show no side-to-side difference at rest, with abnormal joint
determine whether anterior or posterior subluxation is movement only becoming apparent on stress testing. The
present. Comparison with the contralateral shoulder is normal joint width is 5–6 mm with symmetrical appear-
used to demonstrate the abnormality. The relative positions ances. A joint space of greater than 1 cm or more than
are assessed in both the static and dynamic phases of a 50% of the asymptomatic side indicates a Tossy grade 2
simulated throwing manoeuvre to demonstrate dynamic lesion, more than 2 cm is grade 3. Tossy 3 injuries may show
instability. as much as 5-fold joint widening compared with the unin-
Ultrasound is not a useful technique for a comprehensive jured side.
evaluation of the glenohumeral articular cartilage. The static examination is supplemented by a dynamic
assessment. The patient moves the affected side hand from
a position on the ipsilateral knee to the contralateral shoul-
THE ACROMIOCLAVICULAR JOINT der. Repetitive motion with the probe position on the
superior aspect of the joint demonstrates subluxation.
The acromioclavicular joint is best examined from the supe- With disruption of the acromioclavicular ligaments, upward
rior aspect with the probe in the coronal plane. Normally, movement of the distal end of the clavicle occurs (Fig. 4.4).
the clavicle is slightly higher than the acromion, and the In more gross dislocations, tears of the deltoid and trapezius
margins of the joint are smooth. The superior acromiocla- with button holing of the clavicle through the muscle may
vicular ligament is seen as a thin echogenic band of coro- also occur. Increased transducer pressure at the time usually
nally orientated collagen bundles. It extends from the distal reproduces the patient’s characteristic pain.
centimetre of the superior superficial surface of the distal
clavicle to the acromion. It has a flat or mildly convex super-
HIGH-ARC IMPINGEMENT
ficial surface. Occasionally a notch or fissure may be seen
extending across the surface of the acromion, due to an os High-arc impingement is impingement that occurs at
acromiale, a failure of normal secondary ossification fusion greater than 90° abduction. Acromioclavicular joint degen-
that may predispose to subacromial impingement. eration is a common cause and pain is usually localized to
Post-traumatic acroosteolysis is an unusual sequela of the area above the joint itself. With degenerative joint
acromioclavicular joint injury whose pathogenesis is not disease, synovial effusions, osteophyte formation and ero-
fully understood. Sonographically there is marked irregular- sions may be found, although these features are not always
ity of the distal clavicle with associated joint synovitis. The associated with symptoms. High-arc impingement is likely
changes must be differentiated from conditions such as due to inferior osteophytes impinging against the bursa and
primary inflammatory arthropathy or osteomyelitis. supraspinatus tendon. Erosions at the acromioclavicular
a a
* *
Clavicle
Acromium
b b
Figure 4.4 Coronal image of the acromioclavicular joint. There is Figure 4.5 Coronal image overlying the acromioclavicular joint. A
slight subluxation of the joint with the clavicle lying a little superior to moderate sized, mixed, but predominantly low-signal cyst extends
the acromion. When even small degrees of subluxation are present, a from the superior aspect of the joint (*). Such cysts are most common
coronal approach to guided injection of the joint becomes feasible. when there is associated supraspinatus tear with fluid extending from
the GHJ through the defect into the bursa and through the acromio-
clavicular joint into the overlying cyst. This passage of fluid is some-
joint are more commonly due to chronic trauma than times referred to as the geyser phenomenon.
inflammation.
To examine the joint, the probe is placed oblique trans-

GEYSER PHENOMENON
versely across the sternoclavicular joint and along the line
In patients with advanced acromioclavicular joint osteoar- of the clavicle from an anterior approach. The affected joint
thritis associated with cuff tear and large joint effusion, fluid can be compared with the unaffected side. Superior and
may pass from the GHJ into the subacromial subdeltoid anterior subluxation is the common pattern. In patients
bursa and thence into the acromioclavicular joint, causing with acute trauma, sternoclavicular joint dislocation may be
it to progressively bulge its superior joint capsule (Fig. 4.5). either anterior or posterior. Posterior dislocation is more
If pronounced it can result in a large synovial cyst extending significant as it predisposes to vascular injury.
into the supraclavicular fossa. This upward extension is
termed the geyser phenomenon and may be misinterpreted
as a solid mass. NEURAL COMPRESSION AND
SYNDROMES
THE STERNOCLAVICULAR JOINT THE BRACHIAL PLEXUS
The most common presentation of sternoclavicular joint The brachial plexus comprises the roots of the C5/C6/C7/
osteoarthritis is as a painless, hard lump. The mass is due to C8 and T1 levels. They pass between the scalenius anterior
osteophyte, fibrous pannus and partial subluxation. Axial and the medius muscle before passing underneath the clav-
imaging differentiates this common cause from less common icle and pectoralis minor to reach the upper arm. The
causes such as infection or a true mass. The sternoclavicular easiest way to identify the roots of the brachial plexus is to
joints are synovial and as such may be involved in systemic locate the three aligned roots between the scalenus anterior
synovial disorders such as rheumatoid arthritis. Pain due to and medius. From lateral to medial these are C5, C6 and
sternoclavicular arthropathy is sometimes referred to as ter- C7. C8 and T1 are found more inferiorly, as they emerge
tiary impingement. from their foramena. The C8 and T1 roots form the lower
trunk. The C7 cervical level can also be recognized by the

presence of a single (posterior) rather than double (ante-
rior and posterior) tubercle on the transverse process. The
C7 root arises above the C7 vertebral body.
The brachial plexus may be injured by trauma, either
directly or indirectly. Indirect compression against the clav-
icle joint arm abduction is called the thoracic outlet syn-
drome, and is particularly common when cervical ribs or
accessory bands are present. Compression may also occur
from an adjacent neoplasm or haematoma. The roots of the
brachial plexus may also be avulsed during high-energy
trauma, particularly motor vehicle accidents and especially
with falls from motorbikes. Posttraumatic haemorrhage and
meningoceles are found close to where the root emerges
from the cervical canal. Separation of the brachial plexus
trunks, divisions or cords can be seen following penetrating
injuries.
Brachial neuritis typically affects the C5/6 nerve roots,
leading to oedema and atrophy of the supraspinatus and
infraspinatus muscle (Parsonage–Turner syndrome). The
aetiology is unknown but the lesion is generally transient a
and recovery is normal.
LONG THORACIC AND THORACODORSAL

NERVES
The long thoracic nerve can be located anterior to the
lateral margin of the scapula in the midaxillary line. It serves
the serratus anterior muscle, over which it lies. It may be Deltoid
accompanied by a small vessel, in which case Doppler flow
can help locate the nerve. There is another nerve that lies
more posteriorly: this is the thoracodorsal nerve.
Infraspinatus
SUPRASCAPULAR NERVE/SPINOGLENOID
NOTCH/INFRASPINATUS ATROPHY
Infraspinatus atrophy can occur following a tear but is * *
more commonly seen as a consequence of denervation
injury. The nerve involved is the suprascapular nerve that
arises from C5 and C6, the upper trunk of the brachial Glenoid
plexus. The nerve enters the supraspinatus fossa through
b
the spinoglenoid notch, below the superior transverse scap-
ular ligament. Compression on the nerve may be the result Figure 4.6 Axial image over the posterior shoulder. An elongated
of a mass lesion but is more commonly the consequence of cyst (*) extends from the posterosuperior labrum and passes medially
chronic repetitive traction beneath the bridging ligament. to expand in the spinoglenoid notch. Note the diffuse increased
Throwing sports are particularly susceptible and isolated reflectivity within the infraspinatus muscle indicating atrophy second-
infraspinatus atrophy is a commonly recognized entity in ary to compression of the suprascapular nerve.
many throwing sports. The commonest mass lesion causing
compression is a ganglion cyst arising from a tear in the
adjacent posterosuperior glenoid labrum (Fig. 4.6). These
are seen in association with posterosuperior shoulder triceps muscle. In many patients, using a lower frequency
impingement (Fig. 4.7). The ganglion passes medially via probe allows better visualization of the neurovascular
a narrow neck until it reaches the spinoglenoid notch, bundle. The artery is first sought using Doppler to detect
where it expands to compress the adjacent nerve. The gan- the accompanying vessel. Compression of the artery with a
glion may also extend through the notch and supraspinatus reduction in flow when the patient externally rotates is said
atrophy may occur. to be a sign of the quadrilateral space impingement, and
may indicate a lesion within the space. The range of normal
AXILLARY NERVE/QUADRILATERAL flow is wide; however, loss of flow can also be identified in
asymptomatic individuals.
SPACE SYNDROME
Impingement of the axillary nerve within the quadrilat-
The axillary nerve and accompanying circumflex humeral eral space leads to atrophy of either the deltoid or teres
artery may be identified between the teres major and the minor muscle or both, depending on the location of the
atrophy. Central causes include cervical cord injury and

syrinx.
FURTHER READING
Bryan W, Wild J. Isolated infraspinatus atrophy. Am J Sports Med
1989;17:130–1.
Chen A, Rokito A, Zuckerman J. The role of the acromioclavicular
joint in impingement syndrome. Clin Sports Med 2003;22(2):
343–57.
ElMaraghy AW, Devereaux MW. A systematic review and comprehensive
classification of pectoralis major tears. J Shoulder Elbow Surg
2012;21(3):412–22.
Mochizuki T, Sugaya H, Uomizu M, et al. Humeral Insertion of the
Supraspinatus and Infraspinatus. New Anatomical Findings Regard-
ing the Footprint of the Rotator Cuff Surgical Technique. J Bone Jt
Surg 2009;91(Suppl 2, Part 1):1–7.
Safran MR. Clinical Sports Medicine Update: Nerve Injury About the
Shoulder in Athletes, Part 1: Suprascapular Nerve and Axillary
Nerve. Am J Sports Med 2004;32(3):803–19.
Safran MR. Nerve Injury About the Shoulder in Athletes, Part 1: Supra-
scapular Nerve and Axillary Nerve. Am J Sports Med 2004;32(3):
803–19.
Safran MR. Nerve Injury About the Shoulder in Athletes, Part 2: Long
Figure 4.7 Axial T2-weighted MRI image. A thin-necked cyst can
Thoracic Nerve, Spinal Accessory Nerve, Burners/Stingers, Thoracic
be seen extending medially from the posterosuperior labrum. The Outlet Syndrome. Am J Sports Med 2004;32(4):1063–76.
bulk of the cyst is expanded in the spinoglenoid notch. Infraspinatus Simovitch R, Sanders B, Ozbaydar M, et al. Acromioclavicular joint
atrophy is present; compare the internal MRI structure with the over- injuries: diagnosis and management. J Am Acad Orthop Surg 2009;
lying deltoid. 17(4):207–19.
Tagliafico A, Succio G, Serafini G, et al. Diagnostic performance of
ultrasound in patients with suspected brachial plexus lesions in
adults: a multicenter retrospective study with MRI, surgical findings
compression and the branch involved. Causes include infe- and clinical follow-up as reference standard. Skeletal Radiol 2012;
rior dislocation of the humeral head, mass lesions, or, like 42(3):371–6.
Zehetgruber H, Lang T. Distinction between supraspinatus, infra
infraspinatus atrophy, many patients have no obvious lesion spinatus and subscapularis tendon tears with ultrasound in 332
compressing the nerve. In such cases, chronic traction surgically confirmed cases. Ultrasound Med Biol 2002;28(6):
within the confined space is thought to underlie muscle 711–17.
PART 2
ELBOW
55
Arm and Elbow Joint: 5
Anatomy and Techniques
Eugene McNally
CHAPTER OUTLINE
ARM ANATOMY Position Variations

Position 1: Anterior Compartment Proximal Standard Position 1: Lateral Elbow
Position 2: Anterior Compartment Distal Standard Position 2: Medial Elbow
Position 3: Posterior Compartment Proximal Standard Position 3: Anterior Elbow
Position 4: Posterior Compartment Distal Standard Position 4: Posterior Elbow
ELBOW ANATOMY AND TECHNIQUES
Patient Position
latissimus dorsi that lies posterior to the bundle in the upper

ARM ANATOMY arm. Immediately posterior to latissimus dorsi is the teres
major. Teres major muscle forms the floor of the quadrilat
The anatomy of the arm is generally best understood by eral space as it passes anteriorly to insert on the anterior
considering two compartments: flexor and extensor. In aspect of the humerus (as distinct from the teres minor
each, there are proximal and distal configurations roughly muscle, which inserts on the posterior aspect).
delimited by the level of the deltoid insertion on the lateral
aspect of the mid humerus.
POSITION 2: ANTERIOR COMPARTMENT DISTAL
POSITION 1: ANTERIOR As the probe is passed a little more distally, the brachialis
muscle that has an origin from the anteriolateral aspect of
COMPARTMENT PROXIMAL
the humerus appears (Fig. 5.3). As this muscle grows distally,
The neurovascular bundle on the medial aspect of the arm the coracobrachialis diminishes towards its insertion medi
provides a useful landmark to begin to view the anatomy ally. Below the insertion of the coracobrachialis, the biceps
of the proximal arm. The bundle comprises the brachial and brachialis muscles dominate the anterior compartment
artery and veins, with the median nerve anteriorly and (Fig. 5.4). At this level, the ulnar nerve has moved a little
ulnar nerve posteriorly (Fig. 5.1). A number of smaller more posteriorly and is now often contained in a little pouch
cutaneous nerves are all found here. The medial ante on the medial surface of the medial head of triceps (Fig.
brachial nerve lies superficial and anterior while the 5.5). The median nerve maintains its relationship with the
medial brachial cutaneous nerve lies superficial and poste brachial artery. The musculocutaneous nerve emerges from
rior. At a very high level, the radial nerve is also noted in coracobrachialis to lie between the biceps muscle anteriorly
this compartment, posterior to the brachial artery. It will and the brachialis muscle posteriorly as it moves laterally.
soon pass into the posterior compartment as it traverses
from medial to lateral posterior to the humerus. The cora POSITION 3: POSTERIOR
cobrachialis muscle is anterolateral to the bundle. High in
COMPARTMENT PROXIMAL
the anterior compartment, well above the deltoid inser
tion, the pectoralis muscle and tendon is found as it passes The posterior compartment contains the three heads of
to its insertion on the humerus. Deep to this are the two triceps and deltoid. In the proximal arm, however, the
heads of biceps which overlie the coracobrachialis muscle medial head has yet to appear. The long head arises from
(Fig. 5.2). The other important nerve structure is the mus the infraglenoid tubercle of the scapula. It forms the central
culocutaneous nerve which passes through the coracobra third of the bulk of the extensor compartment. The lateral
chialis in its posterior portion to come to lie between this head also arises from the dorsal surface of the humerus.
muscle and the overlying biceps. Proximally, the lateral relation of the triceps is the deltoid
The anterior compartment is separated from the pos muscle, straddling both anterior and posterior compart
terior compartment by the tendinous insertion of the ments. The medial relation is the tendon of latissimus dorsi.
57
58 PART 2 — ELBOW
lateral to the humerus, all three muscles of the posterior

compartment are present and visible (Fig. 5.6). The radial
nerve now lies lateral between the anterior and posterior
compartments, that is, between the brachialis muscle ante
riorly and the lateral head of triceps posteriorly, along with
the posterior antebrachial cutaneous nerve.
As the radial nerve is followed distally, it passes around
the lateral border of brachialis. As it does this, it gains two
new lateral relations: the brachioradialis (Fig. 5.7) first, then
extensor carpi radialis longus as it gradually moves towards
the anterior compartment. These two muscles of the forearm
a compartment are covered more fully in Chapter 10.
The triceps tendon forms principally from the long head,
but then quickly accepts the lateral head to insert on the
posterior aspect of the olecranon. The musculotendinous
Biceps junction of the medial head is much lower, with muscle
LH UN
fibres being traced to the olecranon.
MN
Triceps
LH ELBOW ANATOMY AND TECHNIQUES
is
Biceps
al
hi
SH
ac
Triceps Due to its complex anatomy, the elbow joint is one of the
br
co
Humerus Lat H more difficult joints to examine comprehensively with ultra

ra
sound. To make this easier, standard sections will be

Co
b described using a regional approach. As patients often

present with focal symptoms, this method is helpful in
dealing with the most common clinical presentations.
PATIENT POSITION
Biceps
The simplest method of evaluating the elbow is to have the
patient seated opposite the examiner. In this position, the
elbows can be extended across the examination couch and
Coracobrachialis side-to-side comparison is straightforward. The lateral aspect
of the elbow can be accessed by asking the patient to place
alis
their hands in the praying position. This internally rotates
chi the elbows, bringing the common extensor origin (CEO)
Bra
into view. The medial aspect of the elbow can be examined
by asking the patient to tilt their shoulders to the affected
side and supinate the elbow. The anterior aspect of the
elbow is easily accessible. The posterior aspect can be
approached by asking the patient to flex their elbow and
Triceps internally rotate at the shoulder, placing the palm of their
hand on the examination couch. This is the so-called ‘crab’
position.
c
POSITION VARIATIONS
Figure 5.1 Axial medial upper arm. The brachial artery and sur- Alternatively, the patient can lie on the examination couch
rounding nerves are a useful landmark.
with the affected arm to the side of the examiner. This posi
tion is a little bit easier for assessing the medial aspect of
The radial nerve passes below teres major and enters its the elbow. The flexed elbow can also be drawn across the
groove on the posterior aspect of the humerus. abdomen to allow access to the posterior aspect of the
elbow. Additionally, this position is useful for following
nerves that can be tracked from the brachial plexus to their
POSITION 4: POSTERIOR COMPARTMENT DISTAL
terminal branches. The ulnar nerve in particular is easier to
The medial head of triceps has a much lower origin than follow in this position, particularly in its course through the
the lateral or long head. It arises below the insertion of teres cubital tunnel. The recumbent position is also used for
major, and just below the groove for the radial nerve. In the interventional procedures where there may be a risk of the
proximal arm, therefore, prior to the radial nerve passing patient fainting.
posterior to the humerus, the muscle posterior to it is the For children with elbow joint effusions, an option is to
long head, not the medial head. As the radial nerve emerges have the child sit on the parent’s lap, facing them with one
CHAPTER 5 — Arm and Elbow Joint: Anatomy and Techniques 59
lis
o ra
c t r
Pe ajo
m is
al
t or r
c o
Pe min
Biceps SH
LH
hialis
obrac
Corac
Deltoid
Triceps
Lat H
a
Triceps
La
LH
tD
Te
or
r
es
Pec
si
M
Major
aj
Deltoid
Pec tendo or
n
Biceps
SH
Biceps c
N LH
Coracobrachialis Humerus
A
ML
P
b
Figure 5.2 Axial medial upper arm. The triceps insertion is a marker for the two heads of biceps coming together with the musculocutaneous
nerve (N) posteriorly.
60 PART 2 — ELBOW
Biceps
LH Biceps
SH
Brachialis
Brachio-
radialis
Triceps
Biceps
SH
Biceps
LH
Figure 5.4 The ulnar nerve has separated from the brachial artery
and passes to a compartment adjacent to the medial head of triceps.
N
Brachialis The radial nerve has passed to the lateral aspect of the humerus.
A
LM
P MN
b
3. Identify and trace the important branches of the radial
nerve.
Biceps Biceps TECHNIQUE

LH SH The CEO lies beneath the two muscles that form the bulk
of the proximal lateral part of the elbow. The anterior
Brachialis muscle is brachioradialis and the posterior is extensor carpi
Brachio- radialis longus. Deep to this is a fibrous conglomerate made
radialis up of the remaining tendons of the extensor compartment.
This is the CEO. In many cases the individual tendons are
difficult to separate but in some patients each component
can be recognized. If an abnormality is present, the easiest
Triceps method of identifying individual tendons is to begin more
distally where the muscles have separated, even going as far
as the wrist where the positions of the tendons make the
c individual components easiest to remember. Each muscle
component can then be tracked proximally back to its
Figure 5.3 Axial anterior arm. The biceps and brachialis muscles origin. The anterior and deep part of the CEO is extensor
dominate the anterior compartment. The musculocutaneous nerve (N) carpi radialis brevis. This is the tendon most frequently
lies between them.
involved with tennis elbow. Anterior and superficial is exten
sor digitorum, with extensor carpi ulnaris making up the
posterior portion. The bulky muscle that lies posterior to
knee on either side of the parent. The parent can cuddle the CEO is anconeus.
the child whilst making the posterior aspect of the elbow The lateral aspect of the elbow is examined in both its
available for ultrasound examination and aspiration. short and long axes (Fig. 5.8). A good method for locating
the common tendons is to place the probe first in the axial
STANDARD POSITION 1: LATERAL ELBOW position on the lateral aspect of the distal arm above the
epicondyle. The bony margin of the lateral humerus is fol
IMAGING GOALS lowed distally until it dips sharply just below the epicondyle.
1. Identify the components of the CEO. The ‘space’ below the lateral epicondyle is filled by the CEO
2. Identify radial collateral ligament (RCL) and associated (Fig. 5.9). The probe can then be turned 90° to demonstrate
meniscus. the common origin in long axis. In this orientation, the
Triceps
UN RN
Triceps P
MH Triceps LH ML
Humerus A
b
Figure 5.6 Muscles of the posterior compartment.

lis
hia
ac
Humerus Triceps L
Br
LH A P Careful evaluation of the deep component of the CEO will

L
b often demonstrate fibres that have a slightly different orien
tation. The RCL runs from the lateral epicondyle towards
the radial head, whereas the common extensor tendons are
a little more posterior. A little rotation of the probe ‘this way
and that’ optimizes alignment along the RCL and helps to
visualize it. Another useful landmark is the medial meniscus,
also called the medial plica or flange. This is a fold of fibrous
tissue, usually triangular in shape and similar in appearance
to the knee menisci. It is located between the articular
surface of the radial head and the capitellum. Slight varus
valgus movement can help to demonstrate it. The meniscus
is attached to the deep surface of the RCL and can be used
as a means to locate the ligament.
The RCL is one of three components of the lateral liga
ment complex. The other two components are the annular
ligament and lateral ulnar collateral ligament (LUCL).
Although the RCL has a bony attachment proximally, its
distal attachment is to the annular ligament. As such, a
definitive attachment to bone will not be visualized and this
must not be misinterpreted as an injury. The LUCL has a
common proximal bony insertion with the RCL, but sepa
rates from it as it passes distal and posterior to the radial
c head to insert into the supinator crest of the ulna (Fig.
5.11). The best method of locating it is in the axial plane
Figure 5.5 Ulnar nerve, lower arm. where it runs close to the anterior or anterolateral corner
of the anconeus or where it attaches to the annular
ligament.
Another important structure on the lateral aspect of the
CEO is shaped like a long thin triangle with a striated, elbows is the radial nerve. At the level of the distal humerus,
predominantly reflective structure. Under normal circum the nerve perforates the fascia between the extensor and
stances, there is only minimal Doppler signal present within flexor compartment and comes to lie between the extensor
it. With practice, this standard view of the tendon can be carpi radialis longus and brachialis muscles. As it is tracked
achieved easily. distally, the nerve follows the lateral margin of brachialis
The RCL is located on the deep aspect of the CEO but muscle. During its course across the elbow, the radial nerve
can sometimes be difficult to separate from it (Fig. 5.10). passes deep to a number of fibrous bands that connect
62 PART 2 — ELBOW
a CEO
RCL
flange
Triceps Supinator
LH
is Radius Humerus
radial L
chio I S
Bra M
RN b
Brachialis
Triceps
Humerus
MH
Biceps
LH SH
Brachialis c
Figure 5.8 (A, B) Long axis image and (C) position for the common
extensor origin.
Brach
iorad
ialis
adjacent muscles. It also traverses a complex arterial anas
tomosis called the leash of Henry. At the level of the radial
Triceps
head, it divides into the superficial (sensory) and deep
(motor) nerve branches (Fig. 5.12). The motor division is
the posterior interosseous nerve that passes between the two
heads of the supinator. Neural compression may occur as a
c
consequence of compression from any of these structures.
Figure 5.7 Axial anterolateral lower arm. The radial nerve moves
between the brachioradialis and brachialis before it enters the anterior STANDARD POSITION 2: MEDIAL ELBOW
elbow.
IMAGING GOALS
1. Identify the components of the common flexor origin.
2. Identify the ulnar collateral ligament.
3. Identify and trace the ulnar nerve.
Anconeus
LUC
ECRL L
CEO
L Humerus
S I Ulna
M
b
Bradcioradialis
Figure 5.11 Lateral ulnar collateral ligament. The ligament may be
found alongside the anconeus muscle.
Humerus
L
A P
Radius M
b
TECHNIQUE
Figure 5.9 Common extensor origin in transverse section. The
The medial epicondyle gives rise to the common flexor
tendons fill the space immediately below the lateral epicondyle.
origin (CFO). The tendons of the CFO form into muscles
more quickly than on the lateral side; consequently it has a
more fleshy, less tendinous appearance than the CEO (Fig.
5.13). The bulky anterior muscle on this side is pronator
teres and the common tendon origin lies deep to this. Once
again it is frequently difficult to identify the individual com
ponents of the CFO and, if necessary, a similar method of
identifying the tendons can be employed as described
above for the CEO. The probe is moved distally to the mid
forearm until the muscles have separated from each other.
The individual tendons can then be traced backwards to the
common origin. The most anterior component of the CFO
is made up by flexor carpi radialis with flexor digitorum
superficialis. Flexor carpi ulnaris has a characteristic con
a figuration that makes it easy to recognize. It is made up of
two heads, which form an arch over the ulnar nerve (Fig.
5.14). The flexor digitorum profundus origin lies posterior
to this.
CEO The ulnar collateral ligament, like its radial counterpart,
lies on the deep aspect of the CFO. It is a much thicker liga
RCL ment than the RCL and functionally more important. It also
Supin
ator comprises three bands: anterior, posterior and transverse
(Fig. 5.15), of which the anterior is the largest and most
Humerus significant. The anterior band arises from the undersurface
of the medial epicondyle and inserts on the sublime tuber
M Radius cle of the ulna. It is best examined in long axis with the
S I elbow held in flexion (Fig. 5.16). The degree of flexion is
L different from individual to individual and can sometimes
b be up to 90°.
Figure 5.10 Radial collateral ligament. The deepest fibres of the In addition to looking at its internal structure, like many
‘CEO’ is the RCL. Careful angulation of the probe may reveal that its ligaments, additional information can be gleaned by stress
fibres run in a different direction from the CEO itself, but this is not ing the UCL. This can be achieved in a number of ways.
always apparent. The conventional method is for the examiner to apply a
64 PART 2 — ELBOW
a
a
Brachioradialis
CFO
RN
ECRL
r
A inato
LM Sup Brachialis
Ulna Humerus M
P
I S
Radius
b
L
c
c
Figure 5.13 (A, B) Long axis image and (C) position to assess the
Figure 5.12 (A, B) Axial US and (C) axial MRI below the elbow joint common flexor origin.
and below the division of the radial nerve into the sensory radial nerve
and motor, posterior interosseus nerve.
valgus stress at the wrist whilst assessing the integrity of the valgus stress whilst holding the patient’s arm steady with
ligament. The patient is asked to abduct the affected arm their left hand.
using his or her contralateral hand to prevent external The important nerve on the medial aspect of the elbow
rotation. If the elbow is in flexion, it is no longer necessary is the ulnar nerve. In axial plane it has the typical ultrasound
to stabilize the upper arm and valgus stress can be applied appearance of nerves elsewhere, comprising low-reflective
by the examiner with their free hand. An alternative neural bundles surrounded by bright reflective connective
approach is for the examiner to carry out the manoeuvre. tissue epineurium. In the upper arm, it lies posterior to the
To stress the right ulnar collateral ligament, the probe is brachial artery and becomes superficial as it passes distally.
held in the examiner’s right hand and placed over the lig It enters the forearm by passing through the ulnar groove,
ament. The elbow of the examiner’s left hand is placed a fibroosseous tunnel on the posterior aspect of the medial
medial to the patient’s wrist and the examiner’s left epicondyle. The roof of this bony tunnel is formed by the
hand is placed on the lateral aspect of the patient’s arm. ligament of Osborne and adjacent medial head of triceps
The examiner can then use their left elbow to induce a (Fig. 5.17). The floor is the posteromedial capsule with
FCU
FDP
UN FDS
FCR
P
LM Ulna
A
Figure 5.14 Axial image of the ulnar nerve below the cubital fossa.
The nerve (UN) is bridged by the two heads of flexor carpi ulnaris
(FCU).
Figure 5.15 Anterior band of ulnar collateral ligament.
reinforcing fibres from the CFO. As it emerges from the

tunnel, the nerve passes between the two heads of flexor
carpi ulnaris whose isthmus forms a bridge over the nerve TECHNIQUE
(Fig. 5.18). It then travels on the deep surface of flexor carpi The important anatomical structures on the anterior aspect
ulnaris to the wrist. of the elbow are the biceps tendon, brachialis tendon, the
The ulnar nerve should be examined in proximal and brachial vessels and the median nerve (Fig. 5.19). The
distal cross section to the cubital tunnel to look for changes examination begins in the axial plane over the distal arm
in calibre that might indicate neural compression. In addi where the two heads of biceps are recognized. These can be
tion, the probe should be placed in an axial position over traced distally noting the distal musculotendinous junction
the nerve, and the elbow flexed to look for subluxation. In of each head. The two tendons lie close together as they
most patients, some medial migration of the nerve will be pass through the antecubital fossa to insert on the bicipital
seen, but the nerve is held in the correct location posterior tubercle of the radius. In many cases, the two heads can be
to the medial epicondyle by the action of Osborne’s liga separated using careful flexion/extension and supination/
ment. In 15% of patients, medial and anterior migration of pronation manoeuvres, reflecting the different functions of
the nerve continues until it snaps around the medial epi the two tendons.
condyle to lie in an anterior position. The nerve reduces Good visualization of the distal portion of the biceps ten
back to its usual position as the elbow is extended. In some don is not easily achieved using a simple sagittal approach.
cases, the subluxing nerve may be accompanied by sublux This is due to the oblique course of the tendon as it passes
ation of the medial head or an accessory medial head of deep towards its insertion. In some individuals this can be
triceps, resulting in a double snap. corrected by angling the probe to align it better along the
line of the tendon, but in larger individuals, often those most
STANDARD POSITION 3: ANTERIOR ELBOW predisposed to biceps injury, this can be difficult.
IMAGING GOALS Sidewinder Position
1. Identify the biceps tendon and surrounding bursae. A variety of manoeuvres are suggested to provide better
2. Identify the brachialis tendon. visualization of the tendon. The most useful is to approach
3. Identify and trace the important branches of the median the tendon from the ulnar side. The patient’s arm is flexed
nerve. about 25° and the probe placed in the transverse plane on
66 PART 2 — ELBOW
CFO
UN
UCL
Med Triceps
M Humerus Ulna
S I Humerus
L
b
M
I S
L
b
Figure 5.17 Axial image of the ulnar nerve (UN) in the cubital tunnel.
Osborne’s ligament bridges the nerve.
Figure 5.16 (A, B) Long axis image of the ulnar collateral ligament
(UCL). (C) Elbow flexion helps to locate the ligament.
the ulnar aspect of the forearm. The upper aspect of the

probe is then angled towards the humerus (Fig. 5.20); the
reflective surface of the ulna is easily identified. It has a
more pointed configuration than the radius. Once the ulna Figure 5.18 Ulnar nerve below groove.
is located, the probe is moved anterolaterally until the
radius, with its more rounded configuration, lies centrally.
Keeping the radius in view, the probe is moved proximally
until a tendon appears with an attachment onto the radius. If the probe is moved too quickly proximally, the biceps
This is the biceps tendon. In this position, the tendon is may be passed and the tendon that comes into view first is
frequently orientated parallel to the probe and so is much the brachialis tendon. If there is any doubt, sequential wrist
more clearly visualized. If this is not the case, slight adjust pronation and supination rotate the radius and should
ments of the orientation of the probe in an axial direction move the biceps insertion. If the tendon under scrutiny
are made until the tendon straightens and its internal struc does not move on pronation/supination it must be the bra
ture and enthesis become clearly visible. chialis. Brachialis also has a much lower musculotendinous
a
a
Biceps
Pronator Teres
Pronator Teres
MN
Biceps tendon
Brachialis
Biceps MN
A
tor
A S I
ina
LM P Radius
Sup
P b
Humerus
b
c Figure 5.20 (A, B) Sidewinder view of the biceps tendon insertion.

(C) Approximate probe position to view the biceps distal to its myo-
Figure 5.19 (A, B) Axial image of the antecubital fossa showing the
tendinous junction (MTJ).
relationship between biceps tendon, artery and medial nerve. Note
the bicipital aponeurosis (cream) bridging these structures. (C) Posi-
tion ant elbow.
To help remember the useful pronation/supination

manoeuvre and the assistance it offers in correctly identify
junction; indeed, the tendon is surrounded by muscle right ing the distal biceps, the author refers to this position as the
up to its insertion onto the coracoid process. To check for ‘sidewinder’ position.
this anatomic point, the probe is rotated into the axial
plane. In this position, the brachialis muscle has a charac Cobra Position
teristic appearance in cross section, with prominent medial This name, sidewinder, also distinguishes it from the well-
and lateral components and a tendon forming in the centre known but not as useful cobra position, which has also been
as it passes distally to insert in the coronoid process. Once suggested as a method for identifying the most distal part
the biceps is correctly located, the pronation/supination of the biceps tendon. To reach the cobra position, the
manoeuvre also helps visualize the termination portion of patient places their olecranon on the examination couch
the tendon and the two bursae that might be present in this with the arm pointing upwards. The probe is placed on
location. the dorsal aspect of the forearm at the level of the radial
68 PART 2 — ELBOW
tubercle. When the arm is pronated, the distal part of the

biceps tendon insertion comes into view.
The median nerve is identified in a central location in
the antecubital fossa, just under the anterior margin of
pronator teres. It lies medial to the brachial artery which
itself is medial to the biceps tendon. In the distal arm, the
median nerve has quite a superficial location but comes to
lie deep to pronator teres as that muscle forms. Just above
the level of the elbow joint, the nerve passes through a
fibromuscular tunnel, whose roof is formed by the bicipital
aponeurosis or lacertus fibrosis (Fig. 5.18). The bicipital a
aponeurosis can be located by placing the probe in an axial
plane over the proximal part of the pronator teres muscle.
As the probe is passed distally, the thin ligament appears on Triceps Tendon
its superficial surface and can be followed as it traverses over
the brachial artery and median nerve to blend with the Med Triceps
biceps tendon. Distal to this, the median nerve then passes Ulna
deep between the two heads of pronator teres, where it
divides into the anterior interosseous nerve and median Fat pad
nerve proper. The median nerve passes between the super P
ficial and deep flexor muscles on its route towards the Humerus S I
carpal tunnel, while the anterior interosseous nerve passes b
A
deep to reach the interosseous membrane where it is accom
panied by the anterior interosseous artery.
There are several areas where the median nerve may be
compressed. One of these is in the distal arm, where a
normal bony variant, an exostosis, arises from the medial
aspect of the distal humerus. This is called the supracondy
lar process. A ligament, the ligament of Struthers, may
extend from its tip of the process back to the humerus,
forming a fibroosseous tunnel with the potential to com
press the nerve. The median nerve may also be compressed
as it passes deep to the bicipital aponeurosis or between the
heads of pronator teres.
STANDARD POSITION 4: POSTERIOR ELBOW

IMAGING GOALS c
1. Identify the components of the triceps muscle and Figure 5.21 Posterior elbow anatomy. (A, B) Long axis sagittal
tendon. image and overlay. (C) Arm in crab position.
2. Identify the posterior fat pad and posterior joint recess.
3. Identify an olecranon bursa if present.
TECHNIQUE posterior elbow with the patient seated and their back to
There are several methods for examining the posterior the examiner. The patient places their forearm across their
elbow. As the patient is often sitting opposite the examiner, chest, presenting the flexed elbow for examination. If neces
a simple manoeuvre is to place their hand flat on the exami sary the patient can also be examined supine with their arm
nation couch, then rotate it internally whilst flexing their across their abdomen.
elbow (the ‘crab’ position) (Fig. 5.21). This position pres The principal structure on the posterior aspect of the
ents the posterior joint for easy examination. Intraarticular elbow joint is the triceps tendon. As the name implies, it is
fluid, if present, can be identified lying between the poste formed from three heads, each of which contributes tendon
rior aspect of the distal humerus and the posterior fat pad. components to the insertion. The tendons of the long and
The posterior joint is also a good area to look for intraar lateral heads combine together and insert into the olecra
ticular loose bodies. In the conventional crab position, small non. The tendon of the medial head forms lower and can
quantities of fluid within the joint may gravitate anteriorly be identified separately to its insertion on the medial aspect
and out of view. A variation on this position, the reverse of the olecranon. In the axial plane, the triceps is oval in
crab, is achieved by externally rotating the shoulder 90° shape. It can sometimes be difficult to separate the muscle
from the crab position, so that the hand is held aloft. components of the medial and lateral heads from the adja
Intraarticular fluid now gravitates posteriorly and small cent anconeus muscle and flexor carpi ulnaris respectively.
amounts are easier to detect in this position. Not all patients With the probe in long axis, the triangular-shaped reflec
can manage these manoeuvres, especially if the elbow is tive posterior fat pad is easily identified deep to the distal
painful or stiff. An alternative method is to examine the part of triceps, along with the posterior joint capsule and
synovial space; the posterior fat pad is within the capsule but the level of the radial head, the radius and ulna are sepa
outside the synovial space. It is therefore displaced posteri rated by a triangular-shaped space that contains a superficial
orly when a joint effusion is present. muscle and a number of ligaments. The muscle is anconeus
Rotating the probe into the axial plane and moving it and the ligament passing distally on its lateral aspect is the
medially reveals the ulnar nerve within the ulnar groove. As LUCL. Deep to both this ligament and the muscle lies the
has been previously outlined, this nerve lies deep to a liga posterior component of the annular ligament and the proxi
ment passing between the olecranon and medial epicondyle mal radioulnar joint, a recess of the main elbow joint, which
called Osborne’s ligament. More distantly, the nerve is can be visualized below it.
bridged by the two heads of flexor carpi ulnaris. Occasion Located between the olecranon and the superficial fascia,
ally, the medial head of triceps may be prominent and, on the olecranon bursa acts as a cushion, protecting the super
flexion, may push the ulnar nerve medially, contributing to ficial tissues from compression. In most patients it is no
ulnar nerve subluxation. more than a potential space but fills rapidly when it becomes
Below the level of the joint, a number of other structures inflamed. Care should be taken not to compress too hard
are encountered on the posterior aspect of the elbow. At with the probe as the bursal space may be obliterated.
6 Disorders of the Elbow:
Lateral
Eugene McNally
CHAPTER OUTLINE
LATERAL ELBOW Annular Ligament

Common Extensor Origin Epicondylalgia Cartilage Disease
Radial Collateral Ligament and Plica Radial Nerve Compression
Lateral Ulnar Collateral Ligament
LATERAL ELBOW The ultrasound anatomy and examination techniques

have been described previously. The characteristic findings
COMMON EXTENSOR ORIGIN EPICONDYLALGIA in patients with CEO tendinopathy include loss of reflectiv-
ity and disorganization of the normal reticular fibre pattern
The commonest cause of pain in the lateral aspect of the within the involved tendons. The anterior part is affected
elbow is tendinopathy or enthesopathy of the common more often than the posterior, and the deeper portions
extensor origin (CEO). The term ‘tennis elbow’ originates more than the most superficial. This pattern reflects the
from early descriptions of this condition and it has largely characteristic involvement of extensor carpi radialis brevis.
stuck, passing into common usage. Despite the name, the As the disease progresses, ingrowth of abnormal vessels
condition occurs much more commonly in nontennis (neovascularization or angiogenesis) occurs and abnormal
players and a wide variety of occupations and sports have Doppler signal is commonly found (Fig. 6.1). The degree
been implicated. It is more common in golfers than is of vascular ingrowth is so great in some patients, that it
golfer’s elbow (common flexor origin tendinopathy). has been suggested that much of the high signal within
The characteristic location of pain is over the lateral the tendons identified on fat-suppressed T2-weighted MR
epicondyle. The patients may also note muscle weakness, images represents abnormal vessels. As tendon degenera-
particularly in grip strength. tion progresses, fibre disruption appears and areas of focal
tendon delamination or partial tears are seen (Fig. 6.2). The
disease progresses to involve the adjacent tendons. Involve-
Practice Tip ment of the radial collateral ligament may also occur and
this is said to carry a poor prognosis for conservative man-
Thompson’s manoeuvre: resisted wrist dorsiflexion with the agement. With further progression, the tendon may begin
elbow extended and the forearm pronated results in pain, to separate from its periosteal attachment (Fig. 6.3) and
which radiates down the forearm. ultimately rupture occurs. There appears to be a good
correlation between active Doppler changes and areas of
tendon delamination with patient symptoms (Fig. 6.4).
Enthesopathy is the term used to describe pathological
changes at the enthesis, the point where the tendon inserts
Key Point into the lateral epicondyle. Occasionally this is distinct from
tendinopathy but in practice the two coexist and often
The differential diagnosis of lateral side pain includes CEO merge. Chronic enthesopathy is diagnosed when insertional
tendinopathy, injuries to the radial collateral ligament (RCL)
bone changes are present at the tendon attachment. Such
synovial plica, osteochondritis dissecans (OCD),
radiocapitellar arthritis, radial tunnel syndrome, cervical findings include calcification, which can assume several pat-
radiculopathy and posterolateral rotatory instability. terns: linear or conglomerates. With maturity the calcium
deposits may ossify. Bony irregularity of the attachment site
(Fig. 6.5) leads to spur formation, visible on radiographs. It
should be noted that bony changes at the enthesis may
Pathologically there is angiofibroplastic hyperplasia and persist and become chronic and are, therefore, not neces-
mucoid degeneration of the CEO. The extensor carpi radia- sarily associated with active symptoms. Active Doppler at the
lis brevis component shows the earliest involvement. enthesis is a more helpful sign of an active problem.
70
CHAPTER 6 — Disorders of the Elbow: Lateral 71
a a
Tear
CEO
Brachioradialis
Humerus
CEO Tear
Radius
L
Supinator I S L
M I S
Radius Humerus
M
b b
Figure 6.1 Coronal image of lateral elbow. Increased Doppler activ- Figure 6.2 Coronal image of lateral elbow. There is a split in the
ity is a useful marker of epicondylitis. Note also the loss of common extensor origin at the humeral attachment.
reflectivity.
ligament in isolation and it is relatively uncommon that

Practice Tip
imaging is required. The radial collateral ligament is not as
The ultrasound report of patients with CEO enthesopathy easy to identify as the ulnar collateral ligament but it can be
should confirm the diagnosis, indicate which tendons are found on the deep aspect of the common CEO.
involved and attempt to differentiate between simple
tendinopathy and delamination/partial tears. Doppler activity
and radial collateral ligament involvement help to stage the Practice Tip
disease.
A useful landmark to locate the radial collateral ligament is to
identify the triangular-shaped reflective structure representing
the articular meniscus or synovial flange (Fig. 6.8).
Although in most cases the disease is due to disordered
biomechanics (as outlined above), some cases may be sec-
ondary to systemic disease, drug therapy and crystal deposi-
tion, especially gout. Once the diagnosis is established, Abnormal findings within the ligament include loss of the
treatment revolves around identifying and managing the normal bright fibrillary structure, thickening and fibre dis-
underlying cause. When pain is persistent, ultrasound can ruption when tears or partial tears are present.
be used to guide dry needle therapy and autologous blood Occasionally lateral symptoms have been attributed to
or platelet-rich plasma (PRP) injection (Fig. 6.6). This is thickening of the lateral meniscus/flange, presumed to be
covered in more detail in the intervention chapter. secondary to impingement. Apart from pain, patients may
present with clicking and snapping. Occasionally this condi-
tion can be associated with areas of chondromalacia of the
RADIAL COLLATERAL LIGAMENT AND PLICA
radial head. If symptomatic, the flange is excised and histol-
The radial collateral ligament runs from the lateral epicon- ogy has demonstrated synovitis associated with fibrosis. Pos-
dyle deep to the CEO proximally, to the lateral aspect of the terolateral synovial plica (synovial flange) thickening is also
neck of the radius distally, where it inserts on the annular described. Stability on the lateral side is predominantly due
ligament (Fig. 6.7). Apart from being simultaneously to the lateral collateral ligament; however, there is a greater
involved in patients with CEO tendinopathy and traumatic contribution from the lateral musculotendinous structures
injury, there are relatively few disorders that affect the (CEO) than on the medial side.
72 PART 2 — ELBOW
CEO
Humerus
Tear
L Supinator
S I
CEO
M Radius
b
Figure 6.4 Coronal image of lateral elbow. There is loss of the

normal reflectivity with increased Doppler activity in the common
extensor origin consistent with epicondylitis.
Humerus L
Radius I S
M
Figure 6.3 Coronal image of lateral elbow. Extensive delamination

with partial separation of the common extensor origin from its humeral
attachment. This represents a relatively late and advanced stage of
the disease.
LATERAL ULNAR COLLATERAL LIGAMENT

In addition to the radial collateral ligament and annular
a
ligament, a third ligamentous structure is also present on
the lateral aspect of the elbow. The lateral ulnar collateral
ligament (LUCL) also has its origin on the lateral epicon-
dyle and shares fibres with the proximal attachment of the
radial collateral ligament. Distally it inserts on the sublime
Calcification
tubercle of the ulna.
CEO
Practice Tip Tear
The best method of locating LUCL is in the axial plane where

it runs close to the anterior or anterolateral corner of the
L
anconeus or where it attaches to the annular ligament. Radius Humerus I S
b
M
The function of LUCL is to prevent posterior translation of Figure 6.5 Swollen common extensor origin with calcification indi-
the radial head. It forms a sling on the posterior aspect cating chronicity.
CEO
Humerus Figure 6.7 Schematic diagram of lateral aspect of the elbow

Radius showing three components of the lateral ligament complex. The most
anterior is the radial collateral ligament that inserts on the transversely
L orientated annular ligament. The third component is the lateral ulnar
I S collateral ligament that shares proximal fibres with the radial collateral
M
b ligament and inserts on the supinator crest of the ulna.
Figure 6.6 Coronal image of lateral elbow during dry needle proce-
dure for common extensor origin disease.
a b
Figure 6.8 Schematic diagrams of radial collateral ligament. (A) It can be difficult to separate from the overlying common extensor origin. The
ligament comprises the deepest fibres. Attached to its articular surface is a fibrocartilaginous meniscus or synovial plica/flange. This is a useful
landmark to locate it. The ligament inserts on to the annular ligament. (B) Pulled elbow. The annular ligament has displaced proximally, allowing
minor subluxation of the radial head.
of the head, which has been likened to a mother’s arm ligament complex are also usually involved. Occasionally it
cradling the head of her baby. This relationship is better is sprained in isolation and patients complain of pain and
appreciated on MRI, particularly following arthrography. It instability. The resulting abnormal motion of the olecranon
is most commonly injured following posterior dislocation of leads to chondromalacia of the olecranon cartilage. The
the radial head when other components of the lateral constellation of symptoms/signs related to these findings is
74 PART 2 — ELBOW
called posterolateral rotatory instability of the elbow. The

ultrasound findings in this condition have not been fully
elucidated, though it is helpful to note focal tenderness over
the ligament.
ANNULAR LIGAMENT
The annular ligament is the third component of the lateral
ligament complex. It surrounds the radial head, securing it
to the adjacent ulna. Both ends of the ligament attach to
the ulna, one anterior and the other posterior. The ligament
itself passes as a sling around the radial head in the axial
plane. Laterally, it blends with the distal fibres of the radial
collateral ligament.
Trauma to the ligament is most commonly seen in chil-
dren, where it is referred to as a ‘pulled elbow’. Injury is
thought to occur when the child is lifted or swung by the
parent with the elbow extended. The annular ligament
is pulled proximally, allowing it to partially slip over the
head of the radius. The radius then subluxes or dislocates,
depending on the extent of the ligamentous injury. In most
a
cases the diagnosis of pulled elbow is made on a combina-
tion of clinical history and plain radiography, which shows
slight loss of congruity between the proximal end of the
radius and the capitellum. This can be difficult to detect in
very young children, as the radial head and much of the
CEO
capitellum have not yet ossified. Occasionally, ultrasound is
requested to clarify difficult cases.
Subluxed
AL
Practice Tip
It is difficult to visualize the displaced annular ligament in

children with pulled elbow; however, a slight widening of the
radiocapitellar joint is present and provides a valuable clue to Humerus
the diagnosis (Fig. 6.9). Radius
L
I S
The second circumstance where the annular ligament is M
disrupted is in conjunction with complete tears of the lateral
ligament complex. This usually follows elbow dislocation.
CARTILAGE DISEASE b
In patients with lateral-sided syndromes, if an examination Figure 6.9 Sagittal image of the radiocapitellar joint in a child. The
of the CEO and collateral ligaments does not reveal a cause, radial head is subluxed and the joint is slightly widened. This is due
careful attention should be paid to the capitellum. This is to proximal migration of the annular ligament. The condition is called
particularly true in children, especially young gymnasts. pulled elbow.
PANNER’S DISEASE progressing to mechanical locking if loose osteochondral

Injuries to the capitellum in childhood are divided into two fragments are present within the joint. Unlike Panner’s
groups. Abnormalities detected in the first decade are disease, these lesions may progress.
referred to as Panner’s disease. This is generally regarded Plain radiographs, ultrasound and MRI have all been
as having an excellent prognosis, with spontaneous resolu- used in the assessment of OCD, with CT playing a lesser
tion the most common outcome. It may be no more than a role. Plain films need to be carefully scrutinized for the
variant of ossification. vaguest suggestion of lucency overlying the capitellum.
Although ultrasound cannot demonstrate the articular
OSTEOCHONDRITIS DISSECANS surface of the capitellum in its entirety, it does visualize the
True OCD presents early in the second decade. The cause anteroinferior portion of the articular surface where lesions
is thought to be overtraining, although some authors also most commonly occur (Fig. 6.10). Gentle hyperextension
suggest that there is an associated vascular disorder, typical can be employed to improve visualization. Coupled with the
of OCD elsewhere. Patients complain of pain on activity, advantage of being a less stressful investigation for young
progress to stage 3 and are often converted at arthroscopy.

Attempts to encourage the lesion to heal in situ are often
unsuccessful.
Key Point
The ulnar collateral ligament should be assessed in a patient

with OCD of the capitellum to detect an occult medial
instability.
RADIAL NERVE COMPRESSION

OVERVIEW
Radial nerve injury around the elbow is uncommon but the
diagnosis is often delayed as symptoms are nonspecific. If
common causes of symptoms are excluded, thought should
a
always be given to those that are less common. Even if
abnormalities are confirmed, for example at the CEO, the
possibility of coexisting nerve compression should be con-
sidered. This is more common on the medial side of the
elbow and on the lateral.
As with other nerves, the radial nerve should be traced
throughout its length from brachial plexus to its terminal
Brachialis branches. Only ultrasound can achieve this extent of cover
with relative ease.
The most common location for radial nerve injury is in
the arm in the radial groove, secondary to fractures of the
*
shaft to the humerus. Below this level, and just above the
Radius level of the elbow, the radial nerve is found as it emerges
from the posterior compartment along the lateral margin
of the distal humerus. As it moves anteriorly, it enters the
radial tunnel, a virtual channel between brachialis and bra-
Humerus chioradialis, through which the nerve passes to its first
A major division. The tunnel begins proximally above the
S I
P
capitellum and extends for approximately 5 cm to reach the
supinator. Throughout its course, the radial nerve may be
b impinged by fibrous bands, tendon margins and prominent
vessels (Fig. 6.11). Compression may be due to a fibrous
Figure 6.10 Sagittal image of anterior elbow. There is an osteo-
chondral lesion in the anterior aspect of the capitellum (*). The frag-
arch from the lateral head of the triceps muscle, fibrous
ment is slightly elevated with a step in the subchondral cortex. This bands around the radiocapitellar joint or the tendinous
is the commonest area for osteochondritis dissecans. edge of the extensor carpi radialis brevis. The radial nerve
shares this location with multiple vessels and the vascular
arcade of the recurrent radial artery, known as the leash of
Henry. If this is prominent, it may compress the radial
children, ultrasound is an important screening imaging nerve. Distal to the radial tunnel, the nerve divides into
technique in the paediatric painful elbow. superficial and deep branches at the proximal border of the
In addition to an assessment of the stability of the lesion, supinator muscle. The deep branch or posterior interosse-
the status of the physis and size of the lesion are important ous nerve (PIN) is a motor nerve, innervating the supinator
in overall classification. Lesions are divided into three and most of the wrist and finger extensors. It passes through
stages, with stage 1 further divided into A and B. Stage 1A the two heads of supinator (Fig. 6.12) to emerge in the
lesions involve the subchondral plate only and both plain posterior compartment of the forearm. Within the supina-
films and ultrasound are normal. MRI is the only imaging tor, the PIN may be impinged by the ligament of Frohse
technique for detecting the early stages of both 1A and 1B, (Fig. 6.13), a fibrous arch that lies at the leading edge of
where early cartilage fissuring is the only finding in stage the superficial head of the supinator (Fig. 6.12). Fibrous
1B. Both stage 1A and 1B lesions are treated by load protec- bands occurring within the distal supinator, close to the
tion and rest from sport for a period of 3–6 months. Stage point where the nerve emerges, may also compress the
2 lesions represent involvement of the condylar surface asso- nerve. Entrapment in all these locations may be more prom-
ciated with the bone cleft where the fragment remains in inent after strenuous muscular effort. Athletes, particularly
situ or is only minimally displaced. A stage 3 lesion is a those in sports dependent on upper limb development, may
completely loose fragment. Stage 2 lesions frequently find that these natural areas of impingement can be further
76 PART 2 — ELBOW
compromised by muscle hypertrophy. Compression of the

radial nerve or its branches can also result from trauma,
space-occupying lesions or inflammatory disease.
Key Point
Radial tunnel syndrome is characterized as pain along the

lateral elbow and forearm, which can mimic lateral
epicondylitis. If the motor component is affected, wrist drop
also occurs.
Selective compression of the PIN also produces a motor

palsy, leading to weakness of the wrist and hand extensors;
however, finger drop as opposed to wrist drop occurs with
isolated PIN lesions.
Figure 6.11 Schematic diagram of the course of the radial nerve.

As it enters the anterior aspect of the elbow it traverses below fibrous
bands arising from brachioradialis, and is closely applied to the vas- Figure 6.12 The schematic diagram of the course of the posterior
cular leash of Henry before dividing into the radial sensory nerve and interosseous nerve between the two heads of supinator. A thickened
posterior interosseous nerve, which in turn passes between the two leading edge of the superficial head, termed the ligament of Frohse,
heads of supinator. may impinge the nerve.
a c
Brachioradialis
Brachioradialis
RN
PIN PIN ECRL

Supinator A
A Supinator
ML
Supinator I S P
b Radius P d Radius
Figure 6.13 Long- and short-axis images of posterior interosseous nerve. Dilated proximal to the two heads of supinator and compressed
below.
The superficial branch of the radial nerve is sensory, sup-

plying sensation to the dorsal and lateral aspects of the wrist Key Point
and hand. Compression of the radial nerve proper presents
The main ultrasound findings of neural compression are
as a sensory syndrome, which may be difficult to diagnose
proximal enlargement and narrowing at the level of
as there are relatively few overt clinical signs. Pain is often compression, and atrophy of the affected muscles if a
nocturnal, similar to carpal tunnel syndrome. Chronic motor branch is involved. Tinel’s sign may also be present
lateral pain without associated motor weakness or ultra- but can occur proximal to the compression level.
sound changes in the CEO should prompt a search for
radial nerve compression. Wartenberg’s syndrome is com-
pression of the radial nerve as it crosses the first and second
extensor compartments. Prior to the atrophic phase, a hypertrophic phase with
muscle oedema and enlargement occurs. This phase is not
as readily apparent on ultrasound as with MRI; however,
muscle tenderness in an appropriate distribution should
Practice Tip provide a clue.
On ultrasound, the radial nerve is not as well defined as the
ulnar or median nerves and is often seen to comprise a FURTHER READING
number of separate fascicles. Cain EL, J Dugas JR. History and examination of the thrower’s elbow.
Clin Sports Med 2004;23(4):553–66.
Ciccotti MG, Charlton WPH. Epicondylitis in the athlete. Clin Sports
Med 2001;20(1):77–93.
Izzi J, Dennison D, Noerdlinger M, et al. Nerve injuries of the elbow,
Around the elbow, the radial nerve should be traced from wrist, and hand in athletes. Clin Sports Med 2001;20(1):203–17.
the lateral margin of the humerus into the antecubital fossa, Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
where it enters the radial tunnel, noting any changes in Clin Sports Med 2004;23(4):519–30.
calibre. As it is followed distally, the radial nerve fascicles Porter S, McNally E. Elbow. In: Karantanas AH, editor. Sports Injuries
in Children and Adolescents. Berlin: Springer; 2011: p. 113–23.
separate themselves into two discrete entities: the more
Stevens KJ, McNally E. Magnetic resonance imaging of the elbow in
anterior and central is the radial nerve proper and the more athletes. Clin Sports Med 2010;29(4):521–53.
posterior and lateral is the PIN. The PIN can be followed as
it passes between the two heads of supinator into the exten-
sor compartment.
7 Disorders of the Elbow: Medial
Eugene McNally
CHAPTER OUTLINE
COMMON FLEXOR ORIGIN ENTHESOPATHY ULNAR NERVE COMPRESSION

ULNAR COLLATERAL LIGAMENT MEDIAN NERVE COMPRESSION
NEURAL COMPRESSION
partial tears and ultimately tendon separation from the

COMMON FLEXOR ORIGIN epiphysis (Fig. 7.2). Acute changes, particularly due to
ENTHESOPATHY trauma, may also involve the pronator teres muscle. Chronic
changes include calcification and bony irregularity repre-
Tendinopathy of the common flexor origin (CFO) is less senting enthesopathy at the attachment.
common than its extensor counterpart. The presenting fea-
tures are similar, although the sporting and occupational
associations are different. There is a particular sporting asso- Practice Tip
ciation with golf and the term golfer’s elbow has come into
common use. Other names, such as medial tennis elbow and There is a close association between CFO tendinopathy and
ulnar neuritis, and in many patients the symptoms overlap.
flexor–pronator sprain, are also applied.
Key Point This is because the floor of the cubital tunnel receives
some fibres from the dorsal aspect of the CFO and conse-
Flexor–pronator sprain is a useful term and it draws quently tendinopathy of the CFO may also irritate the
attention to the common association with injury to the overlying ulnar nerve. As symptoms may be difficult to dif-
pronator teres muscle, which overlies the CFO. ferentiate on clinical grounds, an assessment of both of
these structures should be carried out in patients presenting
with medial elbow pain. The differential diagnosis also
includes injuries to the ulnar collateral ligament (UCL),
Pain is worse on resisted flexion, as opposed to extension median neuropathy and pronator teres.
with common extensor origin (CEO) tendinopathy.
The ultrasound findings are similar to CEO tendinopa-
thy. As has been previously discussed, the configuration of ULNAR COLLATERAL LIGAMENT
CFO is different from that on the extensor side.
Stability of the elbow joint depends on intact bony and liga-
mentous structures. Medial stability depends on soft tissue
Practice Tip integrity throughout the majority of the flexion/extension
range, as bony structures only provide stability at less than
The musculotendinous junction is more proximal so the overall 20° and more than 120°. The medial collateral ligament
ultrasound appearance is of a more muscular or fleshy complex is composed of three components, the most
appearance compared with the CEO (Fig. 7.1). important of which is the anterior limb, which is generally
referred to as the UCL. Anatomically the ligament arises
on the under surface of the medial epicondyle as a fan
This more general hyporeflectivity must not be misinter- shaped attachment and inserts onto the sublime tubercle
preted as tendinopathy. Signs of tendinopathy include loss of the ulna.
of the normal fibrillar structure of the true tendinous There has been considerable study of the biomechanics
portion of the CFO. Increased Doppler is a common and of throwing, particularly in North America where throwing
useful sign to draw attention to the diseased area. More sports play such an important role in late childhood and
advanced signs include tendon delamination leading to adolescence. The overhead throwing sequence is divided
78
CHAPTER 7 — Disorders of the Elbow: Medial 79
a a
CFO
CFO
Med Humerus
Epicondyle M
UC S I
L
L
b b
Figure 7.1 Coronal image of the medial elbow. There is loss of Figure 7.2 Coronal image of medial elbow. Further example of
reflectivity and increased Doppler activity in the proximal part of the epicondylitis with disordered reflectivity and increased Doppler.
CFO consistent with epicondylitis.
into a number of phases, with stress being placed on differ-

ent structures in each phase. The phases are an initial wind- Key Point
up, early and late cocking, early and late acceleration,
If medial instability becomes chronic the sequelae include
deceleration and follow through. Poor technique tends to
valgus extension overload, olecranon stress fractures, ulnar
lead to increased valgus forces, which in turn lead to tension neuritis and ultimately ulnotrochlear arthritis.
along the ulnar aspect of the elbow.
Key Point Injuries to the UCL include complete and partial rupture.
Complete rupture is easier to diagnose than partial injuries.
Knowledge of the point in the throwing cycle where Complete rupture may be proximal or distal, and partial
symptoms occur gives a useful clue to the most likely injury. rupture tends to be distal and may be limited to separation
of the joint surface of the ligament from the sublime tuber-
cle of the ulna (Figs 7.3, 7.4 and 7.5). Plain films are rarely
helpful, although they can occasionally identify an entheso-
Stress on the UCL is greatest in the late cocking phase. Tears phyte. Ultrasound and MRI are both used, and MRI arthrog-
of the UCL, shearing between the posteromedial olecranon raphy is superior to MRI for subtle injuries.
and adjacent posterior aspect medial epicondyle, and com- The ultrasound findings in UCL tear include disorganiza-
pression at the radiocapitellar joint may all follow. tion of the normal fibrillary structure, increased size and
80 PART 2 — ELBOW
Figure 7.3 Schematic diagram of proximal tear of the UCL. Figure 7.5 Schematic diagram of the partial tear of the distal ulnar
collateral ligament attachment. The ligament is lifted from the underly-
ing sublime tubercle allowing joint fluid or contrast to pass between
it and the underlying ulna. Fluid pas above and below the line of fluid
in the joint is referred to as the T-sign.
laxity. In the acute phase free fluid may be seen to traverse

the tear and exude from the joint into the surrounding soft
tissues. Partial tears are more difficult to detect but in addi-
tion to disorganization of the ligament on ultrasound, focal
pain is an important aspect of diagnosis.
Practice Tip
Strain of the UCL may only manifest as ligament dysfunction

and stressing the ligament is important to detect these more
subtle injuries.
The methods for stressing the ligament have already been

described in the techniques section.
Medial elbow distraction injuries may lead to compres-
sion injuries laterally. Tears of the UCL may be associated
with osteochondral compression injuries on the lateral side.
Although not strictly osteochondritis dissecans, a similar
Figure 7.4 Coronal schematic of tear of the ulnar attachment of the lesion may be apparent in the capitellum.
ulnar collateral ligament.
Practice Tip
Careful scrutiny of the medial ligament complex is suggested

when capitellar bone lesions are detected, and vice versa.
nerve generally loses some of its reflectivity and becomes

NEURAL COMPRESSION tender to examination, resulting in a positive Tinel’s sign.
Other signs within the compressed nerve include altera-
Nerve compression and contusion around the elbow are tions in echotexture, reduced movement and changes in
common. This is because the main nerve trunks are rela- perineural vascularity. The second important finding is the
tively superficial and are in close proximity to underlying cause at the level of compression. In many cases none is
osseous structures. This combination makes them vulnera- apparent, though clearly any soft tissue enlargement,
ble to acute injury from a direct blow or a fracture. In addi- whether it be due to tendinopathy, tenosynovitis or a syno-
tion, all three main nerve trunks pass through narrow vial extension from an adjacent inflamed joint, mass,
fibromuscular or fibroosseous tunnels around the elbow, tumour or haemorrhage, should all be considered. Most
where they can be compressed or impinged by repetitive present themselves as an obvious mass, but a few are subtle
traction/relaxation movement. All three also pass through (for example: in some cases, thickening of the margins of a
muscle tunnels, which are further potential sources of com- fibroosseous tunnel may be the cause for compression).
pression. The radial nerve passes between the two heads of These are difficult to detect, but the change in calibre of
supinator, the median nerve passes through pronator teres nerve helps to focus attention and comparison with the
and the ulnar nerve passes through the two heads of flexor other side may be helpful. The third finding is the effect of
carpi ulnaris. Muscles that are extremely active during the nerve compression itself, and this depends on whether
throwing are particularly prone to dynamic compression the nerve is sensory, motor or both. Loss of motion function
syndromes. results in muscle denervation. The early signs of these can
There are three principal ultrasound findings in nerve be subtle, particularly on ultrasound, and are easier to find
compression syndromes. The most important is an altera- on MRI. In the early stages, the muscle may enlarge and
tion within the nerve itself. It is narrowed at and dilated become oedematous. Both of these signs are difficult to
proximal to the level of compression (Fig. 7.6). The swollen detect unless the muscle is painful or comparison with the
asymptomatic side is made. In the later stages, muscle
atrophy occurs. The muscle fibres are replaced by fatty
tissue, resulting in a generalized increase in reflectivity (Fig.
7.7). This is an easier sign to detect on ultrasound. If there
is any doubt, MRI is excellent at detecting the early changes
of denervation.
ULNAR NERVE COMPRESSION
Ulnar nerve compression is the most common neural com-

pression syndrome around the elbow. It is particularly
common in throwing sports and occupations where elbow
movement is prevalent as it is under increased tension
during the throwing motion. Pressure within the cubital
tunnel increases with flexion, and increases any natural ten-
dency to compression. This is particularly so in the late
cocking phase of throwing. Ulnar nerve disease may present
a
with aching pain and discomfort over the medial elbow and
forearm. Transient numbness and paraesthesia can occur
UN over the medial aspect of the forearm and hand. Athletes
may complain of clumsiness or heaviness in their throwing
arm, with easy fatigue and loss of throwing speed.
Osborne’s Ligament The cubital tunnel lies on the posterior aspect of the
Ulnar Nerve medial epicondyle, between it and the olecranon.
Key Point
Humerus The floor of the cubital is formed by the joint capsule, the
fibres from the posterior bundle of the UCL and the CFO,
so it is unsurprising that there is a strong relationship
between symptoms of epicondylitis and ulnar nerve
P
I S compression.
A
b
Figure 7.6 Long-axis parasagittal image of posteromedial elbow The roof is formed proximally by a retinaculum called
showing a dilated ulnar nerve above compression within the cubital Osborne’s ligament and distally by a fibrous aponeurosis of
tunnel. the isthmus between the two heads of flexor carpi ulnaris,
82 PART 2 — ELBOW
UN Med H
Triceps
is
al
hi
ac
Br
Pronator Teres Atrophic
Pronator Teres Humerus
M
A P
L
b
Figure 7.8 Axial image of posteromedial elbow. Note the dilated

b ulnar nerve (UN) proximal to compression within the cubital tunnel.
Figure 7.7 Axial image of distal forearm anterior. Side-to-side com-

parison demonstrating atrophy of the pronator quadratus muscle.
This is secondary to compression of the anterior interosseous nerve,
a branch of the median nerve.
the neural bundles of the ulnar nerve are hyporeflective
against a background of bright perineural connective tissue.
The appearance has been likened to a tendon, although
called the arcuate ligament. The space within the cubital nerve fibres are generally larger and are continuous com-
tunnel naturally decreases with elbow flexion as the aponeu- pared with smaller and discontinuous tendinous fibres. The
rosis of the flexor carpi ulnaris becomes taut. During flexion fibres of the ulnar nerve form themselves into a tight, well-
and extension the ulnar nerve also needs to elongate by defined bundle, unlike the more ill-defined radial nerve.
some 5 mm. The combination leads to further increased The ulnar nerve should be traced from the brachial plexus
compression/traction. Thickening of the retinaculum, the through the arm, elbow, forearm, and into Guyon’s canal
presence of an anomalous anconeus epitrochlearis muscle and beyond. Lying the patient supine, with the arm abducted
and fleshy enlargement of the arcuate ligament may all facilitates this. Such extensive coverage is possible with MRI
make compression worse. but is more time-consuming. Sonopalpation can also be used
Ulnar nerve compression may also arise from trauma or to elicit the equivalent of a clinical Tinel’s sign, when symp-
chronic valgus extension overload, when osteophytes may toms are invoked as the probe passes over the area of neural
form on the medial margin of the olecranon and impinge compression.
the adjacent ulnar nerve. Less common causes include com- The commonest ultrasound finding is swelling of the
pression at the arcade of Struthers, a thick fascial band nerve above the level of the compression (Fig. 7.8). The
running between the intermuscular septum and medial calibre of the nerve should be assessed proximal to, within
triceps, and the fascial bands between the two heads of the the proximal part of the tunnel, within the distal part of
flexor carpi ulnaris and the deep flexor–pronator aponeu- the tunnel and distal to the tunnel (Fig. 7.9) and compared
rosis. The nerve may also be compressed by a space-occupying with the contralateral side. There is normally a reduction in
lesion, scarring, posteromedial arthritis or synovitis. the calibre of the nerve as it enters the tunnel. Normal
The ultrasound examination of the ulnar nerve relies pre- values have not been established as they have for carpal
dominantly on the transverse plane. Like nerves elsewhere, tunnel syndrome and it should be appreciated that the
Brachialis Medial head

Ulnar nerve triceps
Humerus
a Normal anatomy b Partially subluxed nerve

Weak but intact Osborne's ligament
FCR
c Subluxed nerve d Subluxed nerve and triceps
UN Single click Double click
Figure 7.10 (A) Normal pattern. The ulnar nerve is constrained by

FDP FDS Osborne’s ligament. (B) Lax Osborne’s ligament. The ulnar nerve
moves anteriorly but does not sublux. (C) The ulnar nerve has dislo-
cated anteriorly. In most cases the patient is unaware. In some, a
palpable and audible click is felt. (D) In a few patients a double click
is reported. This is due to subluxation of both the ulnar nerve and
medial or accessory head of triceps.
Figure 7.9 Axial image posteromedial elbow. The normal nerve lies
below the two heads of flexor carpi ulnaris.
head of the triceps or accessory triceps also subluxes (Fig.
7.10). Subluxation is also more frequent when there is gen-
eralized soft tissue laxity (Figs 7.11 and 7.12). Although
subluxation is not infrequent in the asymptomatic popula-
contralateral nerve may also appear compressed without any tion, repeated subluxation or even frank dislocation may
symptoms. lead to friction neuritis. Subluxation is also thought to exag-
Secondary signs within the compressed nerve include gerate the effects of other causes of neural compression.
alterations in echotexture, reduced movement and changes
in perineural vascularity. If an artery accompanies a particu-
lar nerve through its fibroosseous tunnel, changes in flow MEDIAN NERVE COMPRESSION
characteristics compared with the contralateral side may be
helpful in indicating that localized compression is present. Median nerve compression at the elbow is considerably less
common than ulnar nerve compression. The commonest
cause of median compression is at the wrist, within the
Practice Tip
carpal tunnel.
In addition, examining the elbow in different positions may
cause pressure changes to augment the findings in nerve Key Point
compression.
The commonest cause of median nerve compression above
the elbow joint is due to a supracondylar process, and
In some individuals, the cubital retinaculum/Osborne’s below the elbow it is due to compression between the two
ligament is absent. This allows the nerve to sublux during heads of pronator teres.
flexion. The tendency is exaggerated if there is a prominent
medial head of triceps or bony anomalies of the medial
epicondyle. Subluxation may be accompanied by an audible The supracondylar process is an anomalous bony spur
click or even a double click where a hypertrophied medial arising from the medial aspect of the humerus. The spur
84 PART 2 — ELBOW
a a
Med H
Triceps
UN UN
Med H
lis
ia Triceps
ach
Br
is
al
chi
Bra
Humerus
M Humerus
I S M
L A P
L
b b
Figure 7.11 Transverse image of posteromedial elbow. The ulnar Figure 7.12 On flexion, the ulnar nerve has dislocated anteriorly.
nerve is located within the ulnar groove. Its posterior relation is the
medial head of triceps.
itself can be identified on plain radiographs; however, bicipital aponeurosis (Fig. 7.15). Compression may also
neural compression requires the additional presence of occur from an accessory fibrous band associated with an
Struther’s ligament, a fibrous band extending from the spur anomalous third head of the biceps muscle, by the proximal
to the medial epicondyle. This forms a fibroosseous tunnel arch of the flexor digitorum superficialis muscle, by an
through which the median nerve and brachial artery pass. accessory head of the flexor pollicis longus (Gantzer
Compression at this level leads to pronator teres dysfunction muscle), anomalous vessels. Distension of the large bicipi-
and atrophy. Compression at or below the level of the elbow toradial bursa leads to radial nerve compression.
joint does not lead to pronator teres atrophy as the branch The major branch of the median nerve is the anterior
to that muscle arises above this level. Pronator syndrome is interosseous nerve and compression of this nerve causes
the most common compressive neuropathy just below the the Kiloh–Nevin syndrome. The nerve is motor and com-
elbow. In this condition, compression occurs between the pression leads to dysfunction of the flexor pollicis longus,
two heads of the pronator teres muscle (Fig. 7.13). Patients flexor digitorum profundus to the second and third digits
present with pain over the volar aspect of the forearm associ- and the pronator quadratus muscle. What is challenging
ated with numbness and paraesthesia in the median nerve about this condition is that the involved muscles are distal
distribution. The condition may be precipitated by aug- to the elbow.
mented training and muscle hypertrophy, and symptoms
are made worse by repetitive movements of the forearm
(Fig. 7.14). Sports that entail pronation and supination are Practice Tip
particularly susceptible.
Several other potential sites of median compression may In patients presenting with wrist and hand syndromes related
be detected around the elbow. As it enters the antecubital to muscle weakness, a nerve compression syndrome at the
fossa, the nerve lies medial to the biceps tendon and bra- elbow should be considered.
chial artery, where it may be compressed by a thickened
s
rosi
neu
Apo Pronator
Median Teres
Biceps Nerve
a
Brachialis
A
LM Humerus
b P
Pronator
Teres Figure 7.14 Axial image of anterior elbow. The median nerve is
dilated just above the pronator teres.
Median
Nerve
A
S I Pronator
P Teres
Figure 7.13 Sagittal image of the anterior elbow. There is thickening

of the median nerve proximal and compression at the point where it
passes between the two heads of pronator teres.
In the early stages muscle oedema may be difficult to iden-

tify on ultrasound. Although this condition is uncommon
in the absence of a mass or haematoma, it may occur in
athletes as a result of muscle hypertrophy of the forearm.
Other nerves to consider around the elbow are the
musculocutaneous nerve and the medial and lateral ante-
brachial cutaneous nerves. Injury is rare, but may occur as
a result of needle management for CFO disease. Compres- Figure 7.15 Schematic diagram of the course of the median nerve.
sion of the lateral antebrachial cutaneous nerves is occasion- The common cause of impingement is the distal arm against the
ally due to biceps tendinopathy, as the nerve passes close to supracondylar process. In the anterior elbow, it may become impinged
the enlarged tendon. This is referred to as the Bassett’s against the biceps aponeurosis or between the two heads of pronator
lesion. teres.
86 PART 2 — ELBOW
FURTHER READING Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
Clin Sports Med 2004;23(4):519–30.
Cain EL, Dugas JR. History and examination of the thrower’s elbow. Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in
Clin Sports Med 2004;23(4):553–66. athletes. Clin Sports Med 2010;29(4):521–53.
Izzi J, Dennison D, Noerdlinger M, et al. Nerve injuries of the elbow,
wrist, and hand in athletes. Clin Sports Med 2001;20(1):203–17.
Disorders of the Elbow: 8
Anterior
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION BICEPS RUPTURE

BICEPS TENDINOPATHY CUBITAL BURSITIS
INTRODUCTION
The principal structures of interest in the anterior elbow

are the biceps and brachialis tendons. The biceps tendons
form from its two muscle bellies and each inserts, close to
one another, on the radial tuberosity. The two muscle heads
can easily be distinguished from one another but the
tendons are grouped close together, although the two com-
ponents become more separate as the tendon approaches
its insertion.
Practice Tip
It is important to identify both the biceps and brachialis

tendons in the antecubital fossa as, if only a single tendon is a
present, it means that the other, usually the biceps, is
ruptured (Fig. 8.1).
Apart from rupture, the principal pathological processes

that affect biceps are tendinopathy, cubital and interosseous
bursitis. Tendinopathy of brachialis is rare.
BICEPS TENDINOPATHY
Biceps tendinopathy is most often due to misuse injury,

although frequently there is a background predisposition. Bicipitoradial bursa
Such conditions include diabetes, systemic arthropathy,
renal disease and occasionally drug use. The patient pres-
Interosseus bursa
ents with antecubital pain and not infrequently a palpable
mass, representing a combination of tendon and sheath b
enlargement. Figure 8.1 Axial MRI image of the anterior elbow structures. Two
tendons should always be identified: brachialis inserting onto the ulna
Key Point and biceps on to the radius. The cubital bursa surrounds the biceps
tendon, but is not always visualized.
Occasionally the mass predominates and some patients
with chronic biceps tendinopathy are suspected of having a
tumour.
87
88 PART 2 — ELBOW
Figure 8.4 Sagittal extended field of view image of anterior elbow.

The biceps tendon is ruptured and has retracted out of its sheath. Its
tip lies proximal to the joint, where it can be palpated.
Figure 8.2 Oblique coronal image of the biceps attachment. The

distal biceps can be difficult to image. The technique used to acquire
this view is described on page 67.
BICEPS RUPTURE
Biceps rupture is usually an acute phenomenon, related to

a specific injury or strain. The patient notices acute pain,
often with an audible snap and muscle weakness. Bruising
quickly follows. Elbow flexion against resistance bulges the
muscle belly as the tendon is free to retract. This creates the
typical ‘Popeye sign’. Another useful sign that can be applied
in the ultrasound room is the squeeze test.
Practice Tip
Squeezing the biceps muscle belly should induce forearm

supination if the tendon is intact.
In thin individuals, the retracted tendon end can be pal-

pated and moved as it is not attached distally (Fig. 8.4).
This constellation of clinical features means that the diag-
Figure 8.3 Thickened disorganized distal biceps at the attachment nosis of biceps tendon rupture is generally straightforward
into the radius. The appearances are indicative of biceps tendinopa- clinically. The role of imaging is to confirm that both heads
thy. There is a little fluid in the bicipitoradial bursa. are involved and to identify the degree of tendon retraction
as this can influence surgical decisions. The degree of
tendon retraction depends on whether the bicipital aponeu-
In the earliest stages, fluid gathers within the tendon rosis is involved. The aponeurosis is a connective tissue
sheath and synovial thickening occurs. The tendon remains structure that runs from the tendon at approximately the
normal initially with a typical reticular reflective pattern best musculotendinous junction level to insert on the superficial
appreciated on axial images, but also when good long-axis aspect of pronator teres. If the aponeurosis remains intact,
images are obtained (Fig. 8.2). Ultimately internal signal the degree of tendon retraction is less (Fig. 8.5). If the
changes representing focal tendon degeneration lead to aponeurosis is also torn, the tendon is allowed to retract into
delamination and partial tears (Fig. 8.3). A hypertrophic the distal arm, often well above the level of the elbow joint
pattern is more usual and the combination of tendon hyper- (Fig. 8.6). On axial imaging, the tendon end may appear
trophy, fibre disorganization, fluid distension of the tendon rather mass-like (Fig. 8.7) and heterogeneous, especially
sheath and increased Doppler signal is typical. when reflective haemorrhage is present.
CHAPTER 8 — Disorders of the Elbow: Anterior 89
Figure 8.5 Retracted biceps tendon. The tendon remains in the

groove but no longer lies close to the tuberosity. Figure 8.7 Axial ultrasound image of enlarged and mass like rup-
tured tendon end.
CUBITAL BURSITIS
The bicipitoradial bursa surrounds the biceps tendon close

to its insertion. When bursitis is present, it distends with
fluid and synovial thickening, and the distal portion of the
biceps tendon can been seen to pass through it.
Key Point
If the bicipitoradial bursa is sufficiently enlarged, the

patient may present with symptoms of neural compression,
which most often involves the sensory branch of the radial
nerve, but also occasionally the posterior interosseous
nerve.
Figure 8.6 Axial image of anterior elbow. There is marked enlarge- A second bursa is often described medial to the bicipitora-
ment of the bursa indicative of tendon rupture. The tendon has
dial bursa, between the proximal radius and ulna, called the
retracted, leading to the apparent enlargement.
interosseous bursa (Fig. 8.1). Enlargement of this bursa is
less common and it may arise as a result of impingement
during repeated pronation and supination. It can be subtle
Practice Tip and difficult to detect at ultrasound. Occasionally it can be
seen projecting posteriorly when the biceps insertion is
The location of the tendon end with respect to the elbow joint
examined in the cobra position (see p. 67). Enlargement is
can be used to determine whether the aponeurosis is ruptured
or not.
said to cause median nerve compression. Other causes of
anterior elbow pain include radial and medial nerve com-
pression, tendinopathy of the brachialis tendon and ganglia
Direct visualization of the aponeurosis is also possible. or synovial cysts arising from the anterior joint.
90 PART 2 — ELBOW
FURTHER READING Skaf AY, Boutin RD, Dantas RWM, et al. Bicipitoradial bursitis: MR
imaging findings in eight patients and anatomic data from contrast
Cain EL, Dugas JR. History and examination of the thrower’s elbow. material opacification of bursae followed by routine radiography and
Clin Sports Med 2004;23(4):553–66. MR imaging in cadavers. Radiology 1999;212(1):111–16.
Izzi J, Dennison D, Noerdlinger M, et al. Nerve injuries of the elbow, Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in
wrist, and hand in athletes. Clin Sports Med 2001;20(1):203–17. athletes. Clin Sports Med 2010;29(4):521–53.
Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
Clin Sports Med 2004;23(4):519–30.
Disorders of the Elbow: 9
Posterior
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION SYNOVITIS AND JOINT EFFUSION

OLECRANON BURSITIS OTHER CAUSES OF POSTERIOR ELBOW PAIN
TRICEPS TENDINOPATHY AND RUPTURE
may be active on Doppler or inactive and representing

INTRODUCTION fibrous pannus.
Occasionally aspiration and cortisone injection are carried
The differential diagnosis of pain in the posterior elbow out for simple or inflammatory bursitis, although the latter
includes olecranon bursitis, joint disease, triceps disease, as is controversial and may be associated with secondary infec-
well as less common causes, including olecranon stress fraction and subcutaneous fat atrophy.
tures and posterior impingement syndromes.
OLECRANON BURSITIS
One of the commonest causes of localized pain in the pos-

terior elbow is olecranon bursitis. This is usually a clinical
diagnosis as bursa enlargement is easily palpable in the
typical location above the olecranon. Occasionally in
patients with large limbs, subtle enlargement may be diffi-
cult to detect clinically and imaging may be helpful in these
cases (Fig. 9.1).
The cause is usually due to repetitive friction as the char-
acteristic location of the olecranon bursa makes it particu-
larly susceptible to trauma, leading to haemorrhage within a
the bursa. Conditions associated with inflammatory synovitis
also commonly affect the bursa (Fig. 9.2). Septic bursitis,
particularly related to penetrating injuries, also occurs.
The ultrasound findings are the same as bursitis elsewhere. Bursa
The bursa may be well or poorly defined depending on the
degree of inflammatory changes in the surrounding fat.
Key Point P Ulna

I S
The contents of the olecranon bursa may be clear, A
anechoic, fluid in the case of a pure adventitial bursitis, or
complex if haemorrhage or infection is present. b
Figure 9.1 Sagittal section of posterior elbow. An ill-defined pre-

dominantly low-reflective mass underlies the proximal olecranon.
The wall may be thick or thin depending on the degree of Enlargement of the olecranon bursa is one of the commonest masses
associated synovitis and, if synovial thickening is present, it around the elbow.
91
92 PART 2 — ELBOW
Triceps
Bursa
Bursa
P
I S Ulna
s A
ep
Tric
b
Figure 9.3 Sagittal image of posterior elbow. There is abnormal

reflectivity and increased Doppler in the triceps at its attachment,
consistent with triceps enthesopathy.
Ulna
P
I S Triceps rupture may also occur in association with olecra-
A
non bursitis, infection or following local steroid injections.
b
As the separate insertion of the medial head is usually
Figure 9.2 Sagittal posterior elbow and poorly defined fluid collection spared, tears are technically most commonly partial and
underlying the olecranon. Another example of olecranon bursitis. involve the combined lateral and central heads.
The ultrasound findings include tendon enlargement,
laxity due to proximal migration and hyperechoic
haemorrhage.
TRICEPS TENDINOPATHY AND RUPTURE

Practice Tip
Triceps tendinopathy is distinctly less common than biceps
tendinopathy (Fig. 9.3). Loss of structure, areas of delami- In the presence of triceps rupture, joint fluid can escape
nation and increased Doppler are characteristic (Fig. 9.4). through the tear and fill the posterior soft tissues. Manual
Overuse syndromes are the most common. Ultrasound is compression of the elbow joint or gentle flexion and extension
can exaggerate this fluid movement and augment the
particularly useful in detecting triceps tendinopathy due to
appearance of the tear.
impingement against orthopaedic hardware, where MRI is
often unsuccessful. Tendon rupture is also rare and usually
indicates an underlying condition predisposing to tendon
degeneration, similar to those that might underlie biceps In many cases of acute posttraumatic triceps rupture, a small
rupture. These include diabetes, systemic arthritis, renal fragment of the bony olecranon is attached, making the
failure or drug usage, particularly anabolic steroid use. distal end of the torn tendon easier to locate.
CHAPTER 9 — Disorders of the Elbow: Posterior 93
Trice
ps
Fat pad
Mass
Humerus
P
I S
A
b
Figure 9.4 Abnormal reflectivity and increased Doppler of the

triceps insertion. There is also a small effusion and some surrounding P
reflected soft tissue material. Infection of the triceps insertion was ML
confirmed. Ulna A
Figure 9.5 Large synovial-based mass of posterior elbow consis-

tent with synovial cyst.
Triceps subluxation has been described. This can occur

in conjunction with subluxation of the ulnar nerve. The
medial head or occasionally an accessory slip of the medial
head is involved. Practice Tip
A simple minimally invasive manoeuvre to detect occult loose

SYNOVITIS AND JOINT EFFUSION bodies is to inject the posterior compartment with saline as
the joint is being examined.
Synovitis of the elbow joint may present with posterior
symptoms (Fig. 9.5) and loss of movement, particularly full
extension. Joint effusion (Fig. 9.6), synovial thickening and Loose bodies may displace and become more obvious as
chondral or osteochondral loose bodies (Fig. 9.7) can be the joint is being distended. In patients with synovitis
detected by examining the posterior joint space, particularly undergoing aspiration and injection of corticosteroids
under dynamic flexion and extension (Fig. 9.8). Adherent under ultrasound guidance, screening of the joint during
intraarticular bodies can be difficult to discern against the or immediately after the injection is a useful adjunct,
underlying bony structures. although the normal ultrasound appearances of particulate
94 PART 2 — ELBOW
a
a
Triceps
Triceps
Fat pad
Fat pad
*
*
Ulna
*
Loose bodies
P Humerus
ML
A Humerus
P
S I
b A
Figure 9.6 Transverse section of posterior elbow. There is a large
b
elbow effusion (*). The posterior fat pad is displaced posteriorly. The
fluid is not completely transonic. Complex effusion may be due to Figure 9.7 Sagittal posterior elbow. A low-reflective effusion is
infection or haemorrhage. present and there is displacement of the posterior fat pad. There are
multiple reflective bodies within the effusion. Multiple loose bodies
could indicate primary or secondary osteochondromatosis.
steroid should be recognized and inadvertently injected gas Under these circumstances, aspiration is important to
bubbles should not be mistaken for loose bodies. If there is secure the diagnosis.
doubt, gas bubbles move quickly to the most superficial part Limitation of joint movement, particularly pronation and
of the joint. supination, is a relatively common clinical presentation and
it is sometimes difficult to determine an exact cause. Plain
films should be scrutinized for bony abnormality, particu-
Key Point larly malalignment of radiocapitellar and ulnotrochlear
joints. Soft tissue calcification may also be a cause of
Septic arthritis of the elbow is not uncommon in children, restricted movement and this can be detected at an earlier
secondary only to the hip in joints presenting with stage with ultrasound, compared with plain radiography or
spontaneous sepsis. MRI. Ultrasound is used to detect soft tissue calcification,
ossification, impinging soft tissue structure such as ganglia
CHAPTER 9 — Disorders of the Elbow: Posterior 95
or bursae, although the most common cause remains simple

joint effusion or synovitis.
OTHER CAUSES OF POSTERIOR

ELBOW PAIN
There are several bony causes of posterior elbow disease that

are difficult to detect using ultrasound but can be suspected
on the basis of location of symptoms, clinical history and
exclusion of other causes during the ultrasound examina-
tion. An olecranon stress fracture has been described in
throwers, particularly where there is a torsional element to
the throwing technique, and in weightlifters and gymnasts.
Posteromedial impingement syndrome occurs in associa-
tion with medial flexor or ligament disease. The olecranon
impinges against the posteromedial aspect of the humerus,
resulting in chondromalacia and ultimately full-thickness
cartilage defects with subchondral bone oedema.
a
Key Point
The damage to the articular cartilage that occurs in

posteromedial impingement is not usually visible with
ultrasound, but the reactive bony spurs and secondary
osteophytes that form suggest the diagnosis.
Brachialis
The relationship of these osteophytes to the medially placed

ulnar nerve leading to secondary ulnar nerve impingement
can also be evaluated.
Fat pad FURTHER READING

Cain LE, Dugas JR. History and examination of the thrower’s elbow.
Loose body Clin Sports Med 2004;23:553–66.
A Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
ML Clin Sports Med 2004;23(4):519–30.
P Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epi-
Humerus condylitis, biceps and triceps ruptures. J Hand Surg 2009;34.3:
566–76.
Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in
b
athletes. Clin Sports Med 2010;29(4):521–53.
Figure 9.8 Axial section of anterior elbow. A single reflective focus
is present in the anterior joint space consistent with a loose body.
PART 3
WRIST
97
Forearm and Wrist Joint: 10
Eugene McNally
CHAPTER OUTLINE
FOREARM ANATOMY Position 1: Extensor Wrist Radial Side

Flexor Compartment Position 2: Extensor Wrist Ulnar Side
Extensor Compartment Position 3: Dorsal Wrist Joint
Which Nerve Innervates Which Muscle Position 4: Flexor Wrist Radial Side
Radial Nerve Position 5: Flexor Wrist Ulnar Side
Ulnar Nerve Position 6: The Palm Central Area
Median Nerve Position 7: Thenar and Hypothenar
WRIST ANATOMY AND TECHNIQUES Emminences
Overview
Position Variations
FOREARM ANATOMY
The anatomy of the forearm in one sense is as straightfor-

ward as the arm in that there are only two compartments,
flexor and extensor, separated by an interosseous mem-
brane. It is made a little trickier, however, as the flexor and
extensor muscles begin medially and laterally respectively
and then rotate as they are followed distally. In the midfore-
arm, the flexor compartment occupies the anterior part of
the forearm; the extensor compartment occupies the poste-
rior and lateral part. The easiest method to identify a par- a
ticular muscle of the forearm is to begin at the wrist with
its tendon. The tendons at the wrist are clearly separate
from each and occupy well-recognized compartments. The Flexor
anatomy of the wrist and methods to remember tendon FCR
Superficialis
names are described in a later section. Once the tendon is N
found, it can be followed proximally and its associated FCU
muscle located. Flexor
Profundus
FLEXOR COMPARTMENT
The two main muscles of the flexor compartment are flexor
digitorum superficialis (FDS) and flexor digitorum profun- b
dus (FDP), which occupy the central part of the compart-
ment and make up most of its bulk. Overlying these are Figure 10.1 Axial anatomy flexor compartment with median nerve
(N) centrally.
three muscles, flexor carpi ulnaris (FCU), palmaris longus
and flexor carpi radialis (FCR) (Fig. 10.1). The final member
99
100 PART 3 — WRIST
of the compartment, flexor pollicis longus (FPL), arises

from the radius and lies alongside flexor digitorum profun-
dus in the mid- and distal forearm.
The three principal nerve trunks, median, ulnar and
radial, all lie in the anterior, though strictly the radial nerve
is still in the lateral component of the posterior compart-
ment, albeit in a very anterior location. Ulnar and radial
nerves are accompanied by their corresponding arteries.
The median nerve lies more centrally between flexor digi-
torum superficialis and profundus. Occasionally, the median
nerve is also accompanied by a persistent median artery. a
The anterior interosseous nerve and its accompanying
artery are located between flexor digitorum profundus and
flexor pollicis longus in close proximity to the interosseous
Brachioradialis
membrane.
ECRL
&
EXTENSOR COMPARTMENT
ECRB
In the extensor compartment, three separate layers are dis-
cernible: two posterior (superficial and deep) and one Radius
lateral. The muscles in the lateral compartment are brachio-
radialis, and more distally extensor carpi radialis longus APL
b
(ECRL) and brevis (ECRB) (Fig. 10.2), whose tendons will
ultimately form extensor compartment 2. In the posterior Figure 10.2 Axial anatomy radial aspect forearm.
section, the superficial layer contains extensor digitorum
(ED), extensor digiti minimi (EDM) and extensor carpi
ulnaris (ECU) (extensor compartments 4, 5 and 6) (Fig.
10.3). The deep component contains abductor pollicis
longus (APL) on the radial side of extensor pollicis longus
(EPL), forming extensor compartments 1 and 3 respec-
tively. More distally, abductor pollicis longus will receive an
additional component from extensor pollicis brevis (EPB)
to complete compartment 1. In the proximal forearm, the
extensor compartments from radial to lateral are therefore
2, 1, 3, 4, 5 and 6. It is clear that 1 and 2 are not optimally a
arranged and are going to have to cross each other to reach
their ultimate destination. The crossover occurs just proxi-
mal to the wrist. EDM ED
Although it is not particularly large, the main nerve in ECU
the extensor compartment is the posterior interosseous N
nerve (PIN). This is the major motor division of the radial EPL
nerve, formed below the elbow joint and passing into the
posterior compartment between the two heads of supinator. APL
Unlike its anterior namesake, the posterior interosseous Ulna
b
nerve does not directly lie on the interosseous membrane,
but between the superficial (EDC, EDM and ECU) and deep Figure 10.3 Axial anatomy extensor compartment with posterior
(APL and EPL) muscle groups. It can be followed distally interosseus nerve (N) centrally.
where it is located deep to extensor digitorum communis at
the level of the wrist.
RADIAL NERVE
The radial nerve innervates the following muscles: triceps
WHICH NERVE INNERVATES WHICH MUSCLE?
brachii (lateral and medial heads), anconeus, brachiora
Neural compression syndromes manifest on imaging in two dialis, extensor carpi radialis longus. Via the posterior
ways. At the level of the compression, the nerve is usually interosseous nerve it also innervates: extensor carpi radialis
enlarged and in many cases the lesion causing the compres- brevis (ECRB), supinator, extensor digitorum, extensor
sion can be seen. Distal to the compression, the innervated digiti minimi, extensor carpi ulnaris, abductor pollicis
muscle may atrophy. The ultrasound features of this are longus, extensor pollicis brevis, extensor pollicis longus and
usually late. MRI is more sensitive as it can also pick up the extensor indicis (EI).
oedematous stage of denervation, which ultrasound does
not. It is helpful, therefore, to know the innervation of the ULNAR NERVE
forearm muscle so that the correct pattern of atrophy may The ulnar nerve innervates the following muscles: flexor
be recognized. carpi ulnaris and flexor digitorum profundus (medial half).
CHAPTER 10 — Forearm and Wrist Joint: Anatomy and Techniques 101
Via its deep branch it innervates: hypothenar muscles, oppo- POSITION 1: EXTENSOR WRIST RADIAL SIDE
nens digiti minimi (ODM), abductor digiti minimi (ADM),
flexor digiti minimi (FDM), third and fourth lumbrical IMAGING GOALS
muscles, dorsal interossei (DI), palmar interossei (PI) and 1. Identify extensor compartments (ECs) 1 and 2.
adductor pollicis (AP). And via its superficial branch, the 2. Locate and track extensor pollicis longus.
ulnar nerve innervates palmaris brevis. 3. Locate the dorsal aspect of the scapholunate ligament
(SLL).
MEDIAN NERVE
The median nerve innervates the following muscles: prona-
tor teres, flexor carpi radialis, palmaris longus and flexor TECHNIQUE
digitorum superficialis. Via its anterior interosseous branch: Radial sided wrist pain is common and ultrasound is helpful
flexor digitorum profundus (lateral half), flexor pollicis in detecting many of its causes. These include common
longus and pronator quadratus. conditions like de Quervain’s tenosynovitis and dorsal gan-
glion cyst. The examination begins with the identification
of EC1, EC2 and EC3 (Fig. 10.4). There are two methods
WRIST ANATOMY AND TECHNIQUES
used to identify these three compartments. The easiest
method, and best for beginners, is to identify a bony promi-
OVERVIEW
nence on the dorsal aspect of the radius called Lister’s
The most commonly employed position to examine the tubercle (Fig. 10.5). With the palm of the hand placed flat
wrist and hand is to have the patient seated opposite the on the examination couch, the probe is placed in axial posi-
examiner. Both wrists can be placed on the examination tion over the middle of the forearm. The radius and ulnar
couch, allowing full access and side-to-side comparison. bony margins are identified and the probe is moved dis-
Plenty of coupling jelly is required due to the varied con- tantly along the dorsal aspect of the radius. Just before the
tours of the hand, consequently an absorbent pad placed wrist joint is reached, a bony prominence is seen. This is
beneath the hand is essential. Lister’s tubercle, which separates the second (lateral) from
As with other joints, the patient’s symptoms will direct the the third (medial) compartments. The second compart-
examination and the efficacy of ultrasound is highest when ment contains two tendons and the third compartment a
there is a specific localizing symptom. If pain is more diffuse, single tendon. The probe is then moved further to the
MRI is more likely to be helpful. The wrist examination, radial side to locate the first compartment, which also con-
therefore, will be separated into specific areas with specific tains two tendons. Note that the probe has to be moved
imaging goals in each area. ‘around the corner’ of the posteroradial margin of the
The examination of the patient with pain on the dorsal radius to find compartment 1 (Fig. 10.6).
aspect of the wrist begins with an assessment of the extensor With practice, the examination can begin directly over
tendons. These are arranged in six compartments num- the first. The patient places the ulnar border of their hand
bered accordingly from radial to ulnar. Each compartment on the examination couch. EC1 lies along the uppermost
is associated with specific pathology. As with tendons else- border of the radius in this hand position, in a very super-
where, the extensor tendons are best assessed in the axial ficial location. Placing the probe in the axial position at the
plane. uppermost part of the wrist will reveal EC1 and its two
The tendons on the flexor side of the wrist are also tendons, the abductor pollicis longus and extensor pollicis
arranged in compartments. The largest compartment is the brevis. The two tendons are surrounded by a tendon sheath
carpal tunnel. This contains the superficial and deep flexor and contained within the extensor retinaculum. The exten-
tendons, flexor pollicis longus tendon and the median sor retinaculum is a well-defined fibrous connective tissue
nerve. The finger flexors share a single large synovial com- structure that bridges all six extensor compartments. It is
partment. The flexor pollicis longus tendon has its own important to identify the EC1 retinaculum, as thickening
synovial sheath. The other three flexor tendons are flexor may be the first abnormality encountered in patients with
carpi radialis, flexor carpi ulnaris and palmaris longus.
Flexor carpi radialis has its own compartment on the medial
aspect of the scaphoid and tripezium tubercle and inserts
on the base of the second metacarpal. Flexor carpi ulnaris
*
inserts into the pisiform.
3
4
5 2
POSITION VARIATIONS 6
1
For some interventional procedures, particularly where the
patient is anxious and there is a risk of fainting, an alterna-
tive position is to have the patient lying prone with their
arm extended above their head, the so-called Superman
position. This also allows nearly as much access to all parts
of the wrist and hand. In addition, if an interventional pro-
cedure is required then, the patient’s anxiety will be allayed Figure 10.4 Wrist extensor compartments 1–6. The bony promi-
by being recumbent and not having to sit up and ‘observe’ nence of Lister’s tubercle (*) is a useful landmark, as it separates EC2
the procedure. and EC3. (See text for individual tendon names.)
a a
EPL * ECRB
ECRL
EPB
L
PIN ECR AP
B L
EDC ECR
Radius
Radius
b b
c c
Figure 10.5 Axial anatomy extensor wrist. Listers tubercle (*) sepa- Figure 10.6 Axial anatomy extensor wrist. The first compartment is
rates EC2 and EC3. on the radial aspect of the distal radius, close to EC2.
sclerosing tenosynovitis. The retinaculum is seen as a very anatomical snuff box. Keeping the probe in the axial plane
thin hyporeflective line overlying the tendons close to the and tracing proximally, it will be noted that EC1 passes over
tip of the radial styloid (Fig. 10.7). It may be better seen by the dorsal aspect of EC2 in the distal forearm. This area is
rotating the probe 90° and viewing the tendons in their long called the ‘crossover point’ (Fig. 10.8) and a frictional ten-
axis. If it is difficult to identify, it is unlikely that it is thick- dinopathy may occur in this location. This is called the
ened. Close by, the superficial branch of the radial nerve crossover or intersection syndrome and it is particularly
may also be seen passing over the EC1 as it is tracked common in rowers. Crepitus is a common finding in this
distally. condition and can be felt beneath the ultrasound probe.
A number of variations may be identified in the EC1. The second imaging goal in this section is to identify and
Most commonly, the two tendons share a single compart- follow extensor pollicis longus. This tendon is the sole
ment. Occasionally a septum will be seen between them with inhabitant of EC3. In the distal forearm, it lies on the ulnar
separation into two compartments. Another variation is side of Lister’s tubercle. As extensor pollicis longus is a
that, rather than having two tendons, a number of separate thumb extensor, it uses Lister’s tubercle as a pulley and must
tendon slips may be identified. cross over EC2 to reach its insertion. With the probe held
Returning to the axial plane and moving the probe a little in the axial plane and beginning just proximal to the tuber-
towards the ulnar side reveals EC2. At this stage, it is often cle, the tendon can be followed distally. As the tendon turns
easier for the patient now to rest the palm of their hand on round the tubercle, rotation of the probe is needed to keep
the examination couch. EC2 also contains two tendons: it in true axial plane, as it crosses over extensor carpi radialis
extensor carpi radialis longus and brevis. The brevis tendon brevis and longus in turn (Fig. 10.9). Because of this pulley
is the more ulnar of the two, inserting into the base of mechanism, the tendon is prone to abrasion injury, particu-
the third metacarpal, whereas the longus inserts into the larly if there is bony irregularity of the tubercle, such as
base of the second. They form the dorsal aspect of the might occur with an erosive arthropathy.
a a
EPL
APL
ECRB ECRL
EDC
Radius RSL
D Scaphoid
S I P
V ML Lunate
b A
b
Figure 10.7 Long axis image of EC1 with the thin extensor retinacu-
lum above it.
c
APL
Figure 10.9 Axial image of EPL crossing EC2. Note the rotation of
B ECRL the probe neeed to remain axial to the EPL tendon.
ECR
EPB
wrist pain. The scapholunate ligament is best located in the

Radius
P axial plane. The probe is first positioned in the distal
ML forearm so that the ‘Two Bone’ (radius and ulna) image is
A obtained. It can then be moved distally, until the two bones
b
first disappear (over the radiocarpal joint) and then become
Figure 10.8 Intersection or crossover syndrome occurs where EC1 three, the proximal carpal row. The view of the three bones
crosses EC2 in the distal forearm. comprises the triquetral, lunate and scaphoid. Keeping in
the axial plane, the probe is moved in a radial direction (i.e.
Another important cause of symptoms on the dorsal towards the thumb) to overlie the scaphoid and lunate
radial aspect of the wrist is an occult ganglion. Most com- articulation. The space between the proximal scaphoid and
monly, these arise from the area around the dorsal aspect adjacent lunate will be filled by a small but clearly defined,
of the scapholunate ligament. It is important to be able to striated and reflective ligament (Fig. 10.10). This is the
find this ligament and exclude ganglion cyst in patients with dorsal limb of the scapholunate ligament. Injuries to the
a
a
EDM
ECRB EDC
ECRL
SLL Ulna
Radius
Lunate P
ML
P A
Scaphoid
ML
A b
b Figure 10.11 Axial image of EC4 and EC5. EC5 is a single tendon,
the EDM, and is a good marker for the distal radio-ulnar joint.
Figure 10.10 Axial image over dorsal aspect of the scapholunate
articulation demonstrating the short but strong scapholunate
ligament.
The technique for examining extensor compartment 4

(EC4) is a continuation of the radial side examination. The
ligament may be detected here, but more importantly, the probe remains in the axial plane and positioned centrally
ligament acts as an anatomical reference point to detect over the dorsal aspect of the wrist. EC4 contains the common
ganglion cysts. If there is a dorsal ganglion, it will be seen extensor tendons. It is located on the ulnar side of Lister’s
as a poorly reflective fluid collection arising from the scaph- tubercle, separated from it by extensor pollicis longus. It is
olunate ligament. Occasionally recesses of the wrist joint the largest of the extensor compartments and contains four
filled with synovial fluid can mimic ganglia, but these are extensor tendon slips, one for each finger, and an additional
not usually in this location and, if present, are easily com- extensor indicis tendon (Fig. 10.11). The compartment is
pressible, unlike a more tense ganglion cyst. The ligament somewhat unusual in that it has a much thicker retinaculum
should also be stressed by moving the patient’s wrist into surrounding it than the other extensor compartments. The
radial and ulnar deviation and noting any changes in the retinaculum surrounds the compartment on three sides,
scapholunate distance that may indicate a dysfunctional forming a hypoechoic C-shaped structure. This should not
ligament. be misinterpreted as tenosynovitis. A number of variations
may be identified: in particular, cross linkages between
POSITION 2: EXTENSOR WRIST ULNAR SIDE several extensor tendons may occur. Common ones include
a band extending from the fourth extensor to EDM.
IMAGING GOALS Adjacent is extensor compartment 5 (EC5) (Fig. 10.11)
1. Identify extensor compartments (ECs) 4 to 6. which contains a single tendon, the EDM that inserts in the
2. Look for subluxation of ECU. extensor apparatus of the little finger. This compartment
3. Locate distal radioulnar joint (DRUJ) and adjacent trian- overlies the distal radioulnar joint and is a useful marker for
gular fibrocartilage complex (TFCC). the joint. EDM can be rather small and difficult to identify;
detection is made easier by gentle movement of the little
TECHNIQUE finger. The tendon may be paired or become a paired
There are a number of causes of ulnar sided pain which are tendon as it moves distally. It is joined by the extensor digi-
amenable to ultrasound diagnosis, although accurate assess- torum tendon to the little finger and just proximal to the
ment of the triangular fibrocartilage using ultrasound metacarpal phalangeal joint (Fig. 10.12).
remains challenging. On the extensor aspect of the wrist, Lateral to this, the posterior aspect of the head of the
imaging goals include the identification of the EC4, EC5 ulna is easily found and, keeping the probe in the axial
and EC6 and the distal radioulnar joint (Fig. 10.4). plane, further movement towards the ulnar side (Fig. 10.13)
a
+
*
DI Subsheath
MC
ECU
4 MC
P
ML PI
A
b
M
Figure 10.12 Axial anatomy proximal to MCJ level. The EDM (*) is Ulna
VD
joined by the slip of EDC (+) that goes to the little finger. L
b
reveals the ECU tendon, the sole occupant of extensor com-

partment 6 (EC6). A characteristic feature of ECU is that it
lies within its own groove on the medial margin of the ulnar
head. It is contained within the groove by a fibrous retinacu-
lum called the ECU subsheath. The subsheath is necessary
to keep the ECU in place during the full range of pronation
and supination, as it would otherwise dislocate. Both attach-
ments of the retinaculum should be sought as if either is
injured or deficient, tendon subluxation can occur. A
dynamic examination in pronation and supination should
also be carried out with the probe held over the tendon in
the axial plane. To facilitate this, the patient places their c
flexed elbow on the examination couch, hand in the air, to
allow free movement. Practice is required to coordinate Figure 10.13 Axial anatomy EC6. Extensor carpi ulnaris is contained
pronation/supination while holding an axially positioned with the ulnar groove by a short retinaculum called the ECU
subsheath.
probe over the ECU. Some tendon subluxation is normal
and comparison with the other side is helpful to determine
if the degree is physiological. Once subluxation is excluded, POSITION 3: DORSAL WRIST JOINT
the tendon can then be followed in both long and short axis
to its insertion into the base of the 5th metacarpal. IMAGING GOALS
It has been suggested that ECU acts as a window to 1. Identify the radiocarpal joint.
visualise the triangular fibrocartilage disc. This structure, 2. Identify the midcarpal joint.
however, lies in a deep location some distance from the 3. Identify the dorsal extrinsic ligaments.
undersurface of the tendon and, therefore, in many patients
visualization is rather poor (Figs 10.14 and 10.15). TECHNIQUE
Deep to the ECU is the ulnar collateral ligament. This The wrist joint comprises three compartments. Whilst all
ligament is quite variable and is not infrequently a rather three are visible on both the dorsal and volar aspects of the
attenuated structure. Other prominent ligaments that may wrist, the dorsal aspect gives the best view as the joints are
be identified on the extensor aspect of the wrist include the relatively superficial. The most proximal compartment is
dorsal radiocarpal ligament. This is a fan-shaped ligament the distal radioulnar joint. The round surface of the distal
with its apex at the triquetral bone. There is also a strong ulna is an easily recognized marker for the joint and can be
transverse ligament that attaches to the triquetral and found deep to EC5 (Fig. 10.16). Pronating and supinating
crosses the extensor aspect of the wrist to the scaphoid. the wrist improves visualization of the joint contents.
Figure 10.14 (A, B) Coronal anatomy ulnar side. The meniscal homo-
logue lies deep to the ulnar collateral ligament. The TFCC is deeper
still and is difficult to visualise. (C) Schematic anatomy coronal wrist
showing the relationship of the meniscal homologue with the TFCC
and the intrinsic ligaments.
Flexor carpi ulnaris

Ulnar nerve
Volar ulnotriquetral/lunate ligaments
TFC g
r li
a ulna
dio
l ra
rsa
Do
Triquetral
Extensor indicis
Extensor carpi ulnaris
Lunate Meniscal
homologue Figure 10.15 Axial anatomy ulnar side wrist showing complex volar
and dorsal ligaments supporting the TFCC. These ligaments preserve
the tension in the TFCC and give it its trampoline effect.
TFCC
The radiocarpal joint is found by rotating the probe into
the sagittal plane and moving it distally from the distal
Ulna radioulnar joint (Fig. 10.17). The round contour of the
lunate as it articulates with the radius is a very characteristic
P
I S landmark. In long axis, the low-reflective synovial space can
A be seen extending over the proximal carpal bones deep to
the hyperreflective capsule, ligament and loose connective
b
tissue that surrounds the synovial space. A small quantity of
fluid is usually detected within the joint. Joint fluid is easier
RCJ TFCC
to see by rotating the probe into the axial plane while
keeping it positioned over the joint space (Fig. 10.18).
Triquetral
Larger quantities of fluid are a sign of disease, particularly
when active Doppler signal is present. Occasionally more
Lunate Meniscal prominent synovial recesses are found between the extrinsic
homologue ligaments. If distended, these are easily compressible, distin-
guishing them from ganglia.
The distal compartment is the midcarpal joint. This is also
initially best appreciated in long axis. The synovial space
of this joint is also seen as a thin hyporeflective line, extend-
ing from beneath the distal carpal row. It usually contains
Radius Ulna somewhat less fluid than the radiocarpal joint, though can
expand in its distal portion. Under normal circumstances,
Doppler activity is not present. The vessels of the dorsal and
volar anastomosis overlie the joint, but in an extraarticular
location, and should not be misinterpreted as blood flow
c
within the synovium.
Distal radioulnar joint
Several strong ligament condensations are identified on
the volar aspect of the wrist. The most prominent are the
EDC
a
Radius * MCJ
RCJ
P Lunate Capitate
S I
A
b
Radius
Ulna
P
ML
A
b
Figure 10.17 Long axis image of the radiocarpal and midcarpal

joints. The traversing radiolunotriquetral ligament (*) is seen crossing
the joint.
Figure 10.16 Axial image of the distal radioulnar joint; the EC5 is a
good landmark for the joint.
ligaments that pass from the region of the radial styloid,

traversing several of the carpal bones. The largest of these a
are the radiolunotriquetral ligament and radioscapho
capitate ligaments (Fig. 10.19). There is also a transverse ECRB ECRL
ligament at the level of the midcarpal joint between the
EDC
dorsal aspects of the scaphoid and triquetral. In addition,
there are several smaller ligaments that pass between the RCJ SLL
distal radius and ulna and the proximal carpal row. The
primary function of these shorter ligaments is to reinforce P
the triangular fibrocartilage complex. They include the dor- ML Lunate
A Scaphoid
sal ulnotriquetral ligament. The volar components of these
b
short ligaments are generally considered more important.
The triangular fibrocartilage complex is also reinforced Figure 10.18 Axial image of the radiocarpal joint. Good visualisation
by transversely orientated ligaments that run between the of the scapholunate ligament (SLL) is also apparent.
Lunate
Scaphoid Dorsal
intercarpal
ligament
Dorsal
radiocarpal
ligament a
Raidus Ulna
FCR
Figure 10.19
FDS
MN
FDP
Pronator
Quadratus
A
LM
Radius P
b
Figure 10.21
Figure 10.20 Three main volar extrinsic ligaments. The radiolunotri-

quetral, the radioscaphocapitate and the volar transeverse intercarpal
ligaments. inside margin of scaphoid and out of easy view. Several
manoeuvres are necessary to try to demonstrate this part of
the tendon. Firstly, the probe can be moved medially and
area of the ulnar styloid and the dorsal and volar lip then tilted laterally (Fig. 10.22). In addition, the beam can
of the radius respectively. These are the dorsal and volar be angled so that it is more perpendicular to the line of the
radioulnar ligaments. They meet centrally where they are tendon and finally a degree of wrist flexion can be helpful.
attached, often by a conjoined ligament to the ulnar styloid In the majority of cases, a reasonable view of the distal
(Fig. 10.15). portion of the tendon can be obtained as it heads towards
On the dorsal side, three strong bands emanate from the its insertion at the base of the second metatarsal. The
dorsal aspect of the triquetral. The most proximal and tendon also sends some insertional slips to the base of the
easiest to identify is the radiolunotriquetral ligament. Distal third metacarpal.
to this lies the scapholunotriquetral joint; more distal still is The more ulnar of the two tendons on the radial aspect
a ligament that extends to the dorsal aspect of the triquetral, of the carpal tunnel is the flexor pollicis longus tendon that
across the capitate, to have a multivesicular insertion on the inserts at the base of the distal phalanx of the thumb. It
trapezium and bases of the first and second metacarpals passes through the flexor retinaculum, but has its own syno-
(Fig. 10.20). vial sheath separate from the flexor tendons of the fingers.
Asking the patient to move their thumb helps to locate it
POSITION 4: FLEXOR WRIST RADIAL SIDE within the carpal tunnel.
Occult ganglion cysts may also arise from the volar com-
IMAGING GOALS ponent of the scapholunate ligament. This can be located
1. Locate FCR and follow below scaphoid tubercle. in a similar manner to that used to find the dorsal compo-
2. Locate volar component of scapholunate ligament. nent. Volar ganglia often extend from the ligaments towards
the radial artery. There are three main volar extrinsic liga-
TECHNIQUE ments, two of which emanate from the radius and one trans-
On the flexor aspect of the radial side of the wrist, the FCR verse ligament (Fig. 10.23).
tendon is the most superficial and radial tendon (Fig.
10.21). It is located initially by placing the probe in the axial POSITION 5: FLEXOR WRIST ULNAR SIDE
plane and noting the strong bright reflective tendon close
to the anterolateral margin of the radius. FCR can then be IMAGING GOALS
easily followed to the level of the scaphoid tubercle. Its more 1. Identify the contents of the carpal tunnel.
distal portion is more difficult to assess with ultrasound, as 2. Identify the contents of Guyon’s canal.
the tendon passes into a fibroosseous tunnel along the 3. Identify FCU.
Triquentro-
capitate
ligament
Scaphocapitate
ligament
Radioscapho-
capitate
Ulnocapitate ligament
ligament
a Radiolunate
ligament
Figure 10.23
Reti
nacu
FCR lum
MN
UA UN
FDS
FDP
Scaphoid
A
LM
P
b
Retinaculum FCU
MN
UN Pisiform
FPL FDS
FDP
A
c RLT LM
P
Figure 10.22 (A, B) Axial anatomy radial aspect of radius. Note the b
bright reflective FCR, proximal to the scaphoid. (C) Position to view
distal part of FCR; the probe is moved medially and tilted laterally
(wrist flexion also assists).
TECHNIQUE
There are several common causes of ulnar-sided pain iden-
tified on the flexor aspect of the wrist. The important
structures to locate are the carpal tunnel with the medial
nerve, Guyon’s canal with the ulnar nerve, FCU and the
pisiform triquetral joint (Fig. 10.24). The medial bony
boundary of the carpal tunnel is made up of the hamate
and the triquetral; the lateral bony boundary is the scaph-
oid. Its roof is formed by a thin fibrous band: the flexor
c
retinaculum.
The carpal tunnel contains nine tendons and the median Figure 10.24 Axial anatomy ulnar aspect of the wrist. FCU inserts
nerve (Fig. 10.25). Eight of the tendons are finger flexors into the pisiform and the Guyon’s canal is lateral to it.
FCU UA FDS FPL

UN MN FDP FCR
S S S
Pisiform S P P
P P
Scaphoid
a Triquetral Lunate
Ret FCU
inac
FCR ulu
m
MN
UN Pisiform
Figure 10.26
Scaphoid FDS
FPL
FDP
A
LM the carpal tunnel, radial to the superficial flexors, overlying
P
the deep flexor of the index finger and adjacent to palmaris
b longus. Before it enters the tunnel, it gives off a palmar
cutaneous branch that supplies sensation to the skin on the
lateral aspect of the palm. This is a tiny branch, which can
just be visualized heading proximally and radially away from
the main nerve trunk. Distal to the tunnel, and sometimes
within it, the main median nerve trunk divides into medial
and lateral bundles. The recurrent branch of the nerve
arises within the tunnel and supplies the thenar muscles.
This can have quite a variable position and it is important
to identify during carpal tunnel decompression.
Before entering the carpal tunnel, the medial nerve over-
lies the pronator quadratus muscle. This muscle is easily
recognized because its fibres run in a different orientation
to the other flexor muscles, i.e. transversely rather than
longitudinally. It is a short fleshy muscle and is one of the
c landmarks used to obtain measurements of the medial
Figure 10.25 Probe position and anatomy of the carpal tunnel. nerve. A transverse section of the nerve is compared with
the transverse section within the carpal tunnel and the dif-
ferent cross section area is used to assist with a diagnosis of
carpal tunnel syndrome.
The ulnar nerve runs through Guyon’s canal, its own
(four superficial and four profundus) and the ninth tendon tunnel on the ulnar aspect of the wrist. The floor of this
is flexor pollicis longus (Fig. 10.26). The floor of the tunnel tunnel is formed by the flexor retinaculum itself, which
is made up of extrinsic ligaments, principally the volar radio- inserts below the level of the opening of the pisiform–
lunotriquetral ligament and joint capsule. triquetral joint. The roof is an extension of the flexor reti-
The median nerve can be followed from its location naculum that passes between it and the adjacent pisiform
between the muscle bellies of the superficial and deep bone. The tunnel contains the ulnar nerve, the ulnar artery
flexors in the distal forearm. With practice, the nerve can and several associated veins. It may also contain some muscle
be differentiated from the tendons within the carpal tunnel, slips arising from the adjacent abductor digiti minimi. The
but it is useful to begin in the distal forearm where there pisiform–triquetral joint lies on the ulnar aspect of the
are no tendons. Placing the probe in an axial position over- canal. Synovial cysts arising from this joint may extend into
lying the midforearm will easily locate the nerve as it is the canal and compress the nerve.
surrounded by fleshy muscles and easy to recognize in this Outside the carpal tunnel, the FCU tendon is readily
location. As the probe is swept distally, the nerve will begin found due to its superficial location on the volar ulnar
to migrate around the radial aspect of flexor digitorum aspect of the distal forearm. It is a large tendon and is
superficialis and come to lie in a superficial location within identified by tracing it to its insertion into the pisiform
a
a
EDC3
FDS EDC2
ED
Lumbricals FDP Lumbricals
MC DI
MC DI
Interosseus
2MC Interosseus
3MC A
LM PI P
b P ML
PI A
b
Figure 10.27 Volar axial anatomy of the palm. The paired superficial
and deep flexor tendons provide a good landmark. The lumbrical Figure 10.28 Axial anatomy from the dorsal aspect.
muscles are adjacent and neurovascular bundles overlie these.
(Fig. 10.25). Beyond the pisiform, its distal insertions are the deep layer (Figs 10.12 and 10.28). These are four paired
ligamentous, with slips into the hook of the hamate and sets of muscles with one pair in each of the interspaces. All
base of the fifth metacarpal. The latter two insertions are are bipennate, with one slip arising from each of the adja-
sometimes termed the ‘pisohamate ligament’ and the ‘piso- cent metacarpals. They insert in the proximal phalanges
metacarpal ligament’. FCU is one of the more easily pal- and also contribute to the extensor expansion. The second
pated tendons; a useful landmark is the ulnar artery which and third group insert into the proximal phalanx of the
lies just on its radial aspect. middle finger. The first and fourth group insert into the
base of the index and ring finger respectively. There is no
POSITION 6: THE PALM CENTRAL AREA interosseous insertion into the first or fifth rays.
The palmar interossei are superficial to this. These are
IMAGING GOALS three unipennate muscles that arise between the finger
1. Locate the lumbricals and interossei. metacarpals. Some anatomists regard the flexor pollicis
2. Understand the components of each layer. brevis (FPB) as the fourth palmar interosseous (Fig. 10.30).
There are additional muscles each for the thumb and
TECHNIQUE little finger forming the thenar and hypothenar eminence.
The axial anatomy of the palm is complex, comprising many
small muscles arranged in layers. Collectively they are known POSITION 7: THENAR AND HYPOTHENAR
as the intrinsic muscles of the hand. Recognizing each indi- EMINENCES
vidual one and remembering their names is difficult and
fortunately rarely necessary in practice. On the volar side IMAGING GOALS
(Fig. 10.27), the superficial and profundus tendons are 1. Identify muscles of thenar eminence.
easily recognized landmarks overlying the metacarpals. The 2. Identify muscles of hypothenar eminence.
lumbrical muscles arise from the four finger flexor tendons
and insert onto the extensor expansion, a fibrous layer that TECHNIQUE
holds the extensor tendons in position. They thus have no Four muscles make up the thenar eminence. The most
bony attachment. There are four lumbricals, one for each superficial is the abductor pollicis brevis (APB). This is
of the four profundus tendons. The lumbrical muscles for located just under the skin and contributes the bulk of the
the index and middle fingers are unipennate; the other two thenar eminence (Fig. 10.29). It arises from the flexor reti-
are bipennate. The third lumbrical is, therefore, a bipen- naculum and scaphoid and inserts on the lateral aspect of
nate muscle, with one component each from the flexor the base of the proximal phalanx. Immediately deep to this
tendon of the middle and ring finger. They are supplied by are the FPB medially and the opponens pollicis laterally.
the median (radial two) and ulnar (ulnar two) nerves. Adja- Opponens pollicis also arises from the flexor retinaculum
cent to the tendons and superficial to the lumbricals are the and inserts on the radial aspect of the first metacarpal. As
interdigital neurovascular bundles. the name describes, it is important in thumb opposition by
Between the metacarpals, two layers of muscle are visible. contributing flexion at the first carpometacarpal joint
These are the dorsal and palmar interossei. The dorsal are (CMCJ). FPB has two components, the largest superficial
a a
APB
DM
FDM nens
OP Oppo
1mc
Lumbrical ADM
FPB
Deep
FPL
FPB 5mc
A A
LM ML
AP P b P
b
Figure 10.30 Axial anatomy of the hypothenar eminence.
Figure 10.29 Axial anatomy of the thenar eminence.
and the smallest deep to the easily identified flexor pollicis capitate and bases of second and third metacarpals and a
longus tendon. The deep component is also sometimes transverse head that arises from the volar surface of the
referred to as the first interosseous. third metacarpal.
The flexor pollicis longus tendon itself rests on another The principal bulk of the hypothenar eminence is made
important muscle, the adductor pollicis longus, which forms up of the flexor digiti minimi. The opponens digiti minimi
most of the muscle bulk superficial to the metacarpals. It lies deep to this and on the lateral aspect of abductor digiti
comprises two heads, an oblique head arising from the minimi (Fig. 10.30).
Disorders of the Wrist: Radial
Catherine L. McCarthy
11
CHAPTER OUTLINE
TENDON DISEASE Scapholunate Dissociation

De Quervain’s Disease Occult Scaphoid Fracture
Proximal Intersection Syndrome NEURAL ENTRAPMENT
Distal Intersection Syndrome Wartenberg’s Disease
Extensor Pollicis Longus Tenosynovitis SOFT TISSUE MASSES
Flexor Carpi Radialis Tenosynovitis Dorsal Occult Ganglion
TRAUMATIC CONDITIONS Carpal Boss
Fluid and synovial thickening distend the tendon sheath,

TENDON DISEASE
which is best seen surrounding the tendons distal to the
retinaculum (Figs 11.1 and 11.2). Dynamic scanning shows
DE QUERVAIN’S DISEASE
irregular tendon gliding beneath the retinaculum during
De Quervain’s disease is an overuse tenosynovitis of the thumb extension.
abductor pollicis longus and extensor pollicis brevis tendons
in the first extensor compartment (EC). Low-grade chronic
Practice Tip
microtrauma is thought to underlie the condition, leading
to localized thickening of the extensor retinaculum at the Care should be taken not to confuse the extensor
level of the radial styloid. This results in narrowing of retinaculum, which is noncompressible and located at the
the first extensor compartment with impingement and level of the radial styloid, with fluid within the tendon sheath,
subsequent inflammation of the abductor pollicis longus which is compressible and best seen distal to the radius.
and extensor pollicis brevis tendons. De Quervain’s is most
common in the 30–50 year age group in patients who
perform repetitive thumb movements, such as pianists and Although de Quervain’s tenosynovitis can be associated
typists. Baby wrist affects new mothers as a result of repeated with excess fluid within the sheath, some, if not many,
wrist flexion and extension with abduction of the thumb patients present with a more sclerosing type, with less peri-
against resistance that occurs while holding the baby’s head. tendinous fluid and more tenosynovial thickening. Thicken-
Patients present with pain around the radial styloid with ing of the retinaculum dominates the ultrasound picture.
thumb movement, which typically increases while grasping
heavy objects.
Key Point
Scanning in the transverse plane gives a good view of the
extensor retinaculum, tendon sheath contents and pres- Thickening of the retinaculum of extensor compartment 1
ence of internal septa. A thick layer of gel may help image should be sought in all patients presenting with radial
the contours of the wrist and avoid excessive transducer side pain.
pressure, which can displace the synovial fluid.
The abductor pollicis longus and extensor pollicis brevis
tendons are typically swollen and hypoechoic owing to oede- Increased vascularity of the tendon sheath synovium and
matous change. They may be difficult to distinguish from retinaculum is present in the acute phase due to inflamma-
one another as they become compressed in the confined tory hyperaemia (Fig. 11.3).
space of the osteofibrous tunnel. The extensor retinaculum A vertical septum splitting the first extensor compartment
which is identified over the radial styloid can be thickened into two subtunnels for each of the tendons is encountered
and hypoechoic, which may be an indication for release. more frequently in patients with de Quervain’s disease and
113
a
a
A
ML
P
Figure 11.2 De Quervain’s tenosynovitis. Transverse image shows

b anechoic compressible fluid (arrow) and echogenic peripheral syno-
Figure 11.1 (A) The extensor retinaculum overlies the six extensor vial hypertrophy (arrowheads) distending the abductor pollicis longus
tendon compartments. The part overlying the first extensor compart- and the extensor pollicis brevis tendon sheath.
ment (red) becomes thickened in de Quervains disease. (B) Tendon
sheath fluid and retinacular oedema in extensor compartment one.
between the extensor carpi radialis brevis and longus
tendons with the myotendinous junctions of abductor pol-
is thought to predispose to local tendon friction. Accessory licis longus and extensor pollicis brevis. This condition is
vertical septa appear as thin hypoechoic linear bands typically encountered in occupational or sports activities
between the tendons (Fig. 11.3). The inflammatory process involving repetitive wrist flexion and extension, such as
may selectively involve one tendon when a septum is present. rowing or weightlifting. Patients present with pain and swell-
Identification of a septum is clinically significant as it forms ing along the dorsal radial aspect of the distal forearm. Fluid
a barrier to diffusion of injected steroids and requires and synovitis are present in the tendon sheath of extensor
decompression of both tunnels at surgery. A septum split- carpi radialis brevis and longus at the level at which they are
ting the first extensor compartment and more sclerosing crossed by the musculotendinous junction of abductor pol-
tenosynovitis may be indicative of a more painful injection licis longus and extensor pollicis brevis (Figs 11.4 and 11.5).
owing to limited diffusion of injected steroid and local The area of intersection is usually approximately 4 cm
anaesthetic. proximal to Lister’s tubercle. Clinical crepitus during the
The clinical diagnosis of de Quervain’s disease is usually US examination is a useful sign.
straightforward. The value of ultrasound is to confirm the
diagnosis, exclude underlying tendinosis or tendon tear,
Practice Tip
assess the retinaculum, detect whether septa are present
within the first extensor compartment and guide steroid Tenosynovitis (in intersection syndrome) may not, however,
injection into the tendon sheath or retinacular division in be limited to the site of crossover but can extend distally
resistant cases. beyond the radiocarpal joint.
PROXIMAL INTERSECTION SYNDROME

There is loss of the normal echogenic fat cleavage plane
Proximal intersection syndrome, also known as ‘oarsman’s between the first and second extensor tendon groups. A
forearm’ or ‘crossover syndrome’, results from friction true synovial fluid-filled bursa is a rare finding. The clinical
CHAPTER 11 — Disorders of the Wrist: Radial 115
Figure 11.3 De Quervain’s tenosynovitis. Transverse image with

power Doppler demonstrates increased vascularity of the abductor
pollicis longus and the extensor pollicis brevis tendon sheath
synovium. A paucity of peritendinous fluid is consistent with scleros-
ing tenosynovitis. A thin vertical hypoechoic septum (arrow) is present
between the tendons.
b
Figure 11.4 Proximal intersection syndrome. Transverse image

symptoms may mimic those of scaphoid fracture, osteoar- depicts fluid in the tendon sheaths (arrows) at the crossover of the
thritis of the first carpometacarpal joint, ganglion cyst or de abductor pollicis longus and the extensor carpi radialis tendons.
Quervain’s tenosynovitis.
occasionally assigned to friction between the radial nerve

DISTAL INTERSECTION SYNDROME
and the first extensor compartment as it crosses it (Warten-
Distal intersection syndrome occurs at the crossover between berg syndrome).
the extensor carpi radialis brevis and longus tendons (second
compartment) and the extensor pollicis longus tendon
EXTENSOR POLLICIS LONGUS TENOSYNOVITIS
(third compartment), just distal to Lister’s tubercle. It is
usually not the result of overuse. The deep surface of the The extensor pollicis longus tendon runs in the third exten-
extensor carpi radialis brevis and longus tendons is typically sor compartment along the medial aspect of Lister’s tuber-
impinged by bony spurs due to osteoarthritis, scapholunate cle. Mechanical friction against Lister’s tubercle results
advanced collapse (SLAC) wrist or Colles’ fracture that in tenosynovitis that presents with pain localized around
result in tenosynovitis of the second extensor compartment. the tubercle and, less commonly, with local crepitus during
The biomechanical pulley effect exerted by Lister’s tubercle thumb movement. Restricted space beneath the retinacu-
on the extensor pollicis longus tendon as it leaves the third lum of the third compartment limits distension of the exten-
compartment and crosses over the extensor carpi radialis sor pollicis longus tendon sheath at the level of Lister’s
tendons, together with a likely constricting effect of the tubercle, except in cases of a very large effusion. More com-
retinaculum of the third compartment, puts the extensor monly, tendon sheath fluid accumulates just proximal to
pollicis longus tendon at risk. Ultrasound demonstrates Lister’s tubercle and distally after the tendon has crossed
a variable combination of tendinosis and tenosynovitis of extensor carpi radialis longus (Fig. 11.6).
the second and third extensor compartments centred at Extensor pollicis longus tenosynovitis is seen with distal
the point of intersection and underlying bony spurs imping- radial fractures and impingement by orthopaedic hardware,
ing on the tendons. A third intersection syndrome is which may progress to tendon tears if not treated. An intact
a a
b
b
Figure 11.7 Extensor pollicis longus tendon tear. Longitudinal
Figure 11.5 Proximal intersection syndrome. Longitudinal image image shows an empty extensor pollicis longus tendon sheath
with power Doppler demonstrates tenosynovitis with increased vas- (arrowheads) following rupture of the tendon from impingement on a
cularity at the intersection of the abductor pollicis longus and exten- screw tip (arrow) that has penetrated the distal dorsal radial cortex.
sor carpi radialis tendons, approximately 4 cm proximal to Lister’s
tubercle.
impinging on the tendon. As bicortical screws are often

used, some involvement of the posterior cortex is desired.
It is easy with softened bone for the screw to penetrate
further into the soft tissues and impinge the tendons.
Key Point
Ultrasound is an ideal examination in patients with surgical

fixation hardware as MR imaging may preclude visualization
a of important anatomical structures due to metal artifact.
Also, standard radiographs may not adequately visualize

screw lengths due to the complex shape of the dorsal distal
radius. On ultrasound, a screw typically appears as a hyper-
echoic structure made up by multiple oblique parallel
hyperechoic lines that correspond to the thread of the screw
(Fig. 11.7). Dynamic scanning with finger movement will
show impingement of the tendons against the protruding
b screws and pain with transducer pressure on the protruding
Figure 11.6 Extensor pollicis longus tenosynovitis. Transverse screw tip helps confirm the diagnosis.
image shows fluid and synovial thickening (arrows) distending the Tears of the extensor pollicis longus tendon also com-
extensor pollicis longus tendon sheath just proximal to Lister’s tuber- monly result from rheumatoid tenosynovitis, largely due to
cle. The extensor carpi radialis longus and extensor carpi radialis friction against Lister’s tubercle.
brevis tendons in the second extensor compartment are normal.
FLEXOR CARPI RADIALIS TENOSYNOVITIS

extensor retinaculum causes increased pressure inside the The flexor carpi radialis tendon is held in a division of the
osteofibrous tunnel that, together with a vascular watershed flexor retinaculum and courses over the volar surface of the
in the extensor pollicis longus tendon at the Lister’s tuber- scaphoid and trapezium in a separate fibroosseous tunnel.
cle level, increases the risk of tendon rupture. In extensor Flexor carpi radialis tenosynovitis is most frequently seen in
pollicis longus tenosynovitis or tears that occur following middle-aged women who present with a painful swelling
radial volar plate fixation, ultrasound is useful to show over the volar radial aspect of the wrist. Tingling of the skin
the screw tips perforating the dorsal radial cortex and over the thenar eminence is also described due to the close
a
a
Figure 11.9 Dorsal scapholunate ligament. Transverse image of a

b normal dorsal band of the scapholunate ligament, which is seen as
a triangular echogenic fibrillar structure (between arrows) between the
Figure 11.8 Flexor carpi radialis tenosynovitis. Longitudinal image echogenic cortex of the scaphoid and lunate.
shows fluid (*) distending the flexor carpi radialis tendon sheath with
an osteophyte (arrow) arising from the scaphoid encroaching on the
tendon.
thick dorsal and volar bands with a thin, structurally weaker,

central portion. The dorsal scapholunate ligament appears
proximity of this tendon with the palmar branch of the as a triangular echogenic fibrillar structure that bridges the
median nerve. echogenic cortex of the scaphoid and lunate beneath exten-
sor digitorum tendons (Fig. 11.9).
Key Point
The main cause of flexor carpi radialis tenosynovitis is Practice Tip

osteoarthritis of the scaphotrapezium–trapezoid joints with
The dorsal scapholunate ligament is best imaged in the
volar osteophytes impinging on the dorsal aspect of the
transverse plane with the forearm in the prone position and
tendon during wrist flexion and extension.
slight wrist flexion. The dorsal scapholunate articulation is
characterized by a V shape between the scaphoid and lunate.
Ultrasound is valuable to confirm a tendon sheath synovial
effusion and to detect associated tendinosis of the flexor
carpi radialis tendon, which appears swollen and heteroge- To locate the dorsal scapholunate ligament, the dorsal
neous and may contain intratendinous splits, particularly radial tubercle (Lister’s tubercle) is a useful initial land-
along its dorsal surface. Adjacent osteophytes may be identi- mark. The transducer is advanced distally so the proximal
fied encroaching on the tendon (Fig. 11.8). Thickening of pole of the scaphoid becomes visible just distal to the radio-
the flexor retinaculum and peritendinous soft tissues may carpal joint space. The transducer is then moved toward the
be present. Clinical symptoms often mimic a volar ganglion, ulnar aspect to visualize the adjacent hyperechoic cortex of
which can be excluded at ultrasound. the lunate bone.
High-resolution ultrasound correctly identified the dorsal
scapholunate ligament in 100% of normal subjects. In a
TRAUMATIC CONDITIONS
second study, the dorsal scapholunate ligament was com-
pletely visible in 97% and partially visible in 3% of normal
SCAPHOLUNATE DISSOCIATION
subjects. These findings strongly support that detection of
The scapholunate ligament is an essential stabilizer of the a normal dorsal scapholunate ligament at ultrasound essen-
proximal carpal row during wrist motion. The ligament has tially negates the presence of scapholunate dissociation.
Figure 11.10 Scapholunate ligament rupture. Transverse image

shows hypoechogenicity in the expected location of the scapholunate
ligament (large arrow) with no normal echogenic ligament fibres
between the scaphoid and lunate. Comparison can be made to the
normal echogenic dorsal lunotriquetal ligament (small arrows)
between the lunate and triquetrum. The more superficial hyperechoic
fibrillar band is the dorsal radiotriquetral ligament (arrowheads).
Recent studies have also shown promising results in the b

detection of dorsal scapholunate ligament tears with ultra-
sound. Dorsal scapholunate ligament tears were accurately Figure 11.11 Scapholunate ligament rupture. Transverse image
detected at ultrasound in 94% of patients with MR arthro- shows complete absence of the scapholunate ligament fibres
graphic correlation, in 100% of patients with tricompart- between the scaphoid and lunate with adjacent fluid and associated
small linear echogenic cortical avulsion fracture (arrow).
mental arthrography as the gold standard, and in 100% of
cadavers (n = 4) with MR arthrography and anatomical
sectioning as correlation.
Scapholunate ligament rupture is seen as abnormal (range 2.3–6.3 mm) in the neutral position. Comparison
hypoechogenicity in the expected location of the ligament, with the contralateral wrist is valuable to appreciate subtle
with disruption or absence of normal continuous hyper differences.
echoic ligament fibres between the scaphoid and the lunate
bones (Figs 11.10 and 11.11). Adjacent fluid may be seen
Key Point
extending into the region of the torn ligament or an associ-
ated ganglion may be present. Dynamic scanning with ulnar deviation may show a definite
increase in the scapholunate joint width, which is useful
Practice Tip to support the diagnosis of a complete scapholunate
ligament tear.
Once the anatomic location of the scapholunate ligament is
identified, the transducer should be angulated perpendicular
to the ligament to eliminate anisotropy as an artifactual When the dorsal scapholunate ligament is hypoechoic or
decrease in echogenicity can be misinterpreted as a tear. absent, the dorsal radiotriquetral ligament, if intact, appears
on transverse views of the scapholunate joint space as a
more superficial hyperechoic fibrillar structure. Care must
Although accurate measurement of the scapholunate inter- be taken not to mistake the dorsal radiotriquetral ligament
val is limited by a lack of reproducible anatomical land- for the scapholunate ligament. The dorsal radiotriquetral
marks for caliper positioning, a clear increase in the ligament is superficial to the scaphoid, lunate and scapholu-
interosseous distance with ulnar deviation of the wrist sup- nate ligament and courses obliquely from the radius to the
ports the diagnosis of a scapholunate ligament tear (Fig. triquetrum (Fig. 11.10). Partial visualization and irregularity
11.12). The mean dorsal scapholunate interval is 4.2 mm of the ligamentous fibres indicate a partial tear or fraying.
a c
b d
Figure 11.12 Scapholunate ligament rupture. Transverse images in (A, B) the neutral position and (C, D) with ulnar deviation show absence
of the ligament and widening of scapholunate distance (arrows) with ulnar deviation, which is an indirect sign of a scapholunate ligament tear.
Because of its deep location, the thinner volar scapholu- tubercle. Ulnar deviation elongates the scaphoid and affords
nate ligament is not as clearly visible and may be difficult to the best view of the scaphoid waist.
distinguish from the palmar radiocarpal ligament. The volar The preferred method for imaging occult scaphoid frac-
scapholunate ligament was completely visible in 81% and tures is MRI; however, the bony cortices should be carefully
partially visible in 12% of normal subjects in one study. reviewed during the ultrasound examination in patients
with posttraumatic radial wrist pain as small cortical irregu-
larities can suggest the diagnosis of an occult fracture.
OCCULT SCAPHOID FRACTURE
Ultrasound findings of a scaphoid fracture include focal
The scaphoid is the most common site of occult wrist frac- discontinuity and a step off deformity of the echogenic bony
tures, with negative initial radiographs in up to 20–25% of cortex (Fig. 11.13). Some authors propose that an echo-
cases. Delayed diagnosis has a high complication rate, such genic line parallel to the scaphoid cortex is indicative of
as avascular necrosis of the proximal scaphoid pole, non- periosteal elevation with a subperiosteal fluid collection. A
union and secondary osteoarthritis. The cortex of the scaph- normal scaphoid tubercle and radioscaphoid or scaphotra-
oid is seen at ultrasound as a thin continuous echogenic peziotrapezoid osteoarthritis with osteophyte formation,
line, except for the radial margin of the scaphoid waist, seen as cortical irregularity on ultrasound, should not be
where a small protuberance corresponding to the scaphoid confused with a fracture. Superficial displacement of the
tubercle may appear irregular. The scaphoid cortex can radial artery due to posttraumatic oedema and haematoma
be evaluated by high-resolution ultrasound over the volar, is an indirect sign of an occult scaphoid fracture. This can
lateral and dorsal aspects of the scaphoid. Imaging is best be assessed by an increase in the distance between the scaph-
performed in the longitudinal plane with the transducer oid cortex and the radial artery using a lateral approach.
aligned along the long axis of the scaphoid. Longitudinal These soft tissue changes may also occur after a wrist sprain,
views over the radial margin of the waist of the scaphoid ligamentous injury or with inflammation, and therefore
demonstrate a small ridge corresponding to the scaphoid lack specificity. A radiocarpal or scaphotrapezium–trapezoid
irritation and compression due to its anatomical location.

Wartenberg’s disease may be secondary to trauma, hand-
cuffs, a tight watchstrap or iatrogenic causes such as intra-
venous infusion or retinacular release for de Quervain’s
tenosynovitis. Nerve entrapment between the brachioradia-
lis and extensor carpi radialis longus tendons may also occur
during forearm pronation with simultaneous flexion and
ulnar deviation of the hand. The increased tension on the
nerve causes ischaemia, local inflammation and pain over
the dorsal radial wrist, which radiates distally to the dorsum
of the hand and thumb. Ultrasound is valuable to exclude
de Quervain’s tenosynovitis and trapeziometacarpal joint
a arthritis. High-resolution ultrasound can depict subtle
abnormalities of the nerve, such as swelling, hypoecho-
genicity and loss of the fascicular echostructure. Occasion-
ally scar tissue encasing the nerve may be seen following
previous surgery or a stump neuroma as the result of pen-
etrating trauma. Corticosteroid injection at the site of ten-
derness along the course of the nerve is often an effective
treatment.
SOFT TISSUE MASSES
DORSAL OCCULT GANGLION

b The dorsal occult ganglion is a small painful ganglion that
usually develops within the joint capsule, at the level of the
Figure 11.13 Scaphoid fracture. Longitudinal image shows inter-
ruption and a step-off deformity of the echogenic scaphoid cortex
scapholunate ligament on the dorsal aspect of the wrist.
(between arrows). An adjacent hypoechoic noncompressible haema- These small ganglia cannot be palpated at clinical examina-
toma (arrowheads) slightly displaces the abductor pollicis longus tion and ultrasound is thus valuable to make the diagnosis.
tendon. Mild peripheral vascularity is in keeping with associated post- Pain results from pressure exerted by the ganglion within
traumatic synovitis. the capsule or by direct compression of the terminal sensory
branches of the posterior interosseous nerve, which run
close to the scapholunate ligament. Painful limitation of
dorsal and palmar flexion is often present. Ultrasound is
joint effusion or haemarthrosis may be present. Movement valuable to detect a small hypoechoic lesion located just
at the fracture site has been demonstrated with dynamic dorsal to the scapholunate ligament (Fig. 11.14).
ultrasound and may be of use to assess stability of the frac-
ture ends.
Using cortical interruption along with a radiocarpal or Practice Tip
scaphotrapezium–trapezoid joint effusion as indicative of a
fracture, ultrasound had 92% sensitivity in diagnosing a Detection of a small dorsal occult ganglion may be increased
scaphoid fracture and was 100% sensitive in detecting by examining the wrist in a hyperflexed position.
a proximal or waist fracture, which has a higher potential
risk of complications. Based on cortical disruption, ultra-
sound had 100% sensitivity, 98% specificity and 98% accu-
racy for the detection of fractures of the waist of the Local transducer pressure over the ganglion correlates with
scaphoid. Based on cortical disruption and/or periosteal patient symptoms.
elevation, Herneth et al. showed an 87% accuracy of ultra- Surgical and pathological studies have demonstrated
sound in detecting occult fractures compared with 73% for microcysts in the posterior capsule of the scapholunate
scaphoid radiographic views. joint. These can be responsible for local recurrence if wide
excision of the dorsal capsule is not performed during surgi-
cal removal.
NEURAL ENTRAPMENT
WARTENBERG’S DISEASE CARPAL BOSS

Wartenberg’s disease is a neuropathy affecting the superfi- The carpal boss is a relatively common bony anomaly, an
cial sensory branch of the radial nerve. This terminal branch accessory ossicle that may be fused or unfused and lies at
pierces the fascia between the brachioradialis and extensor the base of the second or third metacarpal dorsally. It is
carpi radialis longus tendons, traverses the first extensor usually not a cause of symptoms but patients may present
compartment and passes into the subcutaneous tissues over when they discover a ‘lump’. Clinically the hard nodule may
the anatomical snuffbox. It is highly vulnerable to trauma, be confused with a ganglion cyst.
Choi SJ, Ahn JH, Lee YJ, et al. de Quervain disease: US identification
of anatomic variations in the first extensor compartment with an
emphasis on subcompartmentalization. Radiology 2011;260(2):
480–6.
Dao KD, Solomon DJ, Shin AY, Puckett ML. The efficacy of ultrasound
in the evaluation of dynamic scapholunate ligamentous instability.
J Bone Joint Surg Am 2004;86–A(7):1473–8.
Dias JJ, Hui AC, Lamont AC. Real time ultrasonography in the assess-
ment of movement at the site of scaphoid fracture non-union. J Hand
Surg Br 1994;19(4):498–504.
Finlay K, Lee R, Friedman L. Ultrasound of intrinsic wrist ligament
and triangular fibrocartilage injuries. Skeletal Radiol 2004;33(2):
85–90.
Fusetti C, Poletti PA, Pradel PH, et al. Diagnosis of occult scaphoid
fracture with high-spatial-resolution sonography: a prospective blind
study. J Trauma 2005;59(3):677–81.
Griffith JF, Chan DP, Ho PC, et al. Sonography of the normal scapholu-
nate ligament and scapholunate joint space. J Clin Ultrasound 2001;
a 29(4):223–9.
Hauger O, Bonnefoy O, Moinard M, et al. Occult fractures of the waist
of the scaphoid: early diagnosis by high spatial resolution sonogra-
phy. AJR 2002;178(5):1239–45.
Herneth AM, Siegmeth A, Bader TR, et al. Scaphoid fractures: evalua-
tion with high spatial resolution ultrasound initial results. Radiology
2001;220(1):231–5.
Hodgkinson DW, Nicholson DA, Stewart G, et al. Scaphoid fracture: a
new method of assessment. Clin Radiol 1993;48;398–401.
Jacobson JA, Oh E, Propeck T, et al. Sonography of the scapholunate
ligament in four cadaveric wrists: correlation with MR arthrography
and anatomy. AJR 2002;179(2):523–7.
Kwon BC, Choi SJ, Koh SH, et al. Sonographic identification of the
intracompartmental septum in de Quervain’s disease. Clin Orthop
Relat Res 2010;468(8):2129–34.
Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection
syndrome. Skeletal Radiol 2009;38(2):157–63.
Mahakkanukrauh P, Mahakkanukrauh C. Incidence of a septum in the
first dorsal compartment and its effects on therapy of de Quervain’s
b disease. Clin Anat 2000;13(3):195–8.
Nagaoka M, Matsuzaki H, Suzuki T. Ultrasonographic examination of
Figure 11.14 Dorsal occult ganglion. Transverse image reveals a
de Quervain’s disease. J Orthop Sci 2000;5(2):96–9.
well-defined anechoic ganglion (between calipers) with through trans- Parellada AJ, Gopez AG, Morrison WB, et al. Distal intersection teno-
mission adjacent to the dorsal scapholunate ligament. synovitis of the wrist: a lesser known extensor tendinopathy with
characteristic MR imaging features. Skeletal Radiol 2007;36(3):
203–8.
Parellada AJ, Morrison WB, Reiter SB, et al. Flexor carpi radialis tendi-
FURTHER READING nopathy: spectrum of imaging findings and association with triscaphe
Bianchi S, van Aaken J, Glauser T, et al. Screw impingement on the arthritis. Skeletal Radiol 2006;35(8):572–8.
extensor tendons in distal radius fractures treated by volar plating: Platon A, Poletti PA, Van Aaken J. Occult fractures of the scaphoid: the
Sonographic appearance. AJR 2008;191(5):199–203. role of ultrasonography in the emergency department. Skeletal
Blam O, Bindra R, Middleton W, Gelberman R. The occult dorsal Radiol 2011;40(7):869–75.
carpal ganglion: Usefulness of MRI and US in diagnosis. Am J Orthop Taljanovic MS, Goldberg MR, Sheppard JE, Rogers LF. US of the intrin-
1998;27(2):107–10. sic and extrinsic wrist ligaments and triangular fibrocartilage
Boutry N, Lapegue F, Masi L, et al. Ultrasonographic evaluation of complex: Normal anatomy and imaging technique. Radiographics
normal extrinsic and intrinsic carpal ligaments: preliminary experi- 2011;31(1):e44.
ence. Skeletal Radiol 2005;34(9):513–21. Taljanovic MS, Sheppard JE, Jones MD, et al. Sonography and sono
Cardinal E, Buckwalter KA, Braunstein EM, Mih AD. Occult dorsal arthrography of the scapholunate and lunotriquetral ligaments
carpal ganglion: Comparison of US and MR imaging. Radiology and triangular fibrocartilage disk. J Ultrasound Med 2008;27(2):
1994;193(1):259–62. 179–91.
12 Disorders of the Wrist:
Ulnar Side
CHAPTER OUTLINE
TENDON DISEASE NEURAL ENTRAPMENT

Extensor Carpi Ulnaris Instability Guyon’s Canal Syndrome
ECU Tenosynovitis TRAUMATIC CONDITIONS
Tenosynovitis of Other Extensor Tendon Triangular Fibrocartilage Tears
Compartments Extrinsic Ligament Injury
Flexor Carpi Ulnaris Tendinopathy Occult Triquetral Fractures
TENDON DISEASE and distal radioulnar joint disease. Pannus disrupts the reti-
naculum and the ECU tendon tends to migrate to the volar
EXTENSOR CARPI ULNARIS INSTABILITY surface of the ulna and behaves like a wrist flexor rather
than an extensor, causing dislocation of the distal ulna rela-
The extensor carpi ulnaris (ECU) tendon passes through tive to the radius.
the sixth extensor compartment, a fibroosseous tunnel Ultrasound is ideal to demonstrate the status of the
over the distal 2 cm of the ulna. tendon and its position relative to the ulnar groove at rest
and during stressing. Some displacement is to be expected
in asymptomatic subjects. In a study using a percentage of
Key Point the width of the ulnar groove, the ECU tendon was seen to
displace by up to 40% beyond the volar lip of the ulnar
The ECU subsheath is a retinaculum, separate from the groove with wrist flexion. In a second study using a percent-
extensor retinaculum, which keeps the ECU tendon in the age of displacement relative to the apex of the ulnar border
correct position during rotation, flexion and extension of of the ulnar groove, the ECU tendon was observed to dis-
the wrist.
place by up to 50% (or 5 mm) volar to the ulnar border of
the groove with forearm supination or wrist ulnar deviation,
and by up to 45% with wrist flexion.
The subsheath may be normally visualized at ultrasound In symptomatic subjects, the ECU tendon may be seen to
as a thin curvilinear hypoechoic structure overlying the sublux along the ulnar border of the ulnar groove with a
tendon. flattened appearance as a result of tensile forces applied on
Tears of the subsheath are the result of acute trauma, it. In more severe cases, the tendon intermittently dislocates
chronic overuse or inflammatory changes of the ECU over the ulnar border and out of the groove.
tendon sheath, such as in rheumatoid arthritis. ECU insta-
bility typically occurs in professional tennis and golf players.
Repeated sudden forceful pronation of the forearm from a Practice Tip
supinated position, such as during a tennis serve, results in
sudden contraction of the ECU tendon and stripping of the Dynamic scanning of ECU in short axis is used to
demonstrate volar subluxation of the tendon with forearm
ventral attachment of the retinaculum from the ulna. This
supination and wrist flexion (Fig. 12.1).
results in anterior (volar) subluxation or dislocation of the
ECU tendon. Patients typically present with painful snap-
ping over the ulnar aspect of the wrist with forearm rotation.
ECU instability is also observed in patients with long- Permanent dislocation of the tendon is uncommon and
standing rheumatoid arthritis causing ECU tenosynovitis is best seen in the transverse plane over the posteromedial
122
CHAPTER 12 — Disorders of the Wrist: Ulnar Side 123
a c
b d
Figure 12.1 ECU instability. Transverse images show (A, B) the ECU normally situated in the ulnar groove (arrowheads) with the wrist in the
neutral position and (C, D) progressive flattening and volar dislocation of the ECU tendon out of the ulnar groove (arrowheads) with forearm
supination and wrist flexion.
ulna. The ulnar groove is empty and the retinaculum is

usually attenuated and irregular.
ECU TENOSYNOVITIS
ECU tenosynovitis is mostly due to mechanical friction of
the tendon against the ulna, secondary to instability. Patients
present with localized pain over the dorsal medial aspect of
the distal ulna and occasionally a snapping sensation if
tendon subluxation is present. Ultrasound is valuable to
identify a tendon sheath effusion and synovial hypertrophy,
associated tendinosis and intratendinous splits (Fig. 12.2),
as well as tendon subluxation (Figs 12.3 and 12.4). a
TENOSYNOVITIS OF OTHER EXTENSOR

TENDON COMPARTMENTS
All of the extensor compartments (ECs) may be affected by
tenosynovitis and tendinopathy, although EC4 and EC5 are
least common. EC4 is normally surrounded by a thick reti-
naculum, much thicker than the other compartments. This
should not be misinterpreted as tenosynovitis. True tenosy-
novitis will fill the compartment unevenly (Fig. 12.5) and
may be accompanied by increased Doppler activity in many
cases (Fig. 12.6). Furthermore, intrasheath synovitis will
result in some separation of the tendons. b
Figure 12.2 There is a longitudinal split in the ECU tendon. A little

FLEXOR CARPI ULNARIS TENDINOPATHY fluid is present in the tendon sheath.
Apart from palmaris longus, flexor carpi ulnaris (FCU) is

the only wrist tendon without a synovial sheath. The most
Figure 12.4 ECU tenosynovitis. Longitudinal image demonstrates

ECU tendon sheath effusion and synovial hypertrophy
(arrowheads).
b
Subsheath
ECU tendon
Ulna
Figure 12.3 ECU tenosynovitis and instability. Transverse image

demonstrates volar subluxation of the ECU tendon over the ulnar
border (arrow) of the ulnar groove. Mechanical friction of the tendon
against the ulna results in ECU tenosynovitis with a tendon sheath
effusion and synovial hypertrophy (arrowheads).
common disorder affecting FCU is calcific tendinitis and

is related to repetitive activities such as typing. This con
dition is usually seen in young to middle-aged women
who present with acute pain over the volar ulnar aspect b
of the wrist, just proximal to the pisiform. Symptoms are
related to rupture of intratendinous calcified deposits into Figure 12.5 Sagittal image of dorsal aspect of wrist. Thickened
the adjacent tissues with secondary acute inflammation. synovium and synovial exudate distend the common extensor sheath.
The extensor tendon visualized appears normal.
Ultrasound demonstrates hyperechoic calcified foci in a
swollen heterogeneous tendon. Calcified deposits may also
be seen in the inflamed peritendinous soft tissues, between
the tendon and the volar aspect of the pisiform. In acute
phases, the calcific deposits may be semiliquid and Doppler
Figure 12.6 Axial image of dorsal aspect of wrist. There is extensive Figure 12.8 Axial image of volar ulnar aspect of wrist. A synovial
tenosynovitis of the common extensor sheath. Marked increased cyst with complex elements extends from the pisiform–triquetral joint
Doppler activity is evident. entering Guyon’s canal. In this location, it may compress the ulnar
nerve.
Key Point
FCU tendinopathy most often occurs in the context of

calcific tendinitis. Hyperechoic calcified deposits are
identified within the tendon and peritendinous soft tissues at
ultrasound. Plain film correlation is useful to confirm the
diagnosis.
Soft tissue impingement may occur between the pisiform

and subcutaneous tissue. This may be the consequence of
repeated use of a computer mouse.
a
NEURAL ENTRAPMENT
GUYON’S CANAL SYNDROME

Guyon’s canal is a small fibroosseous tunnel on the palmar
medial aspect of the wrist, which is also known as the piso-
hamate tunnel or the distal ulnar tunnel. The canal floor is
formed by the flexor retinaculum or transverse carpal liga-
ment, the walls by the superficial palmar carpal ligament
laterally and the pisiform medially.
The ulnar nerve is usually identified in Guyon’s canal lying
between the pisiform and ulnar artery. The overlying super-
ficial palmar carpal ligament is thin. Guyon’s canal consists
b
of three anatomical zones. Zone 1 is the proximal portion of
Figure 12.7 FCU insertional tendinosis. Longitudinal image demon- the tunnel at the level of the pisiform, which contains the
strates thickening of the FCU tendon at its insertion with cortical main trunk of the ulnar nerve with sensory and motor fibres.
irregularity of the pisiform. Zones 2 and 3 are adjacent to each other and located more
distally at the level of the hamate. Zone 2 is the deep portion
of the tunnel and contains the motor branch of the nerve.
Zone 3 is superficial and contains the sensory branch of the
imaging demonstrates hyperaemia. Small cortical erosions nerve. Clinical symptoms correlate with the zone in which
of the pisiform may be seen secondary to local inflammation ulnar nerve compression occurs: the patient may have either
(Fig. 12.7). Plain radiographs are useful to confirm the mixed (zone 1 lesions), purely motor (zone 2 lesions) or
diagnosis, typically demonstrating calcium distal to the ulna. sensory (zone 3 lesions) symptoms.
An oblique view should be obtained to show the calcific Ulnar neuropathy at Guyon’s canal is not common. The
deposits, which may be masked by the adjacent pisiform on leading cause is ganglion cysts, which account for approxi-
standard anteroposterior and lateral views. The clinical dif- mately 30–40% of cases. The ganglia originate from either
ferential diagnosis includes osteoarthritis and ganglion for- the hamate–triquetral or pisotriquetral joints (Fig. 12.8) to
mation at the pisiform–triquetral joint. which they are connected by a pedicle. Ganglia expanding
Figure 12.10 Guyon’s canal syndrome. Accessory abductor digiti

minimi muscle. Transverse image confirms the presence of an acces-
sory abductor digiti minimi muscle (arrows) compressing the ulnar
nerve (arrowheads) in Guyon’s canal. The ulnar nerve lies between
the ulnar artery and pisiform.
Comparative imaging of the contralateral wrist may

be helpful in the detection of anomalous muscles (see
Chapter 13). Ulnar artery injury with thrombosis and pseu-
b
doaneurysm formation may also extend into Guyon’s canal
Figure 12.9 Guyon’s canal syndrome. Transverse image shows a and present with an ulnar neuropathy. Galeazzi fracture-
ganglion arising from the pisotriquetral joint and compressing the dislocation may also lead to a secondary ulnar neuropathy.
ulnar nerve (arrow) in Guyon’s canal. Doppler confirms that the gan- Another site of ulnar nerve compression by extrinsic
glion is avascular and demonstrates flow in the ulnar artery. causes is where the divisional branches of the nerve run
around the hook of the hamate (hammer syndrome).
Chronic blunt trauma on the ulnar aspect of the volar wrist
into Guyon’s canal are readily identified at ultrasound as by crutches, repetitive use of tools during manual work or
well-defined anechoic avascular fluid collections (Fig. 12.9). sporting activity, such as biking, may result in an ulnar neu-
Their relationship to the ulnar nerve is best appreciated in ropathy involving the superficial or deep branch of the
the transverse plane. It may be difficult to confirm the exact nerve. The deep branch is the larger of the two and is a
origin of the ganglion if the pedicle is thin and poorly purely motor nerve, supplying the hypothenar and dorsal
depicted at ultrasound, and MR imaging may be valuable interosseous muscles. The nerve can be located on the ulnar
for preoperative planning. side of the hook of hamate. The superficial branch is more
on the radial side and is accompanied by the ulnar artery.
Key Point The artery may also be injured by blunt trauma, leading to
ulnar artery thrombosis or pseudoaneurysm.
Causes of Guyon’s canal syndrome include ganglion cysts,
occupational neuritis, fractures and other mass lesions such TRAUMATIC CONDITIONS
as lipomas, neural tumours and anomalous muscles: most
commonly an accessory abductor digiti minimi muscle
(Fig. 12.10).
TRIANGULAR FIBROCARTILAGE TEARS
The triangular fibrocartilage complex is located in the ulno-
carpal space to increase stability and absorb mechanical
Practice Tip forces across the ulnar side of the wrist. The complex
includes the triangular fibrocartilage itself and other sup-
Ultrasound is useful in the detection of anomalous muscles by porting structures such as the meniscus homologue, the
demonstrating a mass with echotexture identical to normal ulnar collateral ligament, the volar and dorsal radioulnar
muscle and muscle contraction with movement. ligaments and the sheath of the ECU tendon. The triangu-
lar fibrocartilage can be visualized with ultrasound as a
Figure 12.12 Triangular fibrocartilage tear. Longitudinal image

demonstrates a hypoechoic defect (arrow) within the triangular fibro-
Figure 12.11 Triangular fibrocartilage. Longitudinal image demon- cartilage (between arrowheads), which correlated with a tear at
strates a normal triangular fibrocartilage as an echogenic inverted arthroscopy.
triangular structure (between arrows) situated between ulnar styloid
and triquetrum (Tri) and deep to the striated appearance of the ECU
tendon. Part of the meniscus homologue is seen distal to the trian-
gular fibrocartilage (arrowheads).
triangular fibrocartilage may be seen at ultrasound in the
longitudinal plane as an intrasubstance hypoechoic defect
homogeneous echogenic inverted triangular structure or hypoechoic linear cleft (Fig. 12.12). Absence of a portion
between ulnar styloid and triquetrum (Fig. 12.11). The of the fibrocartilage with focal thinning (<2.5 mm) may also
meniscus homologue is seen as a separate triangular echo- be indicative of a tear. Tears may also be visualized with
genic structure distal to the triangular fibrocartilage and transverse scanning but these views do not provide addi-
extending deep to the striated appearance of the ECU tional information. A ganglion arising from the triangular
tendon. A longitudinal (coronal) view along the ulnar side fibrocartilage may be indicative of a tear (Fig. 12.13).
of the wrist, through the ECU tendon as an acoustic window, The accuracy of detecting triangular fibrocartilage tears
is said to be a useful initial view of the triangular fibrocarti- at ultrasound has mixed results in the literature. Authors
lage, although in many cases the cartilage is too deep for have reported an accuracy of 64–85% with tricompartmen-
accurate assessment. tal arthrography as gold standard, 87.5% with arthroscopic
correlation, 84.6% with MRI correlation and 81% with MR
arthrographic correlation.
Practice Tip In the author’s experience, views of the radial portion of
the triangular fibrocartilage are particularly limited and
The meniscal homologue should not be misinterpreted as the small radial sided tears are difficult to visualize at ultra-
triangular fibrocartilage complex. The TFC lies much deeper sound. In addition, acoustic shadowing from the ulnar
than the ECU, the homologue is more superficial.
styloid may partially obscure part of the triangular fibrocar-
tilage. Some authors suggest scanning the triangular fibro-
cartilage disc with the wrist in the supine position, which
The wide base of the triangle is closest to the transducer allows the styloid process to rotate and move dorsally,
and its apex attaches to the radius. The wide base measures increasing visualization of the radial insertion. It is difficult
about 4.5 mm and the apex normally averages 2 mm. A to differentiate between traumatic and degenerative tears at
more dorsal and volar longitudinal approach should also be ultrasound, which may have therapeutic implications. Ultra-
used to complete the examination. In the author’s experi- sound is, however, useful in detecting associated pathology
ence, imaging in the transverse plane is often of limited such as tears of the ECU tendon.
value.
EXTRINSIC LIGAMENT INJURY
Practice Tip An advantage of ultrasound may be more detailed assess-
ment of the ulnar sided extrinsic ligaments, which contrib-
Positioning the wrist on a pad and scanning in radial deviation ute to ulnar sided wrist pain and instability if injured.
using the ECU tendon as an acoustic window helps optimize The dorsal ulnotriquetral ligament is considered to be a
views of the triangular fibrocartilage. Increasing the gain helps thickening of the dorsal ulnocarpal joint capsule, and may
visualize the fibrocartilage disc attachment to distal radius.
be seen at ultrasound in the longitudinal plane as echogenic
thickening of the dorsal ulnar joint capsule between the
ulnar head and the triquetrum. The dorsal ulnotriquetral
Injury to the triangular fibrocartilage complex is a ligament was completely visible in 63–74% and partially
common cause of ulnar-sided wrist pain. Tears of the visible in 21% of normal wrists.
Figure 12.14 Palmar ulnotriquetral ligament. Longitudinal image

shows the echogenic fibres of the palmar ulnotriquetral ligament
(arrows) extending between the ulna and triquetrum.
views are obtained. These fractures can be seen at ultra-

sound as a small echogenic fragment surrounded by
hypoechoic oedema and fluid, which correlates with the
patient’s site of pain. They occur as a result of avulsion of
the dorsal radioluno-triquetral ligament.
FURTHER READING
Boutry N, Lapegue F, Masi L, et al. Ultrasonographic evaluation of
normal extrinsic and intrinsic carpal ligaments: preliminary experi-
ence. Skeletal Radiol 2005;34(9):513–21.
Chiou HJ, Chang CY, Chou YH, et al. Triangular fibrocartilage of wrist:
b presentation on high resolution ultrasonography. J Ultrasound Med
1998;17(1):41–8.
Figure 12.13 Triangular fibrocartilage tear. (A) Longitudinal ultra-
Elias DA, Lax MJ, Anastakis DJ. Ganglion cysts of Guyon’s canal causing
sound image and (B) corresponding coronal T2-W MR image dem- ulnar nerve compression. Can J Surg 2001;44:331–2.
onstrate a ganglion (arrow) arising from the triangular fibrocartilage. Finlay K, Lee R, Friedman L. Ultrasound of intrinsic wrist ligament and
Extension of the ganglion into a tear of the triangular fibrocartilage is triangular fibrocartilage injuries. Skeletal Radiol 2004;33(2):85–90.
better seen at MRI (arrowheads). Gross MS, Gelberman RH. The anatomy of the distal ulnar tunnel. Clin
Orthop 1984;196:238–47.
Holt PD, Keats TE. Calcific tendinitis: a review of the usual and unusual.
Skeletal Radiol 1993;22:1–9.
The palmar ulnolunate and palmar ulnotriquetral liga- Keogh CF, Wong AD, Wells NJ, et al. High-resolution sonography of the
ments originate from the palmar radioulnar ligament. triangular fibrocartilage: initial experience and correlation with MRI
These may be seen at ultrasound as echogenic fibres with and arthroscopic findings. AJR 2004;182(2):333–6.
the transducer orientated along their long axis with the Lacelli F, Muda A, Sconfienza LM, et al. High-resolution ultrasound
anatomy of extrinsic carpal ligaments. Radiol Med 2008;113(4):
wrist in supination and slight extension (Fig. 12.15). There 504–16.
is no clear proximal demarcation of these two ligaments. Lee KS, Ablove RH, Singh S, et al. Ultrasound imaging of normal dis-
The palmar ulnolunate ligament attaches to the lunate and placement of the extensor carpi ulnaris tendon within the ulnar
is located along the radial aspect of the palmar ulnotriqu- groove in 12 forearm–wrist positions. AJR 2009;193:651–5.
Pratt RK, Hoy GA, Bass Franzcr C. Extensor carpi ulnaris subluxation
etral ligament, which attaches to the triquetrum. The palmar
or dislocation? Ultrasound measurement of tendon excursion and
ulnotriquetral ligament was completely visible in 88% and normal values. Hand Surg 2004;9:137–43.
partially visible in 12% of normal wrists. Taljanovic MS, Sheppard JE, Jones MD, et al. Sonography and sonoar-
thrography of the scapholunate and lunotriquetral ligaments and
triangular fibrocartilage disk. J Ultrasound Med 2008;27(2):179–91.
OCCULT TRIQUETRAL FRACTURES Taljanovic MS, Goldberg MR, Sheppard JE, et al. US of the intrinsic
and extrinsic wrist ligaments and triangular fibrocartilage complex:
Small avulsion fractures of the dorsal triquetrum can be Normal anatomy and imaging technique. Radiographics 2011;
difficult to detect on standard radiographs unless tangential 31(1):e44.
Disorders of the Wrist: 13
Miscellaneous
CHAPTER OUTLINE
NEURAL ENTRAPMENT CALCIFICATION

Carpal Tunnel Syndrome SOFT TISSUE MASSES
INFLAMMATORY ARTHRITIS Ganglion Cysts
Synovitis Palmar Ganglia
Effusion Neurogenic Tumours
Cartilage Anomalous Muscles
Erosions Giant Cell Tumour of the Tendon Sheath
TENOSYNOVITIS AND TENDON TEARS Lipoma
NEURAL ENTRAPMENT Patients with carpal tunnel syndrome (CTS) typically

complain of burning pain, numbness and paraesthesia over
CARPAL TUNNEL SYNDROME the radial aspect of the hand, first three fingers and radial
half of the ring finger. Symptoms typically occur at night
The carpal tunnel is formed posteriorly by the carpal bones and are exacerbated by prolonged manual work. In long-
and extrinsic ligaments, and anteriorly by the flexor reti- standing cases, there may be permanent motor and sensory
naculum or transverse carpal ligament, a thin fibrous band deficit in the median nerve territory with atrophy of the
which inserts into the scaphoid and trapezium on the radial thenar eminence.
aspect and into the pisiform and hook of hamate on the In early CTS, morphological abnormalities of the median
ulnar side. The flexor retinaculum can normally be identi- nerve do not occur and there may be no detectable abnor-
fied as a thin, 1–1.5 mm, slightly convex, hypoechoic band, mality on ultrasound.
which extends over the flexor digitorum superficialis (FDS),
flexor digitorum profundus (FDP), flexor pollicis longus
(FPL) tendons and the median nerve in the carpal tunnel. Practice Tip
The median nerve usually runs superficial to the FDS tendon
for the second finger and medial to the FPL tendon. A normal nerve does not exclude the diagnosis of CTS.
Any condition leading to increased pressure within the
carpal tunnel can lead to compression of the median nerve.
With time, the nerve becomes oedematous with evidence
of progressive demyelination and fibrosclerosis at histology.
When abnormalities are present, the ultrasound findings of
Key Point
CTS can be divided into changes of the median nerve, the
Aetiological factors of carpal tunnel syndrome include flexor retinaculum and the content of the carpal tunnel.
anatomical variants (congenitally narrow tunnel, fracture MEDIAN NERVE CHANGES
malalignment of the carpal bones, persistent median artery
and accessory muscles), systemic and endocrine disorders Size
(diabetes, pregnancy, hypothyroidism and amyloidosis) and The median nerve is typically swollen at the proximal carpal
space occupying lesions within the tunnel. tunnel and flattened as it passes beneath the flexor retinacu-
lum and at the distal extent of the tunnel (Fig. 13.1),
129
Figure 13.2 CTS. Longitudinal image shows swelling and hypoecho-

genicity of the MN just proximal to the carpal tunnel (arrowheads).
b
The nerve is flattened as it passes beneath the flexor retinaculum
Figure 13.1 Sagittal image of volar aspect of wrist. There is a (arrows), resulting in a change in calibre of the nerve, which is referred
change in calibre of the median nerve as it passes under the flexor to as the ‘notch sign’. The MN lies superficial to the FDS tendons.
retinaculum that is consistent with CTS. Some mild separation of the
tendon fibres is evident.
Tilting the transducer over the nerve or slightly changing

regardless of the cause of compression. An abrupt change wrist position can achieve optimal transducer orientation.
in the calibre of the nerve at the proximal carpal tunnel is There is no consensus in the literature regarding the
referred to as the ‘notch sign’ (Fig. 13.2). most appropriate median nerve size for establishing the
diagnosis of CTS.
Practice Tip
Key Point
The cross sectional area of the median nerve should be
measured at the point of maximum enlargement. This usually
An increased cross sectional area of more than 10 mm2 at
occurs just proximal to the flexor retinaculum, a position
the proximal carpal tunnel (scaphoid–pisiform level) is
located slightly cranial to the pisiform.
generally accepted to be diagnostic of CTS.
Two methods are used to measure the cross sectional area

of the median nerve: the direct method, using the ellipse Ranges between 9 mm2 and 15 mm2 have been proposed.
tool on the ultrasound machine, or the indirect method, by
means of the ellipse formula [(maximum anteroposterior
diameter) × (maximum transverse diameter) × ( π 4 )]. There Practice Tip
is a high degree of correlation between the two methods. Comparing cross sectional area measurements of the median
Transducer positioning potentially affects measurement of nerve at the level of the carpal tunnel and pronator quadratus
the median nerve cross sectional area. has been proposed to eliminate interindividual and internerve
variability. A difference in the cross sectional area of 2 mm2
or greater yielded the greatest sensitivity and specificity for
Practice Tip the diagnosis of CTS.
The transducer should always be perpendicular to the nerve,

including when the nerve courses obliquely from superficial Occasionally, the notch sign may occur at the distal edge
to deep. of the retinaculum (inverted notch sign). In these cases, the
nerve is flattened at the distal tunnel and no shape change
CHAPTER 13 — Disorders of the Wrist: Miscellaneous 131
is seen at the proximal tunnel. An inverted notch sign indi-

cates distal compression, which should be highlighted in the
report so that appropriate distal or palmar electrophysiolog-
ical testing is performed.
Distal flattening of the nerve is evaluated with the flatten-
ing ratio, which is calculated at the distal tunnel (hamate
level) by dividing the transverse diameter of the nerve by its
anteroposterior diameter. A flattening ratio of more than 3
has been proposed as an additional finding of CTS.
Appearance
Practice Tip
The median nerve becomes uniformly hypoechoic with loss

of the normal fascicular pattern (in CTS) due to overcrowding a
of oedematous nerve fascicles or fibrosis in chronic cases
(Fig. 13.2).
Care must be taken to keep the transducer perpendicular

to the nerve axis when evaluating the neural echotexture to
avoid anisotropy and incorrect diagnosis of neuritis.
There is usually increased blood flow in the longitu
dinal perineural plexus and intraneural vessels with
Doppler imaging. This is due to disturbances in the intra-
neural microvasculature and hyperaemia of inflammatory
neuritis.
Restricted motion of the compressed median nerve
beneath the flexor retinaculum during flexion and exten-
sion of the fingers may be seen, but this is a subjective b
finding.
Figure 13.3 CTS. Transverse image shows hypoechoic fluid and
FLEXOR RETINACULUM CHANGES synovitis (*) in the flexor digitorum tendon sheaths that separate the
flexor tendons (T). There is flattening of the MN and volar bowing of
Volar bowing of the flexor retinaculum is seen secondary to the flexor retinaculum (arrows).
increased pressure within the carpal tunnel (Fig. 13.3). This
is assessed at the distal end of the carpal tunnel (hamate–
trapezium level). A line joining the hook of the hamate and
the tubercle of the trapezium is made. The largest distance Space occupying lesions within the carpal tunnel are seen
from this line to the retinaculum reflects the degree of well with ultrasound. Ganglia are the commonest and
volar bulging. A value of more than 4 mm is considered appear as well-defined anechoic masses with no internal
significant. vascularity. They usually arise in the deep portion of the
tunnel from the wrist joint and displace the median nerve
CARPAL TUNNEL CONTENT and flexor tendons anteriorly against the flexor retinacu-
The most common cause of CTS is tenosynovitis of the lum. Solid tumours include lipomas (Fig. 13.4), neural
flexor tendons. Ultrasound demonstrates hypoechoic fluid tumours and giant cell tumours of the tendon sheath. A
and synovitis in the tendon sheaths which separate the persistent median artery has been described as a cause of
flexor tendons (Fig. 13.3). Doppler signal depends on the CTS. This is an accessory artery that arises from the ulnar
activity of the synovitis. artery in the proximal forearm and may accompany the
median nerve through the carpal tunnel. Doppler imaging
is useful for identifying it. Acute CTS may be secondary to
Practice Tip
acute thrombosis of this artery. Following penetrating injury,
When scanning for tenosynovitis in the carpal tunnel, dynamic posttraumatic neuroma, which may affect only a portion of
scanning in the transverse plane during finger flexion and the median nerve, may occur (Fig. 13.5).
extension helps differentiate the tendons from echogenic Anomalous muscles inside the carpal tunnel relate to
synovitis. the distal insertion of an anomalous muscle belly of the
FDS of the index finger, the proximal insertion of a lum
brical muscle or an accessory flexor muscle. Accessory
Scanning both proximal and distal to the carpal tunnel muscles have the typical echotexture of muscles with echo-
is important to avoid false negatives as the synovial fluid genic linear septa, change shape during contraction and
accumulates outside the carpal tunnel where there is less relaxation, and can be seen to enter and exit the tunnel with
resistance to sheath distension. finger extension and flexion. Abnormal bone extending
a c
b d
Figure 13.4 Carpal tunnel syndrome. (A, B) Transverse ultrasound image shows a solid mass (demarcated by calipers) displacing and com-
pressing the MN in the carpal tunnel. Corresponding axial (C) T1 and (D) T2 fat saturation MR images confirm a lipoma in the carpal tunnel
(arrow), which returns high-T1 signal and completely suppresses with fat saturation. Increased T2 signal of the MN (arrowhead) is in keeping
with intraneural oedema.
into the carpal tunnel, such as callus formation or a dislo-

cated lunate, is brightly echogenic with posterior acoustic
shadowing.
Treatment for CTS includes wrist splinting, nonsteroidal
antiinflammatory drugs, intracanal corticosteroid injections
and surgical release of the flexor retinaculum. The retinacu-
lum is usually divided close to its ulnar insertion on the
hook of hamate.
Assessment of CTS following surgery may be challenging.
The median nerve is located in a more superficial and
medial location. The resected ends of the flexor retinacu-
lum appear thickened and hypoechoic as they are retracted
a
on either side of the nerve. Persistent symptoms following
surgery may be due to incomplete resection of the flexor
retinaculum or postoperative fibrous scarring involving the
nerve. With incomplete resection, ultrasound may demon-
strate continuity of the retinaculum and persistence of the
notch sign. Postoperative scar tissue is seen as irregular
hypoechoic tissue surrounding the median nerve. Injection
around the nerve is said to release some of the adhesions.
INFLAMMATORY ARTHRITIS
Only factors relevant to ultrasound imaging of wrist joint

arthritis are highlighted in this section.
b
Figure 13.5 Axial image of volar aspect of wrist. There is a low- SYNOVITIS
signal lesion arising from the radial aspect of the MN consistent with
a median neuroma. The patient had a previous neuroma excised and A dorsal approach is usually best to assess carpal joint syno-
this lesion represents a recurrence. vitis. The dorsal recesses of the radiocarpal and midcarpal
a c
b d
Figure 13.6 Synovitis versus extensor tenosynovitis. (A, B) Transverse image shows synovial effusion (*) in the dorsal recesses of the
radiocarpal joint closely applied to the carpal bones and displacing the extensor tendons (T) posteriorly. (C, D) Transverse image demon-
strates extensor tenosynovitis as fluid and synovial proliferation (*) in a more superficial location within the tendon sheath around the extensor
tendons (T).
EFFUSION
Differentiating a joint effusion and synovial proliferation
may be difficult. Synovitis is usually more echogenic and
exhibits Doppler signal in the active phase (Fig. 13.7).
Transducer pressure deforms the synovial tissue, resulting
in only partial collapse of the joint recess. Joint effusion is
hypoechoic, avascular and expelled from the joint recess
with transducer compression.
Practice Tip
Occasionally joint fluid may have a complex echogenic

appearance due to proteinaceous contents, crystal
Figure 13.7 Synovitis vascularity. Longitudinal ultrasound image deposition, fibrin (blood) or cellular debris.
with power Doppler demonstrates solid vascular noncompressible
tissue of mixed echogenicity consistent with active synovitis. Vascu-
lar synovitis extends into an erosion on the dorsum of the lunate Transducer pressure is useful to compress the fluid and
(arrow). produce movement of the internal echoes, the pattern of
movement is different from solid tissue.
Ultrasound is valuable to detect the presence and loca-
tion of effusions in the carpal joint recesses, which can be
joints are best imaged in the longitudinal plane. Transverse differentiated from joint synovitis and tenosynovitis. This
images at these levels are useful to differentiate deep intraar- is useful to direct aspiration of a carpal joint effusion or
ticular fluid and synovitis from superficial extensor tenosy- synovial biopsy. Ultrasound is also used to guide intraarticu-
novitis (Fig. 13.6). The distal radioulnar joint is best assessed lar steroid injections into the appropriate joint space
in the transverse plane, often at a more proximal level than (Fig. 13.8).
the joint line, where the joint capsule is more likely to
distend.
CARTILAGE
Doppler ultrasound is valuable for distinguishing between
active hypervascular synovitis and chronic fibrous pannus Thinning, irregularity and loss of definition of articular
(Fig. 13.7). Small-scale studies have used power Doppler to cartilage may be appreciated with ultrasound. Evaluation
quantify vascular flow in synovitis to monitor disease activity of radiocarpal and midcarpal joint cartilage is, however,
and thus assess therapeutic response. limited at ultrasound by the vertical orientation of many
TENOSYNOVITIS AND TENDON TEARS
Tenosynovitis is common in patients with an inflammatory

arthropathy.
Key Point
Early ultrasound detection of tendon involvement in RA is

important to assess the need for tenosynovectomy to
prevent further tendon damage and tears.
Figure 13.8 Synovitis injection. Longitudinal image demonstrates
the needle (arrowheads) extending between the EDT into an area
of hypoechoic synovitis (arrows) during an intraarticular steroid
injection. In rheumatoid arthritis, the extensor pollicis longus (EPL)
tendon may rupture at the wrist, largely due to friction on
a partially eroded Lister’s tubercle. The extensor tendons
of the ring and little fingers may also rupture secondary to
friction over a dorsally displaced ulnar head. Dynamic ultra-
sound is valuable to confirm complete tendon rupture and
accurately locate the torn retracted tendon ends.
Extensor carpi ulnaris (ECU) instability is also observed
in patients with long-standing rheumatoid arthritis causing
ECU tenosynovitis and distal radioulnar joint disease.
Pannus disrupts the subsheath and the ECU tendon tends
to migrate to the volar surface of the ulna and behaves as a
Figure 13.9 Ulnar styloid erosion. Longitudinal image shows a
defect in the echogenic cortex of the ulnar styloid in keeping with an
wrist flexor rather than an extensor, causing dislocation of
erosion (arrow). Hypoechoic synovial pannus (arrowheads) extends the distal ulna relative to the radius. Volar subluxation of
into the erosion. Fluid and thickened synovium are present in the ECU the ECU tendon is best identified in the transverse plane
tendon sheath, consistent with tenosynovitis. with dynamic scanning during forearm supination and wrist
flexion (see Chapter 11).
joint surfaces relative to the transducer. Distal radioulnar
joint cartilage is poorly visualized with ultrasound.
CALCIFICATION
Practice Tip
Intraarticular calcification is seen as hyperechoic foci within
Dynamic scanning may improve visualization of dorsal carpal the wrist joint, triangular fibrocartilage and wrist ligaments,
joint cartilage. and is indicative of a crystal deposition arthropathy such as
calcium pyrophosphate deposition disease (Fig. 13.10).
Hyperechoic crystal deposition in articular cartilage paral-
For example, the dorsal cartilage of the lunate is better seen lels the echogenic bone interface, resulting in a double
with the wrist flexed and the scaphoid cartilage is better contour sign. Ultrasound findings should be confirmed
seen with the wrist in ulnar deviation and the transducer with plain radiographs.
positioned in the longitudinal plane over the radial aspect
of the wrist.
SOFT TISSUE MASSES
EROSIONS
Ultrasound can be used to confirm the presence of a mass,
evaluate its location and relationship to adjacent vessels,
Key Point nerves and tendons, differentiate solid from cystic lesions,
assess internal vascularity and rule out anatomical variants
Bone erosions appear as well-defined focal defects of the
mimicking disease. A definitive diagnosis is usually made
bony cortex, which are visible in two perpendicular planes.
at ultrasound in the case of ganglion cysts, neurogenic
tumours, lipomas, accessory muscle and anomalous bone.
Erosions may be filled with synovial pannus (Figs 13.7 and

GANGLION CYSTS
13.9). Erosive arthritis in the carpal joint typically involves
the dorsal aspect of the lunate and the ulnar styloid. Other Ganglion cysts are the most common masses around the
common sites for erosions are the triquetrum and capitate. wrist. They are cystic masses usually attached to a joint
With increasing erosions, the carpal bones develop an capsule or tendon sheath that are filled with viscous fluid
indistinct outline and become difficult to differentiate from and surrounded by an epithelial lining. The thick gelatinous
each other. content and lack of synovial lining distinguish ganglia from
Figure 13.11 Palmar ganglion. Transverse image demonstrates a

well-defined anechoic ganglion (demarcated by calipers) extending
between the FCR tendon and the radial artery. A thin pedicle
(A, arrow) is identified extending to the scaphotrapezium joint.
b
Some authors believe that inflammatory change, internal
Figure 13.10 Chondrocalcinosis. (A) Longitudinal ultrasound image
reflectors thought to be due to the mucinous gelatinous
shows echogenic foci (arrows) in the ulnar aspect of the wrist joint
and the triangular fibrocartilage in calcium pyrophosphate deposition
content of ganglia and recurrent internal haemorrhage with
disease arthropathy. (B) Plain radiograph confirms extensive chon- resultant fibrosis may also explain increased echogenicity. A
drocalcinosis (arrows). thin, sometimes tortuous, pedicle is often identified, con-
firming the origin of the ganglion from an adjacent joint
(Fig. 13.11). It is important to identify the pedicle at ultra-
sound as it will need to be excised along with the main body
synovial bursae or joint synovial recesses filled with synovial of the ganglion at surgery to prevent recurrence.
fluid. Two main theories explain the origin of ganglia. The
first proposes that ganglia are originally an extrusion of a
Practice Tip
synovial space, which, due to a valve mechanism, subse-
quently leads to concentration of the fluid content and loss Pressure with the ultrasound transducer or ultrasound
of the synovial lining. The second theory suggests that palpation can be used to help classify cystic lesions.
ganglia arise from degeneration of periarticular connective
tissue with secondary mucoid degeneration.
Ganglia present clinically as an asymptomatic soft tissue Transducer pressure results in compression and displace-
swelling or as a painful mass close to the joint. Variation in ment of synovial fluid accumulation in a joint recess or
size over time is suggestive of the diagnosis. Ultrasound tendon sheath. Solid lesions and ganglia filled with thick
demonstrates a well-defined avascular anechoic mass with viscous material are usually noncompressible.
posterior acoustic enhancement (Fig. 13.11). Chronic
ganglia may have a more echogenic appearance due to DORSAL GANGLIA
thickening of their wall, internal septations and locules. Dorsal ganglia are the most common (60–70%).
Key Point
Dorsal ganglia most commonly originate from the joint

capsule, near the dorsal band of the scapholunate ligament.
The capsule in this region is not reinforced by the dorsal

radiocarpal ligament and seems vulnerable to shear stresses
during wrist flexion. The ganglia may subsequently extend
between the extensor tendons into the subcutaneous tissues
where they may reach a considerable size. A pedicle may
be identified at ultrasound connecting the superficial gan-
glion with the joint capsule or, occasionally, the radiocarpal Figure 13.12 Dorsal ganglion aspiration and injection. Transverse
joint. Particularily painful ganglia may be so because of their image confirms the needle tip (arrows) positioned within a dorsal
proximity to the distal part of the posterior interosseous ganglion (G) during aspiration and corticosteroid injection.
nerve.
The dorsal occult ganglion develops within the dorsal
joint capsule, at the level of the scapholunate ligament, and
results in radial sided wrist pain. This is discussed in more Key Point
detail in Chapter 10.
Ultrasound is valuable for diagnosing ganglia, particularly in
PALMAR GANGLIA cases of small occult dorsal ganglia, identifying the origin
Palmar ganglia are usually located on the radial aspect of and relationship to surrounding structures and guiding
the wrist. They typically originate from the scaphotrapezium aspiration and injection of steroids within its cavity.
or, less commonly, the radioscaphoid joint and expand
proximally towards the distal radius, between the flexor
carpi radialis and the radial artery (Fig. 13.11). These Corticosteroid injection is thought to cause fibrosis of the
ganglia are often large and may displace the radial artery ganglion wall to prevent recurrence (Fig. 13.12). A larger
and superficial sensory branch of the radial nerve. The bore, at least 17–19G needle, should be used during aspira-
relationship of the ganglion with the radial neurovascular tion of ganglia because of the thick internal contents.
structures is well seen at ultrasound. On axial images, the
radial artery is usually closely related to the volar and radial
NEUROGENIC TUMOURS
aspect of the ganglion. Care must be taken not to mistake
the artery as a lobulation of the ganglion, particularly if
aspiration is considered. This is easily avoided by demon- Key Point
strating blood flow in the artery with Doppler imaging,
identifying pulsatility of the artery, which increases with Most peripheral neural tumours around the wrist arise from
transducer pressure, and visualizing the artery in the longi- the median nerve, presenting as a slowly enlarging painful
tudinal plane draped over the palmar aspect of the gan- mass along the volar aspect of the wrist.
glion. Palmar ganglia should also be distinguished from
pseudoaneurysms of the palmar branch of the radial artery,
which most commonly occur secondary to repetitive micro- Neural tumours appear as well-defined hypoechoic solid
trauma of the artery against the scaphoid tubercle. lesions with internal vascularity and posterior acoustic
enhancement that are continuous with the nerve of origin
at their proximal and distal poles. The nerve immediately
Practice Tip adjacent to the tumour may be thickened with a tapered
appearance into the lesion (Fig. 13.13).
In contrast to ganglia, pseudoaneurysms demonstrate internal
blood flow with Doppler imaging and are in continuity with the
adjacent arterial lumen. Practice Tip
Ultrasound is valuable for confirming the diagnosis of a

neural tumour by demonstrating the nerve entering and
exiting the lesion.
The differential diagnosis of palmar ganglia also includes
tenosynovitis of the flexor carpi radialis tendon, which is
frequently associated with triscaphe osteoarthritis and is
seen as thickening and hypoechogenicity of the tendon with Transducer pressure on the lesion often elicits peripheral
an effusion of the synovial sheath. Palmar ganglia located tingling (Tinel’s sign), which helps confirm the diagnosis.
inside the carpal tunnel are clinically not detectable and can Needle biopsy of a neural tumour may be extremely painful
cause compression of the median nerve. for the patient and is often not performed.
volar forearm and wrist. It is associated with syndactyly or

macrodactyly of the index and middle fingers (macrodystro-
phia lipomatosa) in two-thirds of cases. Fibrolipomatous
proliferation infiltrating the interfascicular epineurium is
seen at ultrasound as fusiform enlargement of the median
nerve with large deposits of echogenic fat filling the epineu-
rium, and encasing and separating the linear hypoechoic
neural fascicles (Fig. 13.14). Ultrasound findings correspond
to MRI findings, with the neural fascicles described as having
a
a coaxial cable-like appearance in the axial plane and a
spaghetti-like appearance in the coronal and sagittal planes.
ANOMALOUS MUSCLES
Anomalous muscles at the wrist may be an incidental finding,
present as a painless mass, or with a compressive neuropathy
if located within or close to an osteofibrous tunnel. Familiar-
ity with the more common locations helps make the correct
diagnosis and avoid confusion with pathological lesions.
b
Practice Tip
Figure 13.13 Neurofibroma of the median nerve. Longitudinal image
of a neurofibroma typically seen as a well-defined solid lesion arising Ultrasound is useful for making the diagnosis of anomalous
centrally within the nerve, with proximal and distal nerve continuity muscles as the echotexture of anomalous muscles is
(arrows). There is posterior acoustic enhancement (arrowheads) and identical to other muscles. Dynamic scanning can depict
subtle central hyperechogenicity, suggesting a target sign, which is changes in muscle shape during contraction and relaxation.
attributed to a central fibrocollagenous region and a peripheral myxo-
matous rim.
Scanning the opposite wrist may be useful as anomalous
The two main benign neural tumours derived from the muscles may be bilateral.
nerve sheath are neurofibromas (Fig. 13.13) and neurilem- The accessory abductor digiti minimi is the most common
momas, which are also known as schwannomas. accessory muscle of the wrist, seen in up to 24–47% of
normal individuals. This muscle originates from the deep
forearm fascia, flexor retinaculum or palmaris longus
Key Point tendon and inserts on the abductor digiti minimi and base
of the fifth proximal phalanx. It is usually asymptomatic but
Neurofibromas arise centrally within the nerve and nerve
may cause an ulnar neuropathy by passing through Guyon’s
fascicles may be seen traversing the lesion. Neurilemmomas
are encapsulated, arising at the periphery of the nerve, and canal and compressing the ulnar nerve against the pisoham-
usually grow eccentrically. ate ligament during contraction. Sonography has the advan-
tage of dynamic examination that, when performed during
abduction of the little finger, can show an increase in the
Neurofibromas may have a characteristic echogenic ring muscle thickness and impingement on the ulnar nerve. A
within the lesion or an echogenic centre, referred to as the difference in muscle thickness between asymptomatic sub-
sonographic target sign. Chronic neurilemmomas may cavi- jects (mean 1.7 mm) and symptomatic patients (4 mm) has
tate and calcify. been observed.
The extensor digitorum brevis manus muscle is an ana-
tomic variant of the finger extensors, occurring in 1–3% of
Key Point
the population. It may present as a dorsal wrist mass that is
Distinguishing the lesions is helpful to the clinician as often misdiagnosed as a dorsal wrist ganglion. This muscle
neurilemmomas can generally be separated from the parent arises from the distal radius, dorsal radiocarpal ligament or
nerve, resulting in easy surgical removal, whereas dorsal wrist capsule, deep to the extensor retinaculum, and
neurofibromas cannot be separated from the nerve, inserts into the extensor hood of the index or middle finger.
resulting in more difficult excision which may require The accessory muscle belly is situated medial to the extensor
sectioning of nerve fascicles. tendon of the index finger (Fig. 13.15).
Practice Tip
An unusual neural tumour with a predilection for the
median nerve at the wrist is a fibrolipomatous hamartoma, Dynamic scanning with finger extension against resistance
also known as a neurofibrolipoma or intraneural lipoma. results in contraction of an extensor digitorum brevis manus
This is a developmental abnormality that usually occurs in muscle, which is seen to enlarge and protrude dorsally
young patients, typically presenting in the third or fourth between the second and third extensor tendons.
decade with a long history of painless swelling along the distal
a c
b d
Figure 13.14 Fibrolipomatous hamatoma. Transverse (A, B) and longitudinal (C, D) ultrasound images with corresponding axial (E) and sagittal
(F) T1-weighted MR images show enlargement of the median nerve with multiple hypoechoic thickened neural fascicles, which are dispersed
by echogenic fat (between arrowheads). On the MR images, the hypointense linear neural fascicles have a spaghetti-like appearance in the
sagittal plane and a coaxial cable-like appearance in the axial plane (between arrows). Fat interspersed between the neural fascicles returns a
hyperintense T1-weighted signal.
Figure 13.15 Extensor digitorum brevis manus muscle. Longitudi-

nal image during resisted finger extension demonstrates the acces-
sory muscle (arrows) extending dorsally over the second extensor
tendon.
b
An anomalous muscle belly of the FDS of the index finger
replaces the normal tendon and usually presents as a mass Figure 13.16 GCTTS. Longitudinal image demonstrates a well-
along the volar wrist and palm. The anomalous muscle often defined solid hypoechoic mass (demarcated by calipers) arising from
the FPL tendon sheath.
extends within the carpal tunnel and may result in symp-
toms of CTS. Ultrasound demonstrates movement of the
muscle in both the proximal and distal direction within the Practice Tip
carpal tunnel upon index finger flexion and extension. An
anomalous muscle belly of the FDS of the index finger is As GCTTS arises from the parietal tendon sheath and not
best appreciated at ultrasound. With dynamic scanning the from the tendon itself, they are not seen to move with
muscle is seen to enter and exit the carpal tunnel during dynamic tendon flexion and extension.
extension and flexion of the index finger.
A proximal origin of an unusually long lumbrical muscle
is also pulled into the carpal tunnel during finger flexion GCTTS progressively enlarge, causing pressure erosion on
and may result in CTS. Dynamic scanning during flexion adjacent bone and displacement of the tendons. The extent
and extension is once again helpful in the diagnosis. of adjacent bone erosion can be well seen as a concave
cortical defect at ultrasound. Ultrasound is useful for deter-
mining the solid nature of the lesion and its relationship
GIANT CELL TUMOUR OF THE TENDON SHEATH
to the tendon and neurovascular bundles, but MRI is
Giant cell tumour of the tendon sheath (GCTTS), also usually required to confirm the diagnosis by typically
referred to as localized pigmented villonodular synovitis, is showing low signal on all sequences due to the presence of
a slow growing benign neoplasm which arises from the haemosiderin.
synovium of the tendon sheath.
LIPOMA
Key Point
Key Point
GCTTS tend to occur at or distal to the
metacarpophalangeal joints but may occasionally arise at Lipomas present as soft painless masses that usually
the wrist. develop along the volar palm and the thenar eminence.
Ultrasound demonstrates a well-defined solid hypoechoic Ultrasound typically shows a solid, sometimes rather ill-
mass that is hypervascular on Doppler imaging and inti- defined, mass with echogenicity similar to that of subcutane-
mately related to the tendon sheath (Fig. 13.16). ous fat and no internal flow signals (Fig. 13.17). The
Dias JJ, Hui AC, Lamont AC. Real time ultrasonography in the assess-
ment of movement at the site of scaphoid fracture non-union. J Hand
Surg Br 1994;19(4):498–504.
Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal
tunnel syndrome. AJR 1999;173:681–3.
Ghasemi-Esfe AR, Khalilzadeh O, Vaziri-Bozorg SM, et al. Color and
power Doppler US for diagnosing carpal tunnel syndrome and deter-
mining its severity: a quantitative image processing method. Radiol-
ogy 2011;261:499–506.
Gruber H, Glodny B, Bendix N, et al. High-resolution ultrasound of
peripheral neurogenic tumors. Eur Radiol 2007;17:2880–8.
Harvie P, Patel N, Ostlere SJ. Prevalence and epidemiological variation
of anomalous muscles at Guyon’s canal. J Hand Surg 2004,29:26–9.
Jacobson JA, Oh E, Propeck T, et al. Sonography of the scapholunate
ligament in four cadaveric wrists: correlation with MR arthrography
and anatomy. AJR 2002;179(2):523–7.
a Klauser AS, Halpern EJ, DeZordo T, et al. Carpal tunnel syndrome
assessment with US: value of additional cross sectional area measure-
ments of the median nerve in patients versus healthy volunteers.
Radiology 2009;250:171–7.
Lee D, van Holsbeeck MT, Janevski PK, et al. Diagnosis of carpal tunnel
syndrome. Ultrasound versus electromyography. Radiol Clin North
Am 1999;37:859–72.
Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection
syndrome. Skeletal Radiol 2009;38(2):157–63.
Lin J, Jacobson JA, Hayes CW. Sonographic target sign in neurofibro-
mas. J Ultrasound Med 1999;18:513–17.
Lin J, Martel W. Cross sectional imaging of peripheral nerve sheath
tumours: characteristic signs on CT, MR imaging and sonography.
AJR 2001;176:75–82.
Martinoli C, Bianchi S, Gandolfo N. Ultrasound of nerve entrapments
in osteofibrous tunnels. Radiographics 2000;20:199–217.
Martinoli C, Serafini G, Bianchi S, et al. Ultrasonography of peripheral
b nerves. J Periph Nerv Syst 1996;1:169–78.
Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the
Figure 13.17 Lipoma. Transverse image shows a large superficial tendon sheath: analysis of sonographic findings. AJR 2004;183:
lipoma (demarcated by calipers) with echogenicity similar to subcu- 337–9.
taneous fat extending over the ECR tendon. Ouellette H, Thomas BJ, Torriani M. Using dynamic sonography to
diagnose extensor digitorum brevis manus. AJR 2003;181:1224–6.
Parellada AJ, Gopez AG, Morrison WB, et al. Distal intersection teno-
synovitis of the wrist: a lesser known extensor tendinopathy with
presence of atypical features or other solid masses, particu-
characteristic MR imaging features. Skeletal Radiol 2007;36(3):
larly those that exhibit internal vascularity, which cannot be 203–8.
definitively characterized at ultrasound require further Parellada AJ, Morrison WB, Reiter SB, et al. Flexor carpi radialis tendi-
assessment with MRI. nopathy: spectrum of imaging findings and association with triscaphe
arthritis. Skeletal Radiol 2006;35:572–8.
Rodriguez-Niedenfuhr M, Vazquez T, Golano P, et al. Extensor digito-
FURTHER READING rum brevis manus: anatomical, radiological and clinical relevance.
Aleman L, Berna JD, Reus M, et al. Reproducibility of sonographic mea- Clin Anat 2002;15:286–92.
surements of the median nerve. J Ultrasound Med 2008;27:193–7. Sernik RA, Abicalaf CA, Pimentel BF, et al. Ultrasound features of
Beggs I. Sonographic appearances of nerve tumors. J Clin Ultrasound carpal tunnel syndrome: a prospective case-control study. Skeletal
1999;27:363–8. Radiol 2008;37:49–53.
Beggs I. The ring sign. A new ultrasound sign of peripheral nerve Steiner E, Steinbach LS, Schnarkowski P, et al. Ganglia and cysts around
tumours. Clin Radiol 1998;53;849–50. joints. Radiol Clin North Am 1996;34:395–425.
Breidahl WH, Adler RS. Ultrasound guided injection of ganglia with Teefey SA, Dahiya N, Middleton WD, et al. Ganglia of the Hand and
corticosteroids. Skeletal Radiol 1996;25:635–8. Wrist: A Sonographic Analysis AJR 2008;191:716–20.
Buchberger W, Judmaier W, Birbamer G, et al. Carpal tunnel syndrome: Toms AP, Anastakis D, Bleakney RR, Marshall TJ. Lipofibromatous
Diagnosis with high resolution sonography. AJR 1992;159:793–8. Hamartoma of the Upper Extremity: A Review of the Radiologic
Cardinal E, Buckwalter KA, Braunstein EM, et al. Occult dorsal carpal Findings for 15 Patients. AJR 2006;186:805–11.
ganglion: Comparison of US and MR imaging. Radiology 1994;193: Wang G, Jacobson JA, Feng FY, et al. Sonography of wrist ganglion
259–62. cysts: variable and noncystic appearances. J Ultrasound Med 2007;26:
Chen P, Maklad N, Redwine M, et al. Dynamic high resolution sonog- 1323–8.
raphy of the carpal tunnel. AJR 1997;168:533–7. Wong SM, Griffith JF, Hui AC, et al. Carpal tunnel syndrome: diagnostic
Choi SJ, Ahn JH, Lee YJ, et al. De Quervain disease: US identification usefulness of sonography. Radiology 2004;232:93–9.
of anatomic variations in the first extensor compartment with an Yesildag A, Kutluhan S, Sengul N, et al. The role of ultrasonographic
emphasis on subcompartmentalization. Radiology 2011;260(2): measurements of the median nerve in the diagnosis of carpal tunnel
480–6. syndrome. Clin Radiol 2004;59:910–15.
Dao KD, Solomon DJ, Shin AY, et al. The efficacy of ultrasound in the Zeiss J, Guilluiam-Hadet L. MR demonstration of anomalous muscles
evaluation of dynamic scapholunate ligamentous instability. J Bone about the volar aspect of the wrist and forearm. Clin Imaging 1996;
Joint Surg Am 2004;86(7):1473–8. 20:219–21.
PART 4
FINGER
141
Finger Anatomy and 14
Techniques
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION Position 2: Flexor Aspect of Fingers

Position 1: Base of Thumb Position 3: Extensor Aspect of Fingers
important relationships and the method for stressing the

INTRODUCTION ligament will be covered here.
The UCL is best examined by asking the patient to place
Like the wrist, most patients with finger pathology are exam- their hand palm downwards on the examination couch. For
ined seated opposite the examiner. Interventional proce- an examination of the right hand, the examiner sits oppo-
dures can be carried out with the patient prone and their site and places the probe in their left hand and takes the
hand extended above their head if there is anxiety or faint- painful thumb in their right hand, raising the thumb and
ing risk. hand off the table slightly. The patient’s first proximal
phalanx rests on the examiner’s middle finger in a position
that allows the interphalangeal joint to be moved by the
POSITION 1: BASE OF THUMB examiner’s thumb. The examiner’s index finger is placed
on the ulnar side of the patient’s first metacarpal (Fig. 14.2).
IMAGING GOALS In this position the examiner can use their thumb to gently
1. Identify the scaphotrapeziotrapezoid joint (STTJ) and flex the interphalangeal joint and can use their index finger
the first carpometacarpal joint (CMCJ). and thumb combined to induce valgus stress in the UCL.
2. Locate the ulnar collateral ligament (UCL) and aponeu- The imaging goals for patients with UCL injuries are:
rosis of the first metacarpophalangeal joint (MCPJ). firstly, to determine if the ligament is torn and secondly, to
detect displacement. The ligament is displaced if it lies
proximal and superficial to the adductor aponeurosis that
TECHNIQUE overlies it. To make this determination, the aponeurosis
The basal joint of the thumb or the first CMCJ is best exam- must be located first. Flexion of the interphalangeal joint
ined with the patient seated opposite and placing the ulnar moves the aponeurosis over the UCL. It is seen as a
aspect of their hand against the examination couch (karate thin line with the ultrasound configuration of a ligament
chop position) (Fig. 14.1). The probe is placed in the sagit- moving to the subcutaneous fat and overlying the UCL. It
tal plane aligned along the long axis of the thumb. The first is usually relatively straightforward to identify whether the
metacarpal is distinguished from the much shorter tripe- ligament lies deep to it or has been displaced proximally.
zium and, from this landmark, the CMCJ is easily found. Once a torn ligament and overlying aponeurosis have been
The tripezium separates the CMCJ from the adjacent scaph- detected, the extent of the injury can be classified. This is
oid and scaphotrapeziotrapezoid joint in between. Degen- discussed in more detail on page 158, but simply put, if
erative changes in these two joints are a common cause of the ligament is disrupted but remains deep to the aponeu-
radial-side symptoms. Both are visualized from the sagittal rosis, the injury can be treated conservatively. If the liga-
probe position described above and can be injected together, ment is disrupted and has been displaced (called a Stener
or separately, as symptoms and ultrasound findings dictate. lesion), surgery may be a preferential form of treatment.
The first MCPJ is reinforced by collateral ligaments medi- Once the correct location of the ligament is confirmed,
ally and laterally and by a volar plate on the flexor side. the next step is to gently stress it. Using the tip of the index
Assessment of the UCL of the thumb is a commonly per- finger in the position described above as a fulcrum,
formed examination as this ligament is frequently injured. very gentle abduction stress is placed using the examiner’s
The injury will be dealt with in detail in a later section; thumb against the proximal phalanx. A small degree of
however, the technique for identifying the ligament, its joint opening is normal. This movement can be helpful in
143
144 PART 4 — FINGER
a a
CMCJ
1st MC
Tripezium
Scaphoid
STT
J
Figure 14.2 Position to locate and stress the adductor aponeurosis

and UCL.
TECHNIQUE
The paired flexor tendons run close together to the level
of the proximal end of the middle phalanx (Fig. 14.3).
They are easy to separate in the palm up to the point that
they enter the common tendon sheath just proximal to
c the metacarpal head. Distal to this they are often so close
together that they may appear as a single tendon. By
Figure 14.1 Karate Chop position to examine the CMCJ and fixing the proximal interphalangeal joint (PIPJ) and
STTJ. To examine both sides, the hands are placed in a praying
moving the distal interphalangeal joint (DIPJ), the deeper
position.
profundus tendon moves in isolation and can be seen sep-
arately. Compressing with the probe also tends to move
the two tendons separately due to their slightly different
depicting the torn ligament end. Some advise against stress- angle of curvature. Having said that, differentiating the
ing the ligament because of the potential to displace the tendons in this way is not particularly clinically important.
ligament significantly; however, this is very unlikely to occur At about the level of the middle of the proximal phalanx,
with the usual degree of clinical stress used. The radial the superficial tendon begins to divide into its two slips
collateral ligament is easier to visualize as it lies on the (Fig. 14.4). These gradually separate and deviate away
radial aspect with no adjacent fingers to impede probe from each other and pass one medially and one laterally
positioning. to the profundus tendon and to their insertions near the
base of the middle phalanx. This anatomy is best observed
by holding the probe in the axial plane and gradually
POSITION 2: FLEXOR ASPECT OF FINGERS tracking distally along the tendon. The profundus tendon
then continues on its own to its insertion at the base of
IMAGING GOALS the distal phalanx.
1. Identify both flexor tendons. The flexor tendons and their common sheath are held in
2. Identify the annular pulleys. place as they course through the finger by a number of
3. Locate the volar plate and collateral ligaments. fibrous condensations or bands, called the flexor pulleys.
CHAPTER 14 — Finger Anatomy and Techniques 145
A5
A4
A3
DN
FDP
FDS FDS
A2
Volar plate
Prox P
A1 b
Figure 14.4 Axial section through the flexor tendons at the level of
the distal end of the proximal phalanx. The superficial slips (FDS) have
passed around the profundus tendon and are about to insert into the
Figure 14.3 Schematic diagram of the relationships of the two flexor middle phalanx.
tendons and annular pullies.
There are two types of pulley. The A or annular pulleys form The flexor compartment of the finger joints should each
bands overlying the tendons with a semicircular arrange- be examined in turn. It will be noted that the anterior
ment. The arrangement of the C pulleys is different, with a capsule of each joint extends quite far proximally. Within
crisscross or cruciate pattern. Of the two groups, the A the capsule there is a small quantity of fat surrounding the
pulleys are the more important. They are five in number: synovium and synovial space. It is not uncommon to see
three at the convexities of the tendon and two at the con- a small quantity of fluid within the joint under normal cir-
cavities. The A1 pulley is located at the level of the MCPJ, cumstances. Attached to the base of the each phalanx is a
the A3 pulley at the PIPJ and the A5 at the DIPJ. These fibrocartilaginous triangular structure which is attached
pulleys are at the convexity of the tendon and less prone to proximally by connective tissue struts. These are the volar
injury. The most common problem associated with the A1 or palmar plates, whose role is to prevent hyperextension.
pulley is a fibroma, which may lead to trigger finger. The They are also best seen in the sagittal plane.
A2 and A4 pulley lie close to the midpoint of the proximal Moving the probe medially and laterally from the long-
and middle phalanx, respectively. They are at the concavity axis sagittal position into the coronal position reveals the
of the tendon and are more prone to injury, particularly in collateral ligaments (Fig. 14.7). There are two components
rock-climbing. The C1 pulley lies between A2 and A3, with to each of the radial and UCLs. There is a main collateral
C2 and C3 spaced sequentially. ligament, which passes distally and anteriorly between
The annular pulleys are best identified in long axis. Place the metacarpal head and the proximal phalanx. There is
the probe overlying the MCPJ and look for a thin hypore- also an accessory collateral ligament, which lies more ante-
flective band measuring no more than 5–6 mm in length riorly and condenses with the A1 pulley. The different
and overlying the tendon (Fig. 14.5). Gentle finger move- components are not easy to differentiate and often blend
ment will show that the tendons move independently of this imperceptibly with each other. Indeed, the extensor hood
structure. The A2 pulley has a similar appearance to the A1 can sometimes be followed all the way around the metacar-
but is longer and located just distal to the lowest point of pal head to the A1 pulley. An axial view of the lateral
the tendon (Fig. 14.6). It is not uncommon to identify small aspect of the joint will reveal the two components, often
ganglion cysts in relation to the annular pulleys, which are separated by a slight depression in the underlying metacar-
usually asymptomatic. pal head.
A2 Pulley
A1 Pulley FDS
FDP
FDS
FDP
Volar plate Prox P

A
S I
P
Prox P b
MC
A
S I
P
Figure 14.6 Probe position and sagittal anatomy of the A2 pulley.
Figure 14.5 Probe position and sagittal anatomy of the A1 pulley.

a a
A3 Pulley
Lig Col Lig

Col Volar plate FDP
Acc
FDP
FDS
Prox P Mid P
MC M A
A P S I
L P
b b
Figure 14.7 Axial image on lateral aspect of the MCPJ demonstrat-

ing the separate bundles of the main and accessory collateral
ligaments.
There is a broadly similar appearance to the PIPJ (Fig.

14.8) and DIPJ (Fig. 14.9), although the volar plate is shorter
and fatter in these joints. Beyond the DIPJ, on the flexor
side, is the pulp space, a highly vascular area; on the exten-
sor side, is the nail bed. The nail is hyporeflective and often
a tiny ligament can be seen extending from its base attached
just beyond the DIPJ, perhaps explaining a link between nail
disease and the distal joint involvement in seronegative
arthritis. c
Figure 14.8 Probe position and sagittal anatomy of the A3 pulley

and volar plate of the PIPJ.
POSITION 3: EXTENSOR ASPECT OF FINGERS
IMAGING GOALS
1. Identify and stress the dorsal hood. contribution from extensor compartment 4 joining with
2. Locate the central slip. extensor compartment 5 to form a single extensor tendon
3. Track the extensor tendon to its insertion. for the little finger. There is often also an additional band
more distally.
Whereas the flexor tendons have a system of pulleys to
TECHNIQUE contain them, the extensor tendons are held in place over
The structures on the extensor aspect of the fingers the MCPJs by the extensor expansion or extensor hood.
are much smaller than their flexor counterparts and This is a retinaculum formed from contributions from,
consequently are often challenging to evaluate with ultra- amongst other structures, the lumbricals and interossei. In
sound (Fig. 14.10). The extensor tendons are frequently addition there are strong retinacular fibres linking the
paired, especially the index and little fingers, and there second to fifth extensor tendons, called the junctura ten-
are frequent links between them making for a complex dinium. At their distal ends, the extensor expansions
arrangement. This is most apparent between the fourth coalesce to form lateral bands that insert at the base of the
and fifth extensor tendons, where there is a recognized middle phalanx along with the central slip.
a a
Ext t
Volar plate
FDP
Dist P
Mid P
A Mid p Prox P
S I
b
P
b
c c
Figure 14.9 Probe position and sagittal anatomy of the DIPJ on the Figure 14.10 Probe position and sagittal anatomy of the PIPJ on
volar side. the dorsal side.
Ext T Central slip

Ext T
Sa
git
tal
Ba Mid P
nd
Prox P
b
MC Interosseous
Figure 14.12 Probe position and sagittal anatomy of the DIPJ on

the dorsal side showing the insertion of the central slip.
c
Figure 14.11 Position for stress test for volar plate injuries.
of the tendon to the other side will occur during this stress
manoeuvre.
The insertion of the extensor tendon mimics the flexor
tendon in that, towards the distal end of the proximal
The integrity of the extensor expansion can be tested by phalanx, the tendon splits into three components. The
placing the probe in a transverse position over the head central slip inserts into the base of the middle phalanx,
of the metacarpal and asking the patient to make a fist having united with the lateral bands of the extensor hood
(Fig. 14.11). Some lateral movement of the tendon will (Fig. 14.12). The two remaining slips, one medial and one
be observed under normal circumstances. If the extensor lateral, rejoin and continue as a single tendon to insert at
expansion is torn on one side, more significant movement the base of the distal phalanx.
15 Disorders of the Fingers
and Hand
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION EXTENSOR TENDONS

FLEXOR TENDONS Central Slip Rupture
Anatomy and Clinical Aspects Mallet Finger
Tenosynovitis Dorsal Hood Injury
Tendon Rupture SMALL JOINTS OF THE HAND
FLEXOR PULLEYS What to Look For
Anatomy Synovitis Versus Effusion
Pulley Injury Grading
Ganglion, Fibroma and Trigger Finger
COLLATERAL LIGAMENTS AND VOLAR PLATE
Ulnar Collateral Ligament of the Thumb
Collateral Ligament and Volar Plate Injuries
INTRODUCTION Key Point
This section will be divided into abnormalities that occur on The superficialis tendon is the superior of the two finger
tendons but it inserts first at the base of the middle phalanx.
the flexor side and those that occur on the extensor side of
In order to achieve this, the tendon splits and sends a
the fingers. Each section will deal separately with disorders medial and lateral slip one each side of the profundus
of tendons and ligaments and retinacula. The flexor and tendon to their respective insertions in the proximal part of
extensor tendons of the hand are divided into zones to help the middle phalanx.
describe and plan the treatment of injuries. The extensor
zones are numbered 1 to 7, with the odd numbers overlying
joints, beginning distally. Zone 1 is therefore the area overly-
ing the distal interphalangeal joint (DIPJ) and zone 7 is
overlying the wrist. The even-numbered zones lie between The profundus tendon continues distally to insert on the
the joints. On the flexor side, there are 5 zones, also num- volar aspect of the distal phalanx. The two tendons
bered from distal to proximal. are contained within a common sheath. Vascular supply
is from the adjacent digital arteries, with the vascular
pedicle, or vincula, invaginating the tenosynovium as the
tendovaginum.
FLEXOR TENDONS
Disorders of the tendon and tendon sheath, as with
tendons elsewhere, include tenosynovitis, tendinosis and
ANATOMY AND CLINICAL ASPECTS
tendon rupture. Tenosynovitis refers to inflammation on
There are two flexor tendons to each finger: one superficial the tendon sheath. The term tendinosis is sometimes used
and one deep. Each arises from the corresponding flexor for intratendinous mucinous degeneration, which is not
digitorum superficialis and flexor digitorum profundus associated with symptoms. Tendinopathy is a similar term,
muscle belly. but in the same context indicates that symptoms are present.
150
CHAPTER 15 — Disorders of the Fingers and Hand 151
Others use the term tendinosis regardless of whether symp-

toms are present or not.
TENOSYNOVITIS
Key Point
A synovial sheath surrounds the two flexor tendons in the

finger. These are separate from the tendon sheath
surrounding the flexor tendons within the carpal tunnel.
a
Flexor tenosynovitis may occur as a misuse injury in sport.
Increased fluid and synovial thickening within the tendon
sheath can give rise to the classical ‘sausage digit’ appear-
ance. This pattern is particularly associated with seronega- FDS
tive arthropathy, most typically psoriatic arthropathy. The
soft tissue manifestations of psoriatic arthropathy may FDP
precede the appearance of the typical psoriatic rash, so the
absence of a rash does not exclude the diagnosis. The dif-
ferential diagnosis of sausage digit includes infective teno-
synovitis, although this is uncommon. The history of trauma, A MC
LM
particularly a biting injury and a human bite, is often the P
worst, should be sought. Infection can be acute or chronic. b
Chronic infection in the tendon sheath is less often accom-
panied by heat and redness. In these cases tuberculous dac- Figure 15.1 Transverse section of flexor tenosynovitis of third
tylitis should be suspected. Yaws and syphilis are other finger. Note a thickened low-reflective halo around the otherwise
normal tendon. Compare with the adjacent flexor tendon.
uncommon causes.
Practice Tip
Patients with tenosynovitis may initially complain of stiffness

and inability to form a fist and not infrequently arthritis is
suspected.
Inflammatory changes within the tendon manifest as

increased fluid and, with progress of the disease, thickening
of the synovial lining and increased Doppler signal.
Practice Tip
The earliest ultrasound finding is the appearance of the dark

halo around the tendon.
a
This is due to a thin rim of fluid that comes between the
tendon and tendon sheath (Fig. 15.1). This sign is best
appreciated on axial images, especially by comparing the
affected finger with those that are not involved.
As the amount of fluid increases, the tendon sheath
becomes increasingly distended (Fig. 15.2). In long axis
fluid and synovial thickening will not be evenly distributed
along the length of the tendon (Fig. 15.3), but will be ini-
tially constrained in the areas of the flexor pulleys, creating
a lobulated appearance. This should not be misinterpreted
as multiple ganglia. As the disease progresses, the degree of
synovial thickening (Fig. 15.4) and Doppler activity increases
(Fig. 15.5). At this stage associated tendinopathy is common b
and vascular ingrowth is identified within the substance of Figure 15.2 Flexor tenosynovitis. Fluid surrounds the tendon apart
the tendon itself, alongside accompanying intratendinous from where the tenovaginum attaches. Note the slight thickening of
matrix changes. the synovial lining of the tendon sheath.
Figure 15.5 Transverse section of wrist extensor tenosynovitis.

Increased Doppler activity indicates the areas of active
FDS
inflammation.
Mid P
A
Prox P TENDON RUPTURE
S I
b P Rupture of the flexor tendon may affect either the superficial
or profundus tendon, although the latter is more common.
Figure 15.3 Long axis of flexor tenosynovitis. Note the rind of low-
signal material around the tendon. It has an undulating appearance
where the sheath is constrained by the flexor pulleys.
Key Point
The commonest site of flexor profundus tear is just proximal

to its insertion into the base of the distal phalanx.
This injury is referred to as a jersey finger or rugby finger,

reflecting a common cause of injury. The profundus tendon
of the ring finger is the most commonly affected by the
jersey pull injury. The injured player attempts to grab his
opponent by the jersey but only manages to gain purchase
with the tip of the finger, which is then forcibly extended.
The insertion of the profundus tendon is avulsed from the
underlying bone with a small bony fragment attached, or a
small stump of tendon remains attached to the distal
phalanx (zone 1 injury) and the remainder of the tendon
retracts proximally (Fig. 15.6). The index finger is involved
in 75%.
Clinically there is localized tenderness, pain and swelling
a and inability to flex the DIPJ. The latter can be assessed
during the ultrasound by fixing the proximal interphalan-
geal joint (PIPJ). Additionally, during finger flexion there
will be dysynchronous movement between the proximal and
distal portions of the ruptured profundus tendon. Gentle
finger movements are also helpful to distinguish between
FDS partial and complete tears. Synchronous movement between
Volar plate FDP proximal and distal components of a suspected tear excludes
a complete rupture in the acute phase.
A Practice Tip
Prox P
I S
P The flexor tendons are less strongly attached to the
b
surrounding structures and thus the degree of retraction is
Figure 15.4 Flexor tenosynovitis. Note the sharp reflective margin often quite large.
of the flexor tendon.
A5
A4
A3
A2
FDS
Tear
FDP
A1
Figure 15.7 Schematic diagram of the annular pulleys. Five sets are
Prox P MC present. A1, A3 and A5 are at the level of the articulations on the
A convexity of the tendon. A2 and A4 are on the tendon concavities
I S and are the most prone to injury.
b P
Figure 15.6 Flexor tendons at the level of the palm. The superficial
tendon may itself be avulsed from the avulsed bony frag-
flexor tendon is intact. There is a tear of the profundus tendon that
is retracted.
ment. Retraction of the tendon into the palm is designated
a type 1 and retraction to the level of the PIPJ a type 2,
completing the spectrum of lesions.
Ultrasound is useful not only to confirm the presence of As it is required to cross fewer joints than its deeper
tendon rupture, but also to identify the precise location of counterpart, closed rupture of the superficialis tendon is
the tendon ends. This can be useful for surgical planning uncommon but can occur due to forced extension against
as more precise identification of the tendon ends reduces a contracted muscle. It is also less prone to abrasion against
the need for extensive exploratory surgery. Two small inci- the carpal bones. Open tendon lacerations are a more
sions can be made at the locations identified by ultrasound, common cause of superficial flexor tendon rupture and
thus minimizing the risk of postoperative adhesions. most frequently involve the midsubstance of the tendon.
The location of flexor tendon rupture can also be
reported using the zones method. Zone 1 covers the
segment between the superficialis and the profundus
FLEXOR PULLEYS
insertions. Zone 2 is the area between the superficialis
insertion and the distal palmar crease. In this segment the
ANATOMY
profundus and superficialis tendon lie in close proximity.
Zone 3 is between the level of the A1 pulley and the flexor The flexor tendons of the hand are held in place by a series
retinaculum. Zone 4 covers the section of flexor tendon of connective tissue retinacula that are formed by condensa-
within the flexor retinaculum and zone 5 that portion tions of the fibrous sheath. They are arranged into annular
proximal to it. Jersey finger has its own classification as and cruciate configuration, referred to as the A and C
there is often a small bony avulsion fragment attached to pulleys (Fig. 15.7). The pulley system is important for
the tendon which influences the degree of retraction keeping the flexor tendons close to the phalanges to maxi-
encountered. If a large bony injury is involved, retraction mize their ability to flex the fingers. Clinically, the annular
proximal to the A4 pulley is uncommon. This is designated A pulleys are by far the most important and these are num-
a type 3 lesion. In the rare type 4 lesion the profundus bered A1–5. The A1, A3 and A5 are at the level of the
P
A4 Pulley FD
Dist P
A
S I Mid P
P
b
Figure 15.8 The normal A4 pulley is a low-signal, thin structure

surrounded by a rim of more reflective connective tissue. The A2 and
A4 pulleys overlie the tendon at its most concave portion.
Figure 15.9 With increasing strain, the A2 pulley ruptures. The flexor
tendon separates from the proximal phalanx with bowstringing.
metacarpalphalangeal, PIP and DIP joints respectively. They
are on the convexities of the flexor tendons and are thus
less prone to injury. The A2 pulley is at the level of the
midportion of the proximal phalanx and the A4 pulley at
the midportion of the middle phalanx (Fig. 15.8). These are A small gap (<3 mm) suggests isolated A2 injury and gaps
on the concavity of the flexor tendon and are more prone more than 5 mm suggest multiple pulley involvement. The
to injury. A1 pulley is rarely involved in this injury. Injuries to the
The A2 is the largest of the pulleys. It can be visualized cribriform or C pulleys are reported, but not common.
directly on ultrasound and note is made of any associated
injury. Functionally, it is tested by noting the distance ULTRASOUND IMAGING OF PULLEY RUPTURE
between the profundus tendon and the underlying bone Injury to the pulley itself may be visualized by both ultra-
when the finger is flexed against resistance. With a function- sound and MRI (Fig. 15.10). Ultrasound offers an advantage
ing pulley, the flexor tendon should show minimal separa- over MRI in that the pulley can be stressed dynamically. The
tion from the underlying bone. patient places the back of their hand on the examination
couch and the probe is placed in long axis overlying the A2
pulley. A free finger of the examiner’s hand is placed on the
PULLEY INJURY
distal phalanx of the finger being examined, restraining it
The classic injury leading to pulley rupture is typified by the as the patient flexes (Fig. 15.11). Under normal circum-
crimp grip of rock climbers. Hyperextension occurs at stances, the tendon is constrained by an intact pulley system
the metacarpalphalangeal joint and flexion at the IPJ. If the and there is a minimal gap between the profundus tendon
weight supported by the fingers in this position is suddenly and the underlying bone.
increased beyond the restraining ability of the pulley
system, rupture occurs. The flexor tendons are pulled away
from the phalanges and shorten. This is called bowstring-
ing. The middle and ring fingers are the most vulnerable. Practice Tip
There is some disagreement as to which pulley ruptures
If the A2 pulley has ruptured, the tendons will lift from the
first, although most commonly the injury is said to begin at proximal pahalanx, creating a gap.
the distal portion of the A2 pulley. It then progresses
through A4 with progressive bowstringing of the flexor
tendon (Fig. 15.9).
FIBROMA, GANGLION AND TRIGGER FINGER
Like the A2–A5 pulleys, the A1 pulley is a fibrous retinacu-
Key Point lum that arches over the flexor tendons of the finger.
The normal A1 pulley is easily identified on ultrasound and
The degree of bowstringing measured by the separation of is seen as a very thin, hypointense line surrounded circum-
the flexor tendon from the underlying bone gives a clue on ferentially by an equally thin reflective envelope (Fig. 15.12).
which pulleys are involved. It is best appreciated in the sagittal plane where it normally
measures approximately 1 cm proximal to distal.
Prox P
A1 Pulley
FDS
FDP Volar plate
Figure 15.10 On stressing, the flexor tendon overlying the proximal

phalanx is imaged under tension. Note the separation of the tendon Prox P
from the underlying bone (*) which indicates bowstringing.
MC
A
S I
P
b
Figure 15.12 The normal A1 pulley overlies the MCPJ. It is a shorter

structure than A2. There is also a low signal surrounded by a rim of
more reflective tissue. Note that the A1 pulley overlies the tendon at
its convexity, making it less prone to injury.
Figure 15.11 Injuries to the A2 and A4 pulleys can be assessed by

flexing the finger against resistance. The probe is placed in a sagittal
position over the A2 pulley. The tip of the examiner’s finger is used
to provide resistance to finger flexion.
Practice Tip Figure 15.13 Sagittal image of the flexor tendon overlying the
MCPJ. The A1 pulley is replaced by an ill-defined, low-signal mass
The A1 pulley is rarely torn due to its relationship over the indicative of a pulley fibroma.
convexity of the tendon at the level of the metacarpophalangeal
joint (MCPJ). It is however one of the commonest locations for
symptomatic fibroma, leading to the clinical syndrome known
as trigger finger. Trigger finger is as a combination of a tendon injury
coupled with fibrous enlargement of the A1 pulley (Fig.
15.13). In the early stages, thickening of the pulley causes
little more than a palpable swelling. The underlying flexor
The aetiology of pulley fibroma is incompletely understood tendon is free to move normally beneath it (Fig. 15.14).
but may relate to chronic friction. Some occur as part of the With progression, the flexor tendon becomes chronically
spectrum of palmar fibromatosis. irritated by friction against the thickened pulley and
A1 Pulley
FDS
FDP
Figure 15.15 Trigger finger. A nodule develops in the flexor tendon

secondary to irritation from the pulley fibroma. Initially, it clicks in and
MC out from under the fibroma. In time, on flexion the nodule passes
proximal to the fibroma and will not pass distally without assistance
Prox P A from the patient. This is the classic triggering symptom.
I S
P
b
Figure 15.14 Small pulley fibroma overlying the A1 pulley.
dysfunctional movement is evident. The tendon continues

to pass normally under the pulley, but starts to push against
it, causing the pulley to elevate. In time an intratendinous
nodule develops, causing a sensation of clicking and loss of
the normal smooth flexor tendon movement. The clicking
stage is followed by the triggering stage. In this, the tendon
passes proximally beneath the fibroma on flexion, but the
nodule within it engages at the proximal end of the pulley
a
and cannot pass distally on attempted extension. The
patient must add some additional manual force to push the
nodule back beneath the fibroma and allow the finger to
straighten (Fig. 15.15). This is the classic trigger finger A1 Pulley
symptom. In some patients, the earliest manifestations may FDS
be within the tendon rather than the pulley. FDP
Pulley fibromata have a variable appearance but the
majority are moderately well, though not sharply, demar-
cated and of mixed but predominantly low reflectivity (Fig.
15.14). Occasionally calcification is evident (Fig. 15.16). A
Prox P
I S
Fibromas can occur on any of the other pulleys and Dupuy- P MC
tren’s contracture can itself extend into the finger to the
level of the A1 pulley (Fig. 15.17). Occasionally they can b
occur in children and the thumb is the most commonly
encountered location. Figure 15.16 Small calcified pulley fibroma.
A1 Pulley
A1 Pulley
Volar plate
FDS
FDP
Prox P
MC A
I S
b P
MC Prox P
Figure 15.17 Ill-defined fibrous tissue extends from the palm into A
the level of the A1 pulley. The appearance represents a combination S I
P
of pulley fibroma and Dupuytren’s tissue.
b
The underlying pulley is usually, but not invariably,
obscured by the fibroma. The diagnosis is based on the Figure 15.18 Sagittal image during percutaneous division of pulley
classic location and reflectivity of the lesion. Gentle flexion fibroma. The needle has traversed the fibroma without injuring the
and extension of the finger will identify whether or not tendon.
there is an associated tendon nodule. The movement of the
flexor tendon can also be examined as it passes underneath
the involved pulley. Dysfunctional movement of the pulley
or tendon may be a precursor of the tendon nodule. employed, a digital nerve ‘ring’ anaesthetic block can be
used. Some specialized needles have been described;
TREATMENT OF PULLEY FIBROMA however, an 18 G standard green needle is often sufficient
to cut through the pulley fibroma and disrupt the pulley
itself, thus releasing the flexor tendon. Firm resistance is felt
Key Point
as the needle is passed through the pulley, followed by a
Once detected, pulley fibromas can be treated
sudden reduction when the lesion is fully traversed. A
percutaneously either by direct corticosteroid injection number of passes are recommended to fully divide the
or a combination of corticosteroid injection and needling pulley.
(Fig. 15.18). Depending on the shape of the patient’s fingers, it may
be helpful to create a small angle in the needle. This is
generally placed where the hub meets the needle itself and
The purpose of the needling is to attempt to perform a can be induced using the needle cover as a lever. Additional
pulley release. The fibroma is approached in the sagittal bends can be placed further along the shaft of the needle
plane from either the proximal or distal end, depending on to create a greater cutting angle if there is resistance to
the shape of the patient’s hand. If a distal approach is to be needle passage.
a b c
Figure 15.20 Aetiology of Stener lesion. (A) Before injury. (B) At time
of maximal displacement. (C) Proximal phalanx reduces but ligament
remains displaced external to the aponeurosis.
A2 Pulley
FDS
FDP
recognized for many years under the traditional name of

gamekeeper’s thumb. This reflects the twisting manoeuvre
Prox P used by gamekeepers to dispatch game. Nowadays, the
A injury is more often seen in skiers when the strap of the ski
I S pole acts as a lever to impart an excessive radial or valgus
P
b force at the MCPJ during a fall. This results in a sprain or
tear of the UCLt.
Figure 15.19 Multiple pulley ganglia. The appearances can occa-
sionally mimic tenosynovitis. INJURY
The injury is an avulsion of the distal attachment of the liga-
PULLEY GANGLION ment at its insertion into the base of the proximal phalanx.
Key Point
Key Point
Pulley ganglia are commonly encountered on routine
examination of the fingers and are most often The goal of imaging in tears of the UCLt is to determine
asymptomatic. whether the torn ligament remains reduced or has displaced
proximally.
Ganglia are most frequently observed arising from the A2

pulley, although any of the flexor pulleys may be involved. The commonest circumstance is for the ligament to remain
They are not infrequently multiple (Fig. 15.19). They gener- in place and usually management is conservative. With more
ally arise from one or other end of the pulley; therefore, excessive valgus force at the time of injury (Fig. 15.20), at
when multiple they can simulate tenosynovitis. In most cases the point of maximal displacement, the torn ligament may
the fluid of tenosynovitis surrounding the tendon is com- slip out from underneath the adductor aponeurosis that
pressible and increased Doppler activity is often associated. normally covers it. As the joint reduces, the ligament is
Neither of these phenomena will be present with pulley unable to return to its normal location due to interposition
ganglia. If the lesion is felt to be the cause of the patient’s of the aponeurosis. Displacement of the torn ligament is
symptoms, aspiration can be carried out, although the size referred to as Stener lesion and stable healing will not occur
of the lesion means that very little fluid is actually retrieved without surgical reduction.
and a fenestration procedure is more usually performed. In many cases, the avulsion includes a small fragment of
bone. As this is visible on plain radiographs, the extent of
the injury can be easily determined (Fig. 15.21). If there is
COLLATERAL LIGAMENTS AND no bony fragment, ultrasound or MRI is needed for com-
VOLAR PLATE plete diagnosis.
ULTRASOUND TECHNIQUE
ULNAR COLLATERAL LIGAMENT OF THE THUMB
Careful technique is necessary to identify both the adductor
CLINICAL ASPECTS aponeurosis and the UCL itself. The preferred method of
Injuries to the ulnar collateral ligament of the meta examination is for the patient to sit opposite the examiner,
carpophalangeal joint of the thumb (UCLt) have been palm partially pronated and the probe placed in a long-axis
tightly and a gentle valgus stress can be used using the

examiner’s thumb as a fulcrum. Under normal circum-
stances some widening of the ulnar aspect of the joint is
appreciated but this is increased when the UCLt is torn.
Most ligament tears are reduced and will heal with rea-
sonable stability. The ligament will be swollen, with reduced
reflectivity, but still present ‘within the joint’ under the
adductor aponeurosis. Stress testing may reveal some addi-
tional joint widening compared with the normal side. The
joint should only be stressed if there is uncertainty about
the nature of the stable injury. In these cases, stress testing
is used to differentiate the torn ligament from an old scarred
reattached ligament. The torn end of the ligament may be
easier to see if separation between it and its phalangeal
a b c d
attachment is increased during the stress manoeuvre. Gentle
stress only is needed to make this differentiation, which has
Figure 15.21 (A) Normal anatomy: the UCLt lies deep to the adduc-
tor aponeurosis. (B) Avulsion fracture. A diagnosis can be made on
little impact on management. Vigorous stress should be
plain radiography. (C) In situ ligament avulsion. Ultrasound is required avoided, although the risk of converting a stable to an unsta-
to distinguish this stable injury from (D) Stener lesion, where the ble injury is low.
ligament is displaced proximally and lies outside the adductor
aponeurosis. Key Point
A displaced UCLt injury is called a Stener lesion.
Practice Tip
The tip of the UCLt can be identified, curled up and

associated with a mixed but predominantly hyporeflective
mass, at or proximal to the level of the metacarpal head.
The appearance of the mass and attached ligament has

sometimes been likened to a yoyo (Fig. 15.23). There will
be little substantial tissue in the normal location of the liga-
ment within the joint. Gentle movement of the thumb will
show fluid filling the space deep to the aponeurosis where
the ligament should be. Stener lesions are relatively uncom-
mon compared with injuries where the ligament does not
displace.
Figure 15.22 Slight flexion of the IPJ of the thumb will move the COLLATERAL LIGAMENT AND VOLAR
aponeurosis, helping to visually separate it from the underlying UCLt. PLATE INJURIES
The UCLt itself can be stressed by gentle valgus on the MCPJ.
ANATOMY
Imaging is rarely requested to evaluate the collateral liga-
coronal plane between the thumb and index finger, ments of the small joints of the finger. The anatomy of these
approaching from the extensor side. The injured thumb is ligaments is complex. There is a collateral ligament proper,
then held in the examiner’s free hand with the tip of the one each on the radial and ulnar side of the metacarpalpha-
patient’s thumb held between the middle finger and the langeal joint. These are orientated in the off-coronal plane
thumb, and the index finger placed along the radial aspect with the distal attachment of the ligaments lying slightly
of the injured joint (Fig. 15.22). more volar than the proximal attachment. In addition,
there is an accessory collateral ligament that lies volar to the
proper collateral ligament and is attached, in part, with a
Practice Tip
proper collateral ligament and the volar plate. The volar
In this position, gentle flexion of the IPJ can be used to plate represents a fibrocartilaginous reinforcement of the
identify movement in the adductor aponeurosis. volar aspect of the joint. It is approximately quadrilateral in
shape with its base attached to the base of the proximal
phalanx in the case of the PIPJ volar plate, and the corre-
This manoeuvre does not move the underlying UCLt that sponding proximal bone in the case of the MCPJ and DIPJ.
can thus be appreciated separately. Following this, the index Proximally it attaches by two slips, referred to as the suspen-
finger can be used to secure the patient’s thumb more sory ligaments, on the volar aspect of the distal shaft of the
FDS
FDP
plate
Aponeurosis Volar
Tear
Capsule
UCL
Tear Prox P
MC
b
A MC
Prox P Figure 15.24 Sagittal image overlying the MCPJ. There is separa-
S I
P tion of the volar plate from its attachment of the base of the proximal
phalanx. Degenerative changes are also present in this joint.
Figure 15.23 The UCL has become displaced and forms a mass
just proximal to the level of the metacarpal head. Displaced into this of important respects. They also share a certain similarity.
location, the ligament will not heal without surgical reduction. This is The extensor tendons do not have a tendon sheath and
referred to as a Stener lesion. thus tenosynovitis strictly does not occur; inflammatory
reaction may be present in and around the paratenon
(Fig. 15.25).
metacarpal. The flexor tendon passes volar to the volar plate
outside the capsule of the joint and is constrained by the A1
pulley. Practice Tip
Injuries to the collateral ligament system are common but
are rarely imaged. The most common pathology is inflam- If extensor tendinopathy or paratenonopathy is localized, a
matory and degenerative arthropathies. history of penetrating injury and foreign body material should
be sought (Fig. 15.26).
Key Point
The volar plate, however, can be injured by forced The distal portion of the extensor tendons are most often
hyperextension of the MCPJ either with or without a bony single, as opposed to having a paired superficialis/profundus
fracture on the volar aspect of the base of the middle combination like the flexor tendon. Some are paired in a
phalanx (Fig. 15.24). sense that there are two separate extensor tendons running
side by side. As they approach the PIPJ, they attempt to
simulate the arrangement of the flexor tendons. In this
Static imaging reveals the separation between the plate and location, the tendon divides into a central and two lateral
the underlying bone, with or without an attached bony frag- slips. The central portion, called the central slip, inserts into
ment. Like UCLt injuries outlined above, the presence of a the base of the middle phalanx. The two lateral slips recom-
bony fragment facilitates plain film diagnosis. In its absence, bine and insert as a single extensor tendon into the base of
ultrasound is the primary method for making the correct the distal phalanx.
diagnosis. Gentle flexion and extension show loss of syn- The extensor tendons do not have a true pulley system
chronicity between the plate and the adjacent bone. but are held in place by a ligamentous expansion called
the extensor or dorsal hood. The common injuries to the
extensor system are, therefore, tears of the dorsal hood/
EXTENSOR TENDONS sagittal band, central slip avulsion and avulsions of the
distal insertion. In turn, these are each more commonly
As has already been outlined in the techniques section, the referred to as boxer’s knuckle, boutonniere deformity and
extensor tendons differ from the flexor side in a number mallet finger.
a Ext T
Prox P
P
I S
b A
Ext T
Figure 15.26 Extensor tenosynovitis. In this case, the granuloma-
tous reaction is being stimulated by a small foreign body just visible
between the underlying phalanx and the extensor tendon.
P
I S
A is most commonly due to impact of the fingertip on a ball,
b leading to forced flexion. Clinically, the patient will be
unable to extend the DIPJ with the PIPJ fixed. The diagnosis
Figure 15.25 Extensor tenosynovitis with increased Doppler signal
around the extensor tendon. Fluid is less likely to gather around the
can be made on the plain radiographs if there is an associ-
extensor tendon as there is no loose synovial sheath. ated avulsion fracture. The ultrasound examination demon-
strates interruption of the distal portion of the tendon
either at its attachment or, more likely, just proximal to it,
with a small stump of tendon remaining attached to bone.
CENTRAL SLIP RUPTURE
Some retraction is evident, but the tip of the tendon gener-
The extensor tendon at the IPJ comprises a central slip and ally remains in close proximity to zone 1.
two lateral slips. The central slip inserts into the base of the
middle phalanx. Rupture may be due to hyperflexion injury
DORSAL HOOD INJURY
or penetrating injury. The most common clinical clue is
tenderness centrally over the dorsal aspect of the joint. On The dorsal hood is attached to the underlying metacarpal
occasion, a defect in the tendon may be palpated. Rupture head by medial and lateral sagittal bands (Fig. 15.27). Tears
leads to volar migration of the lateral slips and dorsal dis- of the sagittal bands are most associated with boxing and
placement of the PIPJ, resulting in the classic boutonniere are torn during fist impaction. Tears allow the extensor
deformity. tendon to sublux on flexion. This is usually palpable and
If a bone fragment is included in the avulsion, the diag- imaging is generally not needed.
nosis may be made on plain radiographs.
Key Point
Practice Tip
In cases where there is clinical difficulty or difficulty in
examining large or chubby hands, ultrasound can readily
If a bone fragment is not present, the ultrasound of a central
demonstrate the abnormal tendon movement in dorsal hood
slip tear shows loss of the normal reflective tendon fibrils that
lesions.
are replaced by an ill-defined, low-reflective mass.
The probe is positioned in short axis across the involved

Subluxation of the joint may be evident and gentle flexion metacarpal head. It is sometimes helpful to slightly extend
movements will help to confirm tendon disruption. the wrist to allow the patient to more tightly flex the fingers
when needed (Fig. 15.28). The extensor tendon is usually
located centrally or slightly to one side on the central groove
MALLET FINGER
in the metacarpal head (Fig. 15.29). As the patient flexes
Mallet finger is due to an avulsion of the insertion of the tightly, the extensor tendon moves over the metacarpal
extensor tendon into the distal phalanx. It is also sometimes head (Fig. 15.30). The tear of the sagittal band may also be
referred to as baseball finger or dropped finger. The injury visualized directly.
Ext hood
Ext T
Tear
MC
P
ML
b
A
Figure 15.29 Normal position of the extensor tendon lying central

or just mildly deviated from the centre of the underlying metacarpal
head. Relaxed position; there is a tear of the dorsal hood.
Figure 15.27 Schematic diagram of the extensor expansion. The
dorsal hood is formed in multiple contributions, including interossei.
The dorsal sling preserves the extensor tendon in the current location
on flexion. A tear of one of the components of the hood predisposes
the tendon subluxation.
Ext hood
tT
Ex
Tear
MC
Figure 15.28 The dorsal hood can be stressed by active flexion.

The probe is held in the axial plane over the extensor tendon while
the patient forms a fist with repetitive relaxation.
P
ML
b A
Figure 15.30 Stressed position. The extensor tendon has displaced

around the margin of the metacarpal head.
SMALL JOINTS OF THE HAND
High resolution ultrasound probes with excellent spatial

resolution, particularly for structures near the skin surface,
have led to increasing use of ultrasound in the assessment
of small joint disease. Although a complete examination
which includes both hands and both feet is rather time
consuming, it is considerably less time consuming for the
patient than an MRI examination of these areas. Ultra-
sound can also be targeted to involved joints and cope with
evolving symptoms between clinical referral and imaging.
For the hands, the examination should include at least the
dorsal aspects of the finger and the wrist joints, the radial
aspects of the second MCP, PIP and DIPJs and an assess-
ment of the flexor and extensor tendons. The volar aspects a
of the joints can also be examined during the assessment of
the flexor tendons, although some authors point out that
this is not always additional. The examination of the feet
concentrates on the metatarsophalangeal joints (MTPJs)
but is easily extended to include the interphalangeal and
tarsal joints.
WHAT TO LOOK FOR

The earliest ultrasound finding in joint pathology is MC
effusion.
Trapezium
Key Point L
S I
M
A small quantity of fluid may be detected in the normal joint b
but an increase in quantity is suggestive of underlying joint
disease if there is no history of trauma. Figure 15.31 Long axis coronal view with effusion and synovial
thickening in the first carpometacarpal joint. Low-signal component
represents fluid. Increased reflectivity represents a synovial thicken-
ing with Doppler activity.
In some joints, effusion is common and there is a poor cor-
relation between increasing fluid and symptoms. The first
metatarsophalageal joint is the best example of this. As
the disease progresses, synovial thickening appears with
increased Doppler activity (Fig. 15.31) and, if this remains The use of Doppler colour flow assessment also helps to dif-
uncontrolled, bony erosions can occur (Fig. 15.32). The ferentiate synovial thickening from effusion as well as provid-
role of imaging is to detect clinically occult effusion, syno- ing some measure of synovial blood flow and consequently
vitis and erosion and to help confirm the diagnosis of an inflammatory activity. Without a sensitive assessment of
inflammatory arthropathy, grade it, help determine treat- blood flow, it is difficult to differentiate active synovial thick-
ment and follow improvement during treatment. ening from inactive pannus, fibrosis or complex effusion.
The examiner should take care not to exert undue probe
pressure as blood flow within the smaller vessels may be
SYNOVITIS VERSUS EFFUSION
compressed and obscured. Commercial gel pads are difficult
Synovial thickening has a different appearance on ultra- to secure in position when examining multiple small joints.
sound to joint effusion. Effusion is echo-poor (black), as Liberal use of coupling gel is preferred. The probe can be
opposed to synovial thickening that contains increased floated in the jelly without actually touching the skin and
echoes, reflecting its more complex structure. supported by the operator’s hand, resting on the couch or
the patient.
Practice Tip GRADING

Fluid can also be displaced from one part of the joint to Various grading systems of synovial thickening have been
another either by compression with the ultrasound probe or proposed. Usually a four-point scale (normal, mild, moder-
using joint movement or gravity. Synovial thickening is more ate, severe) is used. Various objective measurements have
difficult to either displace or compress. been proposed; however, these can be difficult to apply to
the normal population.
significant blood flow involving 50% or less of the abnormal

synovium is grade 2. Other authors suggest counting the
abnormal vessels and, if there are between 7 and 10 present,
the Doppler signal is graded 2. Active blood flow involving
more than 50% of the involved synovium, or more than 10
visible vessels is grade 3.
Key Point
The ultrasound report of the involved joint should include

three points: one representing the severity of synovial
thickening, the second referring to the degree of Doppler
activity and the third whether erosions are present.
If necessary, erosions can be further quantified by number

or size or involvement or percentage involvement of the
Ext T
joint surface.
A role for ultrasound contrast medium has also been
proposed. Ultrasound contrast works by releasing micro-
Syno
vium bubbles of gas in the circulation that are easily detectable
by ultrasound. The earliest compounds used microbubbles
of air, whereas later materials use other gases that are more
Radius readily and specifically detected using particular ultrasound
frequencies called harmonics. The combination of tissue
harmonics with contrast injection allows the introduction of
Lunate P subtraction techniques that provide additional information
Capitate
I S on blood flow to the involved joint. Ultrasound contrast can
A be administered either as a single bolus or as continuous
b infusion. Continuous infusion provides a more stable blood
Figure 15.32 Sagittal view of the dorsal aspect of the radiocarpal and level and, consequently, a more accurate assessment of
midcarpal joint. Reflective synovial thickening enlarges the space. The blood flow in the synovium of one joint when compared
underlying bony margin is not smooth, indicative of erosion. with another. Although it has been clearly shown that the
use of ultrasound contrast agents can improve the detection
of blood flow in diseased synovium, the precise clinical role
has yet to be firmly established.
Practice Tip
It should also be appreciated that there is considerable

FURTHER READING
intracapsular but extrasynovial fat in the small joints of the Aronowitz ER, Leddy JP. Closed tendon injuries of the hand and wrist
hand. Consequently, displacement of the capsule or in athletes. Clin Sports Med 1998;17(3):449–67.
periarticular ligaments by increases in periarticular fat should Barton N. Sports injuries of the hand and wrist. Br J Sports Med
1997;31(3):191–6.
not be misinterpreted as joint pathology.
Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg
1990;15(2):268–70.
Doyle JR. Anatomy of the finger flexor tendon sheath and pulley
system. J Hand Surg 1988;13(4):473–84.
Fat tends to be reflective or bright on ultrasound, as opposed Hame SL, Melone CP Jr. Boxer’s knuckle. Traumatic disruption of the
to synovial thickening, which is usually darker. extensor hood. Hand Clin 2000;16(3):375.
Ishizuki M, Sugihara T, Wakabayashi Y, et al. Stener-like lesions of col-
Minimal thickening of the synovium when compared with
lateral ligament ruptures of the metacarpophalangeal joint of the
uninvolved joints is graded as mild or 1. Obvious and major finger. J Orthop Sci 2009;14(2):150–4.
synovial thickening is graded 3, with grade 2 between these McNally EG. Ultrasound of the small joints of the hands and feet:
two extremes. The degree of blood flow is also graded. Care current status. Skel Radiol 2008;37(2):99–113.
should be taken to use a sensitive algorithm; a pulse repeti- Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the
athlete. Clin Sports Med 2006;25(3):527–42.
tion frequency (PRF) of 400–500 is suggested. Grade 1 Rajeswaran G, Lee JC, Eckersley R, et al. Ultrasound-guided percutane-
increased Doppler signal is present when a few additional ous release of the annular pulley in trigger digit. Eur Radiol
vessels are identified within the thickened synovium. More 2009;19(9):2232–7.
PART 5
HIP
165
Hip Joint and Thigh: 16
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION Position 4: Rectus Femoris Origin

Position 1: Adductor Insertion and Quadriceps
Position 2: Anterior Hip Joint Position 5: Lateral Hip
Position 3: Sartorius, Abdominal Wall Position 6: Posterior Hip
and Nerves Position 7: Hamstrings
until the rounded upper border of the adductor muscles

INTRODUCTION gives way to a low-reflective triangular shaped tendon (Figs
16.1 and 16.2). This is the common adductor tendon that
Although a comprehensive hip examination will be is attached to the pubis. The probe should be adjusted until
described, in the majority of cases the examination is it is, as far as is possible, perpendicular to the tendon in
focused on the particular presenting symptom. Potential order to best visualize it. From this location, medial move-
causes of anterior hip pain extend from the pubic symphysis ment of the probe brings it to overlie the pubic symphysis,
to the hip joint itself. Patients with lateral hip pain most which is recognized as a low-signal space between the two
frequently require an examination of the gluteal insertion pubic bones. More laterally, the adductor muscle origin
and associated bursae. Posterior pain could be due to abnor- from the inferior pubic ramus is seen.
malities extending from the hamstring attachment to the The probe is then turned into the axial plane and moved
ischium to the posterior aspect of the hip joint. slightly towards the opposite side to reveal the anterior
margin of pubic symphysis. The integrity of the anterior
POSITION 1: ADDUCTOR INSERTION annulus and the bony contour of the adjacent pubic bones
can be assessed.
IMAGING GOALS
1. Identify the common adductor tendon and its relation-
ship to the pubic symphysis. Key Point
2. Locate the muscle bellies of the adductor compartment.
3. Locate gracilis. A prominent pubis or irregular bony surface may suggest
symphysitis, though similar changes are found in
TECHNIQUE asymptomatic individuals.
The patient lies supine with the hip and knee flexed and
the hip externally rotated into the frog leg position.
Abnormal findings can be correlated with the patient’s

Practice Tip symptoms with gentle sonopalpation.
From the common tendon insertion, the probe is moved
The superficial and most palpable muscle on the medial thigh distally until the three adductor muscles are found. From
is the adductor longus. anterior to posterior they are: adductor longus, brevis and
magnus. The common adductor tendon has usually split by
this point, the larger anterior component being the tendon
The probe is placed on the anteromedial aspect of the of adductor longus. Just behind this, the smaller component
thigh, first in the short axis of the adductor longus, and then opens into a fourth muscle that overlies the adductors, the
rotated into its long axis. The probe is moved superiorly gracilis muscle (Fig. 16.3).
167
168 PART 5 — HIP
Gracilis
Adductor
Longus
Pubis
A
I S
P
b
Figure 16.1 Adductor insertion in long axis. Note the low signal Adductors
triangular shape of the common tendon. Some bony enthesopathy is L
present (this is not always symptomatic). Gentle pressure with the A P
M
probe can provide clinical correlation.
Figure 16.3 Transverse section posteromedial thigh. The Gracilis

muscle overlies the three adductors.
POSITION 2: ANTERIOR HIP JOINT

IMAGING GOALS
1. Locate hip joint.
2. Locate the iliopsoas tendon.
3. Locate the obturator nerve.
TECHNIQUE
Returning to the level of the adductor tendon, the axially
positioned probe is moved laterally along the superior pubic
ramus. Pectineus is the muscle that separates the probe
from the underlying pubic bone. Further lateral movement
Figure 16.2 Frog-leg position for identifying the common adductor reveals the anterior acetabular wall, anterior labrum and
tendon. In this position, the palpable muscle is adductor longus. The rounded contour of the femoral head (Fig. 16.4). A small
probe can be placed lengthways along this muscle and then moved quantity of fluid may be detected in the hip joint. The psoas
proximally until the triangular-shaped tendon appears. muscle/tendon lies lateral to pectineus, with the fleshy
CHAPTER 16 — Hip Joint and Thigh: Anatomy and Techniques 169
a
a
Iliacus
us
or Long
Ad duct
Psoas
evis ON
cto r Br
A ddu
Acetabulum s
erni
to r Int A
Obtura LM
A P
LM Femoral
P Head b
b Figure 16.5 Axial image medial to the hip joint below, the superior
pubic ramus. The obturator nerve can be located as it emerges from
Figure 16.4 Hip joint axial image. The rounded contour of the the obturator foramen.
femoral head provides an easily located landmark.
This is discussed more fully in the anterior hip pathology

iliacus component distinguishable from the tendinous psoas section on page 194.
portion. A little more distally the vastus intermedius appears Returning to pectineus, the probe can be moved a little
in this position. distally to just below superior pubic ramus. Once the bone
falls away from view, a neurovascular bundle is identified just
Key Point beneath pectineus, surrounded by a small cuff fat (Fig.
16.5). This is the obturator nerve and artery. It is easy to
Abnormal iliopsoas tendon movement may underlie the find in thin people, but becomes rather deep and difficult
clicking sensation felt by some patients with snapping hips. to locate with enlarging body habitus. Moving the probe
further distally still, the upper part of the adductor longus
is seen with the other adductor muscles and the obturator
Practice Tip externus below. If the probe is moved a little laterally, the
bony contour of the femur is found and can be tracked
Iliopsoas snap can be elicited by abducting, flexing and distally until the lesser trochanter is visualized. This is a
externally rotating the hip and then bringing it back to the good position to identify the insertion of the iliopsoas
normal neutral position. tendon; some rotation of the probe is required to orientate
the tendon in long axis.
170 PART 5 — HIP
On the anterior aspect of the hip, the anterosuperior

labrum, anterior capsule and femoral head articular carti-
lage are noted.
Practice Tip
The degree of joint effusion is best assessed at the

head–neck junction.
POSITION 3: SARTORIUS, ABDOMINAL WALL

AND NERVES
IMAGING GOALS
1. Identify the sartorius origin.
2. Locate the abdominal wall muscles.
3. Locate the ilioinguinal and lateral cutaneous nerves.
TECHNIQUE a
The area above the hip joint is now examined. The anterior
margin of the iliac bone is followed upwards to the anterior
superior iliac spine (ASIS). The oval-shaped tendon of sar-
torius can be seen to arise from it. Medial to this are the
muscles of the abdominal wall. These form three layers;
from superficial they are: obturator externus, obturator
internus and transversus abdominis (Fig. 16.6). The ilioin-
Obturator Externis
guinal nerve can be located between the second and third
muscle layers. At the lower margin of the abdominal wall, a
ligamentous structure passes from the ASIS to a small tuber- Obturator Internis
cle on the pubic bone. This is the inguinal ligament. The
lateral cutaneous nerve of the thigh lies beneath it, close to
its lateral attachment, surrounded by a small cuff of fat. The Transversus
nerve passes distally on the superior surface of sartorius. Abdominis
The attachment of sartorius itself is better assessed by rotat- Ilium
ing the probe 90° to view it in long axis. Lateral to the ASIS
is the origin of the iliotibial band. A
LM
Iliacus Bowel
P
POSITION 4: RECTUS FEMORIS ORIGIN AND b
QUADRICEPS
Figure 16.6 Muscles of the anterior abdominal wall.
IMAGING GOALS
1. Identify the two heads of rectus femoris.
2. Locate the components of the quadriceps compartment.
3. Locate the femoral nerve. The quadriceps compartment comprises the vastus medi-
alis, lateralis and intermedius in addition to the rectus
TECHNIQUE femoris. The rectus femoris is most recognizable from its
The illac crest is followed inferiorly to the anterior inferior superficial location, oval shape and prominent central
iliac spine (AIIS). The main or direct of the two origins tendon in short axis (Fig. 16.8). These features also help to
of rectus femoris originates here and is the most easily visu- distinguish it from sartorius that lies initially lateral then
alized (Fig. 16.7). As the direct head is followed distally, it medial as it passes distally in the thigh. In the proximal
is joined by the second or indirect/reflected head on its thigh, tensor fasciae latae also lies laterally.
lateral side. This head has its origin from the superior The vastus lateralis is the largest of the quadriceps
margin of the acetabulum. In most cases, it is identified by muscles. It arises from the intertrochanteric line, just below
the anisotropic shadow that it creates rather than directly the gluteus minimus insertion, and the upper half of the
visualizing it, as seeing it in long axis is challenging. In thin lateral lip of the linea aspera. The distal tendon forms from
people, the probe can be moved a little more laterally and an aponeurosis on the surface of the muscle: this aponeu-
tilted medially, which may help to depict it more clearly. The rosis forms part of the quadriceps tendon and inserts on the
two heads combine to form the conjoined tendon. In the superolateral border of the patella. The vastus medialis also
proximal thigh, the rectus femoris lies between the iliopsoas arises from the intertrochanteric line, the linea aspera and
medially, sartorius anteriorly and laterally and tensor fasciae the tendons of the adductor group. Its distal tendon arises
latae laterally. from the deep surface of the muscle and inserts onto the
a a
rius
Sarto
Psoas
Rectus Femoris
TFL
Rectus Femoris
Vastus Lateralis
Gluteus
Minimus Iliacus Vastus Intermedius
Anterior Inferior
Iliac Spine
Gluteus A
LM A
Medius LM
P
P
b b
Figure 16.7 Rectus femoris, origin of the direct head from the ante- Figure 16.8 Axial section proximal thigh. The configuration of the
rior inferior iliac spine. rectus femoris muscle, with its characteristic central tendon, makes
it easy to identify.
superomedial patella. The most inferior portion of vastus The femoral artery and nerve are located in the proximal
medialis has fibres that run more obliquely towards the thigh medially. The nerve is lateral to the artery and vein
tendon. This portion of the muscle is called the vastus medi- that are, in turn, lateral to the femoral canal containing
alis obliquus and is prone to injury due to direct contusion some lymphatics and nodes.
or patellar dislocation. Vastus intermedius arises from the
upper two-thirds of the anterior femur and from the lateral POSITION 5: LATERAL HIP
intermuscular septum. It can be difficult to separate from
vastus medius proximally. Distally it forms the deep part of IMAGING GOALS
the main direct quadriceps insertion along with rectus 1. Identify gluteus medius tendon.
femoris, forming the bulk of the central component of the 2. Identify gluteus minimus tendon.
quadriceps tendon. 3. Identify perigluteal bursae.
172 PART 5 — HIP
a a
ITB
Gluteus
Maximus
s Gluteus Maximus
nimu
s Mi
eu
ut Greater Bursa
Gl anteric
Trochanter Troch
L Gluteus L
A P Medius A P
Gluteus
M M
Minimus Subgluteus
b b Medius Bursa
Figure 16.9 The slightly pointed configuration of the lateral aspect Figure 16.10 Gluteus minimus tendon is visualised just above and
of the proximal femur separates the facet when gluteus minimus posterolateral to the tip of the greater trochanter. The subgluteus
inserts (anteriorly) from the medial facet, where the lateral fibres of medius bursal space is beneath it.
gluteus medius attach.
TECHNIQUE
Key Point
The lateral hip is best examined with the patient in the
decubitus position. The probe is placed axially over the The trochanteric bursa overlies the lateral and posterior
lateral aspect of the femur. aspect of the greater trochanter deep to the gluteus
maximus. The subgluteus medius bursa lies deep to the
gluteus medius tendon above the greater trochanter and the
Practice Tip subgluteus minimus bursa lies between the gluteus minimus
tendon and the anterior aspect of the greater trochanter.
The lateral cortex of the femur is followed superiorly until it
becomes pointed. This point divides the anterior and middle
facets of the gluteus insertion.
The gluteus maximus overlies the medius and minimus and
is mainly responsible for the muscle bulk in the gluteal
compartment. It inserts via a short tendon on the posterior
The gluteus minimus tendon inserts on the anterior facet aspect of the proximal femur. On its anterior margin, overly-
(Fig. 16.9) and the lateral portion of the gluteus medius ing the greater trochanter, is the iliotibial band. This is really
insertion inserts on the middle facet. The remainder of the a thickening of the fascia lata. It originates close to the
gluteus medius tendon inserts onto the superior facet, sartorious origin, just behind the ASIS, and can be followed
which can be located by following the lateral fibres superi- to its insertion on Gerdy’s tubercle on the lateral tibia. It is
orly (Fig. 16.10). The gluteus medius has a short tendon related to a proximal muscle, the tensor fasciae latae, which
below the myotendinous junction (MTJ) (Fig. 16.11). is characterized by a rather fatty structure.
a a
Gluteus Hamstring origin

Maximus
ScN
Gluteus Maximus
Gluteus Medius L P
Greater S I Ischium LM
Trochanter M A
Gluteus Minimus
b b
Figure 16.11 Long axis view of the gluteus medius muscle and Figure 16.12 Hamstring origin.
short tendon.
Key Point TECHNIQUE

The patient is asked to lie prone. The gluteal attachments
In patients with snapping hip, US may show an abnormal
jerky movement of the posterior part of the iliotibial band
are once again identified in the axial plane, and the probe
over the greater trochanter. Occasionally it is the movement is moved medially until the ischial tuberosity is encountered
of the gluteus maximus that accounts for the snap. (Fig. 16.12). In the space between the posteromedial margin
of the tip of the greater trochanter and the ischial tuberosity
lies the hamstring origin medially, the quadratus femoris
Abnormalities may be present within the band that becomes muscle centrally and, deep to this, the tendon of obturator
thickened and disorganized. externus. The quadratus femoris and obturator externus
occupy the ischiofemoral fossa (Fig. 16.13), where muscle
impingement may occur if this space is narrow. If the probe
Practice Tip
is moved proximally, the gemelli muscles are encountered
To snap the ilitibial band, the patient lies on the unaffected immediately overlying the hip joint, recognized by their
side. The hip is adducted and extended, then moved to a prominent tendon and relatively small muscle belly (Fig.
flexed position. 16.14). Deep to this is the round contour of the femoral
head and posterior acetabular wall. Fluid in the posterior
joint space can be located here.
In some patients internal and external rotation may augment The sciatic nerve lies between the gluteus maximus
the phenomenon. and the gemelli. This is tracked proximally until it passes
through the sciatic notch and out of sight into the pelvis.
POSITION 6: POSTERIOR HIP Just before this, the posterior muscle relation (the muscle
lying between the probe and the nerve) changes from
IMAGING GOALS the gluteus maximus alone to the gluteus maximus
1. Locate the posterior hip joint space. and piriformis. In thin individuals the sacrotuberous liga-
2. Identify ischiofemoral space. ment is identified extending medially from the ischial
3. Identify sciatic nerve. tuberosity.
174 PART 5 — HIP
Gluteus Maximus
n
rigi
ringo
Hamst
Gluteus Maximus
Ischium
ScN
P
LM ScN
Quadratus Femorus
A
b
Gemellus
P
Figure 16.13 Ischiofemoral space. ML
A
Hip
Figure 16.14 Axial image posterior hip joint.

POSITION 7: HAMSTRINGS
IMAGING GOALS
1. Identify the tendon origin. Key Point
2. Differentiate semimembranosus from the conjoined
tendon. The bulk of the tendinous origin arising from the ischium
3. Identify the components of the hamstring compartment. is made up of the conjoint tendon of the semitendinosus
and biceps. The deeper and more lateral component is
semimembranosus.
TECHNIQUE
Returning to the ischium and pointing the probe a little
more medially to take account of the laterally pointing The lower portion of the ischium gives rise to adductor
ischial tuberosity, the hamstring origin is evaluated in more magnus and the sacrotuberous ligament. Sciatic nerve is
detail. There are three hamstring muscles arising from the once again identified just lateral to the hamstrings.
ischial tuberosity from two tendons. They form on the upper The semimembranosus tendon arises from the upper
part of the ischium. and lateral portion of the ischial tuberosity and forms a
a a
Semitendinosus
Semitendinosus s
Raphe anosu
embr
Semim
Rectus Semim Semitendinosus
embra
Femoris nosus
Rectus
Femoris
ScN ScN P
P Adductor LM
Adductor Magnus LM Magnus A
A
b b
Figure 16.15 Proximal hamstrings. Figure 16.16 Semitendinosus.
sheet-like (membranous) aponeurosis in the proximal thigh into various locations on the posteromedial tibia. There is
on the anterior aspect of the semitendinosus muscle belly a direct insertion, a reflected insertion (pars reflexa), a
(Fig. 16.15). This epimysial aponeurosis has a configuration posterior oblique component, and a posteroblique liga-
similar to a tadpole or the Nike tick. As the muscles are ment. The posteroblique ligament in turn inserts on the
tracked distally, the membranous origin of semimembrano- posteromedial capsule and medial collateral ligament.
sus becomes a muscle belly on the medial side of semiten- The semitendinosus and biceps femoris originate from a
dinosus. At this level it is considerably smaller than conjoint tendon arising from the lower and more medial
semitendinosus which makes up the main bulk of the ham- aspect of the upper part of the tuberosity. As they are fol-
strings, with the smaller biceps femoris laterally (Fig. 16.16). lowed distally, the conjoint tendon forms itself into two
Descending towards the knee, this size relationship becomes muscle bellies: semitendinosus medially and biceps femoris
reversed. The semitendinosus muscle becomes tendon as laterally.
the semimembranosus muscle enlarges.
Practice Tip
Practice Tip
The sciatic nerve underlies the central tendon, which can be
The semitendinosus tendon lying on the dorsal aspect of the used as a guide to locate the nerve.
now much bulkier semimembranosus muscle gives a very
characteristic appearance and is a good way to identify
which muscle is which (Fig. 16.17).
The appearance of the tendon at this level has been likened
to an ‘arrow’ pointing at the sciatic nerve. A fibrous raphe
crosses semitendinosus, dividing it into two (Fig. 16.16).
If an abnormality is found proximally, this characteristic This should not be misinterpreted as the origin of semi-
appearance can be found, the different muscles identified membranosus. Semitendinosus inserts as the most posterior
and traced proximally to the abnormality, thus helping to part of the pes anserine tendon with sartorius and gracilis
identify which muscle is injured. The insertion of semimem- (Fig. 16.18). The biceps femoris muscle is the most lateral
branosus is complex with multiple components inserting of the hamstrings. It has a second short head, which arises
176 PART 5 — HIP
a a
Semitendinosus
Gracilis
Sarto
rius
Gracilis
us
Semimembranosus nos
ra
Sar
b
em
tor
m
mi
ius
Se
P
Femur
Adductor Magnus LM P
A L N
Femur A
b b
Figure 16.17 Classic image of the bulky semimembranosus muscle Figure 16.18 Pes anserine tendons.
below with the tendon of semitendinosus on top, the ‘cherry on a
bun’ appearance.
from the linea aspera. The short head forms in the distal either side of the insertion of the lateral collateral ligament
thigh, forming a loosely connected conjoint distal biceps onto the head of the fibula. This normal configuration
tendon approximately 5 cm above its fibular insertion. The should not be misinterpreted as a tendon split. Each biceps
distal biceps tendon is bilaminar with long-head and short- also has a tibial insertion. This varies in size and in some
head components. Just above its insertion, these pass on individuals may represent the bulk of the biceps insertion.
Disorders of the Groin 17
and Hip: Groin Pain
Philip Robinson
CHAPTER OUTLINE
INTRODUCTION FEMORAL HERNIA

Normal Anatomy ABDOMINAL MUSCLES
Examination Technique and Normal ABDOMINAL WALL HERNIAS
Ultrasound Appearances SYMPHYSIS PUBIS AND ADDUCTOR MUSCLES
ULTRASOUND APPEARANCE OF INGUINAL Anatomy and Normal Ultrasound
HERNIAS Appearances
‘BULGING’ AND ‘PREHERNIA COMPLEX’ Adductor Muscles
POSTOPERATIVE EVALUATION Acute Adductor Muscle Injury
EVALUATION BY OTHER IMAGING Pubalgia (Chronic Groin Pain)
TECHNIQUES ULTRASOUND-GUIDED INTERVENTION
Herniography CONCLUSION
MRI
NORMAL ANATOMY
INTRODUCTION
Anatomically the groin contains the soft tissues of the
Commoner causes of groin discomfort in the general popu- inguinofemoral region between the anterior superior iliac
lation include inguinal hernias and muscle strains in the spine and the symphysis pubis involving the upper thigh
lower abdominal wall and upper thigh. Muscular strains in and inferior abdominal wall. Soft tissue structures include
this group of patients often do not present to a primary care the skin, superficial fat and fascia, musculature (abdominal
physician and certainly further management in the form of and upper thigh), extraperitoneal (preperitoneal) fat and
imaging is not necessary. The majority of symptomatic ingui- peritoneum.
nal hernias can also be diagnosed clinically but there is a The inguinal canal allows the passage of vessels, nerves,
role for imaging in equivocal cases as there are well- lymphatics and the spermatic cord (round ligament in
recognized limitations to clinical assessment. The clinical females) from within the abdomen to the external genitalia.
role of ultrasound in the assessment of patients with groin The posterior wall of the canal is formed by the muscle,
pain has greatly increased in the last 10 years and this tech- aponeurosis and fascia of transversus abdominis and also
nique is now commonly used for the diagnosis of clinically part of the internal oblique. The anterior canal wall is
indeterminate hernias and for the assessment of postopera- formed from the fascia of the external oblique muscle (Fig.
tive patients with groin pain. 17.1). The deep (internal) inguinal ring is a defect within
The situation in the professional athlete is more con the transversus abdominis fascia that allows the contents of
troversial, with a number of aetiologies for chronic groin the inguinal canal to leave the abdomen and enter the canal
pain described. Especially in the case of osteitis pubis, proper. The canal then extends obliquely, medially and infe-
adductor dysfunction and prehernia complex (or sports- riorly towards the pubic crest where the superficial (exter-
man’s hernia), research has been relatively anecdotal, nal) inguinal ring, a defect in the external oblique fascia,
describing a number of differing pathologies and treat- allows the contents to leave the canal (Fig. 17.2). Superficial
ments. Although there are a large number of pathologies to the canal is subcutaneous fat and skin, whereas the ilio-
that can cause groin pain, including infection, neuralgia or psoas muscle lies deep to it on its medial aspect and the
tumour, this section will concentrate on inguinofemoral external iliac vessels pass on the lateral aspect as they enter
hernias and muscular strain, highlighting the strengths and the thigh. The peritoneum and small bowel lie postero
limitations of ultrasound. superiorly (Figs 17.1 and 17.2).
177
178 PART 5 — HIP
1 2
4
5
Psoas a
Fascia
Figure 17.1 Sagittal section through the lower oblique muscles and
inguinal canal. The oblique muscles with external oblique (1) anteriorly
and transversus abdominis (2) posteriorly lie superior to the canal and
spermatic cord. The subcutaneous fat (3) and deep fascia (4) lie
anterior and blend with the external oblique fascia which inferiorly
forms the inguinal ligament (5). The psoas muscle and femoral vessels
run deep to the canal with the transversus abdominis fascia and Fascia
Pubis
peritoneum lying posteriorly and superiorly. A
LM
Bowel P
b
Figure 17.2 Normal right inguinal canal, transverse sonogram. The

Key Point IEVs lie medial to the internal ring. The thick echogenic inguinal liga
ment (large arrows) lies anteriorly, deep to the subcutaneous fat (*).
Important landmarks include the inferior epigastric vessels Multiple tubular structures are seen (small arrows) passing medially
(IEVs), which arise from the external iliac vessels and course towards the symphysis pubis (SP) and passing through the external
superiorly deep to rectus abdominis (Figs 17.3 to 17.5). ring where a defect (arrowheads) in the inguinal ligament can be
Just after their origin from the external iliac vessels they visualized.
lie immediately medial to the deep inguinal ring. Therefore
if a hernia arises lateral to these vessels, it is indirect
(passing through the internal ring), but if it arises medial
to the vessels it is a direct hernia (bulging through the musculature, although it is relatively easy to identify the
posterior wall). vessels deep to rectus abdominis, it is difficult to continu-
ously follow them because of the patient’s body habitus.
Therefore, another technique is to begin with the femoral
EXAMINATION TECHNIQUE AND NORMAL vessels in the transverse plane and move cranially until the
epigastric vessels are seen at their origin and are beginning
ULTRASOUND APPEARANCES
to pass medially. However, at this point, because the actual
It is important to identify the deep inguinal ring when course of the inguinal canal is in the transverse oblique
assessing for inguinal hernias. The canal can be initially plane, the transducer should also be oblique by rotating the
identified in the long or short axis. Both methods are out- medial aspect of the transducer inferiorly.
lined below and whichever you choose is a personal prefer- In this position a longitudinal image of the canal is
ence as merely rotating the probe through 90° will obtain obtained, which includes the epigastric vessels, femoral
the other view. vessels and proximal inguinal canal. The inguinal ligament
is seen as an echogenic line deep to the subcutaneous fat
LONG AXIS VIEW blending with the deep fascia (Figs 17.2 and 17.4). Deep to
There are two main methods for visualizing the epigastric the ligament are multiple hyperechoic and hypoechoic
vessels, the landmark for assessing the deep ring on dynamic linear structures (representing vessels, nerves and cords)
examination. The first method is to scan the rectus abdomi- within the canal. Their prominence is variable and they pass
nis muscle transversely and identify the inferior epigastric medially to exit the canal through the external ring (seen
vessels (IEVs) within the rectus sheath on its deep aspect as a defect of the inguinal ligament) (Figs 17.2 and 17.4).
(Fig. 17.3). By continuous scanning in the transverse plane Depending on body habitus the amount of fat within the
the vessels can be followed inferiorly as they sweep to join canal will also vary. Deep to the canal lies the psoas muscle,
the external iliac vessels. However, in obese patients with lax but echogenic peritoneum and hypoechoic bowel (and a
CHAPTER 17 — Disorders of the Groin and Hip: Groin Pain 179
a
b
Figure 17.3 Normal IEVs, transverse sonogram, lower abdomen.

Normal appearances of rectus abdominis with its thick investing
fascia (arrowheads). The inferior epigastric artery (large arrow) and
veins (arrowheads) can be seen deep to the muscle but still within
the investing fascia.
varying amount of preperitoneal fat) lie posterosuperiorly

(Figs 17.1 and 17.5).
Assessment of this area with the patient at rest and
straining (performing a slow Valsalva manoeuvre) is now
performed.
Key Point b
With Valsalva manoeuvre, there is normally bulging of the

posterior wall and peritoneum but it should not completely
occlude the canal (Fig. 17.4).
Occasionally the venous structures within the canal can also

distend but again this is quite variable.
Practice Tip
It is important to instruct the patient to perform the Valsalva

manoeuvre slowly (i.e. not cough) and to ensure that
transducer pressure is not applied too firmly otherwise any
potential hernia will be maintained in reduction.
c
If the patient finds this difficult then blowing hard with the
Figure 17.4 Normal right inguinal canal, transverse sonograms.
fist against their lips will produce the same effect. (A) At rest, femoral and IEVs (arrowheads) at the medial aspect of the
canal. Multiple tubular structures are traversing the canal deep to the
SHORT AXIS VIEW
inguinal ligament (short arrows). Note the anteroposterior dimension
The canal should then be assessed in its short axis, which is of the canal (long arrows). (B, C) On straining, there is marked disten
the anatomical sagittal plane (Fig. 17.1). To primarily obtain sion of the vessels (arrowheads) at the medial aspect of the canal,
this view a sagittal image of the hip is obtained. The probe narrowing of the canal anteroposteriorly (long arrows) but no altera
is then moved medially to the external iliac/femoral vessels tion in the contents of the canal itself.
and longitudinally to view the IEVs as they arise and begin
180 PART 5 — HIP
a d
b e
Figure 17.5 Normal left inguinal canal, sagittal sonograms. (A, B) Image obtained
at the level of the inferior epigastric vein (*) as it arises from the femoral vein (FV).
The inguinal canal is seen as an oval shaped soft tissue area containing multiple
tubular structures (arrows) with rectus abdominis (RA) lying superiorly. (C) Medial to
position in (A). (D, E) Medial to (C) at the level of the superficial ring as the contents
c
(arrows) descend over the pubis (Pu) and adductor origin (Add).
to pass superiorly towards rectus abdominis (Fig. 17.5A). At wall into the inguinal canal. Because of this the hernia rarely
this point the transducer should be moved slightly more continues distally along the inguinal canal itself and is more
medially to come off the epigastric vessels. The short axis of localized in comparison to indirect hernias.
the inguinal canal with its hypoechoic tubular contents can On ultrasound the appearance of the normal inguinal
now be visualized with peritoneum and bowel posterosupe- contents can be variable and, unless there is a large irreduc-
riorly (Fig. 17.5). On straining in a normal subject, there ible hernia present, it is difficult to determine a small hernia
may be slight dilatation of the vessels within the canal and within the canal on static imaging.
the bowel should move towards the canal but should not
completely efface or enter the canal (Fig. 17.6).
Key Point
ULTRASOUND APPEARANCE OF It is during the dynamic component of the examination that

INGUINAL HERNIAS the hernia sac and its contents can be observed moving
into the canal and reducing (partially or completely) on rest
with transducer pressure.
Indirect hernias protrude through the internal inguinal ring
and extend along the inguinal canal parallel to its long axis.
The hernia usually consists of peritoneum, fat and bowel.
Occasionally the hernia can be congenital due to a persistent Practice Tip
processus vaginalis; however, this can be an incidental
finding with the condition persisting in 29% of adults. In the transverse plane an indirect hernia arises lateral to the
Direct inguinal hernias occur due to a defect in the pos- epigastric vessels and extends through the long axis of the
terior inguinal wall, within the transversus abdominis fascia, canal (Figs 17.7 and 17.8).
allowing protrusion of peritoneum and bowel through the
a b c
Figure 17.6 Normal inguinal canal, sagittal sonograms medial to the IEVs. (A) At rest, oval shaped inguinal canal (large arrows) with postero
superiorly echogenic peritoneum (small arrow). (B, C) On straining, the echogenic peritoneum (small arrow) and hypoechoic bowel push inferiorly
and anteriorly, compressing the inguinal canal.
a c
b d
Figure 17.7 Right indirect inguinal hernia. (A, B) Transverse sonogram during straining shows the IEVs on the medial aspect of the canal
marking the internal inguinal ring. There is marked distension of the canal by hypoechoic bowel and echogenic peritoneum (arrows) arising
lateral to the IEVs and pushing along the canal. (C, D) Corresponding sagittal sonogram shows psoas (Ps) and marked distension of the canal
with obliteration of the normal contents by bowel (arrows).
182 PART 5 — HIP
with the bowel and peritoneum (Fig. 17.10). Careful note

should also be made on scanning in either plane for other
less common inguinal abnormalities, e.g. lipoma, haema-
toma, lymph node, varicocele, cyst of Nuck or undescended
testicle (Figs 17.11 to 17.13).
‘BULGING’ AND ‘PREHERNIA COMPLEX’
a Bulging of the transversalis fascia, where the posterior ingui-

nal wall almost occludes the canal on straining without
actual herniation, has been proposed as a source of pain or
‘prehernia’ condition (Fig. 17.6).
Key Point
Ultrasound and herniography do not confirm that bulging of

the transversalis fascia correlates with pain or is part of the
spectrum of direct hernia.
As it does not represent a definite hernia it should be cau-

tiously interpreted. Comment can be made when wall
bulging occurs on the symptomatic side and is markedly
asymmetrical with the asymptomatic side.
POSTOPERATIVE EVALUATION
There are a number of surgical procedures described for

b hernia repair, but all involve reduction of the hernia and
Figure 17.8 Incarcerated right indirect inguinal hernia. (A) Trans then correction of the defect by oversewing or mesh
verse sonogram at rest shows the IEVs, hernia of bowel and fat insertion.
(arrows) entering through the deep ring (*). (B) Corresponding sagittal
sonogram shows marked distension of the canal with obliteration of
the normal contents by bowel (arrows). Key Point
When a mass recurs after surgical repair ultrasound can

When scanning sagittally (short axis of the canal) the indi- help differentiate between recurrent hernia and a static
rect hernia can be seen distending the canal and effacing haematoma or seroma (Fig. 17.14).
its contents (Figs 17.7 and 17.8).
If a mesh is used to repair the hernia, it is usually situated

Practice Tip
over the internal inguinal ring or posterior wall depending
In the transverse plane a direct hernia will protrude through on the type of hernia repaired. The metallic mesh can be
the posterior canal wall medial to the epigastric vessels visualized as a hyperechoic serrated linear structure just
(Fig. 17.9A). adjacent to the epigastric vessels (Fig. 17.14). Occasionally,
after operative repair of indirect hernias, peritoneum can
still be seen herniating into the canal, although the repair
In the sagittal plane (short axis of the canal) the direct is sufficient to prevent bowel herniation. This is because the
hernia will push into the canal from the posterior and supe- peritoneal sac is often left intact to reduce any trauma to
rior aspect and efface its contents (Fig. 17.9B). the spermatic vessels during surgery. Patients can also
The contents of any hernia have a similar appearance on develop a preperitoneal ‘lipoma’ within the canal due to
ultrasound, with a relatively hyperechoic margin of the peri- separation from preperitoneal fat. This can show some
toneum and hypoechoic bowel contents (predominantly movement on straining but is usually differentiated from a
fluid and gas) (Figs 17.7 to 17.9). If the hernia is a persistent recurrent hernia by the fact that it is more homogeneous
processus vaginalis it will appear similar to peritoneum, with with increased echotexture (Fig. 17.15). Neuralgia is another
two opposing echogenic layers seen sliding over each other relatively common postoperative complication (2%) but
on straining. Occasionally preperitoneal fat will also herni- in this instance ultrasound is usually normal; however, post-
ate into the canal, appearing more homogeneous and surgical neuromas and stitch granulomas can be detected
hyperechoic compared to the bowel and sometimes moving (Fig. 17.16).
a c
b d
Figure 17.9 Right direct hernia. (A, B) Transverse sonogram during straining shows the IEVs and adjacent transversus fascia (arrows) lateral
to a hernia of bowel and fat (*) entering through posterior wall defect. (C, D) Corresponding sagittal sonogram shows hypoechoic loop of bowel
(small arrows) pushing through the posterior wall (large arrows).
In summary, the clinical indication for ultrasound exami- very sensitive but relatively nonspecific technique, demon-
nation in this context is often to exclude a recurrent hernia, strating a large number of asymptomatic hernias. Although
detect haematoma or granuloma for treatment. A negative herniography has been shown to have a low complication
scan, indicating onward referral for pain management if rate, this procedure is still invasive and requires ionizing
completely normal, for presumed neuralgia. radiation. This procedure is rarely used now, having been
superseded by ultrasound.
EVALUATION BY OTHER IMAGING
TECHNIQUES MRI
The use of MR imaging in evaluating inguinal hernias has
HERNIOGRAPHY
only been described in a limited number of studies, with two
Herniography has been extensively evaluated in patients series comparing the accuracy of MR imaging with ultra-
with equivocal clinical features and has been shown to be a sound and clinical examination. The older study described
184 PART 5 — HIP
a
Figure 17.11 Female presenting with right inguinal swelling. Trans
verse sonogram at rest shows a cystic mass (*) superficial to
and compressing the inguinal canal (arrows), consistent with a cyst
of Nuck.
Figure 17.10 Indirect hernia due to a preperitoneal lipoma. (A) Trans

verse sonogram during straining shows a well-defined homogeneous Figure 17.12 Right inguinal mass, transverse sonogram. A well-
hyperechoic mass extending along the inguinal canal (arrowheads), defined oval homogeneous soft tissue mass lies medial to the IEVs
consistent with a lipoma. (B) Sagittal sonogram confirms the homo and is surrounded by hypoechoic fluid. The inguinal ligament can be
geneous hyperechoic mass filling the inguinal canal and effacing its seen anteriorly (large arrowheads). The features on ultrasound were
contents (arrowheads). consistent with an undescended testicle, confirmed at surgery.
an MR imaging technique involving rapid acquisition of

coronal images while the patient performed a Valsalva FEMORAL HERNIA
manoeuvre. Although accurate (sensitivity 94% and specific-
ity 96%), the majority of the hernias were clinically evident The femoral canal is a large potential space containing fat
and differentiation between direct and indirect hernias was and lymph nodes that lies medial to the femoral vein, just
not always possible. In addition, the authors erroneously distal to the inguinal ligament. Femoral hernias are rela-
recorded ultrasound posterior wall bulging as actual hernia- tively infrequent in male patients and are commoner in
tion and the ultrasound technology has now been surpassed. middle-aged female patients. However, anecdotally it can
A more recent study of subclinical hernias found ultrasound occur in male patients after inguinal surgery, presumably
to be superior in comparison to static MRI. due to scar tissue concentrating abdominal pressure on the
a
a
b
b
Figure 17.13 Female varicocele presenting with right inguinal pain.
(A) Transverse sonogram at rest shows a cystic mass in the inguinal
canal (arrows). (B) Colour Doppler shows multiple vessels.
femoral canal. Pathologically the hernia sac passes from the

abdomen deep to the inguinal canal and into the femoral
canal. Quite commonly the bowel does not completely enter
the canal but pushes preperitoneal fat into it.
Practice Tip
The femoral canal is located by scanning the femoral vessels

in the transverse plane.
Just below the inguinal canal the femoral canal lies imme- c
diately medial to the femoral vein (Fig. 17.17).
Figure 17.14 Left inguinal mass after direct hernia repair, transverse
sonograms. (A, B) A well-defined hyperechoic linear structure (arrows)
Practice Tip lies on the deep aspect of the inguinal canal and has the typical
appearance of a mesh placed over the posterior inguinal wall.
The patient is then asked to perform a controlled Valsalva However, filling the canal is a lobulated, predominantly heteroge
manoeuvre and the femoral vein and canal are assessed. neous soft tissue mass consistent with a postoperative haematoma
(arrows). (C) Colour Doppler shows no flow within the solid areas.
186 PART 5 — HIP
Figure 17.16 Painful lump 8 months after right direct hernia repair,
a transverse sonogram. The tubular contents of the inguinal canal can
be seen (small arrows) with the inguinal ligament anteriorly (large
arrows). The medial aspect of the ligament is displaced anteriorly by
a hypoechoic mass (large arrowheads) containing a small linear
hyperechoic structure (small arrowheads). This small linear structure
had the appearance of a foreign body and was confirmed to be a
stitch granuloma at surgery.
a
b
Figure 17.15 Palpable mass after left indirect hernia repair. (A) Trans
verse sonogram shows a well-defined and homogeneous hyperechoic
soft tissue mass within the canal medial to the IEVs. Features are
consistent with a lipoma. (B) Sagittal sonogram confirms the hyper
echoic lipoma filling the inguinal canal.
Normally the femoral vein should distend and the adjacent

tissues are not distorted (Fig. 17.17). This expansion of the
vein into the potential space of the adjacent femoral canal
implies there is no mass effect from within the canal itself.
Key Point
b
A femoral hernia expands the canal, reducing or preventing Figure 17.17 Normal left femoral canal. Transverse sonograms at
the normal expansion of the femoral vein (Fig. 17.18). rest shows the femoral vein (FV) is not distended, with the femoral
canal (arrows) medially.
a c
b d
Figure 17.18 Right femoral hernia, transverse sonograms. (A, B) At rest shows the femoral vein (FV) and canal (arrows). (C, D) During straining
a hernia of fat and bowel (arrows) expands the femoral canal.
On noting this appearance the hernia should be con- ABDOMINAL MUSCLES

firmed by scanning over the canal in the longitudinal plane.
This can be achieved by obtaining a longitudinal image The musculature of the lower abdominal wall includes the
of the femoral vein and then moving the transducer medi- external oblique, internal oblique, transversus abdominis
ally. On performing the Valsalva manoeuvre the bowel and and rectus abdominis muscles. These muscles have a pos-
peritoneum can be seen extending inferiorly into the canal tural function, with a linear configuration that predomi-
(Fig. 17.18). nantly consists of type T1 fibres. The rectus abdominis lies
188 PART 5 — HIP
a
a
Figure 17.19 Normal abdominal muscles, extended field of view

(SieScape) transverse sonogram. Rectus abdominis (RA) can be seen
medially with the oblique muscles lying laterally (external oblique, EO;
internal oblique, IO; transverse abdominis, TA). Note the thick con
tinuous investing fascia (arrows).
c
Figure 17.20 Abdominal wall hernias. (A, B) Spigelian hernia of the

bowel (arrowheads) extending into the subcutaneous fat through a
either side of the midline raphe, running inferiorly to blend defect (arrows) between rectus abdominis and the oblique muscles
with the superior aspect of the symphysis pubis and the (O). (C) Incisional hernia. Extended field of view sonogram shows a
adductor musculature. The other abdominal muscles form defect in the deep fascia (arrows) with a protrusion of the bowel
three layers at the lateral margin of the rectus abdominis (arrowheads) extending into the subcutaneous fat.
with external oblique outermost, internal oblique and then
transversus abdominis lying innermost (Fig. 17.19). Tears of
these muscles are relatively rare, except in athletes, where
rectus abdominis is the most commonly affected (especially umbilical. All three types of hernia involve protrusion of at
in weightlifters and gymnasts). Haematomas can form after least peritoneum and preperitoneal fat through a defect in
trauma, surgery or spontaneously in patients taking antico- the abdominal wall musculature and fascia.
agulants. However, abdominal wall hernias are also common. Spigelian hernias occur through a weakness of the
The easiest way to examine this group of muscles is to lateral rectus abdominis sheath at its margin with the
scan transversely in the midline, locating rectus abdominis oblique muscles (linea semilunaris) at the point where
and then moving laterally to the oblique abdominal muscles the IEVs penetrate the rectus sheath (Fig. 17.20).
(Fig 17.19). On ultrasound this muscle group has the Incisional hernias arise from muscular weakness due to
appearance of any other skeletal muscle. The rectus sheath previous surgery and resulting scar tissue (Fig. 17.20C). This
is visualized as thick echogenic fascia, which blends with the is a common clinical problem, with an estimated 10% of all
investing fascia of the oblique muscles (Figs 17.3 and 17.19). hernia operations being for repair of this type of hernia.
Once the anatomy of these muscles has been defined, the Umbilical hernias present in the midline and can be con-
position of any pathology can be identified. genital but usually occur in patients who are overweight,
postpartum or have marked abdominal distension due to
ascites.
ABDOMINAL WALL HERNIAS For all these conditions the area to be evaluated can be
confirmed on taking a history. The role of ultrasound is to
Apart from inguinofemoral hernias there are three other confirm the contents of the hernia (fat and/or bowel) and
types of abdominal wall hernia: Spigelian, incisional and determine the size of the fascial defect (Fig. 17.20).
a
a
b Figure 17.22 Normal symphysis pubis. Sagittal sonogram shows

the irregular echogenic pubic cortical margin (arrowheads), overlying
Figure 17.21 Normal symphysis pubis, transverse sonogram. The
capsule (*) merging with the adductor longus tendon (arrows).
irregular echogenic cortical margin of the pubic body (arrowheads)
can be seen. The overlying capsule with its echogenic margin (arrows)
and intra-articular disc (D) are also identified.
ADDUCTOR MUSCLES
The thigh adductor muscle group consists of adductor
longus, brevis and magnus as well as gracilis. These muscles
SYMPHYSIS PUBIS AND ADDUCTOR originate from the pubic body and inferior pubic ramus and
MUSCLES pass distally to the femur and tibia (Figs 17.22 and 17.23).
Their main action is thigh adduction with some hip flexion
ANATOMY AND NORMAL ULTRASOUND and they are functionally important in sports where fre-
quent changes of direction are required (e.g. soccer, ice
APPEARANCES
hockey, fencing, Australian rules football).
The symphysis pubis is a fibrocartilaginous joint of the ante-
rior pelvis and is also the confluence for the thigh adduc-
tors, rectus abdominis and the medial aspect of the inguinal Practice Tip
ligament. The adductor muscles are best visualized as they originate
The symphysis pubis can be visualized on ultrasound by from the pubis and inferior pubic ramus with the thigh in
placing the transducer over the joint after direct palpation abduction and external rotation and the knee flexed (Fig.
or by scanning rectus abdominis transversally and moving 17.24). In this position adductor longus is the most prominent
inferiorly to the joint. Only the superior and anterior aspect muscle and is easily palpable.
of the joint can be visualized by ultrasound. The joint
margin is seen as the echogenic pubic cortex with the echo-
poor joint space in between (Fig. 17.21). An echogenic line On palpating the muscle the transducer can be placed on
spans the joint representing the capsular margin and supe- its longitudinal axis and moved obliquely along this plane
rior pubic ligament with a fibrocartilaginous disc occasion- towards the symphysis pubis, following the muscle through
ally seen within the joint as an echogenic stripe (Fig. 17.21). the myotendinous junction (MTJ) to its tendon and origin
The normal pubic apophysis often ossifies with irregular at the body of the pubis (Figs 17.22 and 17.25). Moving
margins, while chronic degeneration and irregularity are medially and posteriorly, the other adductor muscles (brevis
commonly seen in the elderly population, postpartum and magnus) and gracilis can be visualized. It should be
women and professional athletes (Fig. 17.22). Therefore, noted that adductor brevis usually has a limited proximal
irregularity on ultrasound is a nonspecific finding. tendon and the muscle appears to originate directly from
190 PART 5 — HIP
Adductor
Longus
Gracilis a
Figure 17.23 Line drawing of the normal thigh musculature. Adduc

tor longus is the most superficial muscle extending from the pubic
body towards the femur. Gracilis can be seen to originate posterior
and medial to the adductor longus.
Figure 17.25 Acute adductor longus tendon tear, longitudinal sono

gram. The adductor longus (AL) can be seen retracted from the
symphysis pubis (SP). In the intervening space there is hypoechoic
fluid displacing overlying fascia (arrowheads), consistent with
haematoma.
the bone. The normal ultrasound appearances of muscle

and tendon have already been described.
ACUTE ADDUCTOR MUSCLE INJURY

In the general population serious adductor muscle injuries
or chronic symptoms are relatively rare. Acute injuries
usually occur in the younger population and athletes when
the leg undergoes forced abduction, where the adductor
Figure 17.24 Examination technique for visualizing the adductor longus is the most commonly injured muscle in this group.
longus. The optimal position to examine the adductor longus is with Acute injury in a normal muscle results in a muscle strain
the thigh flexed and externally rotated and the knee flexed. The or tear at the MTJ, although proximal tendon rupture is
transducer is then placed on the most prominent muscle (adductor more common in mature athletes due to proximal tendi-
longus). nopathy, further weakening the MTJ (Fig. 17.25).
PUBALGIA (CHRONIC GROIN PAIN)

Chronic insidious onset groin pain is a significant clinical
problem that has potentially poor prognostic implications
for athletes. Considerable biomechanical stresses are pro-
duced across the anterior pelvis, particularly in single stance
(changing direction or kicking). Players who develop
chronic pain describe slight discomfort at the end of a game
and gradually progressing to stiffness on waking in the
morning. Initially features ease with warming up but soon
symptoms appear during playing and are exacerbated by
cutting in and kicking.
Key Point
Pathologies that have been proposed as the primary cause

of athletic pubalgia include osteitis pubis, adductor a
tenoperiosteal (enthesis) injury, pubic subchondral bone
stress fractures, rectus abdominis insertion tears and inguinal
canal abnormalities (prehernia complex, subclinical inguinal
hernias or external oblique and conjoint tendon dehiscence).
Neuralgia of the ilioinguinal nerve has also been described

either resulting from posterior inguinal canal weakness with
ballooning on straining (see bulging, earlier), or from small
tears in the abdominal muscles (mainly external oblique).
Referred pain from the spine or hip (femoroacetabular
impingement) should also be considered.
Clinical definition of these various pathologies is difficult
as symptoms and examination findings are similar or overlap
markedly. Most players respond to active rehabilitation and b
core stabilization but may take many months to return to
full activity. Several surgical procedures have developed to Figure 17.26 Professional soccer player with acute or chronic right
treat nonresponders but no controlled trials have been groin pain, longitudinal sonograms (dual screen to extend field of
described. view). (A) On the symptomatic right side, there is marked distortion
of the adductor longus tendon that is swollen and replaced by a
Radiological evaluation of athletes with pubalgia includes
mixed hypo- and hyperechoic mass (arrowheads). The adductor
MR imaging, ultrasound and herniography. Conventional longus (AL) muscle appears normal. Features are consistent with an
radiographs and scintigraphy are often unhelpful. Pubic acute tendinous rupture from the symphysis pubis (SP) and haema
sclerosis, irregularity and increased isotope uptake are com- toma. (B) On the asymptomatic side the tendon is predominantly
monly seen in asymptomatic athletes, presumably due to hyperechoic with loss of its normal tissue planes but is homogeneous
chronic shearing forces and remodelling. and not swollen. Features are consistent with chronic tendinopathy.
A number of professional soccer players will also have
previously undergone partial or complete avulsions with
subsequent haematoma and scarring, therefore identifying
abnormal tendon architecture does not necessarily explain If ultrasound is normal and the clinician is confident of
the patient’s current symptoms (Fig. 17.26). Ultrasound is these diagnoses, no other imaging is performed. If the clini-
initially performed in parasymphyseal pain to rule out ingui- cal opinion is that the pain is symphyseal in origin, MR
nal hernia or acute or chronic tendon or muscle strain imaging can assess the degree of symphyseal and adductor
(particularly of adductor longus). Features that suggest that entheseal oedema that significantly correlates with symp-
an area of chronic tendinopathy may be symptomatic are: toms (Fig. 17.27).
marked focal tenderness on transducer pressure and evi- Osteitis pubis is an acute noninfectious inflammatory con-
dence of superimposed acute changes within the tendon, dition of the joint characterized by joint and enthesopathic
including haematoma or oedema causing convex swelling inflammation that is presumed to be mechanical in origin.
(Fig. 17.26). It is most commonly seen in athletes and is usually self-
limiting (over 3–6 months) with complete rest necessary.
Key Point Unfortunately, as mentioned above, ultrasound findings are
nonspecific and, if osteitis pubis, stress fracture or infection
Ultrasound cannot detect the small tears due to external is suspected clinically, MR imaging is usually more sensitive
oblique or conjoint tendon injury described in surgical series and specific than ultrasound as oedema is the predominant
or subtle adductor enthesis oedematous change. imaging feature. However, ultrasound-guided needle place-
ment is valuable in performing joint aspiration in infection
192 PART 5 — HIP
or therapeutic injection in osteitis pubis (see section

Ultrasound-Guided Intervention).
ULTRASOUND-GUIDED INTERVENTION
Ultrasound-guided symphysis pubis injection may help

refine the clinical diagnosis or provide long-term symptom
relief, but its overall benefit is not proven. Some series have
reported an early return to pain-free activity but lacked
control groups. If injecting steroids, caution must be main-
tained in the early rehabilitation phase for athletes to prevent
rupture if the tendons are markedly tendinopathic.
For intra-articular injections full aseptic technique must
be used. A long 20 G or 22 G spinal needle can be intro-
duced using either a midline sagittal approach through
rectus abdominis (Fig. 17.27) or a transverse oblique
approach, as a pure transverse position may lead to piercing
of the medial inguinal contents. The needle is guided into
the joint and manoeuvred until there is free flow of the
a
injectate.
When focally infiltrating around the adductor tendon
origins, a 20 G needle usually suffices, as the adductor
muscle is relatively superficial when the thigh is abducted
and externally rotated.
CONCLUSION
Ultrasound is noninvasive and allows real time evaluation of

the groin, giving this technique a great potential advantage
* over other modalities in the examination of hernias and
A
S I
inguinal pathology. Postoperatively ultrasound can also play
P an important role in differentiating recurrent hernias from
other complications.
In muscle and tendon injuries ultrasound is already estab-
b lished as an accurate and effective technique in diagnosing
and grading acute injuries; however, in the assessment of
Figure 17.27 Professional soccer player with left sided pubalgia.
athletes with chronic groin pain, interpretation should be
(A) Coronal STIR MR image shows left sided symphyseal edema
and cleft (arrow). (B) Sagittal sonogram of the symphysis pubis
more cautious. In this patient group the underlying disease
shows the needle (arrows) passing through rectus abdominis (RA) into mechanisms are not clearly understood at present and there
the joint (*). is often asymptomatic chronic tendon and symphyseal
disease already present. Therefore, identifying an imaging
abnormality does not necessarily imply that this is the source
of the athlete’s current problem. In this troublesome clini-
cal area, a multidisciplinary approach is necessary, for diag-
nosis and treatment, and different imaging modalities may
be necessary to assess all aspects of the injury process.
Disorders of the Groin 18
and Hip: Anterior
Hifz-ur-Rahman Aniq | Robert Campbell
CHAPTER OUTLINE
INTRODUCTION HERNIAS
INTRAARTICULAR HIP PATHOLOGY SOFT TISSUE MASSES
Joint Effusion Inguinal Lymphadenopathy
Synovitis Groin Abscess
Proliferative Synovial Disorders Vascular Lesions
Acetabular Labrum Masses in the Female Groin
EXTRAARTICULAR HIP PATHOLOGY COMPRESSION NEUROPATHY
Muscle and Tendon Disorders HIP PROSTHESIS
INTRODUCTION INTRAARTICULAR HIP PATHOLOGY
The hip region is an area of complex anatomy with numer- JOINT EFFUSION
ous vascular, nervous and muscular structures passing
between the trunk and the lower extremity. Conditions Key Point
remote to the hip joint may present as pain in the groin.
Clinical examination may be nonspecific, and the choice of Hip joint effusion is difficult to diagnose clinically and plain
imaging modality may be difficult. Ultrasound is often used radiographs are insensitive. Ultrasound can detect effusions
as a complementary technique to radiography, MRI and CT. as small as 1 mL of joint fluid.
Ultrasound-guided hip joint aspiration and injections are
frequently utilized as an adjunct to diagnosis of hip and
groin pain. The probe is placed in an oblique longitudinal plane along
Common pathological processes that may be amenable the line of the femoral neck. Joint fluid is identified deep
to ultrasound evaluation include: to the echogenic joint capsule, and may appear from
hypoechoic to anechoic depending on the nature of the
• Intraarticular hip pathology: fluid (Fig. 18.1). In adults, a bone to capsule distance of
• effusions and synovitis 7 mm and an asymmetrical distension of the anterior recess
• labral tears. of more than 2 mm compared to opposite side is diagnostic
• Extraarticular soft tissue pathology: of joint effusion. However, Ultrasound is nonspecific, and it
• lymphadenopathy may be difficult to differentiate simple fluid, septic arthritis
• hernias and synovial thickening.
• bursitis Internal echoes may be seen within an exudative effusion,
• tendon and muscle injury and there may be associated thickening of the joint capsule.
• soft tissue masses. However, the absence of internal echoes does not exclude
• Compression neuropathy. infection, and ultrasound-guided aspiration is indicated to
• Complications of hip prostheses. avoid delay in diagnosis. Ultrasound-guided hip aspiration
193
194 PART 5 — HIP
echogenic synovium may be demonstrated on ultrasound in

the early stages, with areas of low echogenicity that represent
chondral nodules that may not be visible on radiography.
After mineralization, these nodules become echogenic and
produce distal acoustic shadowing (Fig. 18.2).
Other proliferative synovial disorders such as pigmented
villonodular synovitis may be impossible to distinguish from
simple synovitis, but should always be considered in patients
with monoarthritis.
ACETABULAR LABRUM
a
Labral tears most commonly occur in the anterosuperior
labrum and this area is amenable to assessment by ultra-
sound. A labral detachment is identified by separation of
the echobright fibrocartilagnous labrum from the acetabu-
lar rim by a hypoechoic line. Associated femoroacetabular
impingement may be seen during internal rotation on a
dynamic examination.
Labral tears are more apparent in the presence of para
labral cysts, which are analogous to meniscal cysts in the
knee. Paralabral cysts are hypoechoic lobulated lesions and
may have internal septations (Fig. 18.3). They are generally
noncompressible. Most cysts are small in size compared to
b the iliopsoas bursa and may have a thick wall. Uncommonly,
large cysts may extend deep to the iliopsoas muscles and
Figure 18.1 Ultrasound image along the long axis of the femoral neck compress the femoral neurovascular bundle. These can
shows anechoic fluid in the left hip joint elevating the joint capsule
rarely present as a groin mass.
(arrows). The appearances are consistent with a simple joint effusion.
Ultrasound demonstration of a labral tear or a cyst is
often a fortuitous finding as part of a global examination of
or injection in adults is performed in the transverse plane groin pain. When a labral tear and intraarticular pathology
with the probe over the femoral head or neck and a 22 G are suspected from clinical examination, MRI is the investi-
spinal needle introduced from a lateral approach. This gation of choice to evaluate the entire labrum, articular
enables the operator to keep the needle parallel to the cartilage and other intraarticular structures.
probe face for optimal visualization.
Conversely, a negative ultrasound examination reliably
excludes joint effusion and septic arthritis, and may be used EXTRAARTICULAR HIP PATHOLOGY
to avoid unnecessary arthrocentesis. Osteomyelitis, however,
is not excluded. MUSCLE AND TENDON DISORDERS
ILIOPSOAS TENDON
SYNOVITIS
Iliopsoas tendon and paratendon abnormalities are increas-
In inflammatory arthritis, synovial hypertrophy and hyper- ingly recognized as a cause of groin pain, especially in
aemia occurs with distension of the joint capsule anteriorly. athletes and dancers. Snapping hip and iliopsoas bursitis
Simple effusions may also be present. Differentiating fluid account for most cases of iliopsoas tendon abnormality.
from synovitis by evaluation of the echogenicity of fluid is However, tendinopathy associated with osteophytes of the
unreliable, and the use of sonopalpation to displace fluid is anterior acetabulum may be encountered with ultrasound,
less reliable than in small joints. Synovitis is not always asso- and tendon impingement may occur with large size hip
ciated with hyperaemia on Doppler imaging. prostheses.
Marginal erosions may be detected in the periphery of
the femoral head before they are visible on the plain radio- Snapping Hip
graphs. They appear as irregular cortical defects filled with Snapping hip syndrome is a condition in which there is an
hypoechoic, hypervascular pannus. audible or perceptible click during the hip movement, and
may or may not be associated with pain. Snapping hip may
be due to intra- or extraarticular causes. Intraarticular snap-
PROLIFERATIVE SYNOVIAL DISORDERS
ping hip is due to labral tears or intraarticular loose bodies.
Synovial osteochondromatosis is a neoplastic condition of Extraarticular tendon snapping is divided into medial and
the synovial membrane. It presents with joint pain, recurrent lateral types. The lateral type is due to iliotibial band or
swelling and intermittent locking. In the early stage of gluteus maximus snapping over the greater trochanter, and
disease, there is hypertrophy of the synovium, with formation is discussed in Chapter 19.
of chondral bodies that are released in the joint. In the final The medial type is due to abnormal movement of the
stage these bodies may calcify or even ossify. A thickened iliopsoas tendon. It is now recognized that the snapping
CHAPTER 18 — Disorders of the Groin and Hip: Anterior 195
occurs more commonly due to abnormal rotation of the

psoas tendon around the iliacus rather than snapping over
the iliopectineal eminence.
Practice Tip
Dynamic ultrasound is performed in an oblique transverse

plane along the line of the superior pubic ramus, with the
patient in a supine position.
Often the patient can voluntarily perform the specific

manoeuvre that can produce the snapping sensation.
a
Practice Tip
Alternatively, it is possible to dynamically assess the tendon

as the hip is moved from a flexed, abducted and externally
rotated position (frog lateral) to neutral.
A sudden and rapid lateral to medial, or rotatory, movement

of the tendon may be combined with abrupt contact of the
tendon against the pubic bone. This movement may be
quite subtle. The finding on ultrasound should be corre-
lated with the snapping sensation and pain. Associated ilio-
b
psoas tendinopathy and bursitis is encountered variably.
In cases refractory to analgesics and physiotherapy,
ultrasound-guided injection of steroid and local anaesthetic
into the iliopsoas bursa may be beneficial. If the bursa is not
distended, the needle is introduced from a lateral position
in the transverse plane posterior to the iliopsoas tendon and
anterior to the acetabular rim.
Iliopsoas Bursa
Iliopsoas bursitis usually presents as hip and groin pain,
which may be exacerbated by hip flexion. Rarely a very
distended bursa may present as a nonspecific mass in the
groin. The bursa is situated deep to the musculotendinous
junction of the psoas muscle, and communicates with the
hip joint in 15% of patients. It is only visualized on imaging
when it is distended with fluid (Fig. 18.4). A fluid-filled
bursa appears as a thin-walled cystic structure located
between the femoral neurovascular bundle medially and the
iliopsoas tendon laterally. Bursal distension can rarely
produce compression neuropathy of the femoral nerve.
Large bursae may also extend into the pelvis along the
iliacus muscle and may displace the pelvis structures.
Iliopsoas bursitis may also occur in association with several
joint disorders such as osteoarthritis, rheumatoid arthritis,
c gout, trauma and septic arthritis. In these cases synovial
thickening, pannus and loose bodies may also be seen in
Figure 18.2 Ultrasound images (A, B) along the long axis of the
the bursa. Very large bursae may also be seen in association
femoral neck demonstrating multiple echogenic foci (white arrows),
consistent with small intraarticular bodies secondary to synovial
with tuberculosis, in which case it is necessary to document
osteochondromatosis. The radiograph (C) shows subtle calcified the full intraabdominal extension.
loose bodies projected over the femoral neck, confirming the
diagnosis.
SARTORIUS AND QUADRICEPS
Sartorius and rectus femoris tendon injuries are an impor-
tant cause of acute anterior hip pain and acute apophyseal
avulsions may be encountered in skeletally immature
patients (Fig. 18.5). This type of injury is more common in
196 PART 5 — HIP
a c
b d
Figure 18.3 Ultrasound images (A, B) of the hip joint. A paralabral cyst (white arrow) is seen arising through a tear of the labrum (curved white
arrow). The corresponding axial T2FS MR images (C, D) show the cyst arising from the joint margin (white arrow) extending deep to the ilio-
psoas tendon (broken white arrow), with a larger portion of the cyst (black arrow) lying between the iliopsoas tendon and the femoral vessels.
kicking sports when the leg is hyperextended with hyper- dictates the need for surgical intervention. In chronic cases
flexion of knee, leading to eccentric muscle loading. Large calcification or ossification may develop in the injured
bone avulsion fragments are readily diagnosed on plain muscle.
radiographs. Avulsions through the tendon fibrocartilage at
the tendon insertion, with small or absent bone flakes, may Key Point
not be visualized on plain radiographs. Sonography is useful
in these cases as it can show continuity of tendon fibres with In skeletally mature patients, acute rectus femoris tears most
the fibrocartilage and bony avulsion fragments. In a full- commonly affect the direct head of rectus femoris at the
thickness tear, there is tendon retraction and the gap is proximal myotendinous junction at the level of the hip joint.
filled with haematoma. The extent of tendon retraction
a c
Figure 18.4 Transverse ultrasound images demonstrating an iliopsoas bursa in the right groin (A, B). There is an anechoic fluid collection
(arrows) around the iliopsoas tendon. Transverse and longitudinal images (C, D) in different patients with a total hip replacement show a much
larger iliopsoas bursa (arrows).
Chronic tendinopathy presents as localized anterior hip with diffuse pain in the medial thigh and lower abdomen
pain and tenderness over the anterior inferior iliac spine. are referred to as pubalgia. Sports that involve kicking and
This is most commonly seen in sprinters and is due to rapid changes of direction lead to shearing forces in the
overuse. Ultrasound shows tendon thickening with hetero- groin and adductor tendon origin. It is estimated that one-
geneous texture and typically a cone shaped area of low third of soccer players develop groin pain during the course
echogenicity at the insertion. of their career. Different causes of pubalgia such as osteitis
pubis and hernia may have to be considered in the differ-
ADDUCTOR TENDONS ential diagnosis. These conditions are sometimes referred
The adductor tendons originate from the pubic bone, sym- to collectively as ‘chronic exertional groin pain’.
physis pubis, and the inferior pubic ramus. Their main func- The adductor tendon insertion may be affected by tendi-
tion is adduction and flexion of the hip and thigh. The nopathy, partial or full-thickness tear and calcific tendinosis.
adductor tendons also merge with the pubic symphysis There may be isolated involvement of the adductor longus
capsule and rectus abdominis muscle fibres. Due to this or gracilis tendons, or more than one tendon may be
close anatomical relationship, overuse injuries that present involved.
198 PART 5 — HIP
c c
Figure 18.5 Longitudinal ultrasound images (A, B) of the anterior Figure 18.6 Longitudinal ultrasound images of the adductor longus
hip showing the sartorius muscle and tendon (white arrows) with an muscle and tendon (A, B) show a focal hypoechoic defect of the
avulsion of the apophysis from the ASIS. The radiograph (C) confirms tendon at the insertion on the pubic bone consistent with a tendon
the bony avulsion. tear (arrows). The axial T2FS MR image (C) more clearly demonstrates
the partial avulsion of right adductor longus tendon (arrowheads).
Proximal tendon avulsion in mature patients occurs with

underlying chronic tendinopathy. In acute full-thickness Differentiation of a partial thickness tear from chronic
tears, sonography demonstrates adductor longus tendon tendinopathy of the adductor origin may be difficult (Fig.
retraction and haematoma. In a chronic avulsion, the 18.6). Ultrasound may show tendon thickening with convex
retracted tendon and calcified haematoma may sometimes outline with heterogeneous hypoechoic echotexture. MR is
give the appearance of a mass. often considered as the primary investigation for chronic
Figure 18.8 A transverse ultrasound image through the lower abdo-

men shows a midline hernia composed of properitoneal fat (white
arrow) protruding through a defect in the linea alba (curved arrow).
Figure 18.7 Ultrasound image of a direct inguinal hernia during a through the posterior wall and obliterate the contents.
Valsalva manoeuvre. The image is acquired in the sagittal plane just
Sonography is an accurate technique for detection of ingui-
medial to the IEA and cranial to the inguinal ligament. The herniation
of peritoneal fat (white arrow) is identified protruding through the
nal hernias in equivocal cases with sensitivity of 86–100%
superficial inguinal ring (+). Loops of small bowel are seen within the and specificity of 82–97%.
abdominal cavity (*). Sports hernia refers to two inguinal wall pathologies: pos-
terior inguinal wall deficiency and Gilmore’s groin. Poste-
rior inguinal wall deficiency is due to weakness and possible
tearing of the conjoined tendon and fascia transversalis,
myotendinous strain, tenoperiosteal disease (enthesitis) which form the posterior wall of inguinal canal. Gilmore’s
and associated abnormalities of the symphysis. Ultrasound groin is a tear of the medial aspect of the external oblique,
is often used as a secondary tool to rule out hernia when which forms the anterior wall of the inguinal canal and the
MRI is normal, and to localise pain. external inguinal ring.
Most patients respond to active rehabilitation but the Sports hernia is seen in athletes participating in sports
recovery period may be prolonged. Ultrasound-guided sym- that require repetitive twisting and turning at speed: hockey,
physeal or peritendinous adductor injection can be per- football and tennis. They usually present with unilateral
formed to confirm the diagnosis and to provide long-term insidious-onset pain that can occur at low level of activity.
relief. However, steroids should be used with caution, as this Posterior inguinal wall deficiency can be demonstrated
may precipitate a complete tendon rupture. The patient is on ultrasound, as loss of normal valve-like mechanism of the
positioned supine with the hip abducted and with external inguinal canal. When anterior wall contracts, posterior
rotation, to bring the adductor longus into the most super- inguinal wall, instead of becoming taut, bulges anteriorly
ficial position. and there is loss of mild physiological compression of sper-
matic cord, resulting in the increase in size of pampiniform
plexus. However, these findings should be interpreted with
HERNIAS caution as similar findings are often present on the asymp-
tomatic side.
Hernias are rare causes of groin pain and athletic pubalgia. The femoral canal is situated posterior to the inguinal
The deep inguinal ring is the weakest point of the inguinal ligament and medial to the femoral vein. On Valsalva
canal and can result in an indirect hernia. Direct inguinal manoeuvre a femoral hernia expands the canal and pre-
hernias are due to weakness of the posterior abdominal wall vents expansion of the femoral vein. Spigelian hernias occur
and enter into the canal medial to the internal epigastric through a weakness at the lateral margin of the rectus
artery (IEA). Hernias are also discussed in Chapter 17. abdominis sheath where it joins the oblique muscles (linea
On a short-axis scan, the inguinal canal and contents semilunaris). In the midline rectus diverification hernias
appear as an oval structure with the peritoneum and bowel and epigastric hernias occur through defects in the linea
posterosuperiorly. When intraabdominal pressure is raised alba (Fig. 18.8).
during slow Valsalva manoeuvre, there is mild posterior wall
bulge, dilatation of vessels and sliding of contents. However,
SOFT TISSUE MASSES
the bowel should only move towards the canal and should
not completely obliterate it. An indirect hernia will distend
INGUINAL LYMPHADENOPATHY
the canal, effacing its contents. In the long-axis plane, an
indirect hernia arises lateral to the IEA and extends through Inguinal lymphadenopathy is the most common cause of an
the long axis of canal, and may contain peritoneal fat or inguinal mass. Ultrasound can distinguish lymphadenopa-
bowel. A hernia may sometimes be better appreciated thy from other mass lesions, and is useful if clinical examina-
during relaxation immediately after a Valsalva manoeuvre, tion is indeterminate. It is important to differentiate benign
when the hernia contents may be seen to return to the from malignant lymphadenopathy, and clinical history is
abdomen. crucial.
Direct hernias rarely continue distally and are usually In general, larger nodes are more likely to be metastatic,
localized, unlike indirect inguinal hernias (Fig. 18.7). In although size alone cannot be used as a criterion of malig-
short-axis scanning, direct hernias will push into the canal nancy. Benign lymph nodes are generally oval in shape with
200 PART 5 — HIP
Figure 18.9 Ultrasound image through the long axis of a small,

benign reactive lymph node. The echogenic hilum is preserved, and
the longitudinal size exceeds the transverse dimension.
longitudinal/transverse (L/T) ratio of >2 (Fig. 18.9). Malig-

nant nodes become rounded with L/T ratio of <2 (Fig.
18.10), but in early malignant infiltration nodes maintain
their normal shape.
Preservation of the echogenic fatty hilum is a feature of
benign lymphadenopathy. In metastatic infiltration, the
hilum may be eccentric, thin or completely absent. Focal
cortical thickening is also a feature of malignant disease.
A combination of L/T ratio of <2 and absent fatty hilum
has a 93% positive predictive value of metastatic nodal b
involvement.
Nodes with ultrasound features suggestive of malignancy
can be selected for fine needle aspiration cytology (FNAC).
FNAC has a sensitivity of 93% and a specificity of 91% in
predicting metastatic disease. However, sampling errors may
occur in the presence of multiple nodes due to associated
benign lymphadenitis. Caution is recommended for solitary
masses with no specific ultrasound features of a lymph node,
because FNAC is not reliable for diagnosis of soft tissue
sarcoma.
Conversely, lymph nodes that have no ultrasound features
of metastatic infiltration have high-negative predictive value
(96.2%) and can be safely excluded from pathological
confirmation.
GROIN ABSCESS
Groin abscesses usually present with acute painful groin
masses. There is often a history of intravenous (IV) drug
abuse or recent femoral intervention. Groin abscesses may
be located in the subcutaneous tissues but can extend deep
to involve underlying muscles. In these cases it is important
c
to exclude an underlying septic arthritis of the hip. Large
abscesses may compress the femoral vessels. On ultrasound, Figure 18.10 Ultrasound image of a patient presenting initially with
abscesses are hypoechoic with thick irregular walls. Colour a mass in the groin. There is an enlarged lobulated lymph node in the
Doppler may show increased flow in the periphery of the groin with persistent fatty hilum, with two smaller rounded nodes lying
lesion. Liquefaction can be confirmed by sonopalpation. immediately adjacent (A). The Doppler image shows high flow in the
Samples for bacteriological evaluation can be quickly vascular pedicle (B). Biopsy revealed Hodgkin’s disease. The staging
coronal STIR MR image (C) demonstrates extensive bilateral inguinal
obtained by ultrasound-guided aspiration.
and paraaortic lymphadenopathy (arrows).
A pseudoaneurysm is formed when a femoral artery tear

leads to perivascular haematoma formation. The central
liquid part of the haematoma communicates with the
artery through a small tract. Blood flows in and out of
the aneurysm during systole and diastole, producing a
swirling appearance with a typical ‘to and fro’ Doppler
waveform.
Pseudoaneurysm following femoral catheterization may
be treated acutely if the neck of pseudoaneurysm is
narrow, and flow can be eliminated with probe pressure.
Ultrasound-guided injection of thrombin into the pseudoa-
neurysm has also been reported as a safe and quick method
of treatment.
MASSES IN THE FEMALE GROIN

Some soft tissue masses in the groin are specific to females.
The canal of Nuck is invagination of parietal peritoneum,
a
which accompanies the round ligament of the ovaries
during embryonic development. It corresponds with proces-
sus vaginalis in males and is completely obliterated during
the first year of life. However, incomplete obliteration may
lead to formation of encysted fluid collection in this perito-
neal remnant and is known as hydrocele or cyst of canal of
Nuck (Fig. 18.12). This presents as a nontender groin mass
in females. On ultrasound, they typically appear as ‘comma-
shaped’ cystic lesions with a tail pointing towards the ingui-
nal canal. They may also appear as a ‘cyst within cyst’ or as
multi-septated lesions. The most important differential diag-
nosis is an indirect inguinal hernia that may occur with a
patent canal of Nuck. Valsalva manoeuvre on ultrasound
may help to differentiate indirect hernias from cysts.
Endometriosis is due to ectopic localization of endome-
trial cells that is recognized in surgical scars most commonly
following caesarian section (Fig. 18.13). Endometrial cells
can sometimes also pass down a persistent canal of Nuck
and present as a groin mass. Patients may have focal pain
b that is cyclical in nature (Fig. 18.14). On ultrasound endo-
metriomas are typically solid hypoechoic masses with inter-
Figure 18.11 Psudoaneurysm of the right femoral artery following
nal echoes, although there may rarely be a cystic component.
femoral artery puncture. A heterogeneous mass is seen anterior to
the CFA with peripheral thrombus and central anechoic cavity (A). They typically have irregular speculated contours with infil-
On colour Doppler ultrasound, flow is demonstrated within the aneu- tration of the underlying structures, and can mimic the
rysm that communicates with the underlying CFA through a narrow appearances of aggressive fibromatosis. Doppler imaging
neck (B). findings are variable, ranging from a vascular pedicle pen-
etrating into the mass, or more diffuse internal hypervascu-
larity in lesions measuring larger than 3 cm. Some lesions
may be avascular.
VASCULAR LESIONS
Varicosities of the round ligament of ovary occur in
Doppler ultrasound is very accurate for the diagnosis of pregnancy. They may present as a reducible or irreducible
femoral vessel injuries. The commonest cause is iatrogenic inguinal swelling and may even transmit cough impulse.
femoral arterial catheterization (Fig. 18.11). Other causes In this respect they may mimic an inguinal hernia. Varicosi-
include femoral and pelvis fractures, blunt trauma and IV ties usually present in the third trimester due to venous
drug abuse. Haematoma and pseudoaneurysm are most obstruction of the gravid uterus. Other contributing factors
important complications. are progesterone-induced smooth muscle relaxation,
Haematomas can be diffuse or localized. Diffuse haema- increased cardiac output and venous return that produce
toma appears similar to cellulitis on ultrasound as blood dilatation of veins around the round ligament. Ultrasound
infiltrates in the subcutaneous tissues and muscles of the shows the venous plexus with a ‘bag of worms’ appearance
groin and the thigh. A focal haematoma is identified as a with large draining veins (Fig. 18.15). Doppler imaging
hypoechoic mass and can be distinguished from pseudoan- should be performed with a Valsalva manoeuvre, as venous
eurysm by lack of flow on Doppler imaging. However, it may flow may be very subtle. Complications include acute
be difficult to differentiate postcatheterization haematoma rupture and thrombosis in late pregnancy and the peripar-
from a thrombosed pseudoaneurysm. tum period.
202 PART 5 — HIP
a c
Figure 18.12 Diagrammatic representation (A) of the canal of Nuck, which normally closes by birth. A patent canal provides the route for
development of an indirect inguinal hernia in females (curved arrow). Incomplete obliteration of the canal can lead to cyst formation at the distal
end (B). A transverse ultrasound image (C) demonstrates an anechoic cyst medial to the femoral vessels with a characteristic tail (arrow) point-
ing to the inguinal canal. The cyst lies medial to the femoral vessels. A T2FS axial MR image (D) confirms the relationship of the high-signal
intensity cyst (arrow) to the femoral vessels.
COMPRESSION NEUROPATHY
Femoral nerve compression is a rare condition and can be

caused by any space-occupying lesion in the groin such as
haematoma, abscess, iliopsoas bursitis or large paralabral
cyst. Femoral nerve compression can also be secondary
to iatrogenic causes such as inguinal hernia repair. The
Figure 18.13 Transverse ultrasound image through the lower abdo-
men shows a rounded hypoechoic mass within the subcutaneous soft motor branch innervates the iliopsoas (hip flexor) and
tissues overlying the right rectus abdominis muscle; this was with a quadriceps muscles (knee extensor). The sensory branch
caesarian scar. The size of the mass fluctuated according to the of femoral nerve (saphenous nerve) innervates the medial
patient’s periods and coincided with pain. Endometriosis was con- thigh and anterior and medial aspect of the calf. In femoral
firmed on surgical excision. nerve compression patients may have difficulty in walking
Figure 18.15 Ultrasound image of a mass in the groin of a female

patient demonstrating multiple anechoic compressible structures (A).
The colour flow Doppler image (B) confirms the diagnosis of varices
b
of the round ligament of the ovary.
Figure 18.14 Ultrasound image of an irregular hypoechoic mass in

the groin of a female patient (A). The corresponding axial T2FS MR
image (B) shows a heterogeneous mass in the region of the round
ligament in the groin (arrow). The differential diagnosis includes fibro- part of inguinal ligament. Ultrasound can be used for
matosis. Endometriosis was confirmed on biopsy. guided nerve block as a diagnostic technique. Symptoms
generally improve after weight loss and delivery.
due to weakness of quadriceps and experience falls due HIP PROSTHESIS

to knee buckling. Patients may also complain of severe
sensory symptoms on the medial aspect of the thigh. Ultra- Groin pain after total hip replacement may arise from a
sound may be indicated to exclude a compressive lesion number of different complications. Radiography remains
in the inguinal. Obturator neuropathy may be the conse- the primary diagnostic imaging modality for the symptom-
quence of pelvic/hip surgery, pubic ramus fracture, mass or atic total hip replacement. Both CT and MR are affected
haematoma. by metal artifact, which may limit diagnostic quality. Ultra-
The lateral cutaneous nerve passes into the thigh deep to sound can show fluid within the pseudocapsule in both
the lateral margin of inguinal ligament. Compression of the aseptic loosening and infection (Fig. 18.16). In these cases
nerve produces pain and numbness on the anterolateral guided aspiration may be necessary to exclude an infective
aspect of the thigh, also known as ‘meralgia paresthetica’. organism (Fig. 18.17).
It is most commonly seen in patients with bulging abdomi- Iliopsoas tendinopathy is a recognized cause of groin pain
nal wall due to obesity or pregnancy. Ultrasound occasion- after total hip replacement. It is seen in up to 5% of cases.
ally demonstrates thickening of the nerve under the lateral Predisposing factors are oversized (more than 12 mm) or
204 PART 5 — HIP
a
b
Figure 18.16 Echogenic effusion (curved arrow) in a patient with a

hemiarthroplasty in situ. Joint aspiration is required to exclude
infection.
malpositioned acetabular components leading to promi-

nence of acetabular margin. Impingement between the
iliopsoas tendon and the acetabular component leads to
tendinosis, bursitis or iliopsoas snapping (Fig 18.18). On b
ultrasound, the tendon is thickened initially, but becomes Figure 18.17 Infected right hip prosthesis. AP radiograph of the
attenuated with partial thickness tearing. Dynamic sonogra- right hip (A) shows air in the soft tissues adjacent to the greater
phy may direct impingement of the acetabular component trochanter (arrowheads). There is a break in one of the trochanteric
on the iliopsoas tendon, which may be deviated. Snapping wires with a superiorly migrated nonunited greater trochanter oste-
of the tendon may also be demonstrated. Tendon impinge- otomy (arrow). The longitudinal ultrasound image (B) of the lateral hip
ment may also be caused by cement debris or other material shows a heterogeneous fluid collection, which was partly compress-
projecting anterior to the acetabulum, such as acetabular ible on sonopalpation, and which contains multiple echogenic foci
(black arrow) due to the air in the soft tissues. Multiple sinus tracts
fixation screws and bone graft material.
are seen in the lateral subcutaneous tissues (arrowheads).
Second-generation metal-on-metal (MOM) prostheses
have been increasingly used in young and active patients.
The advantage of the MOM resurfacing prostheses is that
the femoral metaphysis and diaphysis are preserved, which
in young patients allows easier revision surgery with con aseptic lymphocytic vasculitis-associated lesions (ALVAL)
version to a conventional prosthesis. Other advantages has been used to describe these features. Patients may
include prevention of polyethylene-induced particle disease, present with pain, soft tissue masses around the hip joint
reduced dislocation rate, and improved wear properties. and spontaneous dislocation. Plain X-rays are often normal.
However, metal hypersensitivity has been reported in up to Ultrasound may show lobulated thick-walled fluid collec-
3% of cases with MOM prostheses. Release of tiny chro- tions around the hip joint (Fig. 18.19). They are present in
mium and cobalt particles from the prosthesis can lead to the periprosthetic region, intimately related to the joint
aseptic loosening. The exact mechanism of failure is not capsule, which suggests that a communication exists between
fully understood but histological analysis has revealed a the cyst and the joint. Anterior collections may distend the
unique lymphocytic perivascular infiltration that may be a iliopsoas bursa, and extend into the pelvis. In this situation
hypersensitivity reaction. The terms pseudotumour and MRI may be better at appreciating the full extent of such
b c
Figure 18.18 A patient with symptoms of a painful hip flexion following hip arthroplasty. The longitudinal ultrasound image (A, B) shows the
iliopsoas tendon (arrows) impinging with a prominent collar of the femoral prosthesis, with interposed echogenic fluid (asterisk). The radiograph
(C) demonstrates inadequate lateralization of the femur with reduced ischiofemoral space.
a b
Figure 18.19 Transverse (A, B) and longitudinal

(C) scan of the right hip shows large anechoic collec-
tion (arrows) anterior to a MOM hip prosthesis and
c
displacing the femoral vessels anteromedially.
206 PART 5 — HIP
lesions. Collections can also be seen lateral and posterior to Jamadar DA, Jacobson JA, Morag Y, et al. Characteristic locations of
the hip joint, possibly within capsular defects created during inguinal region and anterior abdominal wall hernias: sonographic
appearances and identification of clinical pitfalls. Am J Roentgenol
surgery. However, small collections can also be seen in 2007;188(5):1356–64.
asymptomatic patients after MOM hip replacement. Knoeller SM. Synovial osteochondromatosis of the hip joint. Etiology,
The Medicine and Healthcare Products Regulatory diagnostic investigation and therapy. Acta orthopaedica Belgica
Agency (MRHA) UK has now recommended that cross- 2001;67(3):201–10.
Koski JM, Anttila P, Hämäläinen M, Isomäki H. Hip joint ultrasonogra-
sectional imaging (MRI or ultrasound) is performed in
phy: correlation with intraarticular effusion and synovitis. British
patients with hip pain, small sized arthroplasty components, journal of rheumatology 1990;29(3):189–92.
signs of loosening on radiographs and elevated chromium Koulouris G. Imaging review of groin pain in elite athletes: an anatomic
and cobalt ion levels (Medical Device Alert 2010/033). If approach to imaging findings. American journal of roentgenology
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Martinoli C, Bianchi S. Hip. In: Bianchi S, Martinoli C, editors. Ultra-
sion surgery should be considered. sound of the musculoskeletal system. Berlin: Springer; 2007.
p. 551–610.
Mistry A, et al. MRI of asymptomatic patients with metal-on-metal and
FURTHER READING polyethylene-on-metal total hip arthroplasties. Clin Radiol 2011;
Bianchi S, Martinoli C, Keller A, Bianchi-Zamorani MP. Giant iliopsoas 66(6):540–5.
bursitis: sonographic findings with magnetic resonance correlations. Rezig R, et al. Ultrasound diagnosis of anterior iliopsoas impinge-
Journal of clinical ultrasound 2002;30(7):437–41. ment in total hip replacement. Skeletal Radiol 2004;33(2):
Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas 112–16.
tendon and injection of the iliopsoas bursa for diagnosis and man- Robinson P. Hip, Pelvis and Groin injuries. In: Essential Radiol Sports
agement of the painful snapping hip. Skeletal radiology 2006;35(8): Med. New York: Springer; 2010. p. 29–48.
565–71. Robinson P, Barron DA, Parsons W, et al. Adductor-related groin pain
Davies AG, Clarke AW, Gilmore J, et al. Review: imaging of groin pain in athletes: correlation of MR imaging with clinical findings. Skeletal
in the athlete. Skeletal radiology 2010;39(7):629–44. radiology 2004;33(8):451–7.
Deslandes M, Guillin R, Cardinal E, et al. The snapping iliopsoas Robinson P, Hensor E, Lansdown MJ, et al. Inguinofemoral hernia:
tendon: new mechanisms using dynamic sonography. American accuracy of sonography in patients with indeterminate clinical fea-
journal of roentgenology 2008;190(3):576–81. tures. Am J Roentgenol 2006;187(5):1168–78.
Fang CS, et al. The imaging spectrum of peri-articular inflammatory Safak AA, Erdogmus B, Yazici B, Gokgoz AT. Hydrocele of the canal of
masses following metal-on-metal hip resurfacing. Skeletal Radiol Nuck: sonographic and MRI appearances. Journal of clinical ultra-
2008;37(8):715–22. sound 2007;35(9):531–2.
Disorders of the Groin and Hip: 19
Lateral and Posterior
Hifz-ur-Rahman Aniq | Robert Campbell
CHAPTER OUTLINE
INTRODUCTION TFL TENDINOPATHY

GREATER TROCHANTER PAIN SYNDROME TFL MUSCLE HYPERTROPHY
ITB SNAPPING HAMSTRING TEARS AND TENDINOPATHY
LATERAL HIP MASSES SCIATIC NERVE
Morel-Lavallée Effusions ISCHIOGLUTEAL BURSITIS
Tumoral Calcinosis FURTHER READING
mostly unilateral, but sometimes bilateral. Middle aged and

INTRODUCTION elderly women are commonly affected, where a wider pelvis
is thought to be a contributory factor. Symptoms are often
Lateral and posterior hip pain may be due to variety of intra- accredited to trochanteric bursitis, but it is more frequently
and extraarticular conditions. Ultrasound is a useful image due to gluteus medius and minimus tendinopathy associ-
modality for rapid assessment of extraarticular soft tissue ated with subgluteus medius and minimus bursitis. The aeti-
abnormalities, many of which are tendon or muscle related. ology of abductor tendinopathy is unknown, but it is thought
Certain specific soft tissue mass lesions occur around the that microtrauma causes tendon degeneration and tearing
lateral aspect of the hip, and may or may not be associated at the tendon insertion.
with pain. Tendon insertion abnormalities are readily amenable to
Common conditions include: sonographic evaluation. Anisotropy may be encountered
on longitudinal scanning due to the oblique course of
• greater trochanteric pain syndrome gluteus medius tendon fibres, which may mimic a tear or
• iliotibial band (ITB) snapping tendinopathy.
• lateral hip masses
• tensor fasciae latae (TFL) tendinopathy and hypertrophy
• hamstring tendinopathy Practice Tip
• sciatic nerve compression and piriformis syndrome.
In obese patients it may be necessary to use probe pressure
or decrease probe frequency to adequately visualize the
tendon insertion.
GREATER TROCHANTER PAIN SYNDROME
Abductor tendon abnormalities are a common cause of the

so-called greater trochanter pain syndrome: Tendon thickening and diffuse hypoechogenicity are the
hallmarks of gluteal tendinopathy. The anterior fibres of
• abductor tendinopathy gluteus medius are most commonly involved (Fig. 19.1),
• abductor tendon tears and may extend into the gluteus minimus tendon. Isolated
• gluteal bursitis involvement of gluteus minimus is not common. Subgluteus
• abductor calcific tendonitis. minimus and medius bursitis may coexist, seen as fluid-filled
structures deep to the associated tendon with gluteal tendi-
Patients present with a dull, aching pain over the lateral nopathy (Fig. 19.2). Bony irregularity of the greater tro-
and posterior aspect of the greater trochanter, often with chanter due to entheseal bone formation is frequently
focal tenderness on palpation. Pain usually occurs while encountered but does not correlate with disease severity.
walking or lying on the affected side. However, in the major- Increased tendon vascularity on Doppler imaging represent-
ity of patients there is no limitation of movement. Pain is ing neovascularization is less common than in other tendon
207
208 PART 5 — HIP
groups. End stage tendinopathy may result in abductor

tendon tears.
Partial thickness tears usually involve the deep and ante-
rior fibres of the gluteus medius tendon. Partial tears appear
as areas of tendon thinning or anechoic defects in the
tendon substance.
a
Key Point
A ‘bald facet’ and absence of tendon fibres are consistent

with a full-hickness tear (Fig. 19.3).
In an acute full-thickness tear the tendon is retracted with

haematoma and effusion adjacent to the greater trochanter.
b In chronic complete tears, muscle wasting may be evident
Figure 19.1 Gluteus medius tendinosis. A longitudinal ultrasound with loss of muscle bulk and increased echogenicity due
image at the level of the greater trochanter shows thickening and low to fatty replacement. Ultrasound diagnosis of partial and
echogenicity of gluteus medius tendon (arrows). complete gluteal tendon tears has a sensitivity of 90% and
a specificity of 95% compared against surgery as a gold
standard.
The trochanteric bursa, or subgluteus maximus bursa, is
a crescenteric low-echo structure that lies lateral and super-
ficial to the gluteus medius insertion, adjacent to the poste-
rior facet of greater trochanter, and deep to the gluteus
maximus muscle. Trochanteric bursitis is thought to be the
result of an impingement phenomenon and may be present
in up to 40% of patients with gluteus medius and minimus
tendinopathy (Fig. 19.4). If the hip abductors are weakened
by tendinopathy, lateral subluxation of femoral head occurs,
leading to impingement of the soft tissues between the
greater trochanter and the iliotibial tract and development
of bursitis. Therefore, trochanteric bursitis may be a sequela
of hip joint instability, and hence the association with ten-
dinopathy. Bursitis is commonest in the fifth and sixth
decades but may be encountered in other age groups. Other
less common causes of trochanteric bursitis are rheumatoid
arthritis, tuberculosis and other systemic inflammatory
conditions.
Calcification in the gluteal tendons has been reported in
10–40% of cases of gluteal tendinopathy. This can be linear
a
or in the form of multiple small foci near the tendon inser-
tion, and is often a result of degenerative tendinopathy.
However, larger deposits of calcific tendinopathy may occur
in hydroxyapatite deposition disease. The calcification
appears as areas of increased echogenicity, which may or
Gluteus may not cast an acoustic shadow dependent on size and
Medius status of the calcification (Fig. 19.5). Spontaneous resorp-
Gluteus tion of the calcific deposits may occur. Calcific tendinosis
Minimus may be associated with trochanteric bursitis.
Ultrasound-guided injection can be performed to
treat greater trochanter pain (Fig. 19.4). Peritendinous
ultrasound-guided steroid and local anaesthetic injection is
an effective method for the treatment of gluteal tendinopa-
L thy. In the study by Labrosse et al., there was a 55% average
A P
M
reduction of pain level after treatment. One month after
treatment, 72% of the patients showed a clinically signifi-
b cant improvement in pain level, which was defined as a
Figure 19.2 Subgluteus medius bursitis. An anechoic fluid collec- reduction in the visual analogue scale pain score of 30%.
tion is present deep to the gluteus medius tendon at the level of the The long-term prognosis varies according to the evolution
greater trochanter on a transverse ultrasound image. of the tendinopathy, the amount of functional use or overuse
CHAPTER 19 — Disorders of the Groin and Hip: Lateral and Posterior 209
a c
b d
e f
Figure 19.3 Gluteus medius full-thickness tear. Longitudinal (A, B) and transverse (C, D) ultrasound images with a ‘bald’ greater trochanter
due to complete absence of the gluteus medius tendon (arrowheads). The tendon is retracted with fatty atrophy of the distal muscle (arrow).
The axial STIR MR image (E) confirms the diagnosis of a complete tear of the gluteus medius tendon (arrows), and there is associated fatty
atrophy of gluteus medius and minimus muscles (arrow) on the axial T1W image (F).
210 PART 5 — HIP
Gluteus
Minimus
Trochanteric
Bursa Greater
Gluteus Trochanter
Maximus
b
e
Fascia
Trochanteric
Bursa
Gluteus
Maximus Figure 19.4 Trochanteric bursitis. The longitudinal ultrasound
Greater
image scan (A) shows a fluid collection (arrow) superficial to the
Gluteus Trochanter
gluteus medius tendon and deep to the gluteus maximus. A trans-
Medius
verse image (B, C) (in a different patient) at the greater trochanter
shows a distended trochanteric bursa superficial and posterior to
the gluteus medius tendon. An ultrasound-guided injection has
been performed (D, E) with a needle placed in the trochanteric
c
bursa (arrow).
of the involved hip and treatments undertaken to improve snapping is due to intermittent impingement of the poste-
the strength and range of motion of the hip. In trochanteric rior border of ITB or anterior border of the gluteus maximus
bursitis, a posterolateral approach is adopted for the accu- over the greater trochanter (Fig. 19.6). Ultrasound may
rate delivery of steroid and local anaesthetic into the bursa. show thickening and low-reflective change within the ITB.
In cases of calcific tendinosis of gluteal tendons, calcifica- Dynamic scanning demonstrates the sudden displacement
tion may be aspirated and injected under ultrasound guid- of ITB over the greater trochanter associated with palpable
ance. An anterolateral approach is preferred for injecting snapping.
the subgluteus medius and minimus bursae to avoid trans-
gressing the tendon.
Practice Tip
ITB snapping is best visualized with transverse scanning at

ITB SNAPPING the level of the greater trochanter, with minimal pressure so
as not to obstruct the abnormal movement of ITB over the
Clinically, iliotibial snapping hip is similar to iliopsoas snap- greater trochanter. Snapping is mostly produced in the
ping but symptoms are present on the lateral aspect of the adducted hip between flexion and extension.
hip joint. Some patients may be completely pain-free. The
lateral trochanter and proximal thigh. In this region, the

dermis contains a rich vascular plexus that pierces the
fascia lata. After injury, disrupted small vessels may bleed
into the perifascial plane, filling a virtual cavity with blood,
lymph and debris. An inflammatory reaction commonly
creates a peripheral capsule, which may limit growth of the
process.
These lesions are sometimes slow to develop, which can
a make clinical diagnosis difficult. Lesions that enlarge and
become chronic or painful may be misdiagnosed clinically
as a soft tissue tumour. Morel-Lavallée lesions have a variable
ultrasound appearance. In the acute phase they have a lobu-
lated outline but become flat and fusiform over time. Inter-
nal fluid levels may also be appreciated due to sedimentation
of blood cells. Chronic lesions are compressible, anechoic
to hypoechoic in echogenicity and have well-defined mar-
gins (Fig. 19.7). Mural nodules and septations may also be
demonstrated as fluid dissects through the fatty subcutane-
ous tissues. Care should be observed during scanning as
excessive probe pressure may displace fluid away from the
transducer’s field of view, especially in lesions without a
pseudocapsule. They are readily treated by ultrasound-guided
aspiration and local compression postaspiration may reduce
the incidence of recurrence.
TUMORAL CALCINOSIS
Tumoral calcinosis is a benign condition of soft tissue calci-
fication. There are two types. The primary or familial type
occurs in the young black population, with a family history
in 30% of cases. The secondary type is seen in hyperpara-
thyroidism, particularly when associated with chronic renal
failure. Typical lesions commonly arise in the periarticular
soft tissues. Predilection is also noted for areas prone to
b minor trauma, like the extensor surface of elbow, knee and
Figure 19.5 Calcific tendinosis of the gluteus medius tendon. The lateral hip. The differential diagnosis includes gout or,
longitudinal ultrasound image (A) shows a thickened gluteus medius rarely, calcium pyrophosphate deposition disease (CPPD).
tendon with irregular calcification in the gluteus medius tendon On sonography, acute tumoral calcinosis has uniform, inter-
(arrow). The presence of calcification is confirmed on the AP radio- mediate echogenicity with peripheral smooth hyperechoic
graph (B). outline. Chronic lesions have lobulated outline with hetero-
geneous texture and irregular hyperechoic rim of calcifica-
tion. Cysts and septa are also seen in chronic lesions. They
are usually avascular on Doppler imaging. Other common
It may also be seen when an adducted and internally rotated lateral thigh masses include lipomas, fatty hypertrophy and
hip is flexed and externally rotated with flexed knee. fat necrosis.
Patients will usually be able to voluntarily produce the snap-
ping sensation, but sometimes only in standing position,
which necessitates scanning in the erect position. ITB TFL TENDINOPATHY
snapping is treated conservatively with nonsteroidal anti
inflammatory medicines, rest and physiotherapy. However, The musculotendinous unit of TFL is comprised of a proxi-
cases refractory to this treatment can be treated with mal short and broad tendon, a triangular shaped muscle
ultrasound-guided steroid and local anaesthetic injection (about 18 cm length), and the iliotibial tract distally, which
around the ITB. forms at the level of the greater trochanter. The TFL tendon
originates from the anterior superior iliac spine posteriorly
to the iliac tubercle. In the normal population, the thickness
LATERAL HIP MASSES
of the TFL tendon at anterior iliac crest ranges from 1.5 to
3.1 mm (average 2.1 mm), and there is a difference of no
MOREL-LAVALLÉE EFFUSIONS
more than 30% between sides.
Morel-Lavallée effusions, also referred to as posttraumatic TFL tendinopathy is most common in long-distance
‘closed degloving’ injuries, occur when the skin and subcu- runners, probably due to repetitive microtrauma. Twisting
taneous fatty tissue abruptly separate from the underlying injuries have also been thought to be a contributing factor
fascia. Such lesions are particularly common overlying the due to local forces at the level of iliac crest. It is more
212 PART 5 — HIP
a c
Gluteus ITB
ITB Maximus
Gluteus
Maximus
Gl
Greater Greater
ut
L L
eu
Trochanter Trochanter
sM
P A P A
M M
in
im
us
b d
Figure 19.6 Snapping iliotibial band. Panoramic transverse scans at the level of the greater trochanter. In the hyperextended and adducted
hip (A, B) the ITB (arrowheads) maintains a normal position. On hip flexion (C, D) the anterior margin of gluteus maximus is displaced anteriorly
over the greater trochanter. On dynamic scanning this was seen to occur with an obvious snapping motion.
common in females, and it is thought that a wider female pseudohypertrophy, the muscle is enlarged with increased
pelvis may alter the stress at the iliac crest. Clinically, patients echogenicity that represents fat deposition. Care should be
present with pain, discomfort and tenderness over the taken not to confuse the oval shape and increases in echo-
iliac crest. genicity of TFL with a lipoma.
In TFL tendinopathy, the tendon is enlarged with cone
shaped hypoechogenicity in the deep fibres (Fig. 19.8).
More severe disease will also affect the superficial fibres, HAMSTRING TEARS AND TENDINOPATHY
which are usually not involved in isolation. An intrasubstance
anechoic cleft may be seen that represents a partial thickness The hamstring tendons can be injured due to acute tear or
tear. Complete tears of TFL are uncommon. chronic repetitive microtrauma. Acute hamstring injuries
occur most frequently in younger athletes. They occur with
forceful excessive contraction or excessive passive lengthen-
TFL MUSCLE HYPERTROPHY ing at the ischial tuberosity insertion, leading to tendon
avulsion or hamstring injury distally at the proximal muscu-
TFL muscle hypertrophy is an uncommon clinical entity lotendinous junction.
that can simulate a soft tissue tumour. The diagnosis of
muscle hypertrophy is made when there is unilateral asym-
Practice Tip
metric enlargement of the TFL muscle with at least 50% or
greater difference in the transverse diameter of the muscle. The conjoined insertion of biceps femoris and semitendinosus
Muscle enlargement may be caused by true hypertrophy is most commonly involved with hamstring tendinopathy.
secondary to altered weight bearing mechanics, as seen after Patients typically complain of pain in the buttock and have
total hip replacement. The other less common form is pseu- difficulty in walking.
dohypertrophy due to excess deposition of fat and connec-
tive tissue within the muscle, as seen in Duchenne and other
muscular dystrophies. Ultrasound assessment can be difficult in athletes with well-
On ultrasound, true hypertrophy appears as increased developed thigh muscles and in acute cases due to pain, as
muscle diameter with normal echotexture (Fig. 19.9). In it may not be possible to exert sufficient probe pressure.
Key Point
In adolescents prior to skeletal maturity, ischial tuberosity

avulsion is more common than hamstring tendon tears and
can be diagnosed on plain radiographs.
a The avulsed fragment can also be identified separated

from the ischium on ultrasound, surrounded by areas of low
echogenicity haematoma formation. Surgical reattachment
may be required. Sciatic nerve pain may occur due to the
irritation by the avulsed fragment or by haematoma forma-
tion. On ultrasound the sciatic nerve may be normal or
thickened, and there may be surrounding haematoma for-
mation. Rarely chronic scarring may warrant debridement
and surgical release of the nerve.
In chronic repetitive trauma, the proximal attachment of
hamstring tendons is thickened with low echogenicity.
Oedema around the tendon at the insertion due to periten-
b
dinitis is common. Overall MRI is more sensitive than ultra-
sound for the diagnosis of proximal hamstring pathology,
particularly for partial thickness tears, and is able to dem-
onstrate associated marrow oedema in the ischial tuberosity.
However, ultrasound-guided steroid injection around the
hamstring tendons can be an effective therapy for ham-
Vastus string tendinopathy if coupled with a proper physiotherapy
eus
Glut ius Lateralis regimen. The procedure is performed with the patient in
Me d us
im the prone position. The ischial tuberosity and sciatic nerve
in Greater Trochanter L
M are identified and Doppler imaging is ultilized to identify
eus S I
ut vascular structures. Under ultrasound guidance, a needle is
c Gl M
advanced towards the ischial tuberosity medial to the sciatic
nerve. A study by Zissen et al. reviewed 65 peritendinous
hamstring injections. Fifty per cent of patients had symp-
tomatic improvement that lasted longer than 1 month after
percutaneous corticosteroid injection, and 24% of patients
had symptom relief for more than 6 months.
SCIATIC NERVE
d
Sciatic neuropathy in the thigh is the result of either chronic
Figure 19.7 Two examples of Morel–Lavallée lesions with different compression or traumatic injury resulting from fractures of
ultrasound appearances. In (A) there is heterogeneous but predomi- the pelvis, hip dislocation, complications of hip replace-
nantly echogenic fluid collection lying in the subcutaneous tissues on
ment procedures or penetrating injuries. Complications of
the surface of the ITB. In (B, C) the fluid collection is purely anechoic.
Both lesions were avascular on Doppler imaging. Following aspiration
injection therapy caused by either direct needle trauma or
of the case (B, C), the postaspiration image (D) shows almost com- the neurotoxic effect of the injectate may be encountered.
plete resolution of the lesion. There is atrophy of the hamstring muscles and muscles
below the knee. There is also sensory loss in the tibial and
common peroneal nerve distribution. Patients present with
posterior hip pain radiating down the posterior thigh, with
muscle wasting and weakness. There is a limited role for
In a complete tendon tear, ultrasound may show a torn imaging of sciatic neuropathy in the thigh, although ultra-
tendon that is retracted inferiorly with surrounding hae sound may demonstrate an unexpected mass lesion causing
matoma (Fig. 19.10). Due to the deep location of ischial neural compression. Affected nerves show loss of normal
tuberosity, partial thickness tears are difficult to differenti- texture and focal irregular hypoechogenicity.
ate from tendinopathy and MR is the investigation of choice. Although rarely recognized clinically, piriformis syn-
In a study by Koulouris et al., only 7/16 acute hamstring drome is a common cause of buttock and leg pain as a
injuries were picked up on ultrasound whereas MR correctly result of injury to the piriformis muscle. Inflammation,
diagnosed all 16 lesions. Most cases of acute hamstring inju- hypertrophy or normal variants of piriformis muscle mor-
ries are managed by rest, antiinflammatory drugs and phology may lead to irritation or compression of the sciatic
physiotherapy. nerve. Symptoms are aggravated by prolonged hip flexion,
214 PART 5 — HIP
a a
ITB
ASIS Gluteus Maximus
Gluteus Medius L
S I
M b
b
Figure 19.9 Hamstring avulsion.
adduction and internal rotation. There is absence of low

back or hip findings on clinical examination. Ultrasound is
less sensitive than MR for assessment of the proximal sciatic
nerve at the exit of greater sciatic foramen, especially in
obese patients. However, ultrasound can be used to guide
perineural injections. The inferior gluteal artery is identi-
fied in the superomedial quadrant of the buttock medial to
the sciatic nerve. A small study of ultrasound-guided peri-
neural injection showed that symptoms diminished progres-
sively, with all patients being pain free at 2 months.
ISCHIOGLUTEAL BURSITIS
The ischiogluteal bursa is an inconsistent anatomical finding

located between the gluteus maximus and the ischial tuber-
osity. Ischiogluteal bursitis is also known as ‘weaver’s bottom’
and occurs from irritation or intermittent pressure upon the
ischial tuberosity from prolonged sitting. The bursa lies
c close to the sciatic or posterior cutaneous nerve of the thigh
and bursal inflammation may produce radicular symptoms.
Figure 19.8 TFL tendinopathy. The longitudinal ultrasound image
(A, B) shows the thickened and hypoechoic origin of the TFL tendon Alternatively, bursal enlargement may present as a soft tissue
at the iliac crest (arrow). The distal tendon is normal (arrowheads). mass. Ischiogluteal bursitis is seen in cancer patients with
The diagnosis of tendinopathy is confirmed on the coronal STIR MR weight loss and reduced subcutaneous buttock fat. Ultra-
image (C) with a thickened TFL tendon and surrounding peritendinous sound can assess the nature and extent of the bursa and
oedema (arrowhead). help differentiate it from other benign or malignant lesions.
FURTHER READING
Akisue T, Yamamoto T, Marui T, et al. Ischiogluteal bursitis: multimo-
dality imaging findings. Clin Orthop Relat Res 2003;(406):214–17.
Bass CJ, Connell DA. Sonographic findings of tensor fascia lata tendi-
nopathy: another cause of anterior groin pain. Skeletal Radiol 2002;
31(3):143–8.
Blankenbaker DG, Tuite MJ. The painful hip: new concepts. Skeletal
Radiol 2006;35(6):352–70.
Choi YS, Lee SM, Song BY. Dynamic sonography of external snapping
hip syndrome. J Ultrasound Med 2002;21(7):753–8.
Cvitanic O, Henzie G, Skezas N. MRI diagnosis of tears of the hip
abductor tendons (gluteus medius and gluteus minimus). Am J
Roentgenol 2004;182(1):137–43.
Dunn T, Heller CA, McCarthy SW, Dos Remedios C. Anatomical study
of the ‘trochanteric bursa’. Clin Anat 2003;16(3):233–40.
Dwek J, Pfirrmann C, Stanley A, et al. MR imaging of the hip abductors:
normal anatomy and commonly encountered pathology at the
greater trochanter. Magn Reson Imaging Clin N Am 2005;13(4):
691–704.
Gottschalk F, Kourosh S, Leveau B, et al. The functional anatomy of
tensor fasciae latae and gluteus medius and minimus. J Anat
[Research Support, US Gov’t, PHS]. 1989;166:179–89.
Graif M, Seton A, Nerubai J, et al. Sciatic nerve: sonographic evaluation
a and anatomic-pathologic considerations. Radiology 1991;181(2):
405–8.
Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed
internal degloving injuries associated with pelvic and acetabular frac-
tures: the Morel-Lavallee lesion. J Trauma 1997;42(6):1046–51.
Kong A, Van der Vliet A, Zadow S, et al. MRI and US of gluteal tendi-
nopathy in greater trochanteric pain syndrome. Eur Radiol 2007;
17(7):1772–83.
Koulouris G, Connell D. Evaluation of the hamstring muscle complex
following acute injury. Skeletal Radiol 2003;32(10):582–9.
Labrosse JM, Cardinal E, Leduc BE, et al. Effectiveness of ultrasound-
guided corticosteroid injection for the treatment of gluteus medius
tendinopathy. Am J Roentgenol 2010;194(1):202–6.
Martinoli C, Bianchi S. Hip. In: Ultrasound of the Musculoskeleta
System. Berlin Heidelberg New York: Springer; 2007. p. 551–610.
Pelsser V, Cardinal E, Hobden R, et al. Extraarticular snapping hip:
sonographic findings. Am J Roentgenol 2001;176(1):67–73.
Pfirrmann CW, Notzli HP, Dora C, et al. Abductor tendons and muscles
assessed at MR imaging after total hip arthroplasty in asymptomatic
and symptomatic patients. Radiology 2005;235(3):969–76.
Van Mieghem IM, Boets A, Sciot R, Van Breuseghem I. Ischiogluteal
bursitis: an uncommon type of bursitis. Skeletal Radiol 2004;33(7):
413–16.
Young IJ, van Riet RP, Bell SN. Surgical release for proximal hamstring
syndrome. Am J Sports Med 2008;36(12):2372–8.
b
Zissen MH, Wallace G, Stevens KJ. High hamstring tendinopathy: MRI
Figure 19.10 Hamstring tendinosis. and ultrasound imaging and therapeutic efficacy of percutaneous
corticosteroid injection. Am J Roentgenol 2010;195(4):993–8.
20 Disorders of the Groin
and Hip: Paediatric Hip
Eugene McNally
CHAPTER OUTLINE
DEVELOPMENTAL DYSPLASIA OF THE HIP Transient Synovitis vs Infection

Background: Dysplasia vs Instability Ultrasound Technique for Detecting Effusion
Epidemiology Need to Aspirate?
Role of Ultrasound Aspiration
Acquiring a Standard Image Imaging Approach to Hip Pain in Children
Graf Angles vs Coverage Measurements PERTHES’ DISEASE
Dynamic Examination Meyer Dysplasia
Other Techniques Slipped Upper Femoral Epiphysis
Imaging the Older Infant OTHER CONDITIONS
Screening Programmes FURTHER READING
IRRITABLE HIP IN THE OLDER CHILD
active management to optimize femoral head containment

DEVELOPMENTAL DYSPLASIA OF THE HIP and even distribution of weight-bearing force across the
joint, in order to prevent cartilage damage.
Developmental dysplasia of the hip (DDH) is a disorder
where under development of the acetabulum leads to
reduced femoral head coverage which, in turn, predisposes
Key Point
to acetabular labral abnormalities and early cartilage disease.
In essence, clinical examination detects unstable but not
If uncorrected, these abnormalities predispose to prema- stable dysplastic hips. The role of imaging is to identify all
ture osteoarthritis, requiring hip replacement. If dysplasia patients with dysplasia and prevent early cartilage
is severe, the femoral head may sublux or frankly dislocate. degeneration.
The older name for this condition, congenital dislocation
of the hip, is now seldom used, largely because many patients
may demonstrate acetabular dysplasia without frank disloca-
EPIDEMIOLOGY
tion at birth. Femoral head coverage and acetabular dyspla-
sia are related, in that it is generally felt that a concentrically There is variation in the distribution of DDH worldwide.
reduced femoral head can encourage development in a The reported incidence depends on the criteria used but is
dysplastic acetabulum. between 3 % and 10 % live births. It is significantly more
common in girls, with a ratio of 9 :1, and there is an associa-
tion with other congenital anomalies, such as talipes or
BACKGROUND: DYSPLASIA VS INSTABILITY
neuromuscular disorders. The condition runs in families
Infants with more severe dysplasia are easier to detect clini- and there is a higher incidence in babies born in a breech
cally as the hip is either dislocated or can be made to dislo- position, where it has been argued that the hip anomaly
cate on clinical examination. The classical Ortolani and underlies an inability for the baby to correct their position
Barlow manoeuvres look for a clunk as a dislocated hip is during late pregnancy. It is also more common on the left
reduced or a click as a reduced hip becomes dislocated. In side than on the right.
the past, many patients presented late in childhood and
adolescence with a painful limp secondary to established
ROLE OF ULTRASOUND
osteoarthritis. The reason for this was that a child with a
dysplastic acetabulum, but stable hip joint, will be normal Plain radiographs are poor at assessing acetabular dysplasia
on clinical examination, at least initially. Yet they also need and hip subluxation. Some measurements, notably the
216
CHAPTER 20 — Disorders of the Groin and Hip: Paediatric Hip 217
acetabular angle, when combined with careful radiographic aspect of the hip in a long-axis coronal position. No pressure
technique have some value, but difficulties with image is used, and it is better to allow the child to move as they
reproduction and interobserver variation are still a problem. want to and to concentrate on acquiring the correct image
CT and MRI can be effective but the radiation or financial when they choose to relax. This prevents unnecessary dis-
cost of these investigations precludes their use as a screen- tress. With practice, a satisfactory image can be achieved
ing tool, especially in infants. Ultrasound is ideally placed quite quickly within the windows of opportunity. A foot
to assess the infant hip as it can visualize the unossified pedal to freeze the frame and a rewind facility are helpful
components of the acetabulum and femoral head, is for particularly active bubskis!
dynamic enough to assess subluxation and does not carry a The key components of the image are the unossified
radiation risk. femoral head and acetabulum (Fig. 20.2). The ideal image
Ultrasound is used to assess both the depth of the acetab- should demonstrate the acetabulum at its maximal depth
ulum and joint stability. The former can be assessed either
by measuring certain defined angles around the acetabu-
lum, or by determining the proportion of the unossified
femoral head which is contained within the acetabulum.
Both of these assessments are carried out on a static stan-
dardized coronal ultrasound image of the hip. Ultrasound
can also detect when the femoral head is either dislocated
at rest or the ease at which it can be made to sublux by
lateral pressure to the femoral head. A complete neonatal
ultrasound hip examination, therefore, has both static and
dynamic components. These allow the range of abnormali-
ties to be detected and classified, so that appropriate treat-
ment can be instigated.
ACQUIRING A STANDARD IMAGE

In our institution, the child is examined in the decubitus
position, though others advocate an anterior approach.
Practice Tip
The child is placed in a foam-filled trough to provide support

and prevent excessive movement.
To examine the child’s right hip, the examiner’s right hand

secures the infant’s knee with the hip and knee in a gently
flexed position (Fig. 20.1). The fingers of the right hand are
placed along the inside of the child’s thigh. The probe is
held in the left hand and is gently placed on the lateral
Figure 20.2 Standard hip ultrasound image. The lateral margin of

Figure 20.1 DDH examination. The infant is placed in a foam trough the ilium is horizontal to the skin. Note the speckled reflectivity of
in a decubitus position. This is comfortable for the infant and reduces unossified hyaline cartilage in the femoral head and greater
unnecessary movement. trochanter.
218 PART 5 — HIP
through the triradiate cartilage without excessive probe tilt. The Graf classification uses four types. Type I is a normal
The reflective lateral wall of the ilium should be a straight hip anatomically, with an α angle of ≥ 60° and β ≤ 55°. A
line, parallel to the probe. A line drawn along this is called normal α angle but increased β angle, of more than 55, is
the base line. A sharp margin between the base line and the classified as immature and designated Ib. A type II hip has
bony roof of the acetabulum should be present as the roof α > 50°. Type IIb is used if the child is also older than 3
line turns downwards. Between the roof line and the femoral months and IIc if the α is less than 50° but more than 43°.
head lies unossified roof acetabular cartilage onto which the Type III has α less than 43° and type IV when the hip is also
reflective fibrocartilaginous labrum attaches. Most of the dislocated.
femoral head is unossified. An ossified nucleus at various An alternative method of assessing acetabular depth is to
stages of development may be seen within it. Unossified determine what proportion of the femoral head is con-
femoral head cartilage has a typical speckled appearance. tained within the acetabulum. If a line drawn along the base
The speckles represent vessels and in some cases Doppler line is continued, it normally passes through the femoral
activity can be detected within them. The overlying hyaline head. The proportion of the femoral head diameter that lies
cartilage representing articular cartilage has a smoother below this line is measured (Fig. 20.4) and the normal value
low-reflective appearance. is > 40%.
It will be noted from these two measurements that there
is a relationship between the Graf α angle and femoral head
GRAF ANGLES VS COVERAGE MEASUREMENTS
coverage and both are used separately and together in dif-
Graf is an orthopaedic surgeon who pioneered much of the ferent centres. The bigger the α angle, the steeper is the
early work in ultrasound assessment of the dysplastic hip. acetabular roof and the more femoral head will be con-
He describes two angles, α and β, which help define acetab- tained by it. Conversely, a shallow hip has a lower α angle
ular depth and femoral head coverage. The α angle is the (Fig. 20.5) and less of the femoral head is covered by ace-
angle between the base line and the acetabular ‘roof’ line tabulum (Fig. 20.6).
(Fig. 20.3). The β angle is the angle between the base line Correlation between the α angle and femoral head cover
and a line drawn from the tip of the acetabular rim (junc- is lost in babies with very immature hips where there is a
tion of the base line and roof line) through the tip of the large unossified cartilage anlage. In these infants the α
acetabular labrum. The two angles are used to classify the angle will be low, suggesting a shallow acetabulum, but
infant hip into specific types and this classification is used femoral head coverage may be normal. This is because
to determine management. The higher the α angle, the much of the femoral head will be covered by unossified
deeper the acetabulum. cartilage, but covered nonetheless. The α angle is low
because it is measured from the bony and not cartilage
acetabular roof. This situation needs to be viewed with some
caution as there may be a greater deforming pressure on
Figure 20.3 Standard hip ultrasound examination. The iliac line is

horizontal to the probe and the acetabular roof line clearly visible.
Note the speckled reflectivity of unossified hyaline cartilage in the
femoral head and greater trochanter. The α angle is calculated
between the iliac baseline and the acetabular roof line. The β angle Figure 20.4 The proportion of femoral head contained deep to the
is calculated between the iliac baseline and the line joining the ace- iliac baseline can be calculated as a proportion of the femoral head
tabular rim and the tip of acetabular labrum. diameter (d1/(d1+d2)).
a
Figure 20.6 Shallow acetabulum. The proportion of femoral head
coverage is also reduced.
the dynamic stability of the joint. In the standard decubitus

examination position of a right hip, the fingers of the opera-
tor’s right hand are extended along the inside of the infant’s
thigh. Gentle abduction pressure can be applied by the
examiners fingers and the relative position of the femoral
head to the acetabulum noted during this manoeuvre. It is
important not to apply counterpressure with the probe as
this may prevent subluxation. Movement is best appreciated
by observing the deep aspect of the femoral head and its
relationship to the tri-radiate cartilage (Fig. 20.7). More
than 2 mm of subluxation is regarded as abnormal, though
can be acceptable in premature infants. If laxity is detected,
a repeat examination is recommended after 2 to 3 weeks to
ensure that the hip is normalizing. Persistent subluxation
needs to be actively managed.
OTHER TECHNIQUES
b
Figure 20.5 Shallow acetabulum. Alpha angle is decreased.

The coronal plane is most commonly employed for assess-
ing dysplasia and subluxation; however, an anterior approach
has also been used. In some respects this view is better at
demonstrating the anterior component of dysplasia, which
the cartilage anlage than usual. Once this immature carti- is often the most obvious. Both hips can be examined simul-
lage ossifies, the α angle becomes normal. taneously with a wide field of view probe and the child
In addition to the acetabular angle and femoral head supine; this makes the examination more efficient, which is
cover measurements, the shape of the acetabular rim should important for a screening programme.
also be noted. In most cases the angle between the baseline
and roof line is sharp, but in some it can appear notched
IMAGING THE OLDER INFANT
or blunted. It has been suggested that a persistently sublux-
ing hip is the cause of this notch. Ultrasound can be used well into the first year and beyond;
however, as the child becomes more active, acquiring a
good ultrasound image becomes more and more difficult.
DYNAMIC EXAMINATION
Although there is progressive ossification of the acetabu-
Whatever method is used to assess acetabular morphology, lum, the relationship of the femoral head coverage can still
the examination is incomplete without some evaluation of be assessed until the ossification centre becomes so large
220 PART 5 — HIP
Figure 20.8 Transverse T2-weighted MRI. The left hip is subluxed

posteriorly, and there is a joint effusion.
measures, operative reduction is indicated. An attempt at

a reduction is carried out under general anaesthesia. In most
cases this can be achieved; however, if there is a mechanical
block to reduction an open procedure is required. The
cause of a mechanical block can be a tight capsule or an
inverted labrum. A prominent pulvinar fat pad has been
described as a mechanical cause of failed reduction, but this
is likely to be a secondary effect. Once reduction is achieved
by either open or closed methods, a cast is applied. It is
important to ensure that the hip has remained reduced
during application of the cast.
Key Point
Plain films are poor at assessing satisfactory and maintained

hip reduction as bony detail is often obscured by the cast.
Options are to create a window in the cast so that ultrasound

may be used, but at the risk of weakening the structure of
the cast. CT and MR have both been used.
Key Point
b MR is preferred as it is more accurate and does not involve
ionizing radiation (Fig. 20.8).
Figure 20.7 The unossified femoral head is dislocated. The acetab-
ulum appears shallow; however, care should be taken as the section
is centred on the dislocated femoral head rather the centre of the
acetabulum. SCREENING PROGRAMMES
As can be seen from the above, DDH cannot be diagnosed
by clinical examination alone as a stable but dysplastic ace-
that a good assessment of acetabular depth is no longer tabulum will not be detected. Ultrasound is key for diagnosis
possible. In older children, imaging assessment then reverts but there is a quandary in deciding who should be screened.
to using plain radiographs, although variability in acetabu- A few countries favour population screening. This offers the
lar and femoral head measurements can be problematic. greatest chance of detecting acetabular dysplasia but is
Imaging also plays an important role in postoperative work-intensive and risks a small proportion of false positives.
assessment following open or closed reduction for habitu- False-positive diagnosis is not without hazard as there is a
ally dislocated hips. In these children, it is important to small but finite risk of avascular necrosis as a complication
restore hip congruity to encourage normal acetabular devel- of treatment. This is thought to be due to overabduction
opment. If the femoral head cannot be reduced by simple during treatment, causing the vascular supply to the femoral
head to be compromised. It is countered that the risk is ULTRASOUND TECHNIQUE FOR

greatest in patients with severe acetabular dysplasia, in
DETECTING EFFUSION
whom treatment is mandatory, and is very rare in patients
with borderline normal that may occasionally lead to false- The child is supine and the probe is aligned along the
positive diagnosis. femoral neck by rotating it 45° from the sagittal plane. The
Population screening is also expensive and other coun- desired image shows the femoral neck as a reflective line,
tries have adopted what is termed a high-risk screening easily identified by the characteristic appearance to the
programme. In this approach, infants with a family history growth plate and the femoral head above. Anterior to this
of DDH, breech deliveries, those with an abnormality on the reflective anterior capsule can be identified and the
clinical assessment and those with other congenital anoma- space between them is the anterior joint and surrounding
lies that predispose to DDH are screened. Many twins connective tissue. Above the capsule lie the muscles of the
are also screened as often one infant is breech and it is anterior thigh.
easy to examine the twin when the family is present. It is The undistended capsule is concave upwards. As fluid fills
argued that this so-called high-risk screening will detect the the anterior joint space, low-reflective fluid displaces the
majority of patients with DDH; however, approximately 1 in anterior capsule and it becomes convex upwards (Fig. 20.9).
50 infants with DDH have none of these risk factors, are More than 5 mm distension of the anterior joint or more
normal on clinical examination and will therefore remain than 2 mm difference between sides is regarded as abnor-
undetected. mal with the limbs in a relaxed position (Fig. 20.10). False
negatives are uncommon but can occur due to compression
of the anterior synovial space if the hip is externally rotated,
IRRITABLE HIP IN THE OLDER CHILD or decompressed if the femoral head subluxes as a conse-
quence of the effusion. This is uncommon and will result in
A painful irritable hip is one of the commonest causes of an obviously abnormal relationship between the bony struc-
nontraumatic, acute paediatric presentations in orthopae- ture and an increased distance between the acetabular rim
dic practice. The most common cause is transient synovitis, and the physis.
a disorder that is incompletely understood but with self- Simple effusions are echo-free (Fig. 20.11). Complex
limiting and short-lived symptoms. Other causes, such as components or particulate matter should raise suspicion of
septic arthritis, are more serious and can result in significant infection or haemorrhage. Thickening of the anterior cap-
long-term problems if the diagnosis is delayed. Ultrasound sule and synovium is also a suspicious finding but also occurs
is used to differentiate between them. in transient synovitis. Conversely, while the majority of effu-
sions in septic arthritis are reflective, some are echo-free.
TRANSIENT SYNOVITIS VS INFECTION
NEED TO ASPIRATE?
The typical clinical history of transient synovitis is of a child
aged between 5 and 8 years who has been complaining of
hip pain and inability to weight bear, generally of a few days’ Key Point
duration. The incidence is approximately 0.2% and up to
25% will have recurrent episodes. A seasonal variation has The cause of an effusion cannot be determined by its
been noted. The condition is more common in boys, with ultrasound appearances alone.
a ratio to girls of 2.5 : 1. There is no side predisposition. Joint
effusion is present, reflecting the synovitis.
On clinical examination the hip is painful with some Large effusions are typical of benign transient synovitis and
reduction in the range of motion. septic arthritis may be present with even small effusions.
Differentiating among transient synovitis, Perthes’ disease
and septic arthritis can be difficult on clinical grounds
Key Point unless features are marked, at which time damage to the hip
and growth plate may already be established.
Plain radiographs are of no value in the diagnosis of effusion
as they have a high false-positive and false-negative rate.
Key Point
The aim of early diagnosis is to exclude more serious condi- Clinical and laboratory investigations are not often clear-cut,
tions that, if they remain unchecked, can cause serious leading many to conclude that it is not possible to
damage to the developing joint. There are therefore two differentiate patients with benign transient synovitis from
goals for early imaging, one to detect the effusion that is those with septic arthritis on the basis of clinical and
laboratory investigations alone in the important early stages.
the hallmark of transient synovitis and secondly to guide
aspiration and thereby to exclude sepsis. Once sepsis is
excluded, the child can generally be managed conserva-
tively and symptoms tend to resolve, often within days. If Combinations of abnormalities, including pyrexia, raised
pain or effusion persists, MRI is indicated to excluded inflammatory markers and white counts, increase the speci-
Perthes’ disease or occasionally an underlying osteomyelitis ficity but many patients with infection show normal or mini-
with a reactive effusion. mally abnormal values. In some cases, MRI may be helpful
222 PART 5 — HIP
Figure 20.10 Comparative image between abnormal and normal

hip. Note the low-reflective joint effusion displacing the anterior
capsule. A difference of 3 mm or an absolute measurement of 5 mm
a indicates an abnormal quantity of fluid.
Figure 20.11 Further example of distension of the anterior joint

space by effusion.
b
in that marked oedema around the joint is unusual in tran-

sient synovitis, but may occur with infection.
Joint aspiration is the most reliable method of detecting
septic arthritis in the early stages. Those in favour of routine
aspiration place emphasis on the seriousness of septic arthri-
tis should the diagnosis be delayed and emphasize that the
technique of aspiration is quick and with a very low
complication profile. Septic arthritis arising from diagnostic
aspiration is exceptionally rare. It has also been suggested
that the trauma of hip aspiration in experienced hands is
little more than drawing blood and that it is better to obtain
direct evidence of septic arthritis, from synovial fluid analy-
sis, than indirect evidence from combinations of white cell
counts, C-reactive protein or erythrocyte sedimentation rate
c (ESR). Other benefits of direct aspiration include a reduc-
tion of intraarticular pressure, which may reduce the inci-
Figure 20.9 (A, B) Low-reflective fluid distends the anterior joint
space (*). Characteristic anatomical landmarks include the physis
dence of avascular necrosis, more immediate pain relief and
separating the epiphysis from the femoral neck and the overlying the avoidance of hospital admission. Those supporting a
capsule. Note the speckled reflectivity of unossified hyaline cartilage. watching brief point to the relative low incidence of unex-
(C) Transverse T1-weighted MRI section following intraarticular con- pected infection and the large number of aspirations
trast injection. The appearance of the femoral head and neck with the required to detect them. Clumsy aspiration is traumatic for
overlying effusion is similar to the image obtained with ultrasound. the child.
lines joining opposite points identifies the puncture point.

ASPIRATION
Using smaller footprint probes makes identification of the
In view of the difficulty with differentiating benign from midpoint easier than longer footprint probes. Some manu-
more serous causes of effusion, the protocol in many centres facturers now also put a mark on the side of the probes to
is to carry out aspiration in all hips where effusion is dem- denote their midpoints. If only a long footprint probe is
onstrated. When performed skilfully, aspiration is quick and available, a modification of this method is to mark the
in the vast majority of cases can be carried out with minimal central points of the narrow ends of the probe and use a
trauma to the child. movable marker to locate the midpoint of the longer sides.
A small reflective wire, such as a straightened paper clip
(Fig. 20.13), is used as a marker. By sliding it up and down
Practice Tip
under the probe and noting where the acoustic shadows
Local anaesthetic cream is applied, by trained nursing staff, cross the point of maximal joint distension, the optimal
to the skin anterior to the affected hip as soon as the patient point for puncture can be found. Another useful technique
presents. is to apply a little pressure to the probe once the point of
maximal joint distension has been identified. If the probe
is quickly removed from the skin, the blanched footprint
Depending on the preparation used, local anaesthesia is can still be seen and a mark placed at its centre.
achieved in between 20 and 90 minutes. Successful aspira- Combining these techniques means that the aspiration
tion depends on accurate identification of a puncture point point can be identified with great confidence.
that directly overlies the point of maximal joint distension.
Once this point is located, ‘blind’ aspiration is performed
Key Point
with confident knowledge of the location of the effusion.
Several methods are used in combination to identify the The approach to aspiration should be that the probe is not
optimal puncture point and mark it on the child’s skin. removed until the sonologist is completely confident that the
marked point overlies the point of greatest joint distension
Practice Tip (Fig. 20.14).
A key element is that the probe should be held vertically, at

90° to the skin, so that the aspirating needle can follow the Once this is achieved, direct puncture with the needle at
same vertical line down to the joint. 90° to the skin surface will result in aspiration in almost
every case (Fig. 20.15). Aspiration should be as complete as
is possible, as this may reduce pain and shorten hospital stay.
The introduction of angles in the determination of the
puncture point requires that the same angle be used for
IMAGING APPROACH TO HIP PAIN IN CHILDREN
aspiration. Replicating angles other than 90° by hand is
difficult. In young children, there is general agreement that ultra-
The first method involves marking the central point of sound is the best first line tool for imaging acute hip pain.
each side of the probe when the point of maximal disten- If an effusion is detected, aspiration provides the most reli-
sion has been identified (Fig. 20.12). The intersection of able means of excluding sepsis. Following this, if symptoms
Figure 20.12 To identify the optimal position for aspiration, the Figure 20.13 The optimal point can also be calculated by marking
probe is held at 90° to the skin surface. The centre of each of the the centre of the short end of the probe that identifies the puncture
four sides of the probe can be marked and the intersection of a line point in the sagittal plane. The axial plane can be determined by
joining opposite points indicates the puncture point. moving a paper clip between skin and probe and observing when the
acoustic shadow overlies the maximal point of effusion.
224 PART 5 — HIP
Figure 20.14 The final method is by creating a blanched probe

footprint by pressing gently with the probe. The centre of the blanched
footprint (which is difficult to reproduce photographically but obvious
on the patient’s skin) should correspond with other methods for
identifying the optimal puncture point.
Figure 20.16 Coronal gradient echo MR image. There was a large

effusion. Note the fragmentation and flattening of the femoral capital
epiphysis, particularly involving the lateral column.
centres limit this to a frog-leg view, which is also sufficient

to detect the majority of other entities, including Perthes’
disease.
PERTHES’ DISEASE
Perthes’ disease is a condition caused by avascular necrosis

of the femoral head. The disease passes through various
stages with different radiological manifestations at each
Figure 20.15 Once the puncture point is identified, the needle is
stage. Most of the imaging findings reported are from plain
inserted at 90°, corresponding with the prior probe position. With radiographs, although cross-sectional imaging methods,
careful technique, aspiration is straightforward. including ultrasound, are important under specific circum-
stances. The earliest plain film manifestations of the disease
are reduced size of the ossific nucleus, increased density of
settle, and do not recur, then no further imaging is the involved bone, widening of the medial joint space and,
necessary. in older children, subchondral fracture and cyst formation.
Subchondral lucency represents the earliest sign of avascu-
lar necrosis. As the disease progresses, the epiphysis begins
Key Points to fragment and the femoral head flattens, particularly at its
superior aspect (Fig. 20.16). There is loss of height particu-
Patients who fail to settle should be more intensively
larly of the lateral component (sometimes referred to as the
investigated to exclude Perthes’ disease or the uncommon
association of osteomyelitis with a sterile effusion. lateral column) and lateral migration of the fragmenting
nucleus. In the healing phases new bone formation begins
medially and laterally, with the central and anterior portions
In these patients early MRI is indicated. If no effusion is last to reossify. Radiodensity decreases and the shape of the
demonstrated on ultrasound, consideration should be given femoral head improves. The final outcome depends on the
to other potential causes of pain around the hip joint or degree of healing, with changes varying from a normal hip
referred to the hip, such as discitis or other spinal disorders. to a markedly dysplastic one.
Once again MRI is frequently indicated. Perthes’ disease occurs in a similar age group as transient
In the late first decade, radiography should also be synovitis of the hip. As ultrasound is often used in the assess-
obtained to detect slipped upper femoral epiphysis. Some ment of transient synovitis, knowledge of the findings that
finding. The postulated pathogenesis is hypoplasia of the

proximal femoral epiphyseal cartilage with delayed appear-
ance of single or multiple ossification centres. The process
is benign, often bilateral and symmetrical and the hip always
develops normally.
SLIPPED UPPER FEMORAL EPIPHYSIS

Slipped upper femoral epiphysis is an important cause of
hip pain in the older child. Males are more commonly
a
affected than females and the average age is 12 years.
Increased weight is said to predispose to the condition. Slow
and gradual slip is more common than acute presentations
following specific trauma, when the diagnosis is really a
Salter–Harris fracture.
Key Point
In the majority of cases, the diagnosis of slipped epiphysis

is made by plain films and a frog-leg view of both hip joints
b should be obtained in all older children presenting with
hip pain.
Figure 20.17 Ultrasound image demonstrated Perthes’ disease on
the left compared with the normal right. Note the fragmentation
of the ossified epiphysis and corresponding apparent enlargement of
Plain film findings include loss of overlap between the
the overlying unossified articular cartilage.
medial margin of the epiphysis and the acetabulum, failure
of a line drawn along the lateral margin of the femoral neck
to intersect the femoral head and metaphyseal irregularity
can indicate Perthes’ disease is helpful. The earliest finding reflecting chronic stress. Like Perthes’ disease, knowledge
is isolated effusion, which is nonspecific. It is present in of the ultrasound findings of this condition is useful as a few
approximately two-thirds of patients and is more common patients may present for ultrasound assessment in the inves-
in the early stages of the disease. tigation of nonspecific hip pain. An effusion is present in
acute presentations but not chronic cases.
Practice Tip
Practice Tip
Other ultrasound findings in Perthes’ disease include
thickening of femoral head articular cartilage, fragmentation of The key ultrasound finding is loss of congruity between the
the epiphysis (Fig. 20.17) and increased femoral anteversion. epiphysis and metaphysis where a step at the level of the
physis may be found (Fig. 20.18).
Asymmetry may be apparent in the cartilage overlying the

femoral head and probably due to reduction in the size of False negatives occur with chronicity and remoulding. Pos-
the ossification centre, though some have suggested that a teromedial slips also result in a reduction in the distance
true cartilage oedema occurs. A 3 mm difference in thick- between the tip of the acetabular rim and the nearest corner
ness between sides is significant, best measured anteriorly of the metaphysis. A difference of greater than 2 mm
where the femoral head is not covered by acetabulum. The between the normal and an assumed unaffected side is sig-
absence of asymmetry does not exclude the condition, as nificant. MRI may be helpful in slipped upper femoral
the disease may be bilateral. Other signs that have been epiphysis. A T1-weighted image orientated along the femoral
described in the earlier stages include flattening and loss of neck demonstrates displacement and the quantity of new
the round contour of the epiphysis associated with irregular- bone formation at the site of periosteal stripping. In clear-
ity of the metaphyseal margin. Increased density and epiph- cut cases, MRI probably does not add significantly to the
yseal fragmentation can also be seen on ultrasound; however, diagnosis but where there is diagnostic difficulty it may have
at these stages, plain films will usually be abnormal. a role. There may also be a role in incipient slip with equivo-
cal plain radiographs. Bone oedema on the metaphyseal
side of the physis may be an early MR sign of slip.
MEYER DYSPLASIA
Meyer dysplasia is a condition of unknown aetiology, also
known as dysplasia epiphysealis capitis femoris. There is OTHER CONDITIONS
irregularity of the femoral head epiphysis similar to Perthes’
disease but no effusion. Boys are more commonly affected, Transient synovitis, Perthes’ disease and slipped epiphysis
by a factor of five, and few show symptoms or clinical signs. are amongst the common causes of hip effusion in children,
In some a waddling gait occurs but this is an inconsistent but there is a long differential diagnosis. If other joints are
226 PART 5 — HIP
The typical plain film findings are often not present with
the intraarticular variant and cross-sectional imaging; MRI
and CT are helpful to confirm. In older children with snap-
ping hip, US may show an abnormal jerky movement of the
posterior part of the iliotibial band over the greater trochan-
ter. Occasionally it is the movement of the gluteus maximus
over the trochanter that accounts for the snap. Abnormali-
ties may be present within the band, which becomes thick-
ened and disorganized. To snap the iliotibial band, the
patient lies on the unaffected side. The hip is adducted and
extended, then moved to a flexed position whilst the band
is observed. In some patients internal and external rotation
may augment the phenomenon.
To snap the iliopsoas tendon the patient lies supine. The
snap can be elicited by abducting, flexing and externally
rotating the hip and then bringing it back to the normal
a
neutral position. Rare causes of snapping include labral
tears and ischiofemoral impingement.
In general, pain arising from an enthesis can be dif
ferentiated from hip pain in children. The usual cause
of enthesopathy in children is traumatic and the rectus
femoris, sartorius and hamstring attachments are the most
common.
Practice Tip
A full review of the pelvic entheses includes an assessment

of the adductor, iliopsoas, rectus femoris and sartorious
gluteus medius, minimus and maximus and hamstring
insertions.
FURTHER READING
b Fink AM, Berman L, Edwards D, et al. The irritable hip: Immediate
ultrasound guided aspiration and prevention of hospital admission.
Figure 20.18 A small step is noted at the epiphysis–metaphysis
Arch Dis Child 1995;72(2):110–14.
junction. This is suggestive of a slipped epiphysis. There is no effu- Graf R. Profile of radiologic-orthopedic requirements in pediatric hip
sion, suggesting that the lesion here is not acute. dysplasia, coxitis and epiphyseolysis capitis femoris. Radiologe 2002;
42(6):467–73.
Kallio PE, Lequesne GW, Paterson DC, et al. Ultrasonography in
involved, and this is very easy to assess quickly and noninva- slipped capital femoral epiphysis. Diagnosis and assessment of sever-
sively with ultrasound, juvenile idiopathic arthritis should ity. J Bone Joint Surg Br 1991;73(6):884–9.
be considered. MacDonald J, Barrow S, Carty HM, et al. Imaging strategies in the first
12 months after reduction of developmental dislocation of the hip.
J Pediatr Orthop B 1995;4(1):95–9.
Key Point Terjesen T. Ultrasonography for diagnosis of slipped capital femoral
epiphysis. Comparison with radiography in 9 cases. Acta Orthop
Scand 1992;63(6):653–7.
Intraarticular osteoid osteoma can present with synovitis in Terjesen T. Ultrasound as the primary imaging method in the diagnosis
children. of hip dysplasia in children aged < 2 years. J Pediatr Orthop B
1996;5(2):123–8.
PART 6
KNEE
227
Knee Joint and Calf: 21
Eugene McNally
CHAPTER OUTLINE
OVERVIEW Position 4: Posterolateral Knee

Position 1: Anterior Knee Position 5: Anterolateral Knee
Position 2: Medial Knee Position 6: The Calf
Position 3: Posterior Knee
3. Locate patellofemoral ligaments and review the retro

OVERVIEW patellar surface.
As with other larger joints, ultrasound is most useful when TECHNIQUE

the patient’s symptoms are localized to a relatively specific The patellar tendon is very readily assessed with ultrasound
area. More diffuse symptoms suggest internal derangement (Fig. 21.1). It has the striated predominantly reflective
due to meniscal, cruciate and cartilage injuries. These are appearance typical of normal tendon tissue. The low-
diagnosed by MRI with relative ease and, although there reflective areas represent the tendon fibres and the brighter
have been efforts to use ultrasound to depict these struc material is the interspaced connective tissue. In long axis,
tures, it is not sufficiently reliable for general diagnostic the tendon measures approximately 5 cm. In cross section,
use. Until meniscal or cruciate injury can be confidently it is considerably wider than it is thick, cross-sectional dimen
excluded, ultrasound will always play a subservient role to sions 26 × 4 mm are typical. It is convex in both its anterior
MRI. This is not true of trauma to the extraarticular struc and posterior margins. There is no tendon sheath but a
tures, though the possibility of combination injuries within paratenon is present.
the joint must always be borne in mind. Patients with iso The normal appearance of the proximal attachment of
lated injuries of the patellar tendon, quadriceps tendon and the patellar tendon is quite variable. Sometimes it is a similar
iliotibial band (ITB) can be reliably assessed. The medial dimension to the tendon itself whilst in other individuals it
collateral and lateral collateral ligaments are also readily broadens to a triangular shaped insertion. Some of these
accessible to ultrasound examination, though are more variations may be related to the patient’s level of activity.
often associated with meniscal injury. Masses, both cystic The distal tendon more commonly shows some broadening
and solid, are common around the knee and ultrasound at the insertion onto the tibial tubercle. There are transi
affords a cheap and reliable method of investigation. tional changes between the fibrous structure of the tendon
The anterior knee is best examined with the patient and the bone, which can sometimes be seen with high-
recumbent and the knee extended. A dynamic examination resolution ultrasound. The fibrous tendon transitions
can be added later, but the extended knee relaxes the exten through fibrocartilage, hyaline cartilage and, finally, bone.
sor mechanism and does not compress any abnormal vessels Where the tendon lies close to the proximal tibia, some
that may present. This position can also be used to examine entheseal cartilage may be apparent on the undersurface of
the medial structures and the ITB with ease. The postero the tibia with sesamoid cartilage present on the tendon side.
lateral corner, proximal tibiofibular joint and posterior These different cartilage components are more readily
structures are best examined with the patient prone. visible in some patients than in others but it is rare to see
all components together.
POSITION 1: ANTERIOR KNEE The tibial enthesis is also accompanied by two bursae: the
superficial and the deep infrapatellar bursa. Fluid is more
IMAGING GOALS commonly seen in the deep infrapatellar bursa. Gentle flex
1. Identify the patellar tendon and Hoffa’s fat pad. ion and extension of the knee while examining the bursa
2. Identify all four components of quadriceps. in the axial plane makes the fluid more readily visible. The
229
230 PART 6 — KNEE
a a
Patellar Tendon
Quadriceps
Patella
Patella
Tibia
Hoffa
A
A Femur
S I
S I
P
b b P
c c
Figure 21.1 Sagittal approach to the sub patellar extensor Figure 21.2 Sagittal approach to the supra patellar extensor
mechanism. mechanism.
tendon’s superficial relationship is usually subcutaneous fat, and lateralis, which also have separate insertions on the
although in its upper portion a small quantity of fluid may superomedial and superolateral patella. With the knee fully
be identified in the prepatellar bursa and inferiorly in the extended, some kinks may be evident in the tendon, leading
superficial component of the infrapatellar bursa. The pos to areas of altered reflectivity. These disappear when slight
terior relation of the patellar tendon is Hoffa’s fat pad. This flexion is applied, although the knee must be returned to
has a bright reflective appearance typical of fat. It is fairly full extension prior to assessing Doppler activity. Deep to
homogeneous, containing a few blood vessels only. the tendon, there is a triangle of fat, the suprapatellar fat
The other important tendon of the extensor mechanism pad. This fat pad is separated from the prefemoral fat by
is the quadriceps tendon. This has several components and the synovial knee joint. A small quantity of fluid is not infre
care must be taken not to concentrate only on the most quently identified within the joint.
obvious central component. To demonstrate these different The probe is then moved laterally, the upper end of the
parts, it is best to begin with the probe in long axis centrally probe a little more than the lower end, to align along the
positioned over the upper border of the patella (Fig. 21.2). tendon of vastus lateralis (Fig. 21.3). This has a broader
The typical bright, striated appearance of the central part insertion along the superolateral aspect of the patella with
of the tendon will be seen beneath. Often three or four fibres contributing to both the central tendon and the
distinct bands are visualized with interspaced reflective con lateral retinaculum. The probe is finally moved medially,
nective tissue. The upper bands represent the contribution once again the proximal end more than the distal end,
from rectus femoris and the lower the components of vastus to align along the tendon of vastus medialis (Fig. 21.4).
intermedius. There are contributions from vastus medialis The musculotendinous junction of vastus medialis is lower
CHAPTER 21 — Knee Joint and Calf: Anatomy and Techniques 231
Vastus Lateralis
Patella a
A
S I Femur
P
b
lis
Media
Vastus
Patella
A Femur
S I
P
b
Figure 21.3 Parasagittal approach to the supra patellar extensor

mechanism for vastus lateralis insertion.
than vastus lateralis and the tendon arises from the deep
rather than the superficial component of its parent muscle.
The muscle fibres visible here make up the vastus medialis
obliquus.
Both patellofemoral ligaments should be examined in
turn and each followed posteriorly to where they form the c
medial collateral ligament and the ITB respectively. They Figure 21.4 Parasagittal approach to the supra patellar extensor
are traced forwards to their insertions along the medial mechanism for vastus medialis insertion.
(Fig. 21.5) and lateral border of the patella (Fig. 21.6). The
retropatellar surface can also be examined, although not in
its entirety. The medial facet is easier to see and gentle
medial pressure on the lateral border of the patella improves
visualization. This is particularly useful when patellar dislo POSITION 2: MEDIAL KNEE
cation is suspected and cartilage injury in this location may
be found. The presence of fluid within the joint improves IMAGING GOALS
visualization. The patella can be tracked during flexion and 1. Identify the medial collateral ligament and meniscus.
extension using ultrasound, although more accurate tech 2. Identify semimembranosus and its complex insertion.
niques have been described particularly using MRI. Patellar 3. Locate the pes anserine tendons.
maltracking is best assessed with the quadriceps under
tension. This can be achieved either by attaching weights to TECHNIQUE
the patient’s shin that they then have to lift or asking the The principal ligament on the medial aspect of the knee is
patient to extend the knee against the resistance of the the medial collateral ligament. This is examined first in its
examiner’s hand. long axis by placing the probe over the medial aspect of
232 PART 6 — KNEE
a a
LPL
MCL
MPL
Patella Patella
Femur L
M Femur
A P
P A M
b L b
c c
Figure 21.5 Axial approach for the medial patellofemoral ligament Figure 21.6 Axial approach for the lateral patellofemoral ligament.
and medial joint space.
the knee and locating the joint space (Fig. 21.7). This is to the ligament. Running posteriorly from the medial col
achieved by following the bony contour either of the femur lateral ligament in the axial plane and passing more poste
distally or tibia proximally. Move the probe to approximately riorly and distally is the posterior oblique ligament that lies
the midpoint of the medial aspect of the joint and the deep to the semimembranosus tendon.
medial collateral ligament will be found. It is composed of The medial meniscus is easily found, although only its
two layers; the more important superficial layer is usually peripheral two-thirds are seen reliably. As with fibrocarti
the first to be recognized. This arises several centimetres lage elsewhere (the glenoid labrum of the shoulder, the
above the joint from a triangular shaped attachment to the acetabular labrum of the hip), the medial meniscus is a
medial femoral condyle. It inserts approximately 5 cm below reflective structure with a homogeneous speckled internal
the joint where the tibial attachment is thinner than the matrix. It is separated from the medial collateral ligament
femoral attachment. It has the typical ultrasound appear by an area of loose connective tissue, which is usually
ance of a ligament with clearly defined striations. The most echo-poor.
common site of injury of the ligament is proximal, close to The structures outlined above are sometimes collectively
the femoral origin. The deep component of the ligament is referred to as the anteromedial corner. The posteromedial
a much thinner structure composed of two parts. The proxi corner comprises several important tendons, including the
mal part is the meniscofemoral ligament and the distal part tendons of semimembranosus, semitendinosus, gracilis and
is the meniscotibial ligament. As would be expected from sartorius. Each of these should be located in turn. Semi
their names, these ligaments are attached to the medial membranosus is best located by placing the probe in the
meniscus. axial plane in the distal thigh. The characteristic relation
The medial collateral ligament can also be examined in ship of the semitendinosus tendon lying against the muscle
axial plane. It is slightly thicker than the medial retinacu belly of semimembranosus muscle provides a very reliable
lum, to which it is closely attached. Occasionally, the super landmark. This is a similar starting position for evaluating
ficial fibres of the medial collateral ligament are separated semitendinosus. Semimembranosus can then be followed
from the deep fibres by a small quantity of fluid contained distantly, keeping the probe in the axial plane, until the
within the tibial collateral ligament bursa. The medial genic tendon forms (Fig. 21.8). The tendon in turn is followed to
ulate artery (inferior branch) may also be identified deep its insertion. The insertion of semimembranosus is complex.
MCL
Meniscus a
Tibia
M Femur
Semitendinosus
S I Sa
rto
L rio
b
no sus Gracilis us
bra
i mem
Sem
P Femur
LM
b A
Figure 21.7 Long axis coronal image of anteromedial corner.
The principal component continues to insert onto the

dorsal medial aspect of the tibia below the posterior oblique
ligament. There is an additional component, which forms
on the medial aspect of the tendon and travels anteriorly to c
insert in a small depression just below the medial tibial
margin. This is referred to as the pars reflexa. There are also Figure 21.8 Axial image of posteromedial corner for pes anserine
tendons.
components that blend with the posterior oblique ligament,
the popliteal fascia and the oblique popliteal ligament.
Just lateral to the semimembranosus tendon is the tendon
of the medial head of gastrocnemius. The space between
the two tendons is frequently filled by the gastrocnemius over the medial collateral ligament and then the medial
semimembranosus bursa that communicates with the knee relationship is directly with the tibia. Often a bursa sepa
joint. It is therefore frequently filled with fluid that has rates the insertion from the tibia. This is the pes anserine
extended from a knee joint effusion. bursa through which the tendon of semitendinosus passes.
Superficial to the semimembranosus, and passing distal The pes anserine tendons are also unusual in that each
to its insertion, are the three tendons that make up the pes of the three tendons is supplied by a different nerve.
anserine insertion (Fig. 21.9), so called because the inser These are the sartorius/femoral, gracilis/obturator and
tion is said to resemble the foot of a goose or duck. The semitendonosus/tibial.
three tendons are, from posterior, semitendinosus, gracilis
and sartorius. They insert further anterior and considerably POSITION 3: POSTERIOR KNEE
more distal onto the tibia than semimembranosus. Sartorius
has the lowest musculotendinous junction and is therefore IMAGING GOALS
recognized as the most fleshy of the three structures. Graci 1. Identify the medial head of gastrocnemius and bursa.
lis, as might be expected from its name, is the smallest and 2. Identify the lateral head and plantaris.
semitendinosus the largest and roundest. They lie initially 3. Identify the popliteal vessels.
234 PART 6 — KNEE
MHG LHG
Semimembranosus
TN
Semitendinosus MHG
Plantaris
P Semimembranosus
Femur LM
A
b ACL
P
LM Femur ACL
A
Figure 21.9 Axial image of posteromedial corner (from anterior

position).
TECHNIQUE c
The posterior knee is best approached by turning the Figure 21.10 Axial image of posterior knee.
patient prone and placing the probe in an axial position
(Fig. 21.10) in the midline. The two femoral condyles with
the depression of the posterior joint between provides a very lateral head of gastrocnemius (LHG) and deep to this is
recognizable set of landmarks. The characteristic fleshy the echo-poor articular cartilage of the dorsal aspect of the
heads of the gastrocnemius muscle are also very recogniz lateral femoral condyle. As the probe is passed distally, the
able. Between them lie the popliteal vessels and tibial nerve. muscle deep to the lateral head becomes the popliteus
On the medial side, the medial head gastrocnemius tendon muscle. A feature that helps identify this muscle is that it
is adjacent to the semimembranosus tendon. The lateral has two central tendons.
head gastrocnemius tendon lies more centrally within the The sciatic nerve is found in the upper part of the popli
muscle head and frequently contains an accessory ossicle teal fossa. It divides, sometimes quite proximally within the
called the fabella. The plantaris origin lies deep to the thigh, into the tibial and common peroneal nerves (CPNs).
The tibial nerve remains in a central location as it passes

distally, the CPN separates from it and passes laterally. The
lateral border of the LHG and medial border of the biceps
femoris are useful landmarks to locate the CPN. It com
prises multiple fascicles surrounded by an oval shaped cuff
of fat. It can then be tracked distally around the neck of the
fibula and enters the peroneal compartment. In the pero
neal compartment, it divides into its two main branches,
superficial and deep. Articular branches are also given off
close to the point of division and pass upwards towards the
proximal tibiofibular joint. These articular branches are the a
conduit whereby synovial cysts arising from the proximal
tibiofibular joint may track along and compress the common
nerve trunk.
Biceps
FCL
POSITION 4: POSTEROLATERAL KNEE
Popliteus
IMAGING GOALS Lateral
1. Identify the fibular collateral ligament (FCL) and biceps Meniscus
femoris. Tibia
L
2. Follow popliteus to its insertion. S I Femur
3. Locate and track the CPN nerve. M
b
TECHNIQUE
The three principal structures that need to be identified are
the FCL, tendon of biceps femoris and the popliteus tendon
and muscle. The area can be examined with the patient
supine with their knee internally rotated or decubitus. The
head of the fibula is easily palpated and this is a good loca
tion to begin the examination. The probe should be placed
in the long (coronal) axis with its lower edge overlying the
fibular head. The upper part of the probe is rotated anteri
orly until the FCL comes into view (Fig. 21.11). The FCL
has a similar ultrasound appearance to the medial collateral
ligament, although it is thicker in long axis and rounder in
short axis than its medial counterpart. It is also expanded
proximally with a triangular femoral attachment. The proxi
c
mal attachment is larger than the distal attachment, again
similar to the medial collateral ligament. Superficial to the Figure 21.11 Long axis coronal image of posteromedial corner.
FCL, particularly at its proximal extent, are some of the Anterior rotation demonstrates the FCL.
muscle fibres of biceps. The FCL passes over the popliteus
fossa and the lateral meniscus at the level of the joint. There
is a larger space between the lateral meniscus and FCL than variations occur and care needs to be exercised in identify
the corresponding area on the medial side, as the lateral ing the exact anatomical arrangement in a given individual
meniscus is less firmly attached to the peripheral soft tissues before diagnosing injury to this structure.
and capsule than the medial meniscus. In the lower part of The popliteus tendon is one of the more difficult struc
this area of connective tissue, a pair of small arterioles, the tures to identify and evaluate satisfactorily on the lateral
lateral geniculate artery, is frequently seen, and is a useful side. This is because of its curved course as the tendon
marker for injury. passes distally and medially to the muscle attachment on the
The FCL is followed to its distal attachment on the fibular dorsal aspect of the proximal tibia. The tendon is most easily
head. As the attachment is approached, the tendon of located initially by finding the popliteus fossa and this, in
biceps femoris comes into view (Fig. 21.12). These two struc turn, is located by finding the femoral attachment of the
tures usually insert separately, with the two direct heads of FCL just above. Once the fossa is located in long axis the
biceps surrounding the fibular attachment of the FCL. From probe can be rotated within it (upper edge anteriorly) to
this position, the distal end of the probe is held over the align it better along the long axis of the tendon (Fig. 21.13).
insertion while the proximal end is rotated posteriorly, The probe is then swept slowly towards the dorsal aspect of
revealing biceps tendon in its long axis. The tendon should the knee where the tendon will be seen to split into two
be followed to above the musculotendinous junction to main branches. Fluid may be identified around the tendon
detect injuries to this structure. Distally the insertion of both within the popliteus fossa and extending along the
biceps is quite complex. There are two heads of course, each tendon, even as far as the musculotendinous junction. This
with two insertions. One of these insertions is onto the tibia needs to be differentiated from fluid lying within the proxi
and, in some patients, this is the dominant insertion. Other mal tibiofibular joint.
236 PART 6 — KNEE
Biceps
a
Popliteus
LHG
Biceps L
Femur
P A
M
Fibula b
L
Tibia
S I
M
b
Figure 21.12 Long axis coronal image of posteromedial corner. c

Posterior rotation demonstrates the biceps femoris.
Figure 21.13 Long axis coronal image of posteromedial corner.
Upper part of popliteus tendon.
POSITION 5: ANTEROLATERAL KNEE

initially detected at its insertion into a bony prominence on
IMAGING GOALS the tibia called Gerdy’s tubercle. The probe is orientated in
1. Identify the ITB. the coronal plane overlying the lateral aspect of the knee
2. Look for joint effusion and synovitis. joint (Fig. 21.14). Once the ITB has been identified at its
attachment, it is easy to trace it proximally throughout its
TECHNIQUE full extent. Particularly, attention should be given to the
The principal structure of the anterolateral knee is the area where it passes close to the lateral femoral condyle
ITB. This is a thin connective tissue structure that is a con because this is the location of greatest impingement. Once
tinuation of the fascia lata. It extends from the anterior it has been traced in long axis, it is followed in the axial
superior iliac spine and inserts onto the anterolateral tibia. plane. It is thicker than the surrounding capsule and lateral
It is easy to separate it from the surrounding subcutaneous retinaculum, a feature that usually allows it to be easily
fat and capsular structures due to its thickness. It is best separated.
ITB
Lateral
Meniscus
Tibia
Femur
L
S I
M
b
Figure 21.15 Schematic diagram of relationship of post calf

muscles. Plantaris originates deep to the lateral head of gastrocne-
mius, then passes between soleus and gastrocnemius to lie on the
medial aspect of the Achilles tendon.
Figure 21.14 Long axis coronal image of anterolateral corner (ITB).
Deep to the ITB lies some fat separating it from the

underlining knee joint. The anterior and part of the poste
rior margin of the lateral recess of the joint may be identi
fied close by. The posterior recess of the joint should not
extend behind the full width of the ITB, consequently any Figure 21.16 Axial posteromedial knee. A small amount of fluid is
fluid identified posterior to the posterior ITB margin is present in the gastrocnemius-semimembranosus bursa (*) between
likely to reflect impingement of the ITB rather than joint the medial head of gastrocnemius (MHG) and semimembranosus.
fluid. As the lateral recess of the joint is identified in this
location, note should also be taken of any associated syno
vial thickening. In the axial position, moving anteriorly, a The structures of the calf are divided into four compart
further ligamentous condensation can be identified which ments: anterior, lateral or peroneal and posterior, with the
can be traced to the lateral border of the patella. This is the posterior compartment further divided into superficial and
lateral patellofemoral ligament. deep (Fig. 21.15).
SUPERFICIAL COMPARTMENT
POSITION 6: THE CALF
The superficial compartment of the calf contains the bulky
IMAGING GOALS gastrocnemius and soleus muscles, along with the smaller
1. Identify gastrocnemius, soleus and plantaris between. popliteus and plantaris muscles. On the medial side, a
2. Identify the deep posterior, anterior and peroneal prominent gastrocnemius muscle origin contains a periph
compartments. eral tendon that lies adjacent to the semimembranosus
3. Follow tibial nerve (TN) and CPNs. tendon (Fig. 21.16). On the lateral side, a tendon is also
238 PART 6 — KNEE
present within the lateral muscle belly, but it is located more including areas of the anterior aspect of the fibula and
centrally within the muscle head and may contain an acces interosseous membrane, between flexor digitorum longus
sory ossicle called the fabella. origin on its medial side and flexor hallucis origin
Most of the bulk of the superficial posterior compartment laterally.
comprises the soleus muscle. It has a complex origin with
fibres arising from both the dorsal aspect of the fibula and PERONEAL COMPARTMENT
from the aponeurosis between the tibia and fibula. The The peroneal compartment comprises the peroneal longus
tibial nerve passes distally below the arch of soleus where and brevis muscles with the brevis lying more anteriorly. The
the sural nerve arises and passes laterally. important nerve in this compartment is the CPN. The lateral
Distally, it forms the Achilles tendon with the gastrocne border of the biceps femoris is the most useful landmark
mius muscle, blending with the volar aspect of the Achilles for locating the nerve in the popliteal fossa. Below this it
tendon that has already formed within the gastrocnemius can be traced distally as it rounds the neck of the fibula and
muscle more proximally. The two muscles are separated enters the peroneal compartment. The CPN then divides
throughout most of their length by a fibrous aponeurosis. into its two major branches, the superficial and deep pero
Although this contributes to synchronicity between the two neal nerves. There are also cutaneous and articular branches
muscles, it is a potential space where haematoma may form that are given off soon after the nerve enters the peroneal
following injury. The gastrocnemius and soleus muscles are compartment. The superficial peroneal branch passes
also composed of different fibre types, with gastrocnemius between the muscle bellies of peroneus longus and brevis
being more fast twitch and soleus slow twitch, further creat to a superficial location just below the superficial fascia. It
ing the potential for shear injury. Separation of the medial passes deep to the fascia for several centimetres before pen
head of gastrocnemius from soleus as a consequence of this etrating it and entering the subcutaneous fat. The nerve
injury is referred to as tennis leg. crosses the fascia approximately 12 cm above the ankle joint
The origin of the plantaris muscle is deep to the LHG and is particularly prone to impingement at this location.
(Fig. 21.10) and deep to this is the echo-poor articular car After passing through the fascia, it divides into medial and
tilage on the dorsal aspect of the lateral femoral condyle. lateral branches to supply much of the skin on the dorsal
Plantaris has as a short muscle belly, before forming a long aspect of the foot. The deep peroneal branch of the CPN
tendon. The plantaris tendon tracks lateral to medial in the passes medially to lie on the interosseous membrane, where
fascial plane between the gastrocnemius and soleus, to the it travels with the anterior tibial artery to the anterior aspect
medial side of the Achilles tendon. Its distal insertion is of the ankle joint.
variable, either fusing with the Achilles or forming a sepa
rate tendon on the medial aspect of the Achilles, inserting ANTERIOR COMPARTMENT
on the calcaneus. The anterior compartment contains tibialis anterior, exten
sor hallucis longus and extensor digitorum longus. Tibialis
DEEP POSTERIOR COMPARTMENT anterior is the most medial with a strong origin from the
The deep posterior compartment comprises three muscles: anterolateral tibial margin. Proximally, most of the remain
tibialis posterior, flexor digitorum longus and flexor hallu ing bulk of the anterior compartment is composed of the
cis longus. Occasionally the popliteus muscle is included extensor digitorum longus muscle with extensor hallucis
in this compartment. Tibialis posterior is the most medial muscle contributing as it arises in the mid- and distal-thirds
of the three tendons, although its origin lies centrally, from the fibula.
Knee Pathology
Emma L. Rowbotham | Andrew J. Grainger
22
CHAPTER OUTLINE
INTRODUCTION Infrapatellar Bursa

TENDONS Semimembranosus-Gastrocnemius Bursa
Patellar Tendon Pes Anserine Bursa
Osgood–Schlatter’s Disease LIGAMENTS
Quadriceps Tendon MENISCI
Other Tendons JOINT EFFUSION AND SYNOVITIS
Iliotibial Band Friction Syndrome NERVES
BURSAE CARTILAGE
Prepatellar Bursa VASCULAR
Ultrasound has an important role to play in the investiga- Changes of patellar tendinopathy are usually focal, most
tion of pathology relating to the knee. However, it is impor- commonly affecting the deeper fibres of the proximal tendon
tant to recognize it has significant limitations, particularly either centrally or towards the medial side of the tendon.
with regard to the demonstration of intraarticular pathology
involving structures such as the menisci, cruciate ligaments The localized nature of the disease means it is important to
and articular cartilage. Consequently ultrasound is predom- evaluate both the whole length and width of the tendon
inantly used for the assessment of extraarticular pathology using both longitudinal and transverse views.
about the knee and is particularly useful for diagnosing
conditions affecting the tendons, muscles, ligaments, bursae Practice Tip
and soft tissues. Dynamic assessment, comparison with the
contralateral side and the ability to undertake sonopalpa- Neovascularization is best demonstrated on power Doppler
tion (the displacement or movement of structures with imaging with the knee extended and with only light probe
pressure over the tendon.
probe pressure) are all valuable advantages of ultrasound
over other modalities.
The paratenon may be the site of acute inflammation,
although this is more commonly seen at the Achilles tendon;
TENDONS
paratenonitis manifests on ultrasound as an echo-poor halo
around the tendon which often shows increased vascularity
PATELLAR TENDON
on power Doppler imaging . Less commonly, tendinopathy
The patellar tendon is a relatively superficial structure may be seen distally in the tendon close to the tibial attach-
readily examined by ultrasound. Patellar tendinopathy is a ment, although this is most frequently seen in adolescents
condition commonly caused by overuse, particularly as a as part of the spectrum of changes seen in Osgood–
result of running and jumping activities; it has been also Schlatter’s disease.
termed ‘jumper’s knee’ and is thought to result from
chronic microtrauma to the tendon. Patients usually present Practice Tip
with anterior knee pain that is most frequently localized
over the lower pole of the patella. Appearances on ultra- Tendinopathy involving the entire tendon is not usually
sound are of disruption of the normal fibrillar pattern and related to physical activity but to systemic disorders
thickening of the tendon with focal areas of hypoechoic leading to infiltration of the tendon, such as gout and
change within it, associated with neovascularity within the hypercholesterolaemia (Fig. 22.2).
tendon as a result of vascular in-growth (Fig. 22.1).
239
240 PART 6 — KNEE
Figure 22.2 Gout tendinopathy. Longitudinal image of the proximal

patellar tendon (arrowheads) just distal to the patellar origin shows
b
the tendon to have heterogeneous echotexture and diffuse thickening
with loss of the normal fascicular architecture. The patient was known
to have gout and features are suggestive of gout tendinopathy.
Figure 22.1 Patellar tendinopathy. (A, B) Longitudinal image of the

anterior aspect of the knee showing the patellar and proximal patellar
tendon (white arrows) in a patient with patellar tendinopathy. There
is marked thickening of the deep portion of the proximal tendon with
corresponding hypoechoic change (*). (C) Power Doppler imaging
in the same patient reveals neovascularity in the area affected by
hypoechoic change.
Figure 22.3 Patellar tendon rupture. Horizontal beam lateral view of

the knee joint showing a high-riding patella, indicating a full-thickness
Although rare, statin therapy has been linked to tendinopa- tear of the patellar tendon with subsequent proximal retraction of the
thy and tendon rupture as well as myositis. patella.
Rupture of the patellar tendon may occur, resulting in a
complete disruption of the extensor mechanism. This most
frequently occurs on a background of preexisting tendino-
pathic change or in the presence of systemic inflammatory
conditions such as diabetes, rheumatoid arthritis, systemic
lupus erythematosus (SLF) or chronic renal failure. Both
systemic steroids and local steroid injections have also been
shown to be contributing factors. Following rupture, a high-
riding patella may be detected on clinical examination or
conventional radiography as a result of retraction by the
quadriceps mechanism (Fig. 22.3). On ultrasound, patella
alta results in the trochlear groove, normally hidden behind a
the patella, becomes visible, while examination of the
tendon itself will demonstrate the discontinuity (Fig. 22.4).
Interposed haematoma may make visualization of the Patellar Tendon
tendon ends difficult; however, dynamic assessment of the
tendon should allow differentiation of partial- from full- Hoffa
thickness injury. Patella
A Femur Tibia
Acute avulsion injuries involving the patellar tendon are S I
rare in adults and often occur secondary to high-impact b P
trauma or eccentric muscle contraction. In the paediatric Figure 22.4 Patellar tendon rupture. Longitudinal image of the ante-
population this injury is termed a patellar sleeve fracture; rior aspect of the knee showing the patellar tendon (large arrows) with
in this condition a sleeve of cartilage is pulled off the main a full-thickness tear of the proximal tendon (arrowheads). Note the
bony patella, often taking with it a small bony fragment from exposed anterior surface of the femoral trochlea (small arrows) as a
the lower pole. result of the elevated position of the patella.
CHAPTER 22 — Knee Pathology 241
Patellar Tendon
Patella
Hoffa Tibia A a
S I
b
P
Figure 22.5 Osgood–Schlatter’s disease. Longitudinal image of the

patellar tendon in a young patient with anterior knee pain. The proxi-
mal patellar tendon (arrowheads) has normal sonographic appear-
on
ances. The tibial tuberosity is shown to have an irregular anterior ps Tend
drice
cortex at the site of insertion of the patellar tendon, which itself shows Qua
hypoechoic change. An effusion is also seen within the deep infrapa- Patella
tellar bursa consistent with bursitis (*).
A
Femur
S I
P
b
Figure 22.7 Quadriceps tendinopathy. Longitudinal image of the

distal quadriceps tendon and insertion showing thickening of the
tendon (white arrows) with a diffusely heterogeneous echotexture
a thoughout. There is also more focal distal hypoechoic change (*).
bursitis may also be shown. Ultrasound will also demon-

Patellar Tendon strate bony surface irregularity and/or fragmentation of the
tibial tuberosity (Osgood–Schlatter’s disease) or lower pole
A of the patella (Sindig-Larsen–Johansson syndrome).
S I Patella Hoffa
b P
Figure 22.6 Sindig-Larsen–Johansson syndrome. There is irregular-

QUADRICEPS TENDON
ity of the anterior cortex of the inferior pole of the patella at the origin The quadriceps tendon is less commonly affected by tendi-
of the patellar tendon (arrows). Hypoechoic change (*) within the nopathic change than the patellar tendon and when seen it
proximal portion of the tendon indicates associated tendinopathy. usually relates to persistent strenuous overuse. Clinically the
condition presents as focal pain over the distal portion of
the tendon and will manifest on ultrasound as a focal area
OSGOOD–SCHLATTER’S DISEASE
of hypoechoic change within a portion of the tendon, loss
Chronic inflammation of the insertion of the patellar of definition of the normal trilaminar appearance and intra-
tendon onto the tibial tuberosity may be seen in adolescents tendinous vascularity. Transverse imaging of the tendon is
(Fig. 22.5). This condition, called Osgood–Schlatter’s often helpful in more accurately defining the precise loca-
disease, represents a traction enthesopathy and is character- tion of the tendinopathic change. More rarely the full thick-
ized by irregularity of the tibial tuberosity. The tibial tuber- ness of the tendon is involved and appearances will be of
osity may be irregular in asymptomatic patients and care diffuse thickening of the tendon with heterogeneous
should be taken to avoid overdiagnosing this condition. echotexture throughout (Fig. 22.7).
Reactive secondary heterotopic bone formation occurs at Rupture of the quadriceps tendon is a relatively rare
the insertion site of the patellar tendon, resulting in a visible phenomenon.
and palpable lump: the main physical finding in Osgood–
Schlatter’s disease. A similar condition occurring at the Key Point
patellar insertion is termed Sindig-Larsen–Johansson syn-
drome. On ultrasound, thickening of the patellar tendon at The majority of tears are incomplete and involve only one of
the insertion site with low-reflective change and associated the tendon components: most commonly the tendon
intratendinous calcification is seen (Fig. 22.6). Neovascular- component arising from rectus femoris.
ization may also be present in the tendon and peritendinous
242 PART 6 — KNEE
Differentiation between a full and a partial thickness tear is

important for management purposes and may be difficult
to determine clinically. Ultrasound imaging of a partial tear
will reveal discontinuity of one of the layers of the tendon
close to the patellar insertion, often with retraction of the
torn fibres but with other, usually deep fibres, intact.
Dynamic assessment of the tendon may help in establishing
this picture. Full-thickness tears will often have haematoma
interposed between the two tendon ends with no continu- a
ous fibres seen crossing the gap (Fig. 22.8). In the presence
of a complete quadriceps rupture the patellar tendon will
often have a crumpled appearance due to lack of proximal
traction on the patella: this sign may help distinguish a Quads
complete from a partial tear where there is doubt. Patella
Haematoma
Practice Tip A Prefemoral Fat
S I
The squeeze test involves lateral compression of the joint in b P Femur
an attempt to force joint fluid into the prepatellar space. This
can only occur in the presence of a full-thickness defect. Figure 22.8 Quadriceps rupture. Longitudinal image of the distal
quadriceps tendon lying superficial to the distal femur and inserting
into the patella shows a full-thickness tear of the extensor tendon
(arrows) with retraction of the proximal portion of the tendon.
OTHER TENDONS
Other tendons around the knee may also become tendino-
pathic and may rarely rupture. Most commonly involved is
the semimembranosus tendon which presents with pain in
the posteromedial aspect of the joint. The insertion of this
tendon is difficult to visualize on ultrasound due to its depth
and MRI may be more helpful in delineating pathology here.
Tendinopathy of the distal biceps femoris, semitendinosus
(Fig. 22.9), gracilis and sartorius also occur. Distal biceps a
femoris rupture most often occurs in conjunction with
lateral collateral ligament disruption, often in association
with an anterior cruciate ligament (ACL) tear of the knee. Semitendinosus
M Semimembranosus
ILIOTIBIAL BAND FRICTION SYNDROME S I
b L Femur
Iliotibial band friction syndrome (ITBFS) is a condition also
Figure 22.9 Semitendinosus rupture. Extended longitudinal view of
known as ‘runner’s knee’, and is manifested by pain in the
the posteromedial aspect of the knee. There is retraction of the proxi-
region of the lateral femoral condyle that usually occurs mal aspect of the semitendinosus (*) with distal hypoechoic change
after repetitive exercise. ITFBS is thought to be the most and surrounding fluid and haematoma (arrowheads). Features are in
common running injury of the lateral knee. The aetiology keeping with a tear of the distal semitendinosus tendon.
of this condition has been debated in the literature, with
the original theory suggesting the condition results from
friction between the iliotibial band (ITB) and the lateral
femoral condyle during flexion and extension, having been
challenged. Some studies suggest that the ITB is not a dis-
Practice Tip
tinct anatomical structure but a thickened zone within the
lateral fascia and rather than anterior–posterior gliding of In practice it is important to distinguish inflammatory bursal
the ITB it is actually repetitive tightening of the lateral fascia fluid seen deep to the ITB from joint fluid within the lateral
which leads to compression of structures deep to it. It is also synovial recess.
suggested in the literature that a sub-ITB bursa is involved
in the condition and that surgical excision of this bursa
alleviates the symptoms of ITBFS. Clinically this condition presents with lateral knee pain over
the distal portion of the ITB where it makes contact with
Key Point the underlying lateral femoral condyle. Pain in a slightly
more distal location at the preinsertional part of the tendon
Sonographic findings include hypoechoic oedema or fluid is more likely to represent distal ITB tendinopathy. Tendi-
deep to the ITB as it passes over the lateral femoral nopathy manifests on ultrasound as thickening of the band
condyle; the band itself is often normal in appearance. with associated hypoechoic change and loss of fibrillar
pattern, although abnormal findings may be limited to the
tissues deep to the band. This condition is common in

patients with osteoarthritis.
BURSAE
There are numerous and highly variable bursae around the

knee joint, any of which may be symptomatic when inflamed
or thickened. Bursae are lined by synovium and while bur-
sitis (seen as synovitis and effusion within the bursa) is the
most common pathology found, any of the other primary
pathologies of synovial tissue, such as pigmented villonodu-
lar synovitis (PVNS) and synovial chondromatosis, may also
be seen (Fig. 22.10). A normal bursa contains little fluid and
is not readily seen on ultrasound imaging. Power Doppler
signal within the bursal tissue reflects inflammatory change.
PREPATELLAR BURSA
Amongst the most common sites for bursitis are the anterior
bursae. The prepatellar bursa (Fig. 22.11) lies superficial to
the patella and inflammation here is commonly termed
‘housemaid’s knee’. Symptoms include anterior knee pain,
swelling, redness and restriction of flexion at the joint. The
condition usually results from acute or chronic trauma to
the region. It may be related to the patient’s occupation, for a
instance it is frequently seen in carpet fitters.
INFRAPATELLAR BURSA
The superficial infrapatellar bursa is located in the subcuta-
neous tissues overlying the patellar tendon and tibial tuber-
osity. The deep infrapatellar bursa is located deep to the
distal patellar tendon, just proximal to its insertion onto
the tibial tuberosity. A study looking at cadaveric anatomy
of this bursa describes a fat-pad apron extending down from
the retropatellar (Hoffa’s) fat pad to partially divide it into
anterior and posterior compartments. A small amount of b
fluid in this bursa is commonly seen in asymptomatic
patients. Inflammation in this region, with a larger fluid
collection and frequent hypervascularity, is occasionally Patellar Tendon
seen in isolation. However, more commonly it is seen in
association with enthesitis, Osgood–Schlatter’s disease (Fig.
22.5) or tendinopathy.
Bursa
SEMIMEMBRANOSUS-GASTROCNEMIUS BURSA
Tibia A
A Baker’s cyst represents distension of the semimembranosus- S I
gastrocnemius bursa with joint fluid, which in adults is com- Hoffa P
monly associated with underlying joint pathology, most c
commonly osteoarthitis. Clinically, presentation is usually
Figure 22.10 (A) Synovial osteochondromatosis in the deep infrapa-
with a palpable swelling within the medial aspect of the tellar bursa. Lateral radiograph of the knee shows two calcified
popliteal fossa, although many Baker’s cysts are asymptom- bodies within the deep infrapatellar bursa. (B, C) Longitudinal ultra-
atic and are incidental findings. sound of the deep infrapatellar bursa in the same patient which
contains both fluid (*) and hyperechoic foci with posterior acoustic
Key Point shadowing, in keeping with calcified bodies.
The crucial factor in the diagnosis of Baker’s cyst is the This represents the site of communication with the joint
identification of a neck of the fluid collection passing and gives the cyst a characteristic speech bubble configura-
between the medial head of gastrocnemius and the tion (Fig. 22.12). Ultrasound appearances of a Baker’s cyst
semimembranosus tendon. are variable; many will have both solid and cystic compo-
nents, often with increased Doppler flow within the solid
244 PART 6 — KNEE
Figure 22.11 Prepatellar bursitis. Transverse image of the anterior

aspect of the knee shows fluid anterior to the patella within a thick-
walled prepatellar bursa (*) in a patient with chronic anterior knee a
pain.
Figure 22.13 Baker’s cyst loose body. Transverse image of a Baker’s

cyst (*) shows a large lamellated osteochondral body (white arrow)
lying within the dependent part of the cyst within the popliteal fossa.
a
component. They can range in size from small cystic areas

barely discernible on ultrasound to large collections that
may track through the soft tissues proximally and/or dis-
Bursa tally. The most common complication associated with a
Baker’s cyst is rupture or leakage. Acute rupture will usually
present with sudden-onset pain and swelling in the posterior
aspect of the calf and must be distinguished from deep vein
thrombosis which may present in a similar fashion. More
chronic leakage of fluid from the cyst may also occur and
Gastrocnemius may be particularly irritating to the patient. Fluid that has
leaked from a Baker’s cyst may be seen as isolated pockets
Semimembranosus of fluid overlying or deep to the gastrocnemius muscle in
P the calf. Less commonly, leakage may extend more proxi-
LM Bursal Neck mally into the thigh. Loose bodies may pass into the cyst
A from the joint (Fig. 22.13), or may arise de novo in the cyst
b due to chondrometaplasia. Because of the association with
Figure 22.12 Baker’s cyst. Longitudinal image of the medial underlying joint pathology, plain films may be a useful
aspect of the popliteal fossa shows a large fluid-filled Baker’s adjunct to the ultrasound examination. The concept of the
cyst arising between the medial head of gastrocnemius and semi- Baker’s cyst or popliteal cyst is enlarged to include several
membranosus (*). other bursae that may occur in the popliteal compartment.
MCL
Medial
M
Femur Meniscus Tibia
S I
b L
Gracilis
Bursa Figure 22.15 MCL tear. Longitudinal image of the medial joint line
Sem which shows a cleft within the medial meniscus (white arrow) and
iten
din hypoechoic oedematous change within the MCL (*) in keeping with a
osu
M s tear of the deep portion of the ligament.
S I Tibia
b L
the primary restraints to valgus and varus stress at the knee
Figure 22.14 Pes anserine bursitis. Longitudinal image of the medial joint respectively. Injury to these ligaments often occurs in
aspect of the knee (T = medial tibia) with a distended pes anserine conjunction with other structures and, whilst ultrasound
bursa (*) seen immediately superficial to the tibia. Fluid surrounds both may be used to evaluate the medial collateral ligament
the gracilis (white arrow) and semitendinosus tendons (blue arrow). (MCL) itself, excluding injury to other structures, particu-
larly the menisci and cruciate ligaments, will often warrant
Another common location for fluid to emerge from the MRI. The combination of MCL, ACL and medial meniscal
knee is superolaterally, adjacent to the lateral head of gas- damage, known as O’Donoghue’s triad, is a well-documented
trocnemius. This has sometimes been misinterpreted as a injury, although the full triad is not as common as originally
ganglion of the lateral tendon of gastrocnemius. suggested.
As with all ligament damage there is a spectrum of injury
ranging from partial tear, where there is haemorrhage and
PES ANSERINE BURSA
oedema surrounding the ligament with some fibres remain-
The pes anserine bursa is a very superficial structure on the ing intact, to complete rupture, where discontinuity is
medial aspect of the knee that can be a source of localized evident. Partial tear of the MCL usually affects the deep
pain and swelling. Ultrasound features of bursitis here are fibres of the ligament that are relatively weak; these fibres
of a hypoechoic distended bursa with tenderness on scan- contribute only a small degree of stability to the joint and
ning over the region (Fig. 22.14). Assessment of the sarto- therefore a partial deep MCL injury does not usually result
rius, gracilis and semitendinosus tendons is also important in significant instability. Lateral collateral ligament (LCL)
to differentiate bursitis from tendinopathic change as the injury is less common and usually results from varus stress to
cause of symptoms. Ultrasound can be very useful to identify the knee joint. It is usually associated with damage to other
the cause of pain and swelling which may be difficult to dif- structures, most commonly the ACL and more rarely the
ferentiate clinically from other causes of medial joint line structures of the posterolateral corner. Avulsion of the LCL
swelling, such as a meniscal cyst or ganglion. from its distal attachment along with the conjoint tendon of
The aetiology of pes anserine bursitis is not well under- the biceps femoris and posterolateral corner structures may
stood; this represents an unusual site to sustain repetitive be seen on both plain radiographs and MRI, but can be dif-
trauma which is frequently implicated in the aetiology of ficult to appreciate on ultrasound imaging alone.
bursitis elsewhere. Valgus knee deformity either in isolation Low-grade MCL and LCL injuries (grade I representing
or in combination with collateral instability has also been a strain of the ligament) may be difficult to detect with
shown to be a risk factor. Occasionally an underlying cause ultrasound, although hypoechoic fluid may be seen around
can be identified, such as a bony exostosis or seronegative the tendon. A grade II injury represents a partial thickness
arthropathy. tear, in the case of the MCL usually affecting the deep fibres
(Fig. 22.15). Ultrasound changes are of ligament thickening
and loss of the normal ultrasound architecture of the
LIGAMENTS affected component. Adjacent intact superficial fibres may
be appreciated. A full-thickness (grade III) tear will be seen
Both the medial and lateral collateral ligaments are super- as full-thickness fibre discontinuity with no visible intact
ficial structures and readily shown on ultrasound. They are fibres. Meniscal injury associated with a collateral ligament
246 PART 6 — KNEE
Figure 22.16 LCL avulsion injury. Longitudinal image of the lateral

aspect of the knee showing the lateral femoral condyle (F) with an
LCL avulsion injury. A small fragment of bone has been avulsed (*)
and the LCL remains intact (white arrows).
tear may also be demonstrated on ultrasound examination

of the knee, particularly when the peripheral portion of the
meniscus is involved. Bone avulsion may occur rather than
disruption of the tendon itself (Fig. 22.16). Following injury b
to the MCL, chronic calcification around the ligament may Figure 22.17 Meniscal tear with meniscal cyst. Longitudinal image
occur, a condition known as Pellegrini–Stieda disease: this of the medial joint line showing the distal femur and proximal tibia.
will often be most evident on plain film imaging. There is a tear shown within the peripheral portion of the medial
meniscus, seen as a cleft (arrow) with an associated meniscal cyst
present (*).
MENISCI
Ultrasound is not usually the modality of choice for evalua- Meniscal cysts are relatively common and can occur both
tion of the menisci; even using a 3D technique ultrasound medially and laterally. They may be identified on ultrasound
is not sufficiently accurate for clinical use. However, the as hypoechoic fluid-filled structures, which may either be
peripheral portions of both menisci are visible with ultra- contained within the meniscus or, more commonly, extend
sound, and incidental meniscal pathology may be diagnosed into the surrounding soft tissues (Fig. 22.18). While the cyst
when scanning the knee. The most common meniscal tears may track some distance from the joint, …
seen on ultrasound are those that are peripheral and pos-
terior (Fig. 22.17).
Practice Tip
Key Point … all cysts should be followed back to the joint line, where
they may be seen to communicate with a meniscal tear.
Although ultrasound carries a good positive predictive value
if a tear is seen, the negative predictive value is poor and
absence of a tear on ultrasound cannot be used as a If no tear is identified at ultrasound, MRI may be helpful.
reliable indicator of an intact meniscus. MRI will also better assess the morphology of the meniscal
tear if surgery is being contemplated.
a
b
Figure 22.19 Joint effusion. A moderate joint effusion is demon-

strated within the suprapatellar pouch (*). There is also concurrent
synovitis present in this patient (white arrowheads). The extensor
tendon is shown lying superficial to the suprapatellar pouch (white
arrows). The patient had osteoarthritis.
Key Point
Fluid seen within the joint generally appears anechoic or

hypoechoic, but the presence of haemorrhage or pus may
give the effusion a more complex appearance.
Generally fluid is best detected in the anterior joint, but…
b
Practice Tip
Figure 22.18 A small low-reflective parameniscal cyst lies adjacent
to the reflective meniscus. Part of the meniscal tear is also seen. … it is important to examine the patient with their knee both
extended and flexed as any effusion will move around the
joint and movement may displace it into a more easily
visualized position.
Deposition of calcium pyrophosphate dihydrate in the
menisci, synovium and articular cartilage is a relatively
common phenomenon within the knee joint. Calcium The suprapatellar pouch is often the starting point when
deposition results in hypereflective lines and dots within the looking for joint fluid, but it is also crucial to examine the
involved tissues. dependent recesses of the pouch both medial and lateral to
the patella: areas in which effusion and synovitis are com-
monly seen.
JOINT EFFUSION AND SYNOVITIS
Practice Tip
Key Point
Compression of the tissues with the probe is helpful in
Clinical examination of the knee will detect a joint effusion differentiating joint fluid from synovitis.
provided there is sufficient fluid present, but it has been
suggested that an effusion of less than 6–8 mL cannot be
appreciated clinically. Power Doppler is also useful for distinguishing these two
entities. The normal synovium will not be detected on
ultrasound as it is too thin; observation of the synovium
Ultrasound detects smaller effusions and may provide addi- therefore implies it is thickened and will manifest as
tional information such as assessing the presence and extent hypoechoic intraarticular tissue which is nondisplaceable,
of associated synovitis (Fig. 22.19). poorly compressible and may exhibit Doppler signal. It has
248 PART 6 — KNEE
Quads
Haemarthrosis
Patella
Pa nd
Te
te on
S I Femur a
lla
b P
r
Figure 22.20 Haemarthrosis of the knee joint. Longitudinal image Quads
of the anterior aspect of the knee with the distal aspect of the exten-
sor tendon (white arrowheads) inserting into the patella. The supra-
patellar pouch is distended with fluid and debris and has a fluid level
within it.
Suprapatellar
Bursa
Loose
Bodies
Femur
b
Figure 22.22 Intraarticular bodies. Longitudinal image of the supra-

patellar pouch with a large joint effusion present (*) with the extensor
tendon lying anteriorly (arrowheads); there are several calcified bodies
(white arrows) seen lying within the suprapatellar pouch.
Figure 22.21 Gout. Transverse image of the posterior aspect of the

lateral femoral condyle (F) showing echogenic crystals along the
surface of the articular cartilage (blue arrowheads), suggesting an Practice Tip
underlying diagnosis of gout (double contour sign).
Intraarticular bodies may be seen in the joint recesses
(Fig. 22.22) and, in contrast to conventional radiographs,
cartilaginous bodies without ossification may be seen.
to be realized that synovitis may be present in parts of the
knee that are difficult to assess with ultrasound, such as the
intercondylar notch. This is particularly important when Intraarticular bodies arise either secondary to traumatic
considering conditions giving rise to focal pathology, such insult or as a result of various joint disorders, including
as PVNS. osteoarthritis, synovial osteochondromatosis or neuropathic
The finding of a joint effusion or synovitis is generally joint disease.
nonspecific and history and examination of the joint are Generally, blind aspiration and injection of the knee are
important in helping to determine the aetiology. Trauma possible, but in obese patients or those with only a very small
and osteoarthritis are common causes, but other aetiologies, effusion, ultrasound can be helpful to localize the site for
including infection, arthritis and, rarely, tumour also need injection/aspiration.
to be considered. Some specific features may be apparent,
such as the presence of echogenic haemorrhage (Fig. 22.20)
within the effusion, suggesting a traumatic cause, or the NERVES
presence of echogenic crystals in the synovium or layered
along the surface of articular cartilage, indicating gout as Both the tibial and common peroneal nerves are amenable
the underlying diagnosis (Fig. 22.21). to ultrasound evaluation at the level of the knee joint.
Figure 22.24 Osteoarthritis. Transverse image at the level of the

Figure 22.23 Schwannoma. Longitudinal image of a large trochlear groove (T) in a patient with osteoarthritis affecting the knee
schwannoma presenting as a palpable lump to the posterolateral joint. There is thinning of the cartilage over the lateral trochlear
aspect of the knee. This image shows the classic rat’s tail appearance (arrows) with associated cortical irregularity.
(arrow) as the lesion is seen to be in continuity with the common
peroneal nerve.
CARTILAGE
The most common pathology are nerve sheath tumours, With the advent of surgical techniques to repair chondral
with neurilemmoma and neurofibromas making up the damage, evaluation of articular cartilage has become increas-
majority of peripheral nerve sheath tumours. Lesions asso ingly important and preoperative imaging techniques are
ciated with the common peroneal nerve at the level of evolving to meet this demand. At present MRI is the imaging
the fibula head may present relatively early due to the modality of choice for assessment of articular cartilage at
superficial position of the nerve at this site. As with nerve the knee joint; however, ultrasound has been shown to be
sheath tumours at any site, the nerve can often be followed accurate in the measurement of femoral articular cartilage
on both sides of a tumour, giving the characteristic rat’s tail thickness when compared with anatomic measurements.
or comet tail appearance. The lesions themselves tend to Irregularity, fissuring and cartilage defects may be seen with
be iso- or hypoechoic with prominent internal vascularity a high-frequency probe and studies have shown results to
(Fig. 22.23). Biopsy of these lesions can be attempted under be accurate and reliable for detection and grading of
ultrasound guidance, but is frequently not possible due to knee articular cartilage defects. The cartilage overlying the
tenderness. femoral trochlea is assessed with the knee in full flexion in
Ganglia arising from the proximal tibiofibular joint are a an axial plane to reveal the V-shaped femoral trochlea and
relatively rare phenomenon but may, due to their size, cause overlying cartilage (Fig. 22.24). Ultrasound may also be
compression of the tibial and peroneal nerves at the level used to evaluate the depth and configuration of the carti-
of the knee joint and subsequently cause pain within the lage cap of an ostoechondroma adjacent to the knee joint
lower leg. These lesions are fluid-filled and are in continuity (Fig. 22.25). A measurement of more than 10 mm should
with the proximal tibiofibular joint. Typically the cysts have be regarded with suspicion and more than 15 mm is sugges-
a thick and irregular echogenic wall and collect within the tive of chondrosarcoma.
adjacent compartment spaces or muscles. Demonstration of
a connection to the superior tibiofibular joint allows confir-
mation of the diagnosis. A particular form of superior tib- VASCULAR
iofibular joint ganglion is seen as an intraneural ganglia
tracking along the peroneal nerve. This intraneural cystic The popliteal artery and vein are situated between the two
mass causes peripheral displacement of the fascicles and heads of gastrocnemius within the popliteal fossa. A popli-
fusiform thickening of the nerve. It passes from the joint teal artery aneurysm is diagnosed if the diameter of the
into the nerve along a small articular branch of the nerve vessel exceeds 0.7 cm. This is an important diagnosis to
and from there can dissect along the nerve either proxi- make due to the risk of both limb- and life-threatening
mally or distally. The cyst may extend considerable distances complications. Approximately 45% of patients are asymp-
along the nerve and may present as a mass some distance tomatic at the time of referral and this condition may be
from the knee joint that can be followed back to its origin diagnosed incidentally when ultrasound of the knee is per-
at the tibiofibular joint. formed for an alternative clinical symptom. The use of
Common peroneal nerve palsy is a debilitating condition power Doppler will help differentiate a popliteal artery
associated with trauma and, in particular, with dislocation aneurysm from a Baker’s cyst where the grey scale imaging
of the knee, with some studies showing an incidence of up is equivocal. Patency of the aneurysm can be readily assessed
to 50%. In cases of stretching injury, ultrasound may depict as well as assessing for the presence of thrombus.
a long fusiform hypoechoic swelling of the nerve with loss The popliteal artery may also be compressed during
of the fascicular pattern. The nerve is also vulnerable to active foot dorsiflexion, but usually when there is a predis-
iatrogenic injury during knee arthroplasty. posing lesion such as an accessory band or hypertrophied
250 PART 6 — KNEE
muscle. The condition is associated with sports that involve

significant calf muscle development, particularly cycling.
Doppler flow studies of the vessel can be carried out with
the patient prone and flow observed during cyclical foot
dorsi and plantar flexion. Loss of normal flow may indicate
an underlying congenital fibrous band.
The popliteal vein will be examined routinely in the
assessment of a patient presenting with a possible deep vein
thrombosis; however the signs and symptoms of a ruptured
Baker’s cyst are similar and the popliteal vein should be
interrogated for evidence of thrombus where there is clini-
cal doubt regarding the diagnosis. Deep vein thrombosis is
a common condition, which is particularly prevalent
amongst hospital inpatients. Ultrasound findings include
the inability to completely compress the lumen of the vessel,
visualization of thrombus within the vein and an increase
a in over 75% of the diameter of the vein during Valsalva
manoeuvre.
FURTHER READING
Campbell RSD, Grainger AJ. Current concepts in imaging of tendi-
nopathy. Clin Radiol 2001;56(4):253–67.
Ditchfield A, Sampson MA, Taylor GR. Ultrasound diagnosis of Sleeve
Fracture of the Patella. Clin Radiol 2000;55(9):721–2.
Dupuis C, Westra S, Makris J, Wallace EC. Injuries and Conditions of
the Extensor Mechanism of the Paediatric knee. Radiographics 2009;
29:877–86.
Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome
really a friction syndrome? J Sci Med Sport 2007;10:74–6.
Khan KM, Bonar F, Desmond P, et al. Patellar tendinosis (jumper’s
knee): findings at histopathologic examination, US and MR imaging.
Victorian Institute of Sport Tendon Study Group. Radiology 1996;200:
b 821–7.
Martinoli C, Bianchi S, Gandolfo N, et al. US of nerve entrapments in
osteofibrous tunnels of the upper and lower limbs. Radiographics
2000;20(6):199–217.
Sofka CM, Adler RS, Cordasco FA. Ultrasound diagnosis of chondro-
calcinosis in the knee. Skeletal Radiol 2002;31(1):43–5.
Torreggiani WC, Al-Ismail K, Munk PL, et al. The imaging spectrum of
Baker’s cysts. Clin Radiol 2002;57(8):681–91.
Wakefield RJ, Balint PV, Szkudlarek M, et al. Musculoskeletal ultra-
sound definitions for ultrasonographic pathology. J Rheumatol 2005;
32(12):2485–7.
Figure 22.25 Osteochondroma. (A) Lateral view of the knee joint

shows an osteochondroma arising from the posterior aspect of the
proximal fibula. (B) Longitudinal ultrasound image in the same patient
showing a small cartilage cap over the exostosis (arrows). The depth
of the cartilage cap is being measured between the calipers.
PART 7
ANKLE
251
Ankle Joint and Forefoot: 23
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION Position 5: Lateral Ankle — Ligaments

Position 1: Medial Ankle Proximal Position 6: Anterior Ankle
Position 2: Medial Ankle Distal Position 7: Midfoot Dorsal
Position 3: Posterior Ankle Position 8: Midfoot Plantar Anatomy
Position 4: Lateral Ankle — Tendons Position 9: Forefoot
INTRODUCTION TECHNIQUE
The examination begins with the probe in an axial position
Ultrasound examination of the ankle and foot is one of the just above the medial malleolus (Fig. 23.1). The postero
most common examinations in musculoskeletal ultrasound. medial margin of the tibia is easily identified and the largest
The superficial location of most structures means that and most medial of the tendons is the TPT. Deep to the
ultrasound plays an important role in the management TPT, a low-reflective band overlies the tibial cortex repre
of many patients with painful conditions of the foot. As senting the hyaline cartilage of a pulley enthesis. This assists
in many other joints, symptoms guide the ultrasound with the smooth passage of the tendon around the malleo
approach. Patients who present with pain that is located to lus. The presence of cartilage at this location explains why
a single area are most often helped by ultrasound. Patients enthesopathy can occur and why bony spur formation is a
who present with more global symptoms, rather than pain component of patients with chronic TPT disease. The
localized to a particular area, require MRI for more com tendon should have a normal internal structure comprising
plete assessment and in particular to assess the joint areas of low reflectivity, representing the tendon fibres inter
surfaces. spaced with areas of increased reflectivity from the interven
Many of the structures of the ankle benefit from being ing connective tissue support structures. The most medial
examined under stress. It is therefore important to be able aspect of the tendon is in line with the medial border of
to move the foot and the patient’s position should allow for the tibia.
this. This can be achieved by having the patient’s ankle and Lying along the lateral margin of tibialis posterior in close
foot overhang the edge of the couch or by placing a rolled proximity with it is the tendon of flexor digitorum longus
up towel underneath the distal calf so that the ankle and (FDL). This is a much smaller tendon than TPT with a lower
foot are elevated above the couch. The medial, anterior and musculotendinous junction. The other structures in the
lateral aspects of the foot are examined with the patient proximal part of the tarsal tunnel include the posterior
supine. The hindfoot is internally rotated to examine the tibial artery and veins. The medial border of the posterior
lateral side, and externally rotated for the medial side assess subtalar joint is identified deep to the flexor digitorum
ment. The posterior and plantar aspects are best assessed tendon as it passes below the sustentaculum. Immediately
with the patient prone. lateral to this is the tibial neurovascular bundle. The poste
rior tibial artery and its multiple surrounding veins separate
POSITION 1: MEDIAL ANKLE PROXIMAL flexor digitorum from the tibial nerve. The tibial nerve is a
brighter, more reflective structure than the nearby tendons.
IMAGING GOALS Once again low-signal elements can be identified within it,
1. Identify tibialis posterior tendon (TPT). representing the neural bundles, and these are separated by
2. Locate flexor hallucis and its fibroosseous tunnel. intensely bright components representing epineural tissue.
3. Identify tibial nerve and proximal branches. The tibial nerve divides to form the medial and lateral
253
254 PART 7 — ANKLE
supply abductor digiti minimi. This nerve may be impinged

by plantar fasciitis, leading to atrophy of the aforemen
tioned muscle. Compression of the nerve more proximally
may also lead to a syndrome that mimics plantar fasciitis,
called Baxter’s neuropathy.
Tibialis posterior is held in place by the overlying medial
(or tarsal) retinaculum, which can be identified as a thick
striated connective tissue structure that passes over tibialis
posterior, forming the roof the tarsal tunnel. The flexor
digitorum tendon and tibial neurovascular bundle are also
contained within the tarsal tunnel. Medially it blends with
the fascia and periosteum of the tibia.
Although flexor hallucis longus (FHL) is often consid
a
ered in association with tibialis posterior and flexor digito
rum, (the so-called Tom, Dick and Harry), it is in fact
separated from the other two tendons and has its own fibro
osseous tunnel on the dorsal aspect of the os calcis. The
TPT tendon is located by moving the probe medially and distally
FDL and using the overlying tibial nerve as a landmark for the
tendon. Gentle movement of the big toe helps identify the
deeply positioned FHL tendon. The groove in which it is
contained is bridged by a short retinaculum creating a fibro
osseous tunnel helping to guide movement of the tendon.
FHL Occasionally the retinaculum is thickened and tendon
Medial Malleolus
nodules may develop, creating a triggering phenomenon
similar to trigger finger. If an os trigonum is present, FHL
P is medial to this accessory bone.
L M The tendon should be examined in both short and long
A
b axis with and without movement. Rotating the probe 90°
once the tendon is identified and then moving the toe will
serve to demonstrate that there is no adhesion or catching
as the tendon passes into its fibroosseous tunnel. The proxi
mal part of the tendon just below the musculotendinous
junction is usually the first to be identified and it is not
uncommon to see fluid around it in this location. This is
particularly obvious if ankle joint effusion is present as the
tendon sheath communicates directly with the tibiotalar
joint. Generally, simple effusions are not associated with an
increase in Doppler activity.
POSITION 2: MEDIAL ANKLE DISTAL

IMAGING GOALS
c
1. Locate tibialis posterior/tibiotalar/spring ligaments.
Figure 23.1 The ultrasound transducer is positioned in the axial 2. Find where flexor hallucis crosses flexor digitorum.
plane posterior to the medial malleolus, demonstrating the three 3. Identify the medial and lateral plantar nerves.
medial tendons and the tibial neurovascular bundle.
TECHNIQUE
As the probe is advanced distally following tibialis poste
rior, the medial malleolus disappears from view. The struc
plantar nerves. This branching can occur at any point and ture which now is found deep to TPT is the tibiotalar
may already have occurred at the level of the medial malleo ligament, a major component of the deltoid ligament
lus. A smaller branch, the medial calcaneal nerve, arises complex (Fig. 23.2). This ligament is said to have two com
directly from the tibial nerve and can be seen deep and ponents, although the posterior component is more domi
slightly posterior as it heads towards the posterior medial nant and blends with the anterior component in most
corner of the os calcis. Another important branch, the infe cases. In the relaxed position the normal internal structure
rior calcaneal nerve, arises from the lateral plantar nerve. It of the ligament is difficult to discern due to anisotropy as
is sometimes referred to as the first branch lateral plantar the fibres are oriented at various angles to the probe.
nerve. This nerve also passes deep and somewhat posteriorly Tensing the ligament, by dorsiflexing the foot, brings the
to pass around the underside of the hind foot close to the fibres into alignment and reveals the true internal
origin of the plantar fascia. It traverses the hind foot to structure.
CHAPTER 23 — Ankle Joint and Forefoot: Anatomy and Techniques 255
TPT
AHL ent
L Ligam
FD Spring
Os Calcis Talus
FHL
M
QP I S
Figure 23.2 There are three groups in the medial ligament complex.
b L
The deep group comprises the anterior and posterior tibiotalar liga-
ments (dark blue). The superficial group comprises the tibiocalcaneal,
tibiospring and tibionavicular ligaments (mid blue). The principal
transverse ligament is the calcaneonavicular or spring ligament
(light blue).
The normal ligament is triangular or sail shaped with its

narrow end superiorly attached to the medial malleolus and
its wide portion distally attaching to the talus. The tibiotalar
joint is deep to the ligament. If the tibialis posterior is fol
lowed a little more distally, the spring ligament appears
deep to it (Fig. 23.3). The posterior part of this ligament,
the component that is attached to the sustentaculum tali, is
identified first as this is its widest portion. If the upper end c
of the probe is rotated anteriorly, the middle and anterior Figure 23.3 A more distal section just below the medial malleolus
parts of the ligament come into view, passing around the shows the flexor hallucis longus within its own fibroosseous tunnel.
reverse S shape of the talus towards the navicular. A small The tibial nerve (yellow) lies immediately superficial to the tendon. The
bursa, little more than a potential space, is located between spring ligament is located beneath the TPT.
the TPT and the spring ligament. This is called the gliding
layer. A small quantity of fluid may be present around the
tibialis posterior in this location. The other significant com
ponent of the medial ligament complex is the tibiospring the ossicle and the relationship with the underlying bone.
ligament (Fig. 23.4), which is orientated in the coronal Type 1 is a small ossicle located within the tendon which
plane, linking the tibia to the spring ligament. The tibiocal otherwise inserts normally. A type 2 insertion is the most
caneal and tibionavicular can be usually found in most indi problematic. This is where a substantial portion of the
viduals but with a more variable appearance. tendon inserts into a large accessory ossicle which in turn
The examination of tibialis posterior is concluded by fol forms a pseudarthrosis with the underlying navicular. Type
lowing it to its insertion onto the navicular. The insertion is 3 is where the ossicle has fused with the navicular: a stable
complex with slips to the underside of the cuneiforms and condition, but one which may impact on TPT function.
cuboid as well as the navicular. A component also passes Variations include congenital duplication of TPT and a
over the navicular to insert into the medial cuneiform. In common tendon sheath for tibialis posterior and flexor
view of the widely diverging configuration of the tendon digitorum. An accessory FDL may be seen to pass through
insertion, anisotropy can be problematic. the tarsal tunnel adjacent to FHL. Its distal attachment to
An accessory ossicle may be present close to the navicular flexor digitorum usually helps to distinguish it from a sig
insertion. There are several types depending on the size of nificant mass.
POSITION 3: POSTERIOR ANKLE

IMAGING GOALS
1. Identify Achilles tendon and enthesis.
2. Identify plantar fascia and surrounding muscles.
3. Locate plantaris and the paratenon.
TECHNIQUE
The posterior aspect of the hind foot is best examined
with the patient prone and the foot extended over the end
of the examination couch. If patients cannot lie prone, a
supine examination with the foot overhanging can be used.
The imaging goals are to identify the Achilles tendon, the
plantaris tendon and the plantar fascia.
The Achilles tendon is easily located by placing the
probe in long axis in the midsagittal plane above the os
calcis (Fig. 23.5). It is one of the largest tendons in the
body. It can be tracked proximally to where it is joined by
the soleus muscle (soleal incorporation) and further proxi
mally where it is formed within the gastrocnemius muscle.
Note should be made of the distance between the level of
soleal incorporation, usually referred to as the musculoten
dinous junction, and the insertion to the os calcis. A low
incorporation is said to predispose to Achilles tendinopa
thy. Just before its insertion, the anterior relation of the
Achilles tendon is Kager’s fat triangle and the pre Achilles
bursa. Normally a very small amount of fluid can be identi
Figure 23.4 Coronal T1-weighted MR image showing the relation- fied within the bursa. Gentle flexion and extension of the
ship of the tibiospring ligament (arrow) to the spring ligament (blue). foot reveal the movement of the posteroinferior tip of the
The spring ligament lies deep to the TPT.
a c
Achilles Tendon
Os Calcis
Kager
P
S I
A
b d
Figure 23.5 The Achilles tendon is best examined with the patient prone. The foot overhangs the end of the examination couch to make
tendon movement easier.
fat pad within the bursa, helping to define it. This manoeu speckles representing the tendon fibres interspaced with
vre also helps to exclude some forms of pre Achilles bursi the bright connective tissue epitenon. With the probe held
tis that are more complex and may have ultrasound centrally, the medial and lateral margins of the tendon may
characteristics similar to the fat pad. The retro Achilles be difficult to identify in thin individuals as there is often
bursa lies posterior to the tendon at the same level. This an edge artifact extending from them and giving the impres
rarely contains fluid in normal individuals and in many sion that the medial and lateral tendon margins are of low
cases can be difficult to identify. It is important not to signal. The probe needs to be moved first medially then
press too hard with the ultrasound probe as the soft-walled laterally and tilted in the opposite direction to provide clear
bursa can be easily obscured. visualization of the margins.
A number of other signal characteristics may be found at On the medial side, the plantaris tendon is usually visible
the tendon insertion. A low-reflective structure may be seen (Fig. 23.6). This short-bellied muscle has its origin on the
on the dorsal aspect of the underlying os calcis. This is posterior aspect of the lateral femoral condyle. It forms into
entheseal hyaline cartilage and may coexist with low-signal a long tendon that passes from lateral to medial between
sesamoid cartilage within the tendon itself, though the latter the soleus muscle and the medial head of gastrocnemius to
can be rather subtle and difficult to identify. emerge on the medial aspect of the Achilles tendon. It may
The insertion footprint is quite large. The most superfi then insert directly onto the os calcis, but more commonly
cial fibres can be seen to pass over the os calcis and contrib it blends with the Achilles tendon itself at some point along
ute to the formation of the superficial fibres of the plantar its length. Some form of plantaris tendon can be identified
fascia. This is especially apparent in children, and is similar in the majority of patients, though it can be quite vestigial.
to the relationship between the rectus abdominis/adductor A retinaculum similar to the tarsal retinaculum extends over
and quadriceps/patellar tendon. A relationship between the Achilles and plantaris tendons. Like the retinaculum of
symptoms from the Achilles tendon and plantar fascia is well the knee, this can be a little thickened at the level of the
recognized and both should be examined when pathology middle and distal thirds of the Achilles tendon. The pres
in the other is suspected. ence of a prominent retinaculum is also said to predispose
The probe is then turned 90° to examine the Achilles to Achilles tendinopathy.
tendon in short axis. In this plane, the tendon is oval in The Achilles tendon is covered on three sides, dorsal,
shape with a convex posterior border and a flat or slightly medial and lateral, by a paratenon. This may either split to
concave anterior border. The internal structure should pass both superficial and deep to the plantaris or it may
resemble tendons elsewhere, with multiple low-signal include the plantaris alongside the Achilles.
a c
Achilles
Tendon
Plantaris
Figure 23.6 The plantaris tendon is located along the medial aspect of the Achilles tendon. It is located by moving the probe medially
and angling laterally.
calcis. The reflectivity of the plantar fascia is important for

diagnosis. Under normal circumstances it comprises alter
nating and interlaced hyper- and hyporeflective bands
typical of normal ligament tissue. In short axis, the central
band is oval in shape and larger than the lateral band from
which it is easily separated in this plane. The lateral band
itself arises from the lateral tubercle of the os calcis and is
a followed to its insertion at the base of the fifth metatarsal.
The large muscle deep to the central band is the flexor
digitorum brevis (FDB) and deep to this, though difficult to
see in many patients, is another fascial band: the long
plantar ligament.
POSITION 4: LATERAL ANKLE — TENDONS

IMAGING GOALS
b 1. Assess the peroneal tunnel and superior retinaculum.
2. Note calcaneofibular ligament (CFL) and subtalar joint.
3. Follow peroneal tendons to their insertion.
TECHNIQUE
The patient can be examined either supine or semirecum
bent with the hip internally rotated. As with the medial
hindfoot, it is best if the ankle can be held over the edge of
the examination couch or supported over a rolled towel
where there is slight tension on the lateral structures and
ability to move and stress them. The important structures
include tendons, ligaments and retinacula (Fig. 23.10).
The lateral examination begins with the probe held in
the axial plane above and posterior to the lateral malleolus.
The tendons of the peroneus brevis and longus are identi
fied (Fig. 23.11). The musculotendinous junction of pero
neus brevis is lower than peroneus longus and the brevis
tendon lies deep to longus and is smaller than it. Above the
lateral malleolus they both have an oval or slightly oblong
shape with the longus tendon approximately three times the
size of the brevis tendon. Careful control of probe position
is needed as the tendons are followed distally to keep them
perpendicular and free of anisotropic artifact. This is par
ticularly challenging as the tendons take a relatively sharp
c turn anteriorly around the lateral malleolus. At each level,
Figure 23.7 The lateral aspect of the tendon is examined in the axial the tilt of the probe should be adjusted to maximize the
plane. The sural nerve lies within the fatty tissue lateral to the tendon reflectivity from the tendons and remove artifact. Areas of
with the adjacent saphenous vein. decreased reflectivity that are persistent are thus likely to
represent longitudinal split tears.
Up to 3 mm of fluid within the common peroneal sheath
just below the fibula is within normal limits; elsewhere only
If the probe is then moved laterally and angled medially, a trace should be seen. The superior peroneal retinaculum
the lateral margin of the Achilles tendon, the lateral is found above the two tendons and helps to keep them
paratenon and the lateral retinaculum are detected. Lying located behind the lateral malleolus during normal foot
between the lateral border of the Achilles and the peronei movement. Like the tarsal retinaculum, this passes over the
is the sural nerve adjacent to the short saphenous vein that two tendons before blending with the deep fascia on the
acts as a marker for the nerve (Fig. 23.7). lateral aspect of the ankle. The configuration of the poste
The probe is then passed over the heel and rotated to the rior margin of the fibula should be slightly concave, provid
sagittal plain to demonstrate the plantar fascia (Fig. 23.8). ing an excellent pulley for the peroneal tendons to pass
The plantar fascia has three components: medial, central around. A convex posterior fibular margin may predispose
and lateral; however, the medial component is not seen in to tendon subluxation. Laterally the retinaculum attaches
the posterior hindfoot (Fig. 23.9). The main central attach to the posterolateral corner of the fibula where a slight
ment arises from the medial calcaneal tubercle and can be expansion is usually found. Occasionally the retinaculum
followed distally to the level of the metacarpal heads. Its attaches more anteriorly along the fibula, which also predis
footprint measures approximately 1 cm in length and poses to peroneal subluxation. In many cases this pattern is
4–4.5 mm in thickness measured from where it leaves the os the consequence of prior trauma.
a c
a
asci
tar F
Plan
FDB
Os Calcis
I
P A
b
S
Figure 23.8 The prone position used to examine the Achilles tendon is also ideal to assess the plantar fascia. The probe is shown in long
axis over the central bundle.
Medial
Lateral
Central
a
c
Figure 23.9 (A) Schematic diagram of the three bundles of the plantar fascia. (Modified from Drake RL, et al. Gray’s Atlas of Anatomy, 1st
edition. Philadelphia, PA: Churchill Livingstone; 2008; with permission). (B, C) The central bundle is the largest (yellow arrows). The difference in
size between the central and the lateral bundle can be appreciated on the coronal T1-weighted MR image (C).
Once the internal structure of the tendons has been the retinaculum but move abnormally in relation to one
assessed, the ankle should be dorsiflexed and everted to another.
see whether they sublux. There are various classifications As the tendons are followed below the lateral malleolus,
but broadly only two types of subluxation: one where a ligament will appear deep to them; this is the CFL and will
there is complete displacement of one or both tendons be discussed further in the next section.
which come to lie medial or even anterior to the lateral Passing more distally again, the peroneal tendons begin to
malleolus, and the other where the tendons stay within separate from one another. At this point they pass deep to
the inferior peroneal retinaculum, which is a thin reflective
structure passing over the two tendons (Fig. 23.12A). At this
point, a bony prominence may be seen arising from the
lateral calcaneal margin. This is the peroneal tubercle and in
some patients can be quite prominent (Figs 23.12B and C).
A bony prominence measuring more than 5 mm from tip to
base may predispose to peroneus longus tendinopathy.
Below this level, peroneus brevis is followed to its inser
tion on the base of the fifth metatarsal. The attachment of
peroneus brevis needs to be distinguished from the attach
ment of the lateral band of the plantar fascia, which lies
below it. Peroneus longus passes inferiorly through a
fibroosseous tunnel on the undersurface of the cuboid
and across the plantar aspect of the midfoot to insert onto
the medial cuneiform and first metatarsal. Just before
entering the tunnel, an accessory ossicle, the os pero
neum, may be located. The os is susceptible to sesamoid
itis and fracture.
The peroneus quartus muscle is an accessory muscle that
is located on the posterolateral aspect of the ankle, medial
and posterior to the peroneal tendon group. It occurs in
around 10% of the population. The commonest insertion
site is into the os calcis, but it can also insert into either the
peroneus longus tendon, the peroneus brevis tendon or the
cuboid. The peroneus quartus muscle is not to be confused
Figure 23.10 Ligaments and retinacula of the lateral hindfoot. with the peroneus tertius, which lies anterior to the lateral
a c
Retinaculum
us
ong s
e us L i
Per
o n ev
s Br
eu
r on
Pe Lateral
Malleolus
P
M L
b A d
Figure 23.11 The ultrasound transducer is placed in the axial plane posterior to the lateral malleolus to demonstrate the peroneus longus
tendon posterior to the peroneus brevis tendon within the peroneal retinaculum. This superior peroneal retinaculum has a broad attachment
to the lateral malleolus.
the two main components, with the former most com

monly injured. The posterior talofibular ligament is rarely
injured except by complete ankle dislocation. The ATaFL
runs almost horizontally and inferiorly from the anterior
border of the fibular tip to the talus. It has an average
length of 25 mm and a width of 2 mm. Disruption of the
ligament is seen as swelling, often appearing as a soft tissue
mass, with hypoechogenic areas inferior to the fibula. The
ligament should also be examined under stress either on
internal rotation or with an anterior draw. In complete
tears, the degree of abnormal movement is greater and the
free ends of the ruptured ligament can be seen dipping
a into the ankle joint. The ATFL is a much stronger liga
ment that lies more superiorly than the ATaFL. It is part of
the tibiofibular syndesmosis and requires significantly
more energy and a different mechanism, compared with
the usual ankle sprain, to disrupt it. The CFL ligament lies
deep to the peroneal tendons running from the apex of
the lateral malleolus to a small tubercle on the lateral side
of the os calcis.
Assessment of the lateral ligaments starts with the probe
in the axial plane with its posterior tip against the anterior
margin of the fibula close to its tip. The anterior part of
the probe is then rotated superiorly. The anterolateral
margin of the talus passes out of view and the tibia appears.
A short ligament can be seen passing between the tibia and
fibula; this is the dominant inferior portion of the ATFL
(Fig. 23.13).
b From this position, the anterior aspect of probe is rotated
inferiorly. In a reverse of the previous manoeuvre, the tibia
Figure 23.12 A bony spicule, the peroneal tubercle may be present,
separating the two tendons (compare normal A with B). If large, it
passes out of view and the talus appears (Fig. 23.14), recog
may predispose to peroneus longus tendinopathy. nized by its cartilage cover. Occasionally the posterior
margin of the probe needs to also pass slightly distally but
soon the ATaFL comes in to view. This is a longer and
broader ligament than the ATFL but it is not nearly as
strong and is more prone to injury. On the superficial aspect
of this ligament a small artery and vein may be identified,
malleolus on the lateral aspect of the foot. It is closely which can be helpful in locating the ligament beneath.
related to the extensor digitorum longus (EDL) muscle and Deep to the ligament lies the anterolateral gutter of the
inserts at the base of the fifth metatarsal. Its insertion point ankle joint. A small amount of fluid is normally present in
can be used to differentiate it from the extensor digitorum the anterior recess.
tendon of the fifth toe that lies adjacent to it. Another The CFL is best found by following the peroneal tendons
variant that may be encountered is the peroneus digiti as they pass through nearly 90° around the lateral malleolus.
minimi that extends from the peroneus brevis muscle to Just below the tip of the fibula a linear structure appears
insert into the proximal phalanx of the fifth digit. It is rela separating the tendons from the underlying os calcis (Fig.
tively small in size and therefore rarely causes confusion or 23.15). This is the posterior part of the CFL. To see the liga
presents as a mass of unknown nature. Other muscle vari ment along its full length the probe is then rotated with the
ants include a low-lying peroneus brevis musculotendinous upper margin of the probe coming to lie more superiorly
junction that can even extend below the distal tip of the until the length of the CFL is seen as close to its entirety as
fibula. is possible. The very proximal part of the tendon as it passes
deep to the lateral malleolus can be difficult to visualize.
POSITION 5: LATERAL ANKLE — LIGAMENTS The ankle can then be moved through dorsi/plantar
flexion, tightening and relaxing the ligament in turn. This
IMAGING GOALS can sometimes improve visualization of the internal struc
1. Locate and stress the anterior tibiofibular ligament ture of the ligament, but also it should be noted that this
(ATFL). manoeuvre displaces and rotates the peroneal tendons as
2. Identify the anterior talofibular ligament (ATaFL). the ligament tightens. It has been suggested that this dis
3. Locate and stress the CFL. placement and rotation will only occur when the CFL is
competent.
TECHNIQUE The sinus tarsi also opens to the lateral side. The wide
Eighty-five per cent of ankle sprains involve the lateral col mouth of the sinus can be found anterior to the lateral mal
lateral ligaments (Fig. 23.10). The ATaFL and the CFL are leolus (Fig. 23.16).
a c
ATF
L
Lateral
Malleouls Tibia
A
L M
P
b
Figure 23.13 The stronger ATFL has a more vertical orientation.

Note the position on the ligament in the coronal MR image (arrow).
d
The ligament is shorter and stronger than the ATaFL.
a c
ATa
FL
Lateral
Malleouls Anterolateral
Gutter
Talus
A
L M
b P
Figure 23.14 The ATaFL overlies the anterolateral gutter. A small

vessel may be present anterior to the ligament and can help to
locate it. Note the probe position in C (compare with 23.13C and
d
appearance on MR (D)).
a c
Peroneus Brevis
Peroneus Longus
CFL
Fibula
Os Calcis
L
P A
b M d
Figure 23.15 The CFL is found by following the peroneal tendons to the submalleolar region. The striated ligament will be depicted deep to
the tendons. Its posterior attachment is usually the first to be located.
a b
Figure 23.16 The sinus tarsi is a wide space located laterally and found by placing the transducer anterior to the lateral malleolus just below
its distal tip.
POSITION 6: ANTERIOR ANKLE EDL group. As an aid to remembering their positions, TAT
and TPT lie ‘adjacent’ to each other. The relationship of
IMAGING GOALS EHL and EDL is the reverse of the relationship of FHL and
1. Identify all three anterior tendon groups. FDL in the medial ankle and no crossover of these tendons
2. Identify and follow the superficial and deep peroneal is necessary.
nerves. TAT is first followed in its short axis to its insertion in the
3. Evaluate the anterior joint space and midfoot joints. medial cuneiform. It inserts in a small depression on the
dorsomedial aspect of this bone. In long axis, this has
TECHNIQUE the typical striated appearance as with tendons elsewhere;
The anterior examination begins with the probe in the axial however, the overall reflectivity is lower than other tendons
plain over the distal tibia (Fig. 23.17) where three tendons and this should not be misinterpreted as tendinopathy.
can be identified. The most medial is tibialis anterior (TAT), Returning to the starting axial plane, a lateral movement
adjacent to this is the smaller extensor halluces longus of the probe reveals the small thin extensor halluces
(EHL) tendon (EHL) and laterally is the larger and wider tendon, which can be traced to its insertion into the distal
2nd
a
Mid MT
Navicular Cuneiform
Talus
D
P A
b P
Figure 23.18 The classic configuration of the talus with its bi-lobed
dorsal surface is used to identify the joints of the midfoot. In direct
line are the talonavicular, the naviculocuneiform and the second tar-
sometatarsal joints.
Figure 23.17 The three anterior tendons and their associated exten- POSITION 7: MIDFOOT DORSAL
sor retinacula are located anterior to the distal tibia. The tibialis
anterior is the most medial. The deep peroneal neurovascular bundles IMAGING GOALS
are also located here. 1. Identify tarsal joints.
2. Identify important ligaments.
3. Identify nerves.
phalanx of the great toe. The flexor digitorum tendon is TECHNIQUE

recognized not only from its lateral location but as it is fol The joint anatomy in the midfoot is complex but with
lowed distally it splits into the four constituent tendons, careful technique, individual articulations can be easily
one serving each of the toes. TAT and the other anterior identified. As they lie closer to the skin on their dorsal
tendons are constrained by two retinacula: the superior aspect, the bony anatomy will be described from this per
and inferior. The superior retinaculum is band-like and lies spective. The identification of individual joints is best
at the level of the distal tibia below the musculotendinous achieved by placing the probe in long axis, on the dorsum
junction. It represents the anterior portion of a circumfer of the foot and displaying a sagittal image (Fig. 23.18). The
ential band of tissue that includes the tarsal retinaculum, configuration of the talus is very characteristic and is an
overriding the tarsal tunnel, and the superior peroneal reti excellent starting point. It has a bi-lobed superior surface
naculum laterally. In cross section, there may be two com that is easy to recognize. The talonavicular, navicular middle
ponents, superficial and deep, with the TAT passing in a cuneiform and second tarsometatarsal joints are all in line.
tunnel between them. This tunnel may also separate tibialis Once these are identified, other joints may be located by
anterior from the other extensor tendons. The oblique their relationship to this axis. An axial approach can also be
inferior retinaculum comprises two bands, a superomedial used. The neck of the talus is easily identified and is a good
and an inframedial that unite to form a single lateral starting point. Moving the probe distally a two-bone section
attachment. The TAT passes deep to the oblique inferome is achieved, with the navicular the more medial and the
dial ligament just prior to its insertion into the medial cuboid lateral. Moving more distally again, four bones
cuneiform. come into view, the more medial pre-representing
the cuneiforms and the lateral the cuboid bone. Further difficult to locate. Soft tissue swelling and local tenderness
progression distally identifies the five bones representing are important pointers.
the five metatarsals. The anterior tibial artery is located close to the anterior
There are numerous ligaments on the dorsal aspect of margin of the tibia between the muscle bellies of extensor
the foot but only a few have clinical significance. The dorsal halluces and extensor digitorum. The deep branch of the
talonavicular ligament is an easily identified ligament that common peroneal nerve travels with this artery. The other
overlies the correspondingly named joint. This may be nerves to locate are the terminal branches of the superficial
injured in soccer due to the repetitive trauma of kicking. peroneal nerve. The superficial peroneal nerve pierces the
The bifurcate ligament, as the name implies, has two com deep fascia on the anterolateral aspect of the calf approxi
ponents. The thicker is the calcaneocuboid ligament mately 12 cm above the joint. It then divides into two
(CCL). This is located by placing the probe over the CC branches supplying sensation to most of the skin on the
joint and passing it around the lateral margin until the dorsal aspect of the foot. These branches are rather small
band-like ligament comes into view. The calcaneonavicular and further divide to serve sensation to most of the dorsal
component is smaller. It shares proximal fibres with the aspect of the forefoot; the only exception is the first web
CCL that may help to identify it. More important than space, which is supplied by the deep peroneal nerve.
finding the ligament is to note the configuration of the
anterior process of the os calcis and search for an associ POSITION 8: MIDFOOT PLANTAR ANATOMY
ated fracture. The other important ligament on the dorsum
of the foot is the Lisfranc ligament. Stability of the second IMAGING GOALS
tarsometatarsal articulation is preserved by the ligaments 1. Locate the three muscle layers.
that pass between the medial cuneiform and the base of 2. Recognize the knot of Henry and adjacent plantar
the second metatarsal. The strongest of these is the Lis nerves.
franc ligament. Three layers are recognized, dorsal, inter 3. Identify the three fascial bands.
osseous and plantar. The strongest is in the interosseous
layer that passes between the medial cuneiforms and the TECHNIQUE
base of the second metatarsal. This is the lisfranc ligament. Four anatomical layers are present between the plantar and
There is also a strong ligament on the plantar aspect of dorsal aspects of the foot. With the probe held transverse to
these articulations with a Y-shape configuration; its base is the long axis of the plantar aspect of the foot, three super
on the medial cuneiform with one limb each inserting into ficial muscles dominate the ultrasound image and make up
the bases of the second and third metatarsals. The narrow the first layer (Fig. 23.19). Centrally is the FDB with the
space and oblique orientation of the ligament make it abductor hallucis and abductor digiti minimi on either side.
FDB
Lat
PN Med FDL
PN FHL
ADM
AHL
FDB
b c
Figure 23.19 The crossover point (knot of Henry) in the distal part of the tarsal tunnel. Flexor hallucis longus lies first lateral and then medial
to FDL. The tendons cross close to the medial plantar nerve that, along with their lateral plantar nerve, are the two main branches of the tibial
nerve. The MRI is shown in the conventional orientation.
The quadratus plantae (QP) and lumbrical muscles make POSITION 9: FOREFOOT
up the second layer. QP arises from two heads from the os
calcis. The medial is the larger and this forms part of the IMAGING GOALS
floor of the distal part of the tarsal tunnel. QP is somewhat 1. Identify plantar plate.
unusual in that it attaches to the tendon of FDL before it 2. Identify interdigital nerves.
divides into the slips to each of the four lateral toes. Its 3. Examine small joints.
action is continued by the lumbrical muscles. Like their
counterparts in the wrist, these muscles arise from the indi TECHNIQUE
vidual flexor tendons. The anatomy of the metatarsophalangeal joint is similar to
There is a fatty space between the first two layers, strictly the metacarpophalangeal joints of the hand. On the dorsal
between the medial head of QP and the FDB. This contains aspect is the extensor apparatus. There are two collateral
the ‘knot of Henry’ and the medial and lateral plantar ligaments: the principal collateral ligament lies closer to
nerves. The knot of Henry is the intersection and crossover the dorsal aspect of the capsule and the accessory collat
of the FHL and FDL tendons. In the proximal hindfoot, eral ligament is volar. On the plantar aspect of the foot,
FHL is lateral to FDP so they must cross over each other the accessory, collateral ligaments blend with the dorsal
to reach their respective insertions. This takes place at the and plantar interosseous tendons and intertransverse liga
knot of Henry close to the medial plantar nerve. The long ment to form the inferior capsule, which is further rein
plantar ligament also lies in this space. This ligament paral forced by the intraarticular plantar plate (Fig. 23.20). The
lels the plantar fascia and shares its function in maintaining plantar plates are the equivalent of the volar plates of the
the longitudinal arch. It can occasionally be injured like the metacarpophalangeal joints. They are fibrocartilaginous
plantar fascia. It gets additional support from a shorter structures whose function is to limit hyperextension of the
deeper ligament, the short plantar ligament. joint. In addition, the plantar aspect of the first metacarpo
The third layer is really only present in the mid and distal phalangeal joint is reinforced by two sesamoid bones
foot. Its posterior margin is the peroneus longus tendon as formed within the tendinous insertions of the flexor hallu
it traverses from lateral to medial to insert on the base of cis brevis muscle. The oblique and transverse heads of the
the medial cuneiform and first metatarsal. Distal to it there adductor hallucis muscle also insert close to the lateral ses
is a single muscle on the lateral side, the flexor digiti minimi amoid. The flexor tendon is extraarticular and overlies the
brevis. On the medial side there are two additional muscles plantar plate. The flexor tendons are reinforced by a
to the hallux, the flexor halluces brevis and the adductor pulley system similar to that of the fingers, though less
hallucis. The fourth layer contains the interosseii, and the often injured.
only muscle on the dorsal aspect of the foot, the extensor The interdigital nerves pass between the metacarpal
digitorum brevis (although a slip to the hallux is sometimes heads dorsal to the transverse ligaments. The transverse liga
a separate muscle). ments pass between the metatarsal heads, preserving the
Flexor Tendon
Plantar Plate
st
1 Proximal
Phalanx
1st Metatarsal Head
Figure 23.20 Long-axis view of the plantar plate between the sesamoid bones on the plantar aspect of the first metatarsophalangeal joint.
b c
Figure 23.21 Examining for Morton’s neuroma. The probe is in the sagittal plane in the 3/4 interspace. The left-hand of the examiner is pal-
pitating and compressing on the dorsal aspect of the interspace to try to augment visualization of the neuroma intermetatarsal bursal complex.
The sagittal examination is supplemented by rotating the probe into the axial plane. (A) Modified from Drake RL, et al. Gray’s Atlas of Anatomy,
1st edition. Philadelphia, PA: Churchill Livingstone; 2008; with permission.
transverse arch. Morton’s neuroma occurs just distal to the the first metatarsophalangeal joint and this should be con
ligament. Above these lies a potential space or intermetatar sidered normal. Comparison with the contralateral side,
sal bursa (Fig. 23.21). The intermetatarsal bursae extend plus a Doppler assessment of the synovium, can help deter
distal to the level of the transverse ligament where they may mine its significance. It is less easy to assess the interphalan
expand in patients with Morton’s neuroma/intermetatarsal geal joints from the plantar aspect of the foot due to the
bursitis complex. natural curvature of the toes. The use of the small footprint
The small joints of the feet are examined in a similar probe and manual straightening of the toes as far as is toler
fashion to the fingers. Long-axis views of the metacarpopha able is the method of achieving this. The majority of syno
langeal and interphalangeal joints are assessed initially vitis assessment routines do not rely specifically on the
from the dorsal aspect of the foot, which provides the best evaluation of the interphalangeal joints of the toes from the
visualization. There is often a small quantity of fluid within plantar side.
Disorders of the Ankle 24
and Foot: Posterior
Michel Court-Payen | Eugene McNally
CHAPTER OUTLINE
INTRODUCTION HEEL PAD SYNDROME

ACHILLES TENDON DISORDERS OF THE PLANTAR FASCIA
Achilles Tendinopathy Biomechanics
Achilles Paratenonopathy PLANTAR FASCIITIS
Achilles Enthesopathy Clinical Features
Haglund’s Disease Ultrasound Findings
Achilles Tendon Tear TRAUMA
The Postoperative Achilles Tendon PLANTAR FIBROMA
BURSITIS NEURAL COMPRESSION BAXTER’S
PLANTARIS TENDON NEUROPATHY
THE ACCESSORY SOLEUS MUSCLE Xanthoma
SEVER’S DISEASE OTHER DIFFERENTIAL DIAGNOSIS
POSTERIOR IMPINGEMENT TREATMENT OPTIONS
have been increasing for the past decades, reflecting the

INTRODUCTION increase in participation in different types of sporting activ-
ity. Diseases are most commonly divided into two groups:
The most common symptoms leading to an ultrasound insertional and noninsertional. Insertional is further divided
examination of the posterior ankle region are those associ- into enthesopathy (at insertion) and Haglund’s disease
ated with disorders of the Achilles tendon or the plantar (proximal to insertion). In all patients, the differential diag-
aponeurosis (heel pain and/or swelling). In an acute setting, nosis will be based on the patient’s history (pain, swelling,
ultrasound is most often performed for suspicion of Achilles mechanism of disease) and the exact anatomical location of
tendon tear. Other common acute and chronic indications findings on ultrasound. Noninsertional findings include
are Achilles tendinopathy and/or paratenonitis, insertional tendinopathy and paratenonopathy. Tendinopathy, enthe-
Achilles tendon diseases, bursitis and plantar fasciitis. Less sopathy and Haglund’s disease may all lead to tendon tears,
common indications are Sever’s disease, tear of the plantar so it is an important goal for ultrasonography to recognize
aponeurosis, plantar fibromatosis, lesions of the plantaris and describe such a complication, as it might be treated
tendon, an accessory soleus muscle, posterior ankle impinge- surgically. Post-operatively, ultrasound may be required
ment and heel pad syndrome. when tear recurrence or infection is suspected.
ACHILLES TENDINOPATHY
ACHILLES TENDON
Achilles tendinopathy is one of the most common findings
Ultrasonography is the first choice imaging modality for in patients with chronic heel pain. It is a common disorder
examination of the Achilles tendon, with an unsurpassed with an incidence rate of 2.35 per 1000 adult patients in a
resolution and outstanding analysis of the fibrillar tendon large Dutch report on GP-registered patients. Most cases are
structure. In addition, it is the only imaging technique that encountered in the middle-aged population (age 41–60
enables dynamic and functional examination of the tendon. years). It is more a degenerative (tendinosis) than an inflam-
Pathological conditions that may affect the Achilles tendon matory condition, and it is caused by overuse of the tendon
269
fibres, often related to sporting activity, including running.

Sport athletes are at high risk but a relationship with sports
activity is not always present.
Key Point
Development of Achilles tendon degeneration has also been

attributed to hind-foot valgus and hyperpronation of the foot,
a
leading to increased stress in the medial part of the tendon.
Other factors that can play a role in the pathogenesis of

tendinopathy are an imbalance between the gastrocnemius
and the soleus individual contributions to the tendon, age,
weight, sedentary life, vascularity, associated limb torsion P
Achilles Tendon M L
and ankle abnormalities. Symptoms generally develop
A
insidiously. It is difficult to differentiate clinically between
b
tendinopathy and inflammation of the paratenon (para
tenonopathy), all the more since the two conditions can be Figure 24.1 Axial images of bilateral Achilles tendinopathy. The
associated. Patients with tendinopathy present with pain, tendon on the left is considerably more enlarged than the right,
swelling, morning stiffness and impaired performance in although both show areas of decreased reflectivity with focal areas
sport activities and with daily living. Ultrasonography has a of tendon delamination.
high-positive predictive value for visualization of tendinopa-
thy, but has a lower sensitivity than MRI for detection of
paratenonitis. Ultrasonography shows involvement of the paratenon, increased echogenicity of the pre-Achilles fat
hypovascularized tendon midportion (2–6 cm above the pad) should be carefully sought. Conversely, areas of tendi-
insertion), reflecting the histopathological signs of failed nopathy, with or without increased colour Doppler signal,
healing response: disruption of collagen fibres, increase in may be detected in asymptomatic tendons, though there is
ground substance (proteoglycans), tenocyte proliferation an increased likelihood that these tendons will eventually
and neovascularization. Bilateral findings are present in become symptomatic. With time, the tendon may become
more than half the patients, heterogeneous and the hypoechoic areas of degeneration
Most often the degenerative process is diffuse, leading to may present very small anechoic, rounded or longitudinally
a painful spindle-shaped hypoechoic enlargement of the orientated, intratendinous lesions. These are referred to as
Achilles tendon (Fig. 24.1). The fibrillar structure of the microtears or delaminations (Fig. 24.5A, B). Less com-
tendon is nicely appreciated on longitudinal ultrasound sec- monly, calcifications may be found in the Achilles tendon
tions, so areas of preserved and thickened fascicles can be (calcific tendinopathy, Fig. 24.5C). Eventually, complete or
seen (Fig. 24.2A, B). With progressive involvement, the partial tear of the midportion of the tendon may occur.
overall echogenicity of the tendon tends to decrease, as the Treatment of tendinopathy is essentially conservative with
spacing between fibres tends to increase. It is important to a period of rest, nonsteroidal antiinflammatory medication
avoid anisotropic artifact during this assessment. This and heel lift, followed by physiotherapy (eccentric training),
tendon enlargement is quantified by measuring the antero- and sometimes surgery in resistant situations. Some rare
posterior diameter of the tendon: exceeding 6 mm in ten- forms of tendinopathy are related to a specific cause and
dinopathy. In some patients the tendon enlargement is have to be treated accordingly: lipid-storage disorders, rheu-
asymmetrical, often affecting the medial aspect of the matic diseases, treatment by local or systemic steroids, or
tendon more than the lateral (Fig. 24.3). With isolated ten- certain antibiotics.
dinopathy, there is no discontinuity of the tendon borders. Heterozygous familial hypercholesterolemia is an autoso-
On axial sections (Fig. 24.2C, D) the tendon is rounded and mal dominant disease, characterized by elevated low-density
hypoechoic, with loss of the normal anterior flat or slightly lipoprotein cholesterol plasma levels, premature coronary
concave contour. Colour Doppler examination often shows artery disease and cholesterol deposits in extensor tendons
tendinous and/or peritendinous hyperaemia, mostly as (xanthomas) with the Achilles tendon as the most frequently
small vessels entering the anterior border of the tendon at affected tendon (Fig. 24.6). The presence of Achilles tendon
right angles (Fig. 24.2 E, F). This should be performed on xanthomas is pathognomonic of the disease but 25% of
a relaxed tendon and without too much transducer com- patients present with a normal tendon at palpation. Ultra-
pression in order to avoid a false-negative examination due sonography may demonstrate focal anechoic areas, conflu-
to obliteration of the vessels. Some patients may exhibit ent hypoechoic areas or an enlarged heterogeneous tendon.
focal degenerative abnormalities, involving the anterior or Ultrasonography has thus been advocated as a screening
posterior part of the tendon (Fig. 24.4). tool in clinically silent tendons in patients with hyper
When the Achilles tendon is painful at palpation but lipidaemia or with a family history of occurence. Achilles
grossly normal on ultrasound, paratenonopathy should tendinopathy, paratenonopathy, enthesitis, retrocalcaneal
be suspected, and subtle signs of tendinopathy (convexity bursitis and/or joint synovitis are frequent findings in rheu-
of the anterior border, slight hypoechogenity or hyperae- matic disorders such as rheumatoid arthritis, gout or spon-
mia) and/or paratenonopathy (slight thickening of the dylarthritis. Ultrasonography can also show subcutaneous
CHAPTER 24 — Disorders of the Ankle and Foot: Posterior 271
Achilles
P Kager
S I FHL Os Calcis
b A
c
Par
ate
non
Achilles f
P
L M
d
A
Figure 24.2 Achilles tendinopathy. (A, B) Longitudinal section showing spindle-shaped hypoechoic enlargement. (C, D) Axial section showing
rounded cross section and increased anteroposterior diameter (13.2 mm). (E, F) Longitudinal colour Doppler examination showing intratendi-
nous hyperaemia.
rheumatoid nodules (well-circumscribed focal hypoechoic tendinopathy (late stage). Paratenonosis fibrous adhesions
area) in rheumatoid arthritis and intratendinous tophi in can develop in chronic situations (paratendinosis), limiting
gout (heterogeneous hyperechoic areas with shadowing). tendon movement. Other causes of paratenonitis are rheu-
Achilles tendon tears have been reported as a complication matic diseases and especially spondylarthropathies.
of local or systemic steroids. Severe tendinopathy can also Palpation is painful and thickening of the Achilles tendon
occur as a complication of the administration of fluoro is often suspected clinically. Ultrasonography may show an
quinolone antibiotics, with a higher risk in patients with echo-poor thickening of the paratenon, best seen on axial
renal dysfunction. It is most frequently seen at the Achilles scans (Fig. 24.7). The paratenon surrounds the Achilles on
tendon, often bilateral and leading to tendon tear in nearly three sides: posterior, medial and lateral. This explains the
half the cases. shape of paratenonopathy: U-shaped with no enlargement
anteriorly. This thickening of the paratenon is often subtle.
In rare acute cases, a small amount of fluid in the paratenon
ACHILLES PARATENONOPATHY
can be identified. Some patients with inflammatory joint
Paratenonitis means inflammation of the paratenon. The diseases exhibit a marked enlargement, often with associ-
most common cause is mechanical and secondary to an ated tendinopathy. MRI is also sensitive for the diagnosis of
overuse injury, either isolated (initial stage) or associated to paratenonitis, as diffuse soft tissue oedema around the
Figure 24.3 Axial image of posterior ankle. The anteromedial aspect

of the tendon is more involved than the posterolateral aspect. Such
a focal involvement is relatively common. There is some increased
Doppler activity in the paratenon.
Achilles P
L M
A
b
a
Achilles
P Kager
S I FHL Os Calcis
b A
Figure 24.4 Focal Achilles tendinopathy with posterior
involvement.
tendon is easy to detect. In some cases, ultrasonography may

show soft tissue oedema in the pre-Achilles fat pad (diffuse
hyperechogenicity and heterogeneity) or the subcutaneous
tissue, with careful comparison to the contralateral side.
Peritendinous hyperaemia demonstrated with colour
Doppler examination is also helpful for the diagnosis.
c
ACHILLES ENTHESOPATHY
Figure 24.5 Focal intratendinous changes in Achilles tendinopathy.
Achilles enthesopathy is caused by inflammation at the (A, B) Small intratendinous microtear. (C) Small calcifications.
site of insertion of the tendon on the inferior part of the
posterior aspect of the calcaneus. This area comprises
the most distal part of the tendon, the enthesis fibrocarti- tendon, but can also be inflammatory. Inflammatory enthesi-
lage, as described by Benjamin and McGonagle, and the tis is seen in seronegative spondylarthropathies, such as
adjacent bone. The causes of Achilles enthesopathy are ankylosing spondylarthritis and psoriasis. Regardless of the
most often mechanical and related to age, overweight, sport cause, chronic enthesopathy changes can be subtle and
activity, compression by hard footwear, or a short Achilles asymptomatic.
Achilles
Soleus
Kager
P
S I Os Calcis
FHL
A
b
Figure 24.6 Sagittal T1-weighted MRI. There is gross enlargement

of the Achilles tendon secondary to xanthomatosis.
Key Point
The typical ultrasound findings of enthesopathy are

enlargement of the tendon insertion, which becomes
hypoechoic, sometimes with calcifications or spur, and often
hypervascularized on colour Doppler examination (Fig. 24.8). d
Figure 24.7 Paratenonitis of the Achilles tendon with hypoechoic

thickening of the paratenon. (A, B) Longitudinal section. (C, D) Axial
section showing the U-formed paratenon.
Disturbances of the interface between the tendon and the
posteroinferior aspect of the calcaneus are well demon-
strated on ultrasonography, sometimes better than with
plain radiography or MRI. Ultrasound shows irregularity of In addition, ultrasonography enables precise placement of
the enthesis fibrocartilage and the underlying bone surface the tip of the needle for local steroid injection, which can
and posterior bone spur. On the other hand, MRI can dem- be very helpful as the subcutaneous soft tissues often are
onstrate a focal area of bone oedema in the posteroinferior adherent to the enthesis.
calcaneus, close to the enthesis and/or in the bone spur.
Bone spur is a common asymptomatic finding.
Key Point
Signs of enthesitis can be present in different rheumatic

Practice Tip diseases but are a characteristic pathological feature of
spondylarthropathies.
When pain is present around a bony spur, ultrasound often
confirms that focal inflammation at the spur is the cause of
the pain, showing a hypoechoic area in the tendon near and In spondylarthropathies, enthesitis is predominantly
proximal to the spur, containing or surrounded by local encountered in the lower limbs, and especially at the
colour Doppler signal. Achilles tendon insertion. Achilles enthesopathy is often
underestimated clinically.
sports and gymnastics). The use of rigid shoes has also been
incriminated in the pathogenesis.
On ultrasonography the diagnosis is based on the soft
tissue changes (Fig. 24.9A, B): retrocalcaneal bursitis and a
focal hypoechoic area in the anterior part of the distal Achil-
les tendon, corresponding to the sesamoid fibrocartilage
described by Benjamin and McGonagle. Bone irregularities
can be detected on the surface of the calcaneal tuberosity
(corresponding to the periosteal fibrocartilage), but plain
radiography is needed to demonstrate the hypertrophy of
the tuberosity. Different radiological measurement tech-
niques have been developed to quantify this hypertrophy.
MRI has the ability to show all the elements of the diagnostic
triad, but also areas of focal oedema in the posterosuperior
calcaneus and/or the pre-Achilles fat pad (Fig. 24.9C).
Haglund’s disease often leads to partial tearing of the
Figure 24.8 Mechanical Achilles tendon enthesopathy. Longitudinal anterior part of the distal Achilles tendon and rarely to
section showing heterogeneous hypoechoic thickening of the poste- complete tearing. It can also be associated with signs of
rior aspect of the enthesis with posterior spur and hyperaemia on Achilles tendinopathy or signs of enthesopathy. In some
colour Doppler examination. patients, the calcaneal tuberosity is either not or minimally
hypertrophied, and impingement can be suspected on the
presence of bone oedema at the tuberosity or an abnormal
calcaneus tilting. Retrocalcaneal bursitis is not always
Key Point obvious on ultrasound in chronic situations and the diagno-
sis can be based on the other signs of Haglund’s disease or
Ultrasonography has been shown to detect subclinical bursal calcifications.
enthesitis and is increasingly performed as it has the
potential to improve the diagnosis of spondylarthropathy Key Point
and the monitoring of its treatment.
It is important to differentiate Haglund’s disease from other
causes of heel pain and especially from inflammatory
Ultrasonography is especially useful to demonstrate ero- enthesopathy, as these entities have different treatments.
sions of the posterior calcaneus, but cannot visualize associ-
ated bone oedema. Local soft-tissue hyperaemia on colour
Doppler may also be found and is an important feature for If conservative treatment (rest, nonsteroidal antiinflamma-
treatment monitoring. Adjacent bursitis, bilateral involve- tory medication, change of shoe and heel lift) is not effec-
ment and joint involvement with synovitis also occur. tive, surgical treatment with calcaneal osteotomy can be
The main differential diagnoses are Haglund’s disease, considered.
calcaneal stress fracture, heel pad syndrome, and plantar
fasciitis. Calcaneal tumours are rare but calcaneal stress frac-
ACHILLES TENDON TEAR
ture is not and may be seen in runners. Plain radiography
is normal with stress fractures, and the diagnosis is usually Tears of the Achilles tendon are most often complete/full
made using MRI, which shows focal bone oedema around thickness. Partial thickness tears are uncommon and an
a fracture line. Ultrasound is positive only if the cortex is initial impression of a partial tear is often upgraded to full
involved. Isotope bone-scan has been advocated but carries thickness on dynamic assessment. Tears most commonly
a high radiation dose. CT is used to assess healing. occur secondary to a preexisting tendon abnormality, which
explains the different locations and types of tears and their
frequencies. Tears can thus be located at three different
HAGLUND’S DISEASE
levels: the midportion, the musculotendinous junction, and
Haglund’s disease is a mechanical disorder causing heel the distal part of the tendon.
pain, first described in 1928, and classically based on the
Haglund’s triad: hypertrophy of the posterosuperior portion
Practice Tip
of the calcaneal tuberosity (Haglund’s deformity), retrocal-
caneal bursitis and focal changes in the anterior distal Achil- The most frequent type of tear is located in the midportion
les tendon. These pathological findings are located in the of the tendon, 5–6 cm from the insertion in the so-called
proximal, preinsertional part of the enthesis, and not at the critical zone.
level of the tendon insertion. On clinical examination, pain
and swelling are found in the angle between the calcaneal
tuberosity and the Achilles tendon. It is believed to be Tears of the midportion occur in the third to fifth decade,
related to impingement of the tendon on the hypertrophied often related to sport activity (especially racket sports),
tuberosity during dorsal flexion of the ankle, often related more commonly in males, and with a second peak in the
to sport activity in young subjects (running, soccer, racket eighth decade. The onset is often acute, with a sharp
sensation and sometimes a snap in the hind-foot as if the

patient has just been kicked (or struck by an arrow fired by
Paris and guided by Apollo). The patient cannot stand on
his toes on the affected side. After a short period a charac-
teristic haematoma develops, tracking inferiorly on either
side of the tendon. The patient may consult de novo with
tendon rupture or will often present with a preexisting
history of Achilles tendon pain. A complete Achilles tendon
tear is often suspected on clinical examination: spontaneous
slight dorsal flexion of the ankle at inspection, tendon
defect at palpation, and positive Thompson’s test (no
plantar flexion of the ankle during compression of the calf).
However, it is not infrequent that Achilles tendon tears are
a overlooked at the initial clinical examination (20–25%).
Thompson’s test is negative in partial tears and can be false-
negative if the presence of a plantaris tendon produces a
plantar flexion during the test, as there may be infiltration
Achilles by haematoma and inflammation in chronic cases.
Ultrasonographic diagnosis is based on the detection of
a complete or partial interruption of the tendon fibres with
loss of tendon volume and alteration of its borders. Signs
of underlying chronic Achilles tendinopathy are common.
Kager With complete tears retraction occurs and the gap is filled
with anechoic blood and heterogeneous haemorrhage or
Bursa
Os Calcis other debris.
P
S I
A Practice Tip
b
Dynamic examination with gentle dorsal/plantar flexion of the
ankle joint shows displacement of tendon ends, away from
each other, which can help to differentiate between complete
tear, partial tear and tendinopathy.
In partial tendon tears, a substantial portion of the Achilles

tendon is disrupted, with focal loss of function. Dynamic
ultrasonography can reliably detect these partial Achilles
tendon tears and distinguish them from Achilles tendinopa-
thy or from the rare tears of the midportion of the plantaris
tendon. Very small anechoic areas in the Achilles tendon,
without impact on tendon contours and without loss of
function (microtears), should not be referred to as partial
tears, but are changes associated with the underlying tendi-
nopathy. The accumulation of these microtears at one site
may be expected to weaken the tendon and eventually lead
to partial or full-thickness tear.
Overlooked tendon tears are not infrequent and can
lead, like insufficiently treated tears, to chronic complica-
tions, such as a focal area with reduced solidity, lengthening
of the tendon, pain, or muscle atrophy with fat degenera-
tion (echo-rich muscle tissue seen mainly in the soleus
muscle). Interposition of the plantaris tendon and/or ante-
rior fat pad into the tendon gap occurs and needs to be
reported as it may prevent spontaneous healing. Healing
c with in situ plantaris interposition has been described.
Attention should be drawn to any focal thinning of the
Figure 24.9 Haglund’s disease. (A, B) Longitudinal ultrasound tendon, with loss of volume and concavity of the contours.
section of the Achilles tendon insertion showing a hypoechoic area
Complete tears are prone to retraction, leading to better
in the anterior distal Achilles tendon (1), a retrocalcaneal bursitis (2)
and hypertrophy of the calcaneal tuberosity (3). (C) Longitudinal MRI
visualization of tendon ends by their edge artifacts (poste-
section confirms the osseous hypertrophy and shows associated rior shadowing associated with refraction of the ultrasound
focal bone oedema (4). waves). Visualization of the two tendon ends is important
to measure the length of the defect and the degree of
Figure 24.11 Using a surface marker to locate and mark the ends
of a ruptured Achilles tendon. The metal marker, in this case an
untwisted paperclip, casts an acoustic shadow and can be moved
until it overlies the torn tendon. Pressure with the clip leaves an
indentation that can be marked once the ultrasound gel is cleaned.
c
patient’s skin. As contact gel can make this difficult, an
initial impression can be made using an unfolded paperclip
moved under the probe until its shadow lies at the tendon
end, then pressed into the skin to make an indentation (Fig.
24.11). Once the two ends are marked, the skin is dried and
the indentations can be augmented with a skin-marking
pen. An alternative method is to mark the centre of the
tendon gap. Colour Doppler examination does generally
not add much to the diagnosis.
In complete tears a longitudinal fibrillar structure can
often be seen in the medial part of the defect. This represents
an intact plantaris tendon (Fig. 24.10C, D) and should not
be mistaken for residual Achilles tendon fibres and a partial
tear misdiagnosed. In axial sections of the tendon gap, the
heterogeneous haematoma is often still contained by the
intact paratenon, with a small echo-rich rounded plantaris
d tendon in the medial part of the gap. Because of the proxim-
Figure 24.10 Examples of complete tears in the midportion of the ity of the sural nerve, just lateral to the Achilles tendon, injury
Achilles tendon. Longitudinal sections. (A, B) Both the proximal (prox) to this nerve may accompany Achilles tendon tears.
and distal (dist) parts of the tendon are thickened and hypoechoic. The second most frequent type of Achilles tear is an epi-
The gap in the tendon contains anechoic fluid and hyperechoic fat, myseal tear of the musculotendinous junction of the medial
and can be measured (stippled line). (C, D) The fibrillar structure of gastrocnemius muscle, often seen in young athletes. This
the preserved plantaris tendon is visualized medially in the defect. lesion has been called ‘tennis leg’ and occurs typically after
a forced push-off with concomitant rotation of the leg.
proximal tendon retraction (Fig. 24.10A, B) as, in many Practice Tip

centres, this impacts on surgical decision making. Small
gaps, less than 5 mm, may be treated by conservative mea- The presenting symptoms of tennis leg mimic Achilles tendon
sures, whereas larger gaps are often managed surgically, rupture and this injury should be sought if initial examination
either by open or percutaneous methods. If surgery is likely, of the Achilles tendon is normal.
the location of the tendon ends can be marked on the
In the acute phase, an anechoic fluid collection is seen Local infection is a more severe complication. Ultrasonog-
between the medial gastrocnemius and the soleus muscles, raphy may show subcutaneous oedema and fluid collections
with slight retraction of the distal part of the medial gastroc- in or around the tendon. The most important role for ultra-
nemius muscle. The tear is often small and difficult to visual- sonography is, however, to perform an ultrasound-guided
ize as an irregularity of the deep aponeurosis of the distal diagnostic aspiration of such collections. The sural nerve is
gastrocnemius muscle. Treatment is conservative, and can a sensory nerve crossing the upper part of the Achilles
include ultrasound-guided fluid aspiration followed by com- tendon to become lateral to it. Because of this anatomical
pression. Less frequently the musculotendinous lesion is proximity, injury to this nerve may occur as a complication
located at the distal aponeurosis of the soleus muscle. Ultra- of tendon suturing, particularly under minimally invasive
sonography shows changes at the level of the distal soleus surgery.
muscle with a complete tear of both the gastrocnemius and After calcaneal osteotomy in patients with Haglund’s
the soleus aponeurosis (including a defect in the soleus disease, a focal bone defect is seen on the calcaneal tuberos-
muscle). Differential diagnoses of all these Achilles muscu- ity. With time, pain can recur due to fibrotic tissue between
lotendinous lesions are deep venous thrombosis, ruptured the calcaneus and the Achilles tendon (hypoechoic mass).
Baker’s cyst and musculotendinous tears of the plantaris When symptomatic this tissue is painful at palpation and
tendon. Patients with tennis leg may develop chronic pain, can be hypervascularized on colour Doppler examination.
if the injury is overlooked. On ultrasound a hard, heteroge- Hyperaemia can also be found in the focal hypoechoic area
neous, hypoechoic layer of scarred tissue is found between of the anterior part of the distal Achilles tendon, and this
the medial gastrocnemius and the soleus muscles. area should be carefully explored for possible tendon tear.
The third and least common type of tear is situated in
the distal part of the Achilles tendon, and is most often a
partial tear of the anterior distal tendon in patients with BURSITIS
Haglund’s disease. A bone avulsion of the insertion of the
Achilles tendon is rare. It is generally related to an abnor- Inflammation of a bursa (bursitis) may explain heel pain at
mality of the os calcis. Predisposing factors include steroid two different anatomical sites: the retrocalcaneal (or pre-
therapy, diabetes, rheumatoid arthritis, metabolic bone Achilles) bursa and the subcutaneous (or retro-Achilles)
disease and renal failure. The diagnosis is made on ultraso- bursa.
nography and standard radiography. Retrocalcaneal bursitis is sometimes an isolated mechani-
cal pathology caused by overuse. Generally it is associated
with other findings depending on the aetiology: either
THE POSTOPERATIVE ACHILLES TENDON
mechanical with impingement between the Achilles tendon
and the calcaneal tuberosity, like in Haglund’s disease, or
Key Point inflammatory, such as is typically seen in patients with spon-
dyloarthropathy or sometimes other rheumatic diseases.
A previously torn Achilles tendons will always remain The patient’s pain is exacerbated by dorsal flexion of the
enlarged and heterogeneous, regardless of whether it has ankle and palpation of the pre-Achilles space. In all cases,
been managed conservatively or with surgery. the retrocalcaneal bursa is enlarged, rounded and well
demarcated. It is fluid containing and/or filled with synovial
tissue. Any doubt about the nature of a focal hypoechoic
In postoperative patients, ultrasonographic follow-up shows area, bursa or fat lobule should be clarified by a contralat-
a markedly enlarged, hypoechoic and heterogeneous, some- eral examination. Oedema in the surrounding fat is more
times with small residual cystic areas or calcifications. difficult to appreciate on ultrasound compared to MRI. On
Sutures can be visualized as thin intratendinous double colour Doppler examination, signs of hyperaemia in and
lines, with or without acoustic shadowing. Intratendinous around the synovial wall of the bursa can be detected,
colour Doppler signal is often visualized and difficult to except in chronic cases. Careful examination of the adja-
interpret. With time the tendon becomes less hypoechoic cent structures is important, such as the anterior part of the
and tendon hypervascularization should vanish, but this can distal Achilles tendon, the calcaneal tuberosity and the
take many months. Ultrasonography can be performed for fibrocartilage of the Achilles enthesis. Chronic bursitis may
postoperative tendon complications (pain and limping) or be difficult to identify if the bursa is small, hyperechoic,
for tendinopathy in a previously uninvolved contralateral without fluid or sometimes calcified. Ultrasound-guided
Achilles tendon. aspiration for analysis of the fluid (infection and gout) or
Ultrasonography is performed for detection of tear recur- steroid injection is sometimes performed, but treatment of
rence or necrosis, signs of infection, residual tendon length- the underlying pathological explanation is mandatory.
ening, or lesion of the sural nerve. Subcutaneous bursitis is a mechanical problem caused
by friction at the upper border of the heel counter of a
Practice Tip shoe, more often seen in women. The diagnosis is generally
easily done clinically in patients with a large painful sub
Ultrasound diagnosis of recurrence or necrosis depends on cutaneous swelling over the distal Achilles tendon. This
careful dynamic assessment, especially in patients without a usually does not require imaging and treatment is conser
clear anechoic gap, in order to detect a weak focal area with vative with antiinflammatory medication and change of
loss of normal tendon mobility. shoes. Ultrasonography is performed without compression
and with a large amount of gel. The subcutaneous fat is
thickened, surrounding a small flat hypoechoic structure,

and either compressible (fluid) or noncompressible (solid).
Local hyperaemia is detected in patients with acute
symptomatology.
PLANTARIS TENDON
The plantaris tendon in some form is present in the majority

of individuals. A tear of the plantaris tendon is a rare
mechanical disorder, sometimes found on ultrasonography
in patients suspected of tennis leg (epimyseal gastrocnemius
tear) or partial tear of the Achilles tendon (tear of the mid-
portion). A tear of the MTJ may produce a fluid collection
between the medial gastrocnemius and the soleus muscles, a
similar to that seen in tears of the medial gastrocnemius
musculotendinous junction. Rarely, a tear of the midportion
can be seen with an anechoic gap (less than 1.5 cm long)
Achilles Tendon
located 4–6 cm from the distal insertion. This tendon may
also be used as a surgical graft in other areas of the body.
Accessory
THE ACCESSORY SOLEUS MUSCLE Soleus Muscle
Soleus Muscle
The accessory soleus muscle is a rare muscular anatomical
variant found in 0.7–5.5% of the specimens in cadaveric
studies. It can be found as an incidental finding on ultra-
sound or MRI, but can be symptomatic in young adults, with FHL
P
a male predilection, often in relation to sport activity. Symp- M L
toms (pain and/or swelling) are located in the lower leg, A
b
behind the ankle. On palpation, a painful mass is often
bulging medial to the Achilles tendon. Ultrasonography Figure 24.12 Painful mass of the distal part of the posterior leg
rules out a soft tissue tumour and shows the normal muscu- corresponding to an accessory soleus muscle. Axial ultrasound
lar structure of the mass (Fig. 24.12), which can be followed section of the left Achilles tendon. Distal part of the soleus muscle.
distally close to the calcaneus. The presence of this acces- FHL muscle.
sory muscle gives the impression of a very short Achilles
tendon. The distal insertion of the accessory soleus muscle
can be visualized, generally on the superior calcaneus, but investigating the apophysis (fragmentation of the secondary
sometimes on the medial calcaneus or fusing with the Achil- ossification centre, cartilage and soft tissue oedema and
les tendon. Treatment is often surgical. hyperaemia), the Achilles tendon (generally normal) and
the retrocalcaneal bursa (rarely bursitis). Sever’s disease is
self-limiting. Conservative treatment includes limiting sport-
SEVER’S DISEASE ing activity, well-fitting shoes with heel lift and, sometimes,
nonsteroidal antiinflammatory medication.
Calcaneal apophysitis (or Sever’s disease) is a relatively
common problem in physically active preadolescents (8–12
years) with heel pain during running or walking, more often POSTERIOR IMPINGEMENT
in boys. It is said to occur as a result of a chronic traction
injury on the Achilles enthesis, partly cartilaginous at that The posterior ankle impingement syndrome (or os trigo-
age, with microtraumatic disturbances of the growth plate num syndrome) is generally seen in ballet dancers and
(physis) and the secondary ossification centre of the poste- soccer players. Repetitive forced plantar flexion of the ankle
rior calcaneal apophysis, similar to Osgood–Schlatter disease leads to impingement of the soft tissues between the poste-
of the knee. It is a much-debated condition as plain radiog- rior margin of the distal tibia and the calcaneus. The poste-
raphy has not been shown to reveal specific signs. Predispos- rior part of the talus is compressed as well, especially if a
ing conditions are thought to include sport activity, a tight predisposing abnormality of the posterolateral process of
Achilles tendon, a valgus hind-foot with varus forefoot, and the talus, a prominent Stieda process, is present. Failure of
excessive internal femoral rotation. Plain radiography is fusion of the secondary ossification centre forms a separate
often nondiagnostic. It can help rule out other bone lesions ossicle articulating with the talus via a synchondrosis (os
but is generally not specific. Increased sclerosis or fragmen- trigonum). An os trigonum is present in up to 15% of the
tation of the ossification centre is not necessarily a patho- population, can be of various sizes, and does not necessarily
logical finding. These signs are found in asymptomatic give rise to symptoms. When present, it is bilateral in 50%
heels and multiple ossification centres can normally exist. of patients. Repetitive compression may lead to chronic
Ultrasound offers an easy, quick and well-tolerated way of posterior ankle pain, exacerbated by plantar flexion of the
ankle. Posterolateral pain at palpation and sometimes swell- ligaments. The former runs from a more distal point on the
ing are found anterior to the Achilles tendon during physi- under surface of the os calcis to insert into the under surface
cal examination. of the navicular and is difficult to visualize with ultrasound.
Ultrasonography is not easy, as the examination has to be The long plantar ligament also arises from the os calcis and
performed obliquely on one or the other side of the Achilles inserts on the base of the second to fifth metatarsals. It is
tendon. Ultrasound findings include a hypoechoic thicken- separated from the plantar fascia first by the quadratus
ing of the soft tissues in and around the posterior recesses plantae, which inserts onto FHL. Superficial to this are the
of the tibiotalar and posterior subtalar joints, representing bellies of flexor digitorum brevis centrally and then on
synovitis and thickened capsule and ligaments (Fig. 24.13). either side are abductor digiti minimi laterally and abductor
If present, an os trigonum is visualized within this soft tissue hallucis medially.
mass and lateral to the flexor hallucis longus (FHL) tendon. The plantar fascia comprises three bundles: central,
If osteochondritis involves the cortex, the ossicle may have lateral and medial. The medial bundle is the least significant
an irregular border. Fractures occasionally occur. A FHL of these and arises from the midportion of the central
stenosing tenosynovitis may be associated as this tendon bundle, which is the most frequently injured.
runs in the groove between the posterolateral and postero-
medial processes of the talus (Fig. 24.13). It is important to
BIOMECHANICS
be aware that fluid in the FHL tendon sheath results from
a communication with the tibiotalar joint in about 20% of The principal stress on the plantar fascia occurs during
the population. Fluid in this tendon sheath may thus be a walking. The gait cycle can be divided into two phases: the
normal finding if moderate or a sign of tibotalar joint stance and the swing. The stance phase is when the foot is
disease if marked. on the ground. This is divided into four sections, including:
Plain radiography may show the abnormality of the pos- heel strike, foot flat through midstance, midstance through
terolateral process of the talus (Fig. 24.13) but MRI offers heel off, heel off to toe off. Problems with plantar fasciitis
the best imaging modality for detection of this deep entity. appear to stem from the heel strike phase. As the heel is
MRI provides a better overview and detailed analysis of the placed on the ground, the tibia rotates inwards and the foot
bony structures, joint cartilage and the posterior ligaments. pronates. This stretches the plantar fascia and flattens the
Possible associated osteochondral lesion or missed fracture arch of the foot. Repetitive injury results in microtears of
can be ruled out. Focal bone oedema can be detected in the central bundle and particularly proximally. This results
the posterior parts of the tibia, talus or calcaneus, including in plantar fasciitis, though, as with tendon and ligament
in a Stieda process or an os trigonum. Ultrasonography disorders elsewhere, this should more correctly be referred
enables guided palpation for tenderness, dynamic examina- to as plantar fasciopathy.
tion for pain or stenosis of the FHL tendon, colour Doppler
examination for hyperaemia and ultrasound-guided diag-
nostic test with precise injection of an anaesthetic.
PLANTAR FASCIITIS
Treatment options in posterior impingement syndrome
are conservative at first but may require surgical excision of
CLINICAL FEATURES
the os trigonum. A less frequent acute type of posterior
impingement due to capsulitis following severe inversion Patients with plantar fasciitis present a typical clinical
injury has been reported in soccer players, often in the picture. Pain is described as sharp and is especially promi-
absence of an os trigonum. Treatment by ultrasound-guided nent first thing in the morning when the patients place their
local steroid injection has been shown to be effective. feet on the ground for the first time. This is termed post-
static dyskinesia. Walking helps initially and patients will
often stretch the longitudinal arch to try and break down
HEEL PAD SYNDROME what are felt to be painful adhesions. There is tenderness
to palpation at the calcaneal attachment and decreased dor-
Heel pain can be related to acute trauma of the heel pad siflexion. Some patients complain of pain on toe extension.
(fall on the feet) or repetitive stress (e.g. in marathon This is called the windlass test.
runners). In acute trauma, ultrasonography may show Abnormal biomechanics is the most common and is gen-
oedema or haematoma in an enlarged fat pad. In chronic erally seen in overweight middle-aged or elderly patients.
patients, fat pad oedema and fat pad atrophy (patients over Conditions that predispose to plantar fasciitis are diabetes
40 years or obese) can be seen. Differential diagnoses are mellitus and systemic enthesopathies such as ankylosing
plantar fasciitis, foreign body, soft tissue tumours and rheu- spondylitis, Reiter’s disease, psoriasis and seropositive rheu-
matoid nodules (sometimes necrotic). matoid arthritis. Other predisposing factors include chemo-
therapy, retroviral infection and, rarely, gonococcus and
tuberculosis infection. Foreign body injury and fibromatosis
DISORDERS OF THE PLANTAR FASCIA are the other common conditions that affect the plantar
fascia.
The plantar fascia is a strong connective tissue structure that
runs almost the full length of the plantar aspect of the foot
ULTRASOUND FINDINGS
from its origin at the os calcis to its complex insertion at the
level of the heads of the metatarsals. It is the most important The imaging findings in plantar fasciitis include fusiform
of several ligamentous bands that maintain the longitudinal thickening and fibre disorganization (Fig. 24.14), surround-
arch of the foot. The others are the short and long plantar ing soft tissue oedema and entheseal new bone formation.
b d
TN
Achilles TN
Kager
FHL
Talus
P P
L M Talus L M
A A
c e
Figure 24.13 Posterior ankle impingement. (A) Standard radiography showing an os trigonum (arrow). (B, C) Longitudinal ultrasound section
showing the os trigonum (arrow) surrounded by hypoechoic inflamatory tissue. (D, E) Axial ultrasound section showing fluid in the FHL tendon
sheath.
Plantar fascia
b
P Os Calcis FDB
Figure 24.14 Sagittal plantar aspect of the foot. The plantar fascia P A
is thickened with loss of normal reflectivity. D
b
Figure 24.15 Sagittal plantar aspect of the foot. The plantar fascia
is markedly thickened with loss of normal reflectivity.
The fascia is normally less than 4.5 mm thick in the sagittal

plane (Fig. 24.15). Changes in internal reflectivity are more
important than absolute measurements and comparison
with the other side is useful (Fig. 24.16). Increased Doppler
signal within the swollen plantar fascia is not common,
though it is occasionally detected. Bone spurs are common
and in isolation do not indicate plantar fasciitis. Bone
erosion tends to occur at the sites of compression such as
the deep aspect of the plantar fascia.
The clinical features of plantar fasciopathy and poststatic a
dyskinesia in particular are typical and usually indicate a
diagnosis of plantar fasciitis. In atypical cases or in cases
where the imaging findings do not confirm plantar fasciitis
a differential diagnosis should be considered. This includes
trauma, neural compression, plantar fibroma, Achilles ten-
dinopathy, stress fracture, particularly of the os calcis, soft
tissue lesions in the heel pad and occasionally vascular
causes. The medial calcaneal nerve should be examined in
patients with typical features but a normal-appearing plantar b
fascia. If extensive fascial involvement is found, diabetes Figure 24.16 Comparative image, right, versus left sagittal plantar
should be excluded. aspect of the foot. The plantar fascia on the right is thickened with
The lateral branch of the plantar fascia is less often loss of normal reflectivity. Compare with the image on the left.
affected by fasciitis but when it is, the diagnosis is often
delayed as the typical features and location are not antici-
pated. The lateral branch of the fascia originates from the suspected, the relationship of the mass to the plantar fascial
lateral tubercle of the os calcis and inserts onto the base band is recognized and the diagnosis confirmed. Lateral
of the fifth metatarsal. Fasciitis often involves the distal band fasciitis should be considered in patients suspected of
attachment and may present as a small painful mass close peroneus brevis insertion disease and trauma to the base of
to the base of the metatarsal. Once the correct diagnosis is the fifth metatarsal.
TRAUMA
Whilst most cases of plantar fasciitis are due to chronic

trauma, acute traumatic injuries also occur. More acute tears
or partial tears can occur following high-energy impact.
They are often related to a strong axial compression force,
for example, a jump from a height, especially onto uneven
ground, where the forefoot strikes first and the heel later.
The patient may note a snapping sound and bruising may
be detected at the site of the injury. Subacute injuries may
develop as a consequence of chronic subclinical plantar
fascial disease. In these instances, the history is more diffi- a
cult to differentiate from plantar fasciitis. Up to 30% of
patients give a history of previous steroid injections.
Acute injuries tend to involve the central bundle of the
fascia just distal to, rather than at, the proximal attachment Plan
of the ligament, usually around 2–3 cm from the insertion. tar
fasc
ia
The lateral branch is less commonly affected. They tend to
Fibroma
have more focal areas of high signal that are often conflu-
ent. Partial tears are common and the superficial fibres are
more affected than the deep fibres.
Penetrating injuries are associated with more bizarre pat- FDB
terns but are characterized by greater involvement of the P
heel pad and superficial structures. They will often demon- P A
strate a linear component marking the track of the nail or D
b
other foreign body. Artifact related to residual metal frag-
Figure 24.17 Sagittal image of plantar aspect of the foot. Small
ments might also be present. Superadded infection is a
plantar fibroma causing mild enlargement of the plantar fascia. There
significant risk associated with these injuries that will further is loss of the internal structure of the fascia.
alter the imaging appearances.
PLANTAR FIBROMA
Plantar fibromatosis or Ledderhose’s disease is character-

ized by fibrous proliferation of the plantar fascia, which
forms nodules of varying sizes throughout the fascia. The
exact aetiology of plantar fibromatosis is unknown and
trauma does not appear to have a predisposing role. A
genetic predisposition and alteration in the collagen profile
of the plantar fascia have been suggested. Concomitant
palmar fibromatosis (Duyputren’s contracture) is seen in up
to 65% of patients. There is also an association with keloids
and Peyronie’s disease.
a
The typical plantar fibroma appears as a focal, oval-shaped
area with disorganization of the plantar fascia internal struc-
ture (Fig. 24.17). Larger lesions may be lobulated (Fig.
Fibroma
24.18) and can demonstrate a central scar-like appearance,
with fibres radiating from the plantar fascia, particularly on
transverse images. The mass is elongated in the sagittal Plantar fascia
plane and typically measures less than 2 cm in length. There
is usually no acoustic enhancement. There may be exten-
sion to involve the deep structures of the foot. On Doppler
interrogation the lesion may exhibit minor vascularity. ADM
FDB
The presence of multiple lesions centred on the plantar
Abductor P
fascia is characteristic. Some of these may be small (Fig.
Hallucis M L
24.19) and difficult to see on MR as the low-reflective lesion
b D
blends with the normal low-intensity plantar fascia. Small
lesions are more easily detected on ultrasound because the Figure 24.18 Sagittal image of plantar aspect of the hind foot. Mark-
contrast resolution between the poorly reflective fibroma edly swollen plantar fascia. There is marked loss of internal structure
and the brighter, striated plantar fascia is more obvious. that is diffusely hypoechoic.
XANTHOMA
Xanthomas represent collections of lipid containing histio-
cytes that arise in many hyperlipidaemia states. Bilateral and
symmetrical disease is most common. The finger extensors
and the Achilles tendon are tendons that are frequently
involved. Xanthomata are occasionally seen in the plantar
fascia where they are usually asymptomatic but can cause
pain. Patients can also find them unsightly and surgical
removal is often for cosmetic rather than symptomatic
reasons. Like fibromas, there is a tendency for xanthomas
Figure 24.19 Sagittal plantar aspect of the foot. A further example to recur following excision. In the majority of cases of
of small plantar fibroma. plantar fascia involvement, the Achilles is also expected to
be abnormal.
Ultrasound also allows both sides to be examined, which is OTHER DIFFERENTIAL DIAGNOSIS
significant as multiplicity and bilaterality are quite common
and important differentiating features. Occasionally the symptoms of plantar fasciitis may resemble
Plantar fibromas are easily differentiated from plantar Achilles tendinopathy, perhaps because of dermatomal
fasciopathy in the majority of cases. Plantar fibromatosis innervation or anatomical continuity in fibres from the
may on occasion be associated with thickening of the plantar Achilles tendon to the plantar fascia. Both structures should
fascia at the bony attachment that mimics the appearances be carefully scrutinized, even when symptoms point to one
of the plantar fasciopathy. In such cases, the classical history or the other. Inflammatory enthesopathy may affect both
of plantar fasciitis is not present. areas independently. Other diagnoses to be considered in
Similar conditions include juvenile infantile fibromatosis patients presenting with symptoms of plantar fasciitis include
and desmoid tumour. Juvenile infantile fibromatosis is rare stress fractures of the os calcis, heel pad lesions and vascular
and mainly affects children and adolescents. Fibrous tissue causes. Heel pad lesions include fat necrosis, which may be
containing chondral elements is seen in the deep palmar the consequence of injection or trauma. Fat atrophy and fat
fascia of the hand and wrist. Infiltration of local structures necrosis present a rather nonspecific appearance on ultra-
and bony erosion can be seen. Desmoid tumour, also known sound, which is more useful than MRI in detecting whether
as fibromatosis, is a benign but aggressive lesion seen most foreign material is present. Occasionally tumours such as
commonly around the shoulder, pelvis and abdomen. They haemangioma and fibroma may involve the heel pad. Vas-
are not usually centred on the plantar fascia. cular insufficiency may be a cause suggested by other general
features such as diminished or absent pulses, trophic skin
changes and loss of hair distally.
NEURAL COMPRESSION BAXTER’S
NEUROPATHY
TREATMENT OPTIONS
The plantar fascia is innervated predominantly by the infe-
rior calcaneal nerve, which arises from the lateral branch of As in any other condition, the treatment of plantar fasciitis
the tibial nerve. The nerve supplies the motor innervation can be divided into conservative and nonconservative. Con-
to the flexor digitorum brevis, the quadratus plantae and servative measures include weight loss, orthoses and activity
the abductor digiti minimi. It passes along the medial modification, as well as physiotherapy, including stretching
border of the os calcis before passing between abductor and taping measures. Whilst many patients find the simple
hallucis and quadratus plantae muscles. It then passes in a measures beneficial, there is no evidence based on random-
soft-tissue tunnel between abductor hallucis and flexor digi- ized control trials for their long-term benefit. Nonconserva-
torum brevis before reaching the plantar fascia. The nerve tive methods include steroid injection, shock wave, dry
may become entrapped, particularly if there is muscle needle therapy with autologous blood or platelet-rich
hypertrophy, leading to symptoms which mimic plantar plasma (PRP) injection and ultimately surgery. Shockwave
fasciopathy. therapy has received considerable attention in the litera-
The most common cause is compression as it traverses ture, though most well-performed studies show no benefit.
underneath the heel by a large plantar spur either in isola- There are no good studies of dry needling therapy, although
tion or in association with plantar fasciitis. Compression may many patients describe immediate relief of symptoms fol-
also occur as the nerve passes between abductor hallucis lowing these procedures. Of the proliferants described, the
and quadratus plantae. Muscle hypertrophy is generally most commonly used is autologous blood, although PRP,
the cause of compression in this location, rather than a 50% glucose and other agents have been used in other
synovial cyst ganglion or a neuroma. In the absence of a tendons and ligaments.
specific compression cause, chronic traction is assumed to In addition to methods directed against the tendon,
underlie symptoms. A positive Tinel’s sign over the nerve success has been reported in directing therapy against
aids diagnosis. the abnormal blood vessels that frequently accompany
tendinopathy. Sclerosing agents such as Aethoxysklerol Court-Payen M, Cardinal E, Dakhil Delfi A, et al. Lésions distales du
(polidocanol) have been used successfully in patients with tendon calcanéen. In: Le Pied, Morvan G, Bianchi S, et al, (eds),
Sauramps Médical, France, 2011. p. 331–44.
patellar tendinopathy, Achilles tendinopathy and tennis de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion
elbow. For reasons that are uncertain, vascular proliferation, Achilles tendinopathy in the general population. Br J Sports Med
so-called angioneogenesis, is not a prominent feature of 2011;45:1026–8.
plantar fasciitis. Gibbon WW, Cooper JR, Radcliffe GS. Sonographic incidence of
tendon microtears in athletes with chronic Achilles tendinosis. Br J
Sports Med 1999;33:129–30.
FURTHER READING
Haglund P. Beitrag zur kliniken der Achillessehne. Z Orthop Chir
Benjamin M, McGonagle D. The anatomical basis for disease localiza- 1928;49:49–58.
tion in seronegative spondyloarthropathy at enthuses and related Robinson P, Bollen SR. Posterior ankle impingement in professional
sites. J Anat 2001;199:503–26. soccer players: Effectiveness of sonographically guided therapy. AJR
Bianchi S, Sailly M, Molini L. Isolated tear of the plantaris tendon: 2006;187:W53–8.
ultrasound and MRI appearance. Skeletal Radiol 2011;40:891–5.
Bude RO, Nesbitt SD, Adler RS, et al. Sonographic detection of xan-
thomas in normal-sized Achilles tendons of individuals with hetero-
zygous familial hypercholesterolemia. AJR 1998;170:621–5.
and Foot: Anterior
Eugene McNally
CHAPTER OUTLINE
TENDONS JOINT DISEASE GANGLION/SYNOVIAL CYST

Tibialis Anterior AND IMPINGEMENT
Extensor Halluces Anterior Impingement
Extensor Digitorum Joint Disease of the Midfoot
LIGAMENTS NERVE COMPRESSION
Syndesmosis Injuries Superficial Fibular Nerve
Talonavicular Ligament and Navicular Deep Peroneal Nerve Entrapment
Stress Fracture
Bifurcate Ligament
Lisfranc Injury
Key Point
TENDONS
There are two areas where tibialis anterior is susceptible to
TIBIALIS ANTERIOR injury. The first is between the retinacula, where tendon
rupture occurs, and the second is at the insertion, where
ANATOMY tendinopathy and enthesopathy are more common.
The tibialis anterior tendon is the strongest of the anterior
ankle tendons. Its parent muscle arises from the upper two-
thirds of the lateral aspect of the tibia. It has a high muscu- TENOSYNOVITIS AND TENDINOPATHY
lotendinous junction and a strong distal tendon, which is Tendinopathy of the tibialis anterior tendon is rare, but may
constrained by a transverse superior and an oblique inferior occur as an overuse injury. Repetitive foot dorsiflexion
retinacular band. The relationship of tibialis anterior to during sports such as running, skiing, cycling, and moun-
the retinacula is complex. The superior retinaculum is tain climbing has been implicated in the aetiology of the
band-like and lies at the level of the distal tibia below the disorder. On other occasions, footwear has been blamed
musculotendinous junction (Fig. 25.1). This retinaculum and, in particular, direct irritation from the upper edge of
represents the anterior portion of a circumferential band of the shoes or boots may be the cause.
tissue that includes the tarsal retinaculum, overriding the The earliest changes are found around the tendon where
tarsal tunnel, and the superior peroneal retinaculum later- it abuts the retinacula. Fluid may gather around the tendon
ally. In cross section, there may be two components, super- (Fig. 25.2), though it will be constrained in the area where
ficial and deep, with the tibialis anterior tendon passing in the retinaculum compresses it (Fig. 25.3). With progression,
a tunnel between them. This tunnel may also separate tibi- the tendon itself becomes involved, leading to thickening
alis anterior from the other extensor tendons. The oblique and decreased reflectivity (Fig. 25.4).
inferior retinaculum comprises two bands, a superomedial
and an inframedial, which unite to form a single lateral Practice Tip
attachment. The tibialis anterior tendon passes deep to the
oblique inferomedial ligament just prior to its insertion into In some cases, the tibialis anterior tendon synovial sheath
the medial cuneiform. The tendon insertion is quite far may be uninvolved, but there is thickening of the retinaculum,
medial onto a facet of the medial cuneiform and base of the leading to a type of stenosing tenosynovitis (Fig. 25.5).
first metatarsal.
285
Tibialis
Anterior EHL
Figure 25.2 Axial image of anterior ankle. Fluid is present around

the tibialis anterior tendon which is thickened and shows decreased
reflectivity, indicative of tenosynovitis and tendinopathy. There is also
fluid around extensor halluces longus (EHL).
Figure 25.1 Retinacular anatomy on the dorsum of the ankle.

Modified from Drake RL, et al. (eds). Gray’s Atlas of Anatomy, 1st edn. a
Philadelphia, PA: Churchill Livingstone, 2008; with permission.
Tibialis Anterior
Secondary changes occur within the tendon as a conse-

quence of impingement against the thickened and stiff reti-
naculum. This process may also progress to tendon rupture.
TIBIALIS ANTERIOR ENTHESOPATHY Navicular

D Talus
P A
Practice Tip P
b
Isolated enthesopathy may involve the distal portion of tibialis Figure 25.3 Sagittal image of anterior ankle. There is thickening of
anterior tendon at its insertion. the superior retinaculum (grey) and fluid within the tendon sheath.
New bone formation may be present with bony ingrowth

into the tendon (Fig. 25.6). Tendon hypertrophy and Attention has been drawn to an area of poor vascularity
increased Doppler signal may also be detected by ultra- within the tendon in this area. Rupture may also occur
sound. Comparison with the asymptomatic contralateral beneath the oblique superomedial limb of the inferior
side may be helpful. Focal tenderness will also help to dif- extensor retinaculum. A further site of tendon injury is at
ferentiate the clinically involved tendon. its insertion into the medial cuneiform. It is not uncommon
to identify enthesophyte formation in this location that, if
TENDON RUPTURE marked, may abrade the tendon, leading to rupture.
The commonest site for tibialis anterior rupture is in the Symptoms of anterior tibialis tendon rupture are often
space between the superior and the inferior retinaculum. subtle. This is because the loss of dorsiflexion resulting from
CHAPTER 25 — Disorders of the Ankle and Foot: Anterior 287
Synovitis
Tibialis Anterior
Talus Navicular D
Tibialis Anterior
P A
b P
Figure 25.5 Sagittal image of anterior ankle. There is thickening of

the superior retinaculum of tibialis anterior. Minor changes only are
present in the underlying tendon.
Talus Cuneiform
Navicular
D
P A
P
b
Figure 25.4 Sagittal image of anteromedial midfoot. There is thick-

ening and loss of reflectivity of the tibialis anterior tendon consistent
with tendinopathy.
the injury may be compensated by other tendons. A common

presentation is with an anterior mass (Fig. 25.7), often suf-
ficiently prominent to lead to concerns that a soft tissue
tumour is present (Fig. 25.8). The mass is due to a combina- a
tion of fibrosis in the extensor retinaculum and the torn lax
tendon. Other ultrasound findings include a tapering
appearance to the tendon end (Fig. 25.9) and retraction
(Fig. 25.10).
Tibialis Anterior
EXTENSOR HALLUCES
Injuries to the extensor halluces longus (EHL) are relatively
uncommon and the majority are secondary to laceration
rather than the result of overuse or misuse injury. The
typical history is a knife dropping onto the patient’s foot. Navicular
Other causes of laceration include the so-called ‘boot-top Cuneiform
injuries’ that occur in ice hockey. Indirect or closed injury
D
tends to occur in predictable locations. It has been described
P A
with martial arts, particularly taekwondo, where there is P
forced flexion against resistance. Rupture at the level of the b
metatarsophalangeal joint may be due to impingement Figure 25.6 Sagittal image of anteromedial midfoot. There is new
against osteophytes, perhaps augmented by tendon fixation bone formation at the tibialis anterior insertion indicative of enthe-
within the extensor hood. Rupture at the insertion has also sopathy. The patient’s symptoms were localized to this area.
Tibialis Anterior
D Talus 2MT
P A Navicular Cuneiform
P
b
Figure 25.7 Sagittal extended field of view image. There is a tear of

the tibialis anterior tendon that has retracted proximally to the level a
of the naviculocuneiform joint.
Tibialis Anterior
a Talus
Tibia D
A P
b P
Figure 25.9 Sagittal images of a tibialis anterior tendon tear. The
tendon end has retracted to the level of the tibiotalar joint. Osteo-
phytes and erosions lead to bony irregularity which may contribute
to tendon rupture.
Figure 25.8 Anterior tibialis tendon tear. The combination of tendon

retraction and retinacular thickening creates an anterior ankle mass
sometimes misdiagnosed as sarcoma.
been reported in taekwondo. Predisposing conditions to

rupture include chronic tendinopathy, steroid injection,
chronic disease or interference in blood supply. Occasion-
ally an accessory tendon may be detected close to the inser-
Tibialis Anterior
tion of the EHL tendons.
EXTENSOR DIGITORUM
Like impingement of the EHL, stenosing tenosynovitis of Tibia
the extensor digitorum longus (EDL) tendon occurs most D
commonly where the tendon is contained within the exten- A P
sor retinaculum. Impingement against the inferior retinacu- P
b
lum is often referred to as ultramarathon ankle. In addition
to mechanical factors, the presence of osteophytes or syno- Figure 25.10 Sagittal image of anterior ankle. There is laxity of the
vitis arising from the head of the talus, or the talonavicular tibialis anterior tendon suggestive of rupture.
a
EDL
Tenosynovitis
ED
Tibia Talus
D
P A
b P
Figure 25.12 Anterior ankle, sagittal image of EDL tenosynovitis.

A
M L
P
A
L M injured ligament in syndesmosis injuries, though these are
b P uncommon compared with inversion lateral ligament inju-
Figure 25.11 Axial image showing fluid around the common exten- ries. The posterior component, the posterior inferior tibio-
sor tendons. There is loss of reflectivity within the tendon itself, fibular ligament, is not readily amenable to ultrasound
indicating associated tendinopathy. examination.
Traumatic injury to the anterior inferior tibiofibular liga-
ment is also known as high-ankle sprain. Certain sports are
particularly predisposed to external rotation injury, includ-
joint, may contribute to impingement (Fig. 25.11). The ing slalom skiing and American football. The clinical test
clinical features are localized to the area of the talonavicular for high-ankle sprain is external rotation of the foot with
joint and the ultrasound findings are typical of tendinopa- the knee flexed that causes pain at the site of injury. Lesions
thy elsewhere (Fig. 25.12). are divided into acute, subacute and chronic, related to the
length of time following injury: subacute lesions occur 3
weeks to 3 months after injury. An external rotation force
LIGAMENTS
stresses the syndesmosis, particularly if the knee is fixed.
The anterior component is the first to rupture, followed by
SYNDESMOSIS INJURIES
the interosseous ligament and membrane.
Syndesmosis injuries refer to injuries of the distal ankle The ultrasound findings are typical of ligament injury
stabilizers comprising the anterior inferior tibiofibular liga- elsewhere. There is hypertrophy, loss of the normal fibrillary
ment, the interosseous ligament, the interosseous mem- structure and the increased Doppler activity within the
brane and the superficial and deep components of the ligament. The ligament acquires a more prominent convex
posterior tibiofibular ligament. The ligament most amena- anterior configuration when injured compared with normal.
ble to ultrasound examination is the anterior inferior tibio- There is pain on sonopalpation. Comparison with the con-
fibular ligament. This attaches medially on the anterolateral tralateral side may be helpful unless injuries are bilateral.
tubercle of the tibia and then passes laterally and inferiorly If the ligament has been avulsed, a small bony fragment
to attach to the distal fibula. It is often multifascicular and may be attached. Separation of the ends of the ligament
the lowermost component is sometimes referred to as the can be augmented by squeezing the proximal calf medial to
accessory or Bassett’s ligament. It is the most frequently lateral.
Talonavicular
ligament
Spring
a
ligament Bifurcate
ligament
nt
Ligame
vicular
Talona
Synovitis
Talus
Navicular D
Figure 25.13 Dorsal tarsal ligaments. A P
P
b
TALONAVICULAR LIGAMENT AND NAVICULAR Figure 25.14 Axial image of anterior ankle. There is thickening, fluid
STRESS FRACTURE and increased Doppler signal within the anterior talonavicular liga-
ment, indicative of a tear.
The talonavicular ligament is a short ligament that rein-
forces the capsule on the dorsal aspect of the talonavicular
joint (Fig. 25.13). Its lateral relationship is with the medial proximal insertion of the ligament is on the anterior process
limb of the bifurcate ligament. The spring ligament lies in of the os calcis. Injuries are generally caused by inversion of
its medial aspect. Enthesopathy of the talonavicular liga- the midfoot. They may be isolated to the ligament but asso-
ment is reported in footballers secondary to chronic impac- ciated fractures of the anterior process of the os calcis
tion (Fig. 25.14). Increased thickening, loss of reflectivity should be specifically sought (Fig. 25.15). Injuries to the
and increased Doppler activity are the characteristic fea- ligament may also be associated with fractures of the base
tures. The differential diagnosis is a stress fracture of the of the fifth metatarsal.
navicular. These tend to occur on the superior surface of
the bone and can often be detected, though not fully evalu-
LISFRANC INJURY
ated, on ultrasound. Focal tenderness may help alert the
sonologist to the presence of this injury. Cortical irregular- There is a complex arrangement of ligaments around the
ity, associated soft tissue changes and an increase in Doppler base of the first and second tarsometatarsal joints. Three
activity are the cardinal features. The injuries are often layers are recognized: dorsal, interosseous and plantar. The
chronic. strongest is in the interosseous layer that passes between the
medial cuneiforms and the base of the second metatarsal.
This is the Lisfranc ligament. There is also a strong ligament
BIFURCATE LIGAMENT
on the plantar aspect of these articulations with a Y-shaped
The bifurcate ligament, as its name implies, has two compo- configuration. Its base is on the medial cuneiform with one
nents (Fig. 25.13). The lateral portion is the medial calca- limb each inserting into the bases of the second and third
neocuboid ligament, which lies on the superior aspect of metatarsals.
the cuboid. Medial to this is the dorsolateral calcaneona- The commonest cause of injury is heavy impaction on the
vicular ligament, making up the bifurcate complex. The dorsal aspect of the foot either from a load being dropped
Calc
one
Fracture o
Liga navicul
men ar
t
a
Navicular
Os Calcis D
A P
P
b EDL
Figure 25.15 Fracture of the anterior process of the os calcis at the
attachment of the calcaneonavicular component of the bifurcate
ligament.
Synov
itis
or the wheel of a car running over the midfoot. This form

of injury to the Lisfranc ligament and tarsal metatarsal joint Tibia
is classified according to Myerson. Type A injury is complete
subluxation of tarsometatarsal joint in the same direction.
Type B1 involves displacement of the first ray, B2 of the Talus
lateral four rays. Type C1 is a diverging pattern with partial D
subluxation and C2 diverging with total subluxation. These A P
injuries are rarely assessed by ultrasound but it is useful to P
understand the more extreme natures of these injuries. b
Injuries occurring in sport occur when a longitudinal
Figure 25.16 Sagittal image of anterior ankle. An irregular bony
force is applied in plantar flexion. The pattern is not uncom-
enthesophyte arises from the anterior aspect of the distal tibia. The
monly reported in gymnastics, usually following a fall. Asso- findings are suggestive of anterior impingement
ciated bony injuries include fractures of the cuboid and
stress fractures of the base of the metatarsals.
the distal tibia just to the lateral side of the midline, com-
JOINT DISEASE GANGLION/SYNOVIAL bined with a spur, divot or combination of both of these on
the dorsal aspect of the talus. The two bony findings do not
CYST AND IMPINGEMENT
always correspond in location (i.e. they are not always
‘kissing osteophytes’) as the more common location for the
ANTERIOR IMPINGEMENT
talar bone changes are just medial to the midline (Fig.
Anterior ankle impingement refers to the combination of 25.16). The aetiology of the bony spurs remains uncertain
the clinical symptoms of anterior ankle pain, reduction as they do not always occur at the side of capsule attach-
in dorsiflexion and pathological/radiological findings of ment. In some cases they may be due to traction but in
a combination of bone and soft tissue abnormalities local- others they may be due to impaction. There is also a sug-
ized to the anterior compartment of the ankle joint. The gested relationship between the formation of bony spurs
aetiology of anterior ankle impingement is thought to relate and the recurrent ankle injury. Professional soccer players
to recurrent capsuloligamentous traction. In football, this is and ballet dancers who are particularly prone to anterior
due to repetitive kicking in full plantar flexion. Traction impingement are also prone to multiple and recurrent
leads to spur formation and thickening of the synovium in ankle sprains. It is, therefore, difficult to separate out the
the local area of impingement. consequence of recurrent ankle sprain and the develop-
The classical imaging features in anterior impingement ment of bone spurs relating to anterior impingement.
are divided into bony and soft tissue findings. The common- The classic soft tissue changes present in this condition
est bony abnormalities are a spur on the anterior aspect of are effusion, synovial thickening and fibrosis in the anterior
EDL
Figure 25.17 Further example of anterior impingement. There is

bony irregularity of the anterior tibia and associated synovial
thickening.
Tibia sion
Effu
Talus D
joint space between the bone spurs (Fig. 25.17). The imaging P A
diagnosis of anterior impingement is made on a combina- b P
tion of plain film and cross sectional imaging findings. The
lateral plain radiograph will demonstrate the bony findings Figure 25.18 Sagittal image of anterior ankle. The configuration of
and exclude associated arthritis. An oblique anteromedial the tibiotalar joint is easy to recognise. There is increased fluid deep
to the intracapsular, extrasynovial fat indicative of effusion.
view, with the beam tilted 45° craniocaudal and the leg in
30° of external rotation may demonstrate the anteromedial
talar osteophyte to greater effect. This is not necessary if
ultrasound is available, as all of the features are readily
apparent.
JOINT DISEASE OF THE MIDFOOT
Ultrasound of the anterior joint space demonstrates an
increase in size with displacement of the anterior fat pad. Ultrasound is an excellent method for detecting synovial
Simple effusion (Fig. 25.18) can be distinguished from syno- disease in the joints of the midfoot, though it is poor at
vial reaction by the presence of increased reflectivity within demonstrating associated cartilage injury. Joint disease pre-
the synovium. The bony changes are also readily demon- dominating on the plantar aspect of the midfoot is also
strable on ultrasound and dynamic assessment demonstrates more difficult to assess. In the sagittal plane, the classic
the actual impingement and provides useful correlation configuration of the dorsal aspect of the talus is easily rec-
with patients’ symptoms. As the foot dorsiflexes, the synovial ognized by its bi-lobed appearance. Continuing in the same
mass is squeezed between the tibia and the talus, particularly plane, the joint between the talus and the intermediate
if bony spurs are present. Further extrusion of synovium and cuneiform, the second tarsometatarsal joint and the second
joint fluid anteriorly with stretching of the anterior capsule metatarsophalangeal joint are found in line. Once these
may be seen. In some patients, the soft tissue component structures are identified and localized, the other joints of
predominates and bony changes are minimal. In a few cases, the midfoot can be identified. Although this approach facili-
there is marked enlargement of the anterior joint space and tates anatomical localization, in practice it is not particularly
a mass is palpable. This needs to be differentiated from tibi- necessary as the presence of osteophytes, synovial thicken-
alis anterior tendon rupture. The presence of increased ing and enthesopathy, along with reproduction of symptoms
Doppler signal is variable. by sonopalpation, identifies the symptomatic joint. Once
In addition to its dynamic capability, ultrasound offers the the diagnosis of synovitis is confirmed, ultrasound-guided
advantage of facilitating a guided corticosteroid injection, injection is straightforward. Midfoot arthropathy is dis-
which may help to alleviate symptoms. Steroid can be cussed on page 324.
directed either into the anterior joint space directly or, pref-
erably, into the anterolateral gutter where access is often
NERVE COMPRESSION
easier. One disadvantage of ultrasound, however, is the dif-
ficulty in detecting associated chondral damage if the plain
SUPERFICIAL FIBULAR NERVE
film is negative. As with other misuse injuries, management
should also include attention to technical aspects of the The superficial peroneal (fibular) nerve supplies peroneus
footballer’s or professional ballet dancer’s biomechanics. longus and brevis muscles as well as the skin over most of
the dorsal aspect of the foot. It does not supply the area of
skin around the first web space, which is innovated by the
deep peroneal nerve.
Key Point
The superficial peroneal nerve pierces the deep fascia

between peroneus longus and brevis in the distal third of
the calf.
It divides into its terminal branches, the medial and inter-

mediate dorsal cutaneous branches, above the level of the
ankle joint and, distal to this, into the divisions that supply
the dorsal aspect of the foot and toes. Occasionally the
nerve divides much more proximally with the larger medial
dorsal cutaneous branch following the usual track of the
superficial peroneal nerve. The smaller intermediate branch
perforates the superficial fascia more distally and laterally.
Entrapment of the superficial peroneal nerve is uncom-
mon. Symptoms include pain in the dorsum and outer
aspect of the calf and foot associated with numbness over
the dorsum of the foot. Compression may occur where the
nerve courses through the superficial fascia. This may
present with tenderness in an area of approximately 12 cm
above the ankle joint. In this location it may be compressed
by fascial thickening, trauma or external compression from
a mass of any aetiology. The precise aetiology of compres- Figure 25.19 The anterior ankle, demonstrating the relationship of
sion due to the fascia alone is incompletely understood, the anterior tendons to the peroneal nerves. Modified from Drake RL,
although mechanical irritation, related to the oblique et al. (eds). Gray’s Atlas of Anatomy, 1st edn. Philadelphia, PA: Churchill
course the nerve takes through the fascia, has been impli- Livingstone, 2008; with permission.
cated. Compression from boots, callus formation around
fibular fractures, neuroma, prolonged kneeling and squat-
ting have also been suggested as potential causes, as has
iatrogenic injury during arthroscopy. Compression of the
common peroneal nerve more proximally may produce (EHB) and the adjacent tarsal joints. The medial branch lies
similar symptoms and lead to diagnostic confusion. medial to the dorsalis pedis artery, passes between EHB and
If compression of the nerve at the level of the fascia is EDL and supplies the skin in the first web space.
suspected from clinical assessment but there is no obvious The most common entrapment occurs at the level of the
calibre change, ultrasound-guided local anaesthetic injec- extensor retinaculum, particularly at its proximal margin.
tion can help diagnostically. Conservative treatment options The traversing extensor hallucis tendon may augment the
include steroid injection around the nerve, radiofrequency compression. Other causes of compression include osteo-
denervation and attention to footwear. Surgical decompres- phytes arising from the tibiotalar and more particularly the
sion is carried out in refractory cases. talonavicular and navicular cuneiform joints, accessory ossi-
cles, particularly an os intermetatarseum, ganglia arising
from the intertarsal joints and enlarged tarsal joint liga-
DEEP PERONEAL NERVE ENTRAPMENT
ments. As with superficial peroneal nerve compression,
The deep peroneal nerve is the other major branch of the certain footwear may predispose to injury. Iatrogenic injury
common peroneal nerve. Unlike the superficial peroneal may occur during midfoot injections and the nerve should
nerve, it travels on the deep aspect of the anterior compart- be located prior to any intervention.
ment anterior to the interosseous membrane along with the As the nerve supplies a relatively small area of skin on the
anterior tibial artery. It courses between the tibialis anterior dorsum of the foot, symptoms are more subtle than super-
and the extensor digitorum proximally and between the ficial peroneal nerve compression. Any vague or unusual
artery and extensor hallucis in the distal aspect of the leg pain or ache on the dorsal aspect of the foot might be
(Fig. 25.19). EHL crosses over the nerve approximately attributed to compression and the nerve should be exam-
5 cm above the ankle joint with the nerve now lying lateral ined in these cases. The more proximal the level of entrap-
to this tendon. It passes underneath the extensor retinacu- ment, the more likely there is to be a motor as well as
lum before dividing into its lateral and medial branches sensory deficit. The nerve should be examined along its full
below the ankle joint. The lateral branch supplies the exten- length, in particular seeking a positive Tinel’s sign during
sor digitorum brevis (EDB) and extensor hallucis brevis sonopalpation.
FURTHER READING Numkarunarunrote N, Malik A, Aguiar RO, et al. Retinacula of the foot
and ankle: MRI with anatomic correlation in cadavers. AJR Am J
Blair JM, Botte MJ. Surgical anatomy of the superficial peroneal nerve Roentgenol 2007;188(4):W348–54.
in the ankle and foot. Clin Orthop Relat Res 1994;305:229–38. Roesen HM, Kanat IO. Anterior process fracture of the calcaneus.
Kobayashi H, Sakurai M, Kobayashi T. Extensor digitorum longus teno- J Foot Ankle Surg 1993;32(4):424.
synovitis caused by talar head impingement in an ultramarathon Trout BM, Malik A, Aguiar RO, et al. Rupture of the tibialis anterior
runner: a case report. J Orthop Surg (Hong Kong) 2007;15(2): tendon. J Foot Ankle Surg 2000;39(1):54–8.
245. van Dijk CN. Anterior and posterior ankle impingement. Foot Ankle
Negrine JP. Tibialis anterior rupture: acute and chronic. Foot Ankle Clin 2006;11(3):663–83.
Clin North Am 2007:12(4):569–72.
and Foot: Lateral
Michel Court-Payen
CHAPTER OUTLINE
INTRODUCTION Lesions of the Retinacula and Peroneal

PERONEAL TENDONS Tendon Instability
Tenosynovitis LATERAL LIGAMENT COMPLEX
Peroneal Tendinopathy and Tendon Tear FRACTURES
The Peroneus Brevis Enthesis
INTRODUCTION Practice Tip
The most common indications for an ultrasonographic In normal individuals, a small amount of fluid can often be
examination of the lateral aspect of the ankle are suspicion found in the tendon sheath, distal to the tip of the malleolus,
and should not be mistaken for tenosynovitis.
of peroneal tendon pathology or lesions of the lateral liga-
ment complex. Patients with ligament injuries are generally
examined in a chronic phase to detect late complications of
ligament tears or undiagnosed associated lesions. Ultraso- Any doubt should lead to examination of the contralateral
nography, allowing a dynamic assessment of the structures, asymptomatic side, where a similar finding can help to
is the best imaging modality for examination of the tendons establish these changes as normal. In tenosynovitis the
and ligaments, but may also detect lesions of the bones amount of fluid may vary but is generally more important
(fractures) or retinacula (tendon instability). An important and fluid surrounds the tendon transversally (‘halo sign’)
drawback is the inability to display osteochondral lesions of (Fig. 26.1) and extends longitudinally.
the ankle joint and tears of the interosseous ligaments
(talocalcaneal).
Key Point
PERONEAL TENDONS Sonopalpation is, as always, very important to establish a

correlation between ultrasound findings and focal pain.
Peroneal tendon pathology is frequent, especially tenosyno-
vitis, but more significant changes like tendinopathy, tendon
tears or tendon instability also occur. Of the two peroneal In patients with lateral ankle pain, colour or power Doppler
tendons, the peroneus brevis tendon is the most prone to examination often displays signs of hyperaemia in the syno-
injury as it is closely related to the lateral malleolus. Inflam- vial hypertrophic tissue, inside the tendons and/or around
mation may also occur at the insertion of the peroneus the tendon sheath.
brevis tendon at the base of the fifth metatarsal bone Tenosynovitis may be mechanical, due to overuse or
(enthesopathy). trauma, or associated with inflammatory joint diseases. Trau-
matic tenosynovitis is seen in patients with ankle derange-
ment and ligament lesions, but it is important to know that
TENOSYNOVITIS
effusion in the peroneal tendon sheath may just be a sign
Inflammation of the peroneal tendon sheath (tenosynovi- of communication to the ankle joint through an acute com-
tis) leads to effusion and hypoechoic synovial thickening plete tear of the calcaneofibular ligament. Serous tensosy-
with or without Doppler around both tendons. novitis is frequently found in patients with tendon overuse
295
us
ong
u sL
ne
ro
Pe
s
e vi
Br
e us b
ron Fibula
Pe L Figure 26.2 Painful os peroneum syndrome. Peroneus longus teno-
P A synovitis (arrows) with a small os peroneum (arrowhead).
M
b
Figure 26.1 Peroneal tenosynovitis. Axial section behind the lateral

malleolus. Effusion in the peroneal sheath. Thickening of the synovial
Key Point
wall (arrows) and mesotendon (asterisk). Hyperaemia on colour
Doppler. Injuries are not always symptomatic, especially in the
older population and are most frequently seen in the
retromalleolar part of the peroneus brevis tendon because
of its position against the bone.
without a history of trauma, either in a sport setting or in The configuration of the peroneus tendon varies with the
elderly patients. Ultrasonographic signs of tendon tear severity of the lesion. With overuse, the peroneus brevis
should always be carefully searched for. In patients with tendon can be seen as a U-shaped flattened tendon in the
inflammatory joint diseases, e.g. rheumatoid arthritis or axial plane, with the concavity embracing the peroneus
gout, tenosynovitis is generally of a proliferative type with longus tendon. In more advanced stages, a partial tear of
marked pannus-like synovial thickening, hyperaemia in the peroneal brevis tendon appears with a longitudinal split
patients with active disease, tendinopathy, irregular tendon into two tendon parts. This tendon split extends in both
borders, and thinning or complete tear of the tendons. directions, and the peroneus longus tendon can insinuate
Calcifications in chronic synovial sheath thickening are rare itself between the separated parts of the peroneus brevis
and seen as echo-rich focal areas with shadowing. They tendon. This appearance of three tendons within the sheath
should be distinguished from a fracture of an os peroneum must be differentiated from the presence of an accessory
with retraction of the proximal tendon part behind the tendon, the posteriorly situated peroneus quartus tendon.
lateral malleolus. Tenosynovitis may also occur around an If there is an associated tear of the superior peroneal reti-
accessory peroneal bone, called the painful os peronei syn- naculum, the anterior part of the peroneus brevis tendon
drome (Fig. 26.2). may dislocate between the lateral malleolus and the skin. A
complete axial tear of one or both peroneal tendons (Fig.
26.3) is less frequent, with an ‘empty’ sheath, only contain-
PERONEAL TENDINOPATHY AND TENDON TEAR
ing fluid or hypoechoic synovial tissue between the level of
Overuse and chronic tendon instability can lead to tendi- the tear and the retracted proximal tendon end. Axial tears
nopathy with hypoechoic tendon thickening or tendon tear. of the peroneus tendons are generally situated behind the
Peroneal tendon tears are also seen in acute ankle sprains, malleolus. The peroneus longus tendon may also be torn
or in patients with inflammatory joint diseases. more distally at the level of the cuboid bone, either as a
CHAPTER 26 — Disorders of the Ankle and Foot: Lateral 297
Peroneus Longus
Os
Peroneus Brevis Peroneum
L a
P A Cuboid Bone
b M
Figure 26.3 Complete tear of both peroneal tendons: brevis behind Peroneus Brevis
the lateral malleolus and longus just distal to an os peroneum. Ret
ina
Longitudinal section. cul
um
Peroneus
Longus
tendon rupture or as an os peroneum fracture. In complete
fracture of the os peroneum the proximal tendon part Lateral
Malleolus Peroneus Brevis
can retract behind the lateral malleolus with the proximal
L
pole of this accessory bone seen as an echo-rich shadowing A P
structure. In all situations, inflammation is generally found b M
in the tendon sheath of symptomatic patients, which facili-
tates the ultrasound examination: effusion, synovitis and/or Figure 26.4 Axial section showing avulsion of the superior peroneal
hyperaemia. retinaculum (arrows), longitudinal tear (split) of the peroneus brevis
tendon with dislocation of its anterior part in front of the lateral
malleolus.
THE PERONEUS BREVIS ENTHESIS
The insertion of the peroneus brevis tendon on the base
of the fifth metatarsus is easy to access with ultrasonography and/or soft tissue oedema. In all cases, ultrasonography
and is focally enlarged and hypoechoic in patients with allows visualization of the abnormal position of the peroneus
inflammatory joint disease and enthesopathy. High signal brevis tendon (rarely, both peroneal tendons), subluxated
on the colour Doppler examination in and around the or dislocated over the edge of the lateral malleolus, and
insertion reflects disease activity. A spur or calcifications may detection of possible associated tendon lesions. Injury of the
appear in chronic cases. Traumatic bony avulsion of the base retinaculum generally occurs at the level of the malleolar
of the fifth metatarsal is easily diagnosed on ultrasound but insertion, and takes several forms, including hypoechoic
can be missed on plain radiography. In athletically active thickening, hyperaemia, incomplete avulsion with periosteal
older children and adolescents, apophysitis of the base of stripping, complete avulsion, bone avulsion or, rarely, intra-
the fifth metatarsal bone (Iselin’s disease) is better assessed substance defect. Signs of inflammation in the tendon
by ultrasonography than plain radiography, showing frag- sheath are associated and sometimes there is thickening,
mentation of the secondary ossification centre but also split or complete tear of the peroneus brevis tendon (Fig.
oedema and hyperaemia in and around the cartilage of the 26.4). A predisposing shallow or even convex retromalleolar
apophysis. Recognition of the disease and treatment may groove can be identified. If there is no clinical and ultraso-
prevent long-term complications. nographic tendon dislocation at rest but clinical suspicion
of dislocation and/or lesions of the retinaculum on ultra-
LESIONS OF THE RETINACULA AND PERONEAL sound, it is important to perform a dynamic examination.
The transducer is placed transversally at the level and behind
TENDON INSTABILITY
the lateral malleolus without too much pressure. The foot
Peroneal tendon subluxation or dislocation is secondary to is dorsiflexed and everted against resistance and any abnor-
a lesion of the peroneal retinaculum, which can be repaired mal movement of the tendons are noted. As tendon laxity
surgically. The most frequent site of injury is the insertion may be found without retinaculum or tendon lesions in
of the superior peroneal retinaculum on the lateral malleo- patients with generalized joint laxity, comparison to the
lus. The retinaculum may be stretched, avulsed or torn, contralateral side is important.
generally following a sport trauma (skiing, soccer, skating,
rugby or gymnastics) with sudden dorsal flexion of the foot Key Point
and reflex forceful contraction of the peroneal muscles.
Another cause is an inversion ankle injury with lesion of the Some patients may experience pain associated with an
anterior talofibular ligament. Patients may complain of a abnormal motion of the peroneal tendons inside the groove
painful click. The diagnosis is often suspected on clinical without subluxation over the edge of the groove (intrasheath
examination (focal pain, swelling and palpation of a dislo- subluxation).
cated tendon), except in acute patients with marked pain
Peroneus Peroneus
Peroneus
Longus Brevis
Longus
Peroneus
Brevis Os Calcis a
L
P A
b M
Figure 26.5 Axial sections of the lateral surface of both calcaneus

bones, showing tear of the inferior peroneal retinaculum on the left
side and dislocation of the peroneus longus tendon over the peroneal
tubercle. L
ATaF
Fibula
Tears or avulsion of the inferior peroneal retinaculum at the A

level of the calcaneus is less frequent. The patient’s pain and Talus M L
swelling are distal to the tip of the lateral malleolus and b P
ultrasonography displays similar changes as seen with lesions
Figure 26.6 Acute supination trauma of the ankle. Section along the
of the superior peroneal retinaculum: tear of the retinacu- anterior talofibular ligament that is thickened and covered by
lum and dislocation of the peroneus longus tendon over the hypoechoic oedema with hyperaemia.
peroneal tubercle (Fig. 26.5). Hypertrophy of the peroneal
tubercle is a predisposing factor to stenosing tenosynovitis
of the peroneal tendons and may cause pain and swelling
in the same area.
peroneal tendons or the anterior tibiofibular ligament
(which untreated could lead to chronic pain), in profes-
LATERAL LIGAMENT COMPLEX sional athletes and in patients with chronic complications.
Ultrasonographic signs of acute anterior talofibular liga-
Due to its high resolution and the possibility of imaging ment injury depend on the severity of the injury. With mild
sections in all planes, ultrasound is a very effective tech- stretching the ligament is thickened, sometimes diffusely
nique for the detection of isolated or multiple ankle and/ hypoechoic, and without tear. A thin layer of hypoechoic
or tarsal ligament lesions. Inversion ankle injuries are oedema may outline the ligament (Fig. 26.6) and hyperae-
among the most frequent injuries in sports. Most frequently mia is found in and around the ligament. In partial tears
the anterior talofibular ligament is the only ligament there is a hypoechoic area or a partial-thickness defect in
involved (70%). When associated with other ligament tears, the midportion of the ligament (Fig. 26.7) or a partial avul-
it is generally the first to be torn, followed by the calcaneo- sion at one insertion, sometimes with periosteal stripping.
fibular ligament in more severe sprains (20%), and rarely Complete tears are seen as a hypoechoic gap through the
also by the posterior talofibular ligament, which is not well midportion of the ligament (Fig. 26.8) or as a complete liga-
visualized by ultrasound. Isolated tears of the calcaneofibu- ment or bone avulsion at one insertion. There may be
lar ligament can also occur with varus injury but are less extravasation of anechoic joint fluid through the gap into a
frequent. Other structures that can be injured are the ante- localized fluid collection superficial to the ligament.
rior tibiofibular ligament, the interosseous talocalcaneal
ligaments, some tarsal ligaments (dorsal talonavicular liga-
Practice Tip
ment, Y-ligament, lateral calcaneocuboideal ligament) and
the peroneal tendons. Fractures should also be ruled out. A gentle dynamic inversion test can be useful to differentiate
Focal tenderness guides the ultrasound examination. partial from complete tears when the ligament ends are not
There is no consensus about the treatment of ankle liga- retracted.
ment injuries, but most acute lateral ankle sprains are
treated conservatively. Surgery is sometimes indicated in
severe, multiple ligament tears. Ultrasound is performed Lesions of the calcaneofibular ligament are most frequently
in severe or complicated cases, when the clinical examina- situated at the proximal (fibular) insertion, which is difficult
tion is difficult, when there is doubt about a tear of the to visualize on ultrasonography. Two important indirect
CHAPTER 26 — Disorders of the Ankle and Foot: Lateral 299
a
ATaFL
Fibula
ATa A
FL
Talus M L
P
b
Fibula
Figure 26.9 Chronic lateral pain after supination trauma of the
ankle. Section along the anterior talofibular ligament, which is
hypoechoic, thickened and distended.
A
Talus
L M
b P
Figure 26.7 Acute supination trauma of the ankle. Section along the
anterior talofibular ligament, which is hypoechoic thickened with a signs of tear are: absence of tightening of the ligament
deep partial tear. during a dynamic examination with dorsal flexion of the
ankle and effusion in the peroneal tendon sheath caused by
a communication to the joint line without tenosynovitis.
The latter may not be present if the injury is chronic.
Syndesmotic sprains generally involve the anterior tibio-
fibular ligament and are secondary to an eversion ankle
injury. They are accurately detected by ultrasonography
which picks up: hypoechoic ligament thickening, local
hyperaemia, ligament defect and/or ligament/bone avul-
sion. An associated fibular fracture is best appreciated on
plain radiography.
In lateral ankle sprains, osteochondral lesions of the talar
dome and lesions of the interosseous talocalcaneal liga-
ments are not directly visualized by ultrasonography as they
a
are by MRI.
Acute tears of the talocalcaneal ligaments can be sus-
pected if a haematoma is found in the tarsal sinus, but
haematoma should be differentiated from ganglion cysts or
ATFL posterior subtalar effusion.
Late complications to inversion ankle injuries, such as
residual pain, swelling, joint instability and recurrent ankle
sprains, are quite frequent and have been found in more
than 30% of the patients after 6 or 7 years in large clinical
Talus follow-up studies. In these patients, ultrasonography may
Fibula
A show nonunion of ligament ends, ligament thickening,
L M calcification, bone avulsion (Fig. 26.9), focal hyperaemia
b P
and joint laxity. Palpation is particularly important in order
Figure 26.8 Acute supination trauma of the ankle. Axial anterior to correlate ultrasonographic findings with clinical symp-
section showing a complete tear with a defect in the midportion of toms. The anterolateral impingement syndrome is poorly
the anterior tibiofibular ligament (arrow). understood and refers to chronic pain anterior to the lateral
FRACTURES
Fractures of the anterior calcaneal process are seen in

patients with an inversion ankle injury or an eversion impac-
tion fracture. They should be regarded as a bone avulsion
at the proximal insertion of the Y-ligament, which can easily
be visualized on ultrasound at the site of maximal pain,
distal to the tip of the lateral malleolus (Fig. 26.10). They
are often undiagnosed on plain radiography, which can lead
to pseudoarthrosis and chronic pain. Fractures of the fifth
a
metatarsal bone (Jones fractures) or of the lateral process
of the talus can also be suspected by ultrasound and require
Peroneus
X-ray and/or CT to confirm. Stress fractures of the fibula
Brevis or metatarsal bones are also detectable as a focal cortical
Fracture irregularity surrounded by oedema and hyperaemia.
Peroneus
Longus
FURTHER READING
Bianchi S, Delmi M, Molini L. Ultrasound of peroneal tendons. Semin
Musculoskelet Radiol 2010;14(3):292–306.
Demondion X, Canella C, Moraux A, et al. Retinacular disorders of the
L
Os Calcis A P ankle and foot. Semin Musculoskelet Radiol 2010;14(3):281–91.
M Konradsen L, Becht L, Ehrenbjerg M, et al. Seven years follow-up
b
after ankle inversion trauma. Scand J Med Sci Sports 2002;12(3):
Figure 26.10 Lateral pain after supination trauma of the ankle. 129–35.
Longitudinal section of the lateral foot showing an avulsion fracture Krappel F, Schmitz R, Harland U. Sonographic diagnosis of anterior
syndesmosis rupture. Z Orthop Ihre Grenzgeb 1997;135(2):116–19.
of the lateral process of the calcaneus.
Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evalua-
tion of peroneal tendon subluxation. AJR 2004;183(4):985–8.
Peetrons P, Creteur V, Bacq C. Sonography of ankle ligaments. J Clin
Ultrasound 2004;32(9):491–9.
malleolus, associated with a fibrotic mass (sometimes ‘menis- Raikin SM. Intrasheath subluxation of the peroneal tendons. Surgical
coid’) in the anterolateral gutter, as a consequence of a technique. J Bone Joint Surg Am 2009;1:91(supplement 2):146–55.
poorly healed anterior talofibular ligament tear. Ultrasono- Sobel M, Geppert MJ, Olson EJ, et al. The dynamics of peroneus brevis
graphic findings of a painful heterogeneous hypoechoic tendon splits: a proposed mechanism, technique of diagnosis, and
classification of injury. Foot Ankle 1992;13(7):413–22.
mass, calcification or local hyperaemia may raise a suspi- Verhagen RA, de Keizer G, van Dijk CN, et al. Long-term follow-up of
cion, but a precise diagnosis by imaging is difficult and may inversion trauma of the ankle. Arch Orthop Trauma Surg 1995;
be helped using MRI arthrography. 114(2):92–6.
Disorders of the 27
Ankle and Foot: Medial
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION MEDIAL LIGAMENT DISEASE

TIBIALIS POSTERIOR TENDON Anatomy
Clinical and Radiological Staging Posteromedial Impingement
Tenosynovitis Spring Ligament Injury
Hypertrophic, Atrophic and Calcific NERVE COMPRESSION SYNDROMES
Tendinopathy Tarsal Tunnel Syndrome
Insertional Tendinopathy Accessory Medial Calcaneal Nerve
Navicular Inferior Calcaneal Nerve (Baxter’s
Tibialis Posterior Rupture Neuropathy)
Tibialis Posterior Subluxation BONE DISEASE
FLEXOR DIGITORUM LONGUS Coalition
FLEXOR HALLUCIS LONGUS Anterior Process Fracture and Stress
Tenosynovitis Fracture
Sclerosis and Friction Syndrome
with extrinsic and abnormal biomechanics to lead to tendon

INTRODUCTION degeneration. Intrinsic factors include strain on the tendon
as it passes a curved course around the medial malleolus. A
Due to the superficial location of many of the structures that zone of hypovascularity is said to occur in the watershed
contribute to medial sided symptoms, ultrasound plays an area between the proximal portion of the tendon supplied
important role in their assessment. Abnormalities of the by the posterior tibial artery and the distal portion of the
medial tendons predominate, but disorders of the neurovas- tendon supplied by a combination of the posterior tibial
cular structures, ligaments and even bones need to be con- and dorsalis pedis arteries. Other areas of relative hypovas-
sidered. The technique for examining the medial ankle has cularity occur as the tendon sheath does not extend the full
already been discussed. Important points include the domi- length to its insertion and there is no associated mesoten-
nant role that axial images play in the assessment of tendon don. The combination of these anatomical features may
disease and this is particularly important in the medial ankle predispose to tendon degeneration in this location. Other
where the tendons follow a curved course around the medial intrinsic factors include systemic disease, particularly diabe-
malleolus. Each of the conditions that can contribute to tes, renal disease and rheumatoid arthritis, hypertension
medial side of symptoms will be discussed in turn. and use of steroids. Histologically, tendinosis is associated
with replacement of the normal collagenous architecture
with mucinous material that lacks structure or fibre organi-
TIBIALIS POSTERIOR TENDON zation. There is a decrease in the ratio of type 1 to type 3
collagen, and a reactive vascular ingrowth. This maladaptive
The tibialis posterior tendon (TPT) is the most powerful repair is associated with tendon dysfunction.
inverter of the foot and helps to stabilize the medial longi- Tendinopathy of the TPT is most common in middle-
tudinal arch. TPT dysfunction is one of the commonest aged females who complain progressively of pain followed
causes of medial sided ankle pain and is particularly preva- by flat foot deformity. Classically patients describe difficulty
lent in the middle-aged and older population. The cause of with walking on uneven ground, climbing and descending
tendinopathy is multifactorial. Intrinsic factors combine stairs. Clinically, tenderness is found on the medial aspect
301
of the ankle along the line of the tendon. With advancing

disease, the patient is unable to carry out a single heel raise.
The action of tibialis posterior in plantar flexing and
everting is to maintain congruity at the talonavicular and
calcaneocuboid joints during walking. Failure of this mecha-
nism leads to flexion stresses of the midfoot and ultimately
failure.
Key Point
The TPT maintains the longitudinal arch of the foot and

consequently its failure leads to flat foot deformity followed
by sequential failure of the spring ligament and ligaments of
the sinus tarsi.
a
Flat foot deformity is assessed with the patient standing.

Looking from the posterior, more toes are visible lateral to
the heel on the affected side. ulum
inac
Degenerate TPT tears usually occur at the level of the Ret
TPT
medial malleolus, whereas tears in athletes are usually at the
navicular insertion. FDL
TN
CLINICAL AND RADIOLOGICAL STAGING
Both clinical and imaging staging has been described. The
lower grades include the presence of pain without structural
abnormality. This progresses through tendon degeneration P
to complete rupture when flat foot deformity is obvious. L M
The clinical classification describes progressive dysfunction A
b
from stage I paratenonopathy, tenosynovitis and tendon
degeneration with normal tendon length, through stage II Figure 27.1 Earliest sign of tenosynovitis. A small quantity of fluid
with tendon elongation leading to correctable flat foot with minimally thickened synovium surrounds the tendon on the axial
deformity, stage III with rigid flat foot deformity and finally image.
stage IV with secondary medial ligament failure leading
to valgus deformity. The imaging findings reflect clinical
progression though is often normal in the early stages. Posi- Synovial thickening may become quite marked, even mass-
tive findings can be divided into those that involve the like (Fig. 27.5). Even at this stage, the tendon may remain
tendon sheath called tenosynovitis, and changes within the completely normal, although in most cases some degree of
tendon itself. underlying tendon disease is apparent, especially if high-
resolution equipment is used. Detecting even small degrees
of tendinopathy may have important implications in plan-
TENOSYNOVITIS
ning treatment.
A small quantity of fluid is frequently found in the normal
tendon sheath, particularly in the submalleolar region. A HYPERTROPHIC, ATROPHIC AND CALCIFIC
useful rule of thumb is that the cross-sectional area of fluid
TENDINOPATHY
should not exceed that of the adjacent tendon. In the earli-
est stages, findings may be limited to excess fluid within the
tendon sheath (Fig. 27.1). Key Point
The earliest ultrasound changes of tendinopathy are focal

Practice Tip areas of decreased reflectivity within the tendon.
Distension often begins in the immediate submalleolar area

as this is where the sheath has room to expand (Fig. 27.2).
These are due to loss of the normal tendon architecture
with areas of focal hypointensity representing tendon
As tenosynovitis progresses, synovial thickening as opposed degeneration. The tendon may begin to delaminate and
to echo-free fluid becomes more apparent (Fig. 27.3) and longitudinal splits appear. Progression leads to enlargement
increased Doppler signal develops within it (Fig. 27.4). of the tendon and areas of further focal breakdown and
Apart from the nutrient artery, Doppler signal will not partial tear. The name hypertrophic tendinopathy or type 1
under normal circumstances be found in the synovial lining partial tear is applied to this condition. Increased Doppler
and its presence is generally indicative of tenosynovitis. activity can be detected within the tendon at an early stage.
CHAPTER 27 — Disorders of the Ankle and Foot: Medial 303
a
Figure 27.4 Axial image of posteromedial ankle. There is increased
Doppler signal within the tendon and surrounding tendon sheath
indicative of tibialis posterior tenosynovitis and tendinopathy.
Figure 27.2 Advanced tenosynovitis. The long axis shows the fluid
is predominantly submalleolar and more than the diameter of the
associated tendon. This indicates an abnormal quantity of fluid.
Figure 27.3 Early tenosynovitis. Note the slightly thickened synovial Figure 27.5 Axial image of posteromedial ankle. There is tibialis
sheath lining. posterior tenosynovitis. A split traverses the TPT.
Practice Tip Key Point
Under normal circumstances, blood vessels should not be Signal changes within the tendon should be carefully sought
found within a tendon apart from perhaps an occasional as their detection indicates progression to a more significant
vessel close to the nutrient artery. form of the disease.
The detection of intrinsic tendon abnormalities also has a

significant impact on therapeutic decision making and
many feel that corticosteroid injection therapy for tenosy-
novitis is contraindicated when the tendon becomes abnor-
mal. Others argue that minor signal changes within the
tendon, particularly using sensitive ultrasound, are not a
contraindication to corticosteroid injection; however, in all
cases the patient should be warned about the potential for
tendon rupture and protected against it.
These early abnormalities predominate in the submalleo-
lar region and may be associated with other findings. There
is a fibrous pulley enthesis on the posterior aspect of the
medial malleolus where the TPT passes around it. Involve-
ment of the enthesis may lead to bony hypertrophy and the
formation of a spur on the posterior aspect of the medial a
malleolus (Fig. 27.6). This may be visible on plain films and
is a useful plain film clue to the underlying tendon disorder.
It is also clearly visible on MR imaging, particularly in the
axial plane.
As the tendon begins to further elongate and as the arch
of the foot drops, the tendon becomes further stretched. In
some cases, there is a decrease in the cross-sectional area of
the tendon that now appears of equal size to or smaller than
the adjacent flexor digitorum tendon. The appearance of
atrophic tendinopathy, as it is called (Fig. 27.7), has been
likened to a fraying rope. As the individual strands begin to
dissociate, they slide apart, reducing the tendon cross-
sectional area in the most involved segment (Fig. 27.8). As
has previously been outlined …
b
Key Point Figure 27.6 Axial image of posteromedial ankle. There is marked
bony irregularity of the posterior margin of the medial malleolus with
… the TPT is normally at least twice the size of flexor a posteromedial bony spur. Chronic enthesopathy may occur in asso-
digitorum. Loss of this ratio is termed atrophic tendinopathy ciation with TPT disease.
or type 2 partial tear.
In general this is a relatively straightforward diagnosis with common area for overuse disease in the athlete; however,
ultrasound as the tendon sheath is frequently involved and there is a potential pitfall.
the internal structure of the tendon is grossly abnormal. On
MRI, however, the abnormalities of the tendon sheath may
be less obvious and the degenerating tendon may preserve
Practice Tip
its low signal on both T1 and T2 weighting. An alteration
in size is therefore often the only feature of type 2 partial Care should be taken when considering areas of decreased
tear and the diagnosis may be overlooked. signal close to the insertion as pathological.
Other forms of tendinopathy include acute calcific (Fig.
27.9) and insertional tendinopathy. Fibrosing tenosynovitis
is uncommon in the TPT, although it has been described.
Calcification in the tendon sheath leading to acute calcific Although a major component of the tendon inserts into
tenosynovitis is rare. A few flecks of calcification within the the navicular, there are significant slips which pass inferiorly
tendon, particularly at tendon insertions, should not be to insert in the undersurface of the cuneiforms even as far
regarded as significant and calcification of this type is fre- as the medial aspect of the cuboid. Diverging tendon fibres
quently asymptomatic. As with the supraspinatus tendon, create anisotropic artifact, which is difficult to eradicate in
occasionally acute calcific tendinopathy presents very this location. The presence of a normal Doppler pattern
acutely. The skin is red, the subcutaneous tissues are swollen and the absence of local symptoms on sonopalpation are
and the tendon is very tender to touch. Calcium may be helpful to confirm that the tendon is normal. Abnormal
seen as a conglomerate within the tendon that can be associ- fluid around the distal portion of the tendon is more strictly
ated with an increase in Doppler signal. a paratenonopathy as opposed to tenosynovitis, as the
Insertional tendinopathy involves the area of tendon tendon sheath ends at approximately the level of the
close to its attachment onto the navicular. This is a more midtalus.
a
a
TPT
Ret
inac
ulum
FDL
TN
b P
M L
Figure 27.7 Axial image of posteromedial ankle. There is marked A
reduction in the diameter of the TPT, indicative of a type 2 tear. This b
is less common than the hypertrophic-type 1 tear. Figure 27.8 Axial image of posteromedial ankle. There is marked
loss of reflectivity, particularly in tibialis posterior, which is decreased
in size compared with flexor digitorum. This indicates a type 2 atro-
phic tear. The abnormality extends into the tendon sheath of flexor
digitorum, which can be a shared sheath with TPT.
INSERTIONAL TENDINOPATHY ACCESSORY
NAVICULAR
Key Point source of symptoms. Tenderness will be localized to the

pseudarthrosis and this may be elicited by sonopalpation
Insertional tendinopathy can occur in isolation but is more during the examination; increased Doppler signal may also
frequently associated with an accessory ossicle. be detected (Fig. 27.12). On MRI, bone oedema may be
detected on either side of the pseudarthrosis. Painful pseud-
arthroses are difficult to treat. Surgical options include
An accessory navicular is present in approximately 4% of fixing the accessory article onto the navicular. Prior to this,
the population but there is a higher association of TPT a corticosteroid injection can be attempted to alleviate
disease in this group. Three types of accessory ossicles have symptoms. The patient should be warned that there is a
been described. Type 1 is a small, well-corticated bony significant risk of rupture that will precipitate surgical
ossicle fully contained within the distal portion of the fixation.
tendon. It is rarely associated with symptoms. A type 2 acces- The third type of accessory ‘ossicle’ is where there is
sory ossicle is larger and contains most of the TPT attach- an elongation of the medial aspect of the navicular, as
ment. There is a fibrous or cartilaginous joint between the though a type 2 had fused with its parent bone. This is also
accessory ossicle and the navicular that is essentially a pseud- referred to as a cornuate navicular. This is the least trouble-
arthrosis (Figs 27.10 and 27.11). These can be a significant some variant, although it is also said to predispose to
Calcium
TPT
Spring Ligament
b
M Os Calcis
P A Figure 27.10 Os Naviculare, Type 2, with tibialis posterior enthe-
L sopathy. Longitudinal ultrasound shows tibialis posterior insertional
b
tendinosis (arrowheads) with bony irregularity (arrow).
Figure 27.9 Axial image of medial ankle close to TPT insertion.
There is enlargement of the tendon sheath that is filled with reflective
material representing milk of calcium.
tendinopathy, due to shortening of the tendon and reduc-

tion of the curve around the medial malleolus.
TIBIALIS POSTERIOR RUPTURE

The most advanced stage of TPT disease is tendon rupture
which on imaging grading is referred to as a type 3 tear. As
with tendinopathy the typical location is in the submalleolar
region. The aetiology is generally chronic but can occur
following an acute injury superimposed on an already
damaged tendon. Axial images above the malleolus will a
demonstrate an intact but damaged tendon. As the tendon
is followed distally it disappears at the level of the rupture
(Fig. 27.13). Tendon retraction is not a prominent finding
as adhesions between the tendon sheath and the adjacent
tibia occur. The distal portion of the tendon will appear lax TPT
helping to make the diagnosis.
One of the principal functions of TPT is to preserve the
medial arch of the midfoot. If it fails, considerable stress is Spring Ligament
placed on the spring ligament and it is not uncommon that
spring ligament failure follows TPT failure.
Talus M
TIBIALIS POSTERIOR SUBLUXATION P A
b L
Subluxation of the TPT is uncommon but has been described
following trauma and following release of the flexor reti- Figure 27.11 Os Naviculare, Type 1. A large Os occupies more than
naculum for tarsal tunnel compression. The configuration 50% of the TPT diameter. The tendon is otherwise normal.
a a
b
b
Figure 27.13 Axial image of posteromedial ankle. There is no visible
Figure 27.12 Axial image of medial midfoot. A large accessory tendon within the TPT sheath indicating complete rupture (type 3 TPT
ossicle overlies the navicular at the site of TPT attachment. There is tear). A few strands of thickened synovium and tendon debris are
increased Doppler activity at the type 2 Os Naviculare pseudarthrosis, evident. There is a small osteophyte at the most medial margin.
and enlargement of the component of TPT that crosses the joint to
insert onto the navicular itself.
of the torn retinaculum should be reviewed to determine close proximity to the knot of Henry. Repetitive friction,
whether the periosteum is also involved. Stripping of the such as might occur in runners, may underlie the syndrome,
retinaculum, with or without the attached periosteum, which is sometimes referred to as runner’s foot.
creates an elongated sulcus that allows medial subluxation
of the TPT during flexion and inversion. The abnormality
is best appreciated on dynamic ultrasound. Surgical treat- FLEXOR HALLUCIS LONGUS
ment is generally advised.
The FHL tendon also follows a curved course as it passes
from the distal calf, through the hindfoot into the midfoot.
FLEXOR DIGITORUM LONGUS FHL is often considered along with tibialis posterior and
flexor digitorum (Tom, Dick and Harry); however, this is
Disorders of flexor digitorum longus (FDL) are consider- not particularly appropriate as the tendon lies at some
ably less common than tibialis posterior disease. Many cases distance from the other two, separated from them by the
occur in conjunction with tibialis posterior disease if a posterior tibial neurovascular bundle. It also has its own
common sheath is present (Fig. 27.14). The ultrasound fibroosseous tunnel on the posterior aspect of the os calcis.
findings are similar to TPT disease, with tenosynovitis ini- The tendon is not as easy to locate as the TPT as it is a much
tially (Fig. 27.15) followed by involvement of the tendon deeper structure.
itself (Fig. 27.16).
More distally a friction syndrome is described where FDL Practice Tip
crosses flexor hallucis longus (FHL) on the undersurface of
the foot. The area is referred to as the knot of Henry and Useful techniques to help locate FHL include using the
is located between the superficial and second muscle layers. overlying tibial nerve as a landmark and moving the great
The crossover occurs at approximately the level of the toe, which will also move the tendon.
navicular-cuboid joint. The medial plantar nerve lies in
Figure 27.15 Axial image. Increased Doppler activity is present

around the tibialis posterior and flexor digitorum tendons. There is
b loss of reflectivity within flexor digitorum on its lateral margin.
Figure 27.14 Axial image. There is loss of reflectivity in tibialis pos-

terior that is decreased in size compared with flexor digitorum. This
indicates a type 2 atrophic tear. Abnormal signal indicative of tendi-
nopathy extends into the tendon sheath of flexor digitorum as well. Because of this, the presence of fluid alone is insufficient to
diagnose tenosynovitis of FHL and …
FHL lies medial to the location of the Stieda process or os

Practice Tip
trigonum.
Disorders associated with FHL include tenosynovitis, scle- … synovial thickening and Doppler activity are used to
rosing tenosynovitis, posterior impingement syndrome and distinguish talonavicular joint effusion from true FHL
tendon rupture. One of the sensitive findings in patients tenosynovitis.
with tenosynovitis generally is an abnormal quantity of fluid
around the tendon. This sign cannot be used with FHL as
there is often communication between the tendon sheath As the disease progresses, internal signal degeneration,
and the adjacent ankle joint. Effusion within the ankle joint tendon splits, hypertrophic tendinopathy and ultimately
easily extends into the tendon sheath, where often quite rupture may occur.
large quantities of fluid may accumulate (Fig. 27.17).
SCLEROSIS AND FRICTION SYNDROME
TENOSYNOVITIS
Key Point
Practice Tip
Sclerosing tenosynovitis of FHL is similar to de Quervain’s
Extension of ankle joint effusion into the FHL sheath is tenosynovitis or pulley fibroma in that there is thickening of
common and may distend the sheath even to the level of the retinaculum that forms the roof of the fibroosseous
the midfoot. tunnel in which the tendon is contained.
TN
Figure 27.16 Axial image of posteromedial ankle. There is marked

loss of reflectivity in the flexor digitorum tendon consistent with ten- FHL
dinopathy. Minor changes are present in the TPT with two areas of
focal delamination.
The condition classically occurs in ballet dancers where it is

said to occur due to repeatedly standing on point. Thicken- Os Calcis P
ing of the retinaculum irritates the underlying tendon L M
A
which itself becomes thickened developing a focal nodule.
b
Movement of the unaffected tendon under the retinaculum
may be asymptomatic initially; however, as the tendon begins Figure 27.17 Axial posterior ankle. A small quantity of fluid sur-
to thicken a clicking sensation occurs. The patient may also rounds the FHL tendon. This is a normal finding. The fluid may enter
describe a triggering sensation as the tendon nodule locks the tendon sheath from the adjacent tibiotalar joint.
beneath the thickened retinaculum.
MEDIAL LIGAMENT DISEASE

most significant component of the transverse group. Like
ANATOMY
ligaments elsewhere, the normal ligament should be gener-
There is a complex arrangement of ligaments on the medial ally reflective with an organized internal structure.
aspect of the ankle. They are best understood by consider- The medial ligaments are less frequently injured than
ing them as three groups: superficial, deep and transverse. their lateral counterparts. They are injured acutely when
The superficial group comprises three slips, all originating overstretched, leading to partial or complete tears. Tears
from the tibia and named after their attachments. These may involve the substance of the ligament of either of its
are the tibiocalcaneal, tibionavicular and the tibiospring attachments when a bony fragment may be avulsed. Com-
ligaments. The main ligament of the deep set is the pression injuries also occur during valgus strain, leading
posterior tibiotalar ligament. There is also an anterior tib- to haemorrhage within the ligament. Chronic sequelae
iotalar ligament that blends with the posterior. The spring of injury include synovial reactions, calcification, enthe
ligament (superficial calcaneonavicular ligament) is the sopathy (chronic fibrosis, angiogenesis and calcification)
and instability. This constellation is called posteromedial

impingement.
POSTEROMEDIAL IMPINGEMENT
Posteromedial impingement refers to chronic enthesopathy
of the deep portion of the deltoid ligament, specifically the
posterior tibiotalar ligament. Patients typically present 3 to
12 months after injury with chronic posteromedial pain.
The normal ligament is a triangular shaped structure that
runs from the posterior aspect of the medial malleolus to
the adjacent talus. It is best found by following TPT in the
axial plane. As the tendon passes below the medial malleo-
lus, the structure on its deep surface is the posterior tibio-
talar ligament. As with many other ligaments, the tibiotalar
a
ligament should be stressed to ensure that it is properly
visualized.
Practice Tip
Foot dorsiflexion is used to straighten the normal tibiotalar

ligament and demonstrate its bright reflective structure with
a well-organized internal architecture.
Abnormal ultrasound findings include loss of the

normal fibrillary structure, increased Doppler signal and
internal increased reflectivity representing calcification
(Fig. 27.18). Care should be taken to examine the liga-
ment under tension as a relaxed ligament may mimic
several of these findings. Once diagnosis is established, b
ultrasound-guided injection therapy has been used to treat
the condition. Figure 27.18 Coronal image of medial ankle. There is swelling, loss
of reflectivity and marked increased Doppler in the tibiotalar ligament
indicative of posteromedial impingement.
SPRING LIGAMENT INJURY
The calcaneonavicular ligament complex plays an impor-
tant role in stabilization and maintenance of the medial with a fluid-filled gap (Fig. 27.19). The other involves thick-
longitudinal arch. It has several distinct components, the ening of the ligament with loss of the normal fibrous archi-
most important of which is the superomedial calcaneona- tecture, decreased signal (Fig. 27.20) and increased Doppler
vicular or spring ligament. The spring ligament is so named activity.
as it is reputed to have some elastic properties; however,
histologically there is no evidence of either elastic fibres or
properties. Injuries to the spring ligament most commonly Key Point
occur as a consequence of chronic TPT disease. Failure of
the TPT places a strain on the spring ligament which ulti- Secondary intertarsal subluxation has been described
mately also fails. Tears that occur as a result of direct injury following complete rupture of the spring ligament.
are less common but may be the result of landing heavily
on the feet or an overuse injury. These injuries tend to
occur in younger patients, most commonly males, and the There is plantar rotation of the talus and valgus angulation
injury may follow an unaccustomed increase in impact of the calcaneus. There may be a dorsal subluxation of the
loading. Impaction injuries with compression of the liga- navicular. The differential diagnosis of injuries to the spring
ment against the lateral aspect of the head of the talus have ligament or talonavicular ligament includes a stress fracture
also been described. The normal size of the ligament is up on the dorsal aspect of the navicular. Such fractures occur
to 7 mm in asymptomatic individuals. Injuries to other in the area between the first and second metatarsals related
components of the calcaneonavicular ligament are less to differential compression forces.
commonly encountered and are difficult to diagnose with
ultrasound. FRICTION INJURY
In addition to spring ligament injuries, impingement can
INJURY occur between the TPTs and the spring ligament, within
Two patterns of ultrasound abnormality have been described. the so-called gliding layer. This layer represents a small
One is complete disruption of a portion of the ligament potential bursa facilitating movement of the tendon over
TPT
Spring Ligament
TPT
M
Talus
P A
L
b Spring Ligament
Figure 27.19 Axial section of medial midfoot. There is loss of
normal volume of the spring ligament with fibre disruption indicative
of a tear.
M Talus
P A
b L
Figure 27.20 Axial section of medial ankle. There is disorganization

the ligament. Ultrasound findings include fluid distension
of the normal fibrillary structure and decreased reflectivity from the
and increased Doppler signal within the gliding layer,
spring ligament consistent with spring ligament partial tear. Reflectiv-
although it is difficult to separate this from disease of the ity in the overlying TPT is normal.
surrounding tendon and ligament (Fig. 27.21). Fluid within
the TPT sheet itself should extend beyond the confines of
the gliding layer. Combined injuries, however, are more
usual.
Like the tibialis posterior and flexor digitorum tendons,
MEDIAL MALLEOLAR BURSA the nerve must pass through a 75° turn as it rounds the
Medial-side symptoms may also be due to distension of an medial malleolus. To prevent subluxation of these struc-
adventitial bursa and it is sometimes described medial to the tures, they are contained within a fibroosseous compart-
medial malleolar bursa. This is uncommon. ment called the tarsal tunnel. The tarsal tunnel is roofed by
a connective tissue band similar to the flexor retinaculum
at the wrist and similarly named. The retinaculum is attached
NERVE COMPRESSION SYNDROMES
superiorly to the medial malleolus and inferiorly it blends
with the superficial fascia. An additional septum may be
TARSAL TUNNEL SYNDROME
present separating the medial and lateral plantar branches
The tibial nerve is the main branch of the sciatic nerve. of the tibial nerve. The tibial artery and at least two sur-
It passes through the calf deep to soleus muscle. Just above rounding tibial veins are also contained within the tunnel.
the medial malleolus, the tibial nerve gives off a small Increased pressure within the tunnel from whatever cause
branch, called the medial calcaneal nerve, and starts to leads to the neural compression. Clinically patients com-
divide into its two main branches: the medial and lateral plain of a burning sensation, felt in the plantar aspect of the
plantar nerves. The medial is the more anterior of the foot and toes, which may be associated with frank numbness
two. The first branch of the lateral plantar nerve is the infe- and muscle atrophy. Symptoms are exacerbated by standing
rior calcaneal nerve, which passes inferiorly to the plantar and walking and improved by rest. A particular feature is
fascia. pain that continues during rest, referred to as afterburn.
TPT
Spring Ligament
Ganglion
Talus
M TN
P A Spring Ligament
Os Calcis
L
b
Figure 27.21 Axial image of midfoot. Increased Doppler activity is

present between the TPT and the underlying spring ligament. The Os Calcis Talus
finding suggests spring ligament enthesopathy with involvement of M
the intervening sliding layer. P A
L
b
Symptoms are also exacerbated when compression within
the tunnel is increased by eversion or dorsiflexion. As with Figure 27.22 Axial image of medial ankle. A multiloculated ganglion
carpal tunnel syndrome, night pain is a feature. is present within the tarsal tunnel. The ganglion has been punctured
prior to aspiration.
Intrinsic lesions that can cause tarsal tunnel syndrome
include accessory muscles, ganglia, tumours, varicose veins,
synovial hypertrophy and scar tissue. Extrinsic lesions
include foot deformities, hypertrophic and accessory often multiloculated and generally noncompressible lesions.
muscles and excessive pronation. In about half of all cases, There is no internal Doppler flow, which helps to distin-
the cause of tarsal tunnel syndrome cannot be identified. guish them from other hyporeflective structures such as
The goal of the ultrasound examination is to detect nerve sheath tumours.
calibre changes in the nerve as it traverses the flexor reti- Other space-occupying lesions may include tumours
naculum, to note any retinacular thickening and identify any of any aetiology, lipomas, osteochondromas and venous vari-
treatable underlying causes, particularly ganglion or synovial cosities. Anomalous muscle variants or disease of the other
cysts. During the examination any paraesthesia induced by components of the tarsal tunnel, such as tenosynovitis, may
probe compression should be noted. The so-called sonopal- underlie symptoms. Bony lesions such as the abnormal bony
pation-induced Tinel’s sign can occur with generalized mass that can form around a medial subtalar coalition
neural sensitization and, therefore, does not always corre- should be considered.
spond with the exact site of neural compression. In many cases, there is no obvious underlying compres-
Whilst any mass lesion can lead to compression within the sive lesion. There is a tendency, with increasing age, for
tarsal tunnel, the commonest are synovial or ganglion cysts. progressive loss of the medial arch and a valgus hindfoot.
The medial margin of the tibiotalar and the posterior sub- This leads to stretching of the structures of the medial
talar joints forms part of the floor of the tarsal tunnel. aspect of the foot leading to increased traction of the pos-
Consequently effusion arising from these joints may lead to terior tibial nerve and increasing its susceptibility to injury.
compression within the tunnel. Ganglion or synovial cysts Some cases of presumed diabetic peripheral neuropathy
may also track posteriorly and inferiorly from the talona- may also be due to compression of the tibial nerve within
vicular joint (Fig. 27.22). Ganglion cysts are hyporeflective, the tarsal tunnel. The precise aetiology is uncertain but
in some studies patients with diabetic neuropathy have

responded to tarsal tunnel decompression and division of a JOGGER’S FOOT
thickened retinaculum. Patients who present with symptoms Although a variety of conditions have been given the name
of tibial nerve compression should also have more proximal ‘jogger’s foot’, the term is often applied to compression of
causes excluded. Compression around the knee may relate the medial plantar nerve where it lies close to the intersec-
to masses within the popliteal fossa, including popliteal tion area between FHL and flexor digitorum profundus. In
cysts, muscle variants and fibrous bands, which may also the hindfoot, FHL lies lateral to FDL. The insertion anatomy
compress the posterior tibial artery. is the reverse of this and consequently these two tendons
Several other neural compression syndromes may occur must cross each other. They do this in the posterior aspect
on the medial aspect of the hindfoot. To differentiate these of the midfoot just distal to the tarsal tunnel. The area is
various entities, the terms proximal tarsal tunnel syndrome referred to as the knot of Henry. The medial plantar nerve
and distal tarsal tunnel syndrome are sometimes used. Prox- lies close to this point and may be impinged by tenosynovitis
imal tarsal tunnel syndrome refers to the classic tarsal tunnel or tendinopathy. The presence of fluid in the FHL tendon
compression and to compression of the medial calcaneal sheath, a common occurrence if there is a tibiotalar joint
nerve. Distal tarsal tunnel syndrome refers to compression effusion, and tenosynovitis of flexor digitorum may exacer-
of the inferior calcaneal nerve or the medial and lateral bate this condition. An alternative aetiology suggests that
plantar nerves. valgus and external rotation during running stretches the
medial plantar nerve in this vicinity.
MEDIAL CALCANEAL NERVE
The medial calcaneal nerve arises from the tibial nerve most
BONE DISEASE
commonly before it divides into its medial and lateral
branches. In general it is an uncommon cause of medial
COALITION
sided symptoms, but it may be impinged during the place-
ment of traction pins in the os calcis. Occasionally entrap- Ultrasound is not generally considered a useful technique
ment can occur in patients with over-pronated hindfeet or to evaluate bone disease; however, it does provide reason-
from pressure from tight-fitting shoes. The nerve can be able depiction of the cortical surface and surrounding peri-
located as it arises from the tibial nerve and penetrates the osteum. As such, it can provide some clues that there is an
tarsal retinaculum. Occasionally radio-ablation of this nerve underlying bone disorder. Abnormal articulations, bony
is advocated as therapy for unremitting heel pain. prominences and osteophytes can also be clearly defined.
Several potential bony causes of medial-sided symptoms
should be considered.
INFERIOR CALCANEAL NERVE
Tarsal coalition most commonly involves either the medial
(BAXTER’S NEUROPATHY) subtalar facet or the calcaneonavicular joint. The pseudar-
throsis that occurs may be either osseous or nonosseous, the
Practice Tip latter further divided into cartilaginous or fibrous articula-
tions. Of these, the osseous coalitions are the most difficult
The inferior calcaneal nerve is identified at its origin from the
lateral plantar nerve.
to identify, particularly at the calcaneonavicular joint. The
smooth bony surface of an osseus coalition is difficult to
identify unless it is specifically sought. The nonosseous coali-
tions are more obvious, as they are associated with irregular
It then passes inferiorly before turning 90° at the inferior bony margins reflecting the mechanical changes secondary
border of the abductor hallucis muscle to pass between the to the abnormal articulation. Pain at the pseudarthrosis also
quadratus plantae and the flexor digitorum brevis muscles draws attention to the area of abnormality. It is not easy
to the abductor digiti minimi. It is also called the first branch for ultrasound to differentiate fibrous from cartilaginous
of the lateral plantar nerve. The nerve supplies the abductor coalitions.
digiti minimi and its compression leads to a painful syn-
drome that mimics plantar fasciitis, associated with atrophy ANTERIOR PROCESS FRACTURE AND
of this muscle. This has been referred to as Baxter’s neu-
STRESS FRACTURE
ropathy. The inferior calcaneal nerve should therefore be
examined carefully in all patients with plantar fasciitis, par- Other bony causes of medial-sided pain include occult
ticularly if the plantar fascia is normal. fractures and stress fractures. An important occult fracture
The most common cause of compression is by a large is a fracture of the anterior process of the os calcis. These
plantar spur as it traverses underneath the heel, either in fractures occur following inversion injury, are difficult to
isolation or in association with plantar fasciitis. Compression diagnose and initial plain radiographs often appear
may also occur as the nerve passes between abductor hal- normal. Persistent pain either on the medial or lateral
lucis and quadratus plantae. Muscle hypertrophy is gener- side following an inversion injury should prompt a careful
ally the cause of compression in this location, rather than a clinical search for this fracture. CT or MRI are most often
synovial cyst ganglion or neuroma. In the absence of a spe- used when the fracture is suspected; however, patients
cific compression cause, chronic traction is assumed to with persistent medial or lateral pain may also present for
underlie symptoms. A positive Tinel’s sign over the nerve ultrasound examination and the sonologist needs to be
aids diagnosis. alert to this diagnosis. This injury will also be discussed in
Anterior Ankle (page 290) in relation to bifurcate liga- Kohls-Gatzoulis J, Angel JC, Singh D, et al. Tibialis posterior dysfunc-
ment injuries. tion: a common and treatable cause of adult acquired flatfoot. Bmj
2004;329(7478):1328–33.
Stress fractures of the os calcis will only be detected if Lau JT, Daniels TR. Tarsal tunnel syndrome: a review of the literature.
there is cortical involvement. Focal tenderness may help Foot Ankle Int 1999;20(3):201.
alert to the presence of this injury. Cortical irregularity, Louisia S, Masquelet AC. The medial and inferior calcaneal nerves: an
associated soft tissue changes and an increase in Doppler anatomic study. Surg Radiol Anat 1999;21(3):169–73.
Lui TH, Chow FYH. ‘Intersection syndrome’ of the foot: treated by
activity are the cardinal features. Stress fractures of the
endoscopic release of master knot of Henry. Knee Surg Sports Trau-
navicular are discussed in Anterior Ankle (page 290) as matol Arthrosc 2011;19(5):850–2.
they are more prominent on the dorsal aspect of the Paterson RS, Brown JN. The Posteromedial Impingement Lesion of
bone. the Ankle. A Series of Six Cases. Am J Sports Med 2001;29(5):
550–7.
Trnka HJ. Dysfunction of the tendon of tibialis posterior. J Bone Joint
Surg Br 2004;86(7):939–46.
FURTHER READING Tryfonidis M, Jackson W, Mansour R, et al. Acquired adult flat foot due
Edwards MR, Jack C, Singh SK. Tibialis posterior dysfunction. Curr to isolated plantar calcaneonavicular (spring) ligament insufficiency
Orthop 2008;22(3):185–92. with a normal tibialis posterior tendon. Foot Ankle Surg 2008;
Gazdag AR, Cracchiolo A III. Rupture of the Posterior Tibial Tendon. 14(2):89–95.
Evaluation of Injury of the Spring Ligament and Clinical Assessment Wieman TJ, Vijaykumar GP. Treatment of hyperesthetic neuropathic
of Tendon Transfer and Ligament Repair. J Bone Joint Surg pain in diabetics. Decompression of the tarsal tunnel. Ann Surg
1997;79(5):675–81. 1995;221(6):660.
and Foot: Forefoot
James L. Teh
CHAPTER OUTLINE
INTRODUCTION Epidermoid Cyst (Epidermal Inclusion Cyst)

TECHNICAL ASPECTS Haemangiomas and Vascular Malformations
TRAUMA Peripheral Nerve Sheath Tumours
Foreign Body MALIGNANT SOFT TISSUE TUMOURS
Stress Fracture Synovial Sarcoma
Plantar Plate Injury SYNOVITIS
Sesamoiditis Imaging of Inflammatory Synovitis
Freiberg’s Infraction Osteoarthritis
MASSES Bursitis
Morton’s Neuroma Gout
Ganglia and Synovial Cysts Infection
Pigmented Villonodular Synovitis Cellulitis
Giant Cell Tumour of the Tendon Sheath Abscess
Plantar Fibromatosis (Ledderhose Disease) REGIONAL PAIN SYNDROME
and beam edge artifact. Anisotropy occurs in structures that

INTRODUCTION have fibres running in a single direction, such as tendons
and ligaments. When the angle of insonation is not perpen-
The foot can be divided into three compartments according dicular to the structure there may be a dramatic drop-off in
to the bony anatomy: the forefoot (comprising the metatar- echogenicity, which may simulate an abnormality. Technol-
sals and phalanges, the midfoot (the cuneiforms, cuboid ogy such as beam steering and compound imaging may help
and navicular) and the hindfoot (calcaneus and talus). to minimize this artifact. Beam edge artifact occurs at the
Midfoot pain and metatarsalgia are common clinical com- edge of tendons with loss of signal and distal acoustic shad-
plaints. The aetiology of the symptoms is often difficult to owing that may obscure adjacent structures.
establish clinically and imaging therefore plays an impor- A copious layer of jelly is very helpful when evaluating
tant role in the evaluation of patients. Although radiographs superficial structures, particularly if skin contact cannot
give a good overview of bony anatomy and allow the evalu- easily be achieved across the length of the probe. An inter-
ation of bony lesions, they may be unhelpful in the assess- posed layer of gel can also help to minimize skin pressure
ment of soft tissue lesions and early bony abnormalities. and avoid compression of vessels when examining superfi-
With its superficial soft tissue structures, the midfoot and cial structures with Doppler. Extended field of view imaging
forefoot are ideally suited to evaluation with ultrasound. is useful in giving an overview of the anatomy and improves
This chapter covers the wide range of pathology that may image presentation when demonstrating abnormalities to
give rise to midfoot and forefoot symptoms, including colleagues.
trauma, masses, synovitis, infection and tendinopathy. Doppler imaging has a crucial role in musculoskeletal
ultrasound, allowing a real-time evaluation of regional
blood flow, which may be altered in a variety of pathological
TECHNICAL ASPECTS conditions, including inflammation, infection and tumours.
Doppler imaging also has an increasingly important role in
High-frequency linear array probes (7.5 MHz or higher) the follow-up imaging, to assess therapeutic response. In
should be used. Focal zones should be centred at the level general, power Doppler is preferred over colour Doppler
of interest. Important artifacts to be aware of are anisotropy for musculoskeletal ultrasound, as the former is subject to
315
less background noise, is not affected by aliasing and is

STRESS FRACTURE
independent of the angle of insonation.
Plain radiographs may be normal for several weeks before
a periosteal reaction or fracture line appears in patients
TRAUMA
with stress fracture. The gold standard for the early detec-
tion of stress fractures is considered to be MRI. Ultrasound,
FOREIGN BODY
however, does have a role. Moreover, the recognition of
Foreign bodies are commonly found in the sole of the foot stress fractures on ultrasound is important, as this is a rela-
and may present as localized masses. Often the patient will tively frequent unexpected finding in patients presenting
recall a penetrating injury. with metatarsalgia. The middle and distal portions of the
second and third metatarsal shafts are most commonly
IMAGING affected.
Foreign bodies appear as hyperechoic fragments, usually
with a linear configuration. Glass or metal often results in IMAGING
posterior acoustic shadowing but organic material such On ultrasound an acute stress fracture appears as a focal
as splinters may not demonstrate this finding. Abscesses area of cortical disruption with associated hypoechoic hae-
surrounding foreign bodies appear as heterogeneous, matoma and periosteal elevation. There is usually increased
ill-defined, low-echogenicity collections with peripheral Doppler signal around the periosteal lesion. If a suspected
increased vascularity on Doppler. stress fracture is seen it is prudent to obtain plain radio-
graphs to confirm the lesion and act as a baseline (Fig. 28.3).
Key Point
PLANTAR PLATE INJURY
Granuloma formation may occur around foreign bodies with Plantar plate injury or insufficiency may be the result of
a hypoechoic halo surrounding the foreign body. wearing high-heeled shoes, hypermobility, acute hyperex-
tension trauma or overuse. Although overall the second
metatarsophalangeal joint (MTPJ) is most commonly
The position of the foreign body in relation to other struc- involved, turf toe describes an acute hyperextension injury
tures should be assessed, as should its size and depth beneath of the first MTPJ with rupture of the plantar plate. This
the skin. If an organic foreign body such as a thorn enters condition is usually associated with playing sports on a hard
a joint or tendon sheath this may elicit a foreign body surface such as artificial turf. The injury typically occurs at
synovitis or tenosynovitis. Ultrasound can be used to mark the distal insertion of the plantar plate. Running and push-
the position of a foreign body prior to surgical removal or off are usually compromised. In the long term, the injury
to guide minimally invasive removal using microforceps may result in hallux rigidus and hallux valgus.
(Figs 28.1 and 28.2).
ANATOMY AND IMAGING
The plantar plate is a fibrocartilaginous supporting struc-
ture that connects the base of the proximal phalanx to the
Figure 28.1 Wood splinter. Extended field of view image demon- Figure 28.2 Wood splinter (same patient as in Figure 28.1). Power
strating a clearly defined linear echogenic foreign body in the sole of Doppler demonstrates marked increased vascularity within the
the foot with surrounding foreign body granuloma (arrowheads). foreign body granuloma.
CHAPTER 28 — Disorders of the Ankle and Foot: Forefoot 317
a Plantar Plate
Metatarsal
Proximal P
Phalanx A P
b D
Figure 28.4 Plantar plate insufficiency.
P Metatarsal
P A
b D
Figure 28.3 Stress fracture. Longitudinal scan showing focal peri-

osteal reaction around the metatarsal shaft (short arrows) and a break
in the cortex (long arrow). There is surrounding soft tissue swelling
with increased vascularity on Doppler.
metatarsal neck, blending in with the sesamoids and tendons

of the flexor hallucis brevis. Its function is to resist hyperex-
tension of the MTPJ.
a
Practice Tip
The plantar plate is best visualized in the longitudinal plane,

and appears as a low-echogenicity band, curving over the
Plantar Plate
metatarsal head to insert into the proximal phalanx.
The fibres of the plantar plate have a grainy homogeneous Proximal

texture. Tears manifest as discontinuity of the plate or Phalanx Metatarsal
altered echogenicity (Fig. 28.4). There may be associated
synovitis of the MTPJ, flexor tenosynovitis and persistent P
A P
hyperextension of the proximal phalanx. If MRI is per- D
b
formed bone oedema may be seen in the metatarsal head
and proximal phalanx due to hyperextension of the joint Figure 28.5 Turf toe. Longitudinal scan showing an avulsion of the
(Fig. 28.5). base of the proximal phalanx (arrow) with discontinuity of the fibres
Most plantar plate injuries can be managed nonsurgically of the plantar plate (arrowhead).
with insoles and strapping, with severe injuries requiring
long-term immobilization in a boot or cast. If conservative
treatment is unsuccessful, surgery is considered.
the joint. The medial sesamoid is most affected and it is
usually bipartite.
SESAMOIDITIS
The term ‘sesamoiditis’ covers a spectrum of pathological IMAGING
conditions, including stress fractures, osteochondritis, chon The hallux sesamoids are embedded within the medial and
dromalacia and avascular necrosis of the sesamoid bones of lateral slips of the flexor hallucis brevis tendon at the level
the first hallux. Sesamoiditis is usually caused by repeated of the first metatarsal head. A thick intersesamoid ligament
forefoot loading such as dancing and running. The onset connects the sesamoids, which in turn are attached to the
may be acute or develop insidiously. Patients complain of base of the proximal phalanx by the sesamoid-phalangeal
pain beneath the first MTPJ, with restricted movement of ligament. The anatomical arrangement forms part of a
EHL
a
Proximal
Phalanx
FHL
Metatarsal
D
P A
Lateral Sesamoid b P
Figure 28.7 Freiberg’s infraction. Longitudinal scan showing irregu-

larity of the second metatarsal head (arrows) with associated
synovitis.
Metatarsal
P
M L FREIBERG’S INFRACTION
b D
Freiberg’s infraction is characterized by collapse of the
Figure 28.6 Sesamoiditis. Transverse scan showing a bipartite second or third metatarsal head, which is thought to be
irregular medial sesamoid (arrows), with a normal appearance of the related to repetitive trauma, resulting in microfractures and
lateral sesamoid (arrowhead). avascular necrosis. It occurs more commonly in females and
typically affects adolescents. The disease is more common
when the first metatarsal is shorter than the second.
IMAGING
gliding mechanism that reduces friction and protects the On radiographs there is initially sclerosis of the metatarsal
tendon. A primary function of the hallux sesamoids is to head, followed by collapse and irregularity. On ultrasound
absorb the weight-bearing force of the medial forefoot. the metatarsal head is flattened and irregular. There is often
Plain radiographs should be obtained to assess for sclero- synovitis at the MTPJ, which may be associated with increased
sis or fragmentation of the sesamoids. In nearly all cases of vascularity on Doppler (Fig. 28.7).
sesamoiditis, the sesamoid bone is bi- or multipartite. On With most cases of Freiberg’s infraction off-loading the
MRI there may be bony fragmentation with bone oedema metatarsal head may be sufficient. If synovitis is a major
on fluid-sensitive sequences. If there is avascular necrosis feature, steroid injection may give long-term pain relief.
the affected sesamoid is of low signal on all sequences. Surgery can be helpful in patients with on-going pain.
Ultrasound may show fragmentation of the sesamoids, and
in some cases there may be associated tendinopathy of the
flexor hallucis longus tendon. Bipartite sesamoids can be MASSES
difficult to differentiate from sesamoid fractures and most
may even be fractures. Acute fractures have sharp, uncorti- Ultrasound is often the first imaging modality used in the
cated margins, but this cannot usually be appreciated on evaluation of soft-tissue masses. It allows a quick and effec-
ultrasound (Fig. 28.6). tive means of confirming the presence of a lesion, and
Patients are usually managed by offloading the sesamoid provides valuable information on the site, size, morphology
by activity modification and orthotics. Ultrasound-guided and anatomical relations. Ultrasound can readily determine
injection of steroid between the sesamoid and the metatar- the cystic nature of ganglia, synovial cysts and bursitis. The
sal may also decrease pain. Surgery may alter the biome- location of the lesion in the foot can help narrow the diag-
chanics of the forefoot and cause hallux valgus or claw toe nosis. For example, lesions between the metatarsal heads
deformity, and so should be undertaken with caution. are almost invariably Morton’s neuromas or bursae.
Key Point
The differential for lesions in the sole of the foot includes

plantar fibromatosis, fat necrosis, epidermoid inclusion cyst
and foreign body granuloma.
MORTON’S NEUROMA
In 1876 Thomas Morton described ‘a peculiar and painful
affection of the fourth metatarsophalangeal articulation’
which subsequently became known as a Morton’s neuroma.
Morton’s neuroma is not a true neuroma, but instead rep-
resents perineural fibrosis and neural hypertrophy of the a
interdigital nerve as it passes between the heads of the
metatarsals. The 2/3 interspace is most commonly affected,
followed by the 3/4 interspace. The female-to-male ratio for
Morton’s neuroma is around 5 : 1, which is thought to relate
to footwear. Patients typically present with pain and paraes-
thesia, with burning or tingling sensations in the affected
toes. The symptoms may be intermittent with episodes
related to activity. Often patients describe the sensation of
a pebble in the shoe. With lateral compression of the fore-
foot the pain is reproduced and there may be a palpable
and audible Moulder’s click.
IMAGING
The patient should be positioned supine on the couch with b
their foot in the neutral position. As described in Chapter
Figure 28.8 Morton’s neuroma. Sagittal plane ultrasound at the
23, evaluation for Morton’s neuroma is best performed with level of the metatarsal heads shows a well-defined rounded low-
the probe in the sagittal plane positioned either on the echogenicity nodule with the intermetatarsal nerve identified leading
dorsum or plantar aspect of the forefoot. The forefoot is into the nodule (short arrows).
held steady with one hand while the probe is passed slowly
across the MTPJ into the intermetatarsal space, and then
across to the next MTPJ. When the probe is directly over
the intermetatarsal space… Practice Tip
Practice Tip … Moulder’s click has been shown to be a very nonspecific

sign with clicks occurring with or without an accompanying
… it can be very helpful to press a finger into the dorsal neuroma or the click occurring in one interspace and the
aspect of the space to try to elicit symptoms and also neuroma in another.
improve the conspicuity of a suspected Morton’s neuroma.
On Doppler interrogation there is normally no increased
Typically, a Morton’s neuroma appears as a round or vascularity (Figs 28.8 and 28.9).
ovoid hypoechoic nodule, in the sagittal plane on the Ultrasound has been shown to have a very high sensitivity
plantar aspect of the intermetatarsal ligament. They can be and specificity for the diagnosis of Morton’s neuromas, with
of varying size, often 1 cm in diameter or greater. The sig- a high correlation with MRI and surgical findings. Imaging
nificance of smaller lesions is uncertain. Careful evaluation can have an important bearing on the management of
may reveal the intermetatarsal nerve entering the nodule. patients with Morton’s neuromas. A tentative diagnosis of
Occasionally, a bilobed configuration may be present with Morton’s neuroma can be made during clinical assessment,
a component extending dorsally. A Morton’s neuroma is but imaging correlation allows exact localization and detec-
usually slightly compressible, whereas a highly compressible tion of multiple lesions, which may guide intervention. In
lesion suggests an associated intermetatarsal bursa. However, addition, ultrasound allows other causes of metatarsalgia to
a clear distinction between these two entities is difficult and be excluded.
often they coexist. This has led to the more generally used
descriptive term ‘Morton’s neuroma and intermetatarsal Key Point
bursal complex’ or, more simply, Morton’s bursa complex.
In the transverse plane a Morton’s neuroma can be visual- The presence of a Morton’s neuroma is not always
ized as a mushrooming lesion arising on the plantar aspect associated with symptoms, so clinical correlation is crucial
between the heads of the metatarsals, particularly on lateral and the sonographer should report if symptoms were
compression of the forefoot (Moulder’s manoeuvre). In reproduced during the examination.
some patients a palpable click occurs, although …
a Figure 28.10 Ganglion. Small anechoic nodule with posterior

acoustic enhancement. Note the reverberation artifact at the anterior
aspect of the nodule (arrow).
causing irritation with footwear. A ganglion arising in the

tarsal tunnel may cause compression of the tibial nerve or
Neuroma its plantar branches, resulting in tarsal tunnel syndrome.
FT This usually manifests as pain and paraesthesia affecting the
FT sole of the mid- and hindfoot.
IMAGING
3 MT Foot and ankle ganglia typically measure 1–3 cm versus less
4 MT
than 1.5 cm for most wrist ganglia. On ultrasound ganglia
appear as anechoic or hypoechoic masses, often with inter-
nal septations. There is usually posterior acoustic enhance-
ment. Occasionally there may be debris within the cyst. A
careful search for the origin of the ganglion should be per-
b
formed, as the neck or duct will need to be removed if
Figure 28.9 Morton’s neuroma. Transverse scan at the level of the surgery is contemplated. Reverberation artifact produces
metatarsal heads shows ‘mushrooming’ (arrows) of a Morton’s anterior echoes at the anterior wall of the cyst and should
neuroma. not be mistaken for internal echoes. Using copious ultra-
sound gel or using a stand-off can eliminate this (Figs 28.10
and 28.11).
Some studies have shown that the size of the lesion has no Asymptomatic lesions may be left alone, and can spontane-
significant bearing on patients’ symptoms but others have ously resolve. Treatment options include aspiration with or
shown that lesions larger than 5 mm are more likely to cause without injection of steroid, and surgical excision. The tech-
symptoms. niques for ganglion aspiration are discussed in Chapter 29.
Management of Morton’s neuromas involves offloading,
with the use of appropriate footwear and orthotics. Steroid,
PIGMENTED VILLONODULAR SYNOVITIS
alcohol injections or radiofrequency ablation may be effec-
tive alternatives to surgical excision. Pigmented villonodular synovitis (PVNS) is a synovial pro-
liferative disorder associated with haemosiderin deposition.
The condition may occur in any structure that has a synovial
GANGLIA AND SYNOVIAL CYSTS
lining, such as joints, tendon sheaths or bursae. It is most
A ganglion is a unilocular or multilocular cyst containing frequently seen in the knee, hip, ankle and elbow. PVNS
mucoid material surrounded by a fibrous capsule, but usually affects adults aged between 20 and 50 years and may
lacking a true synovial lining (unlike a true synovial cyst). manifest as a focal mass or as a generalized lesion involving
Ganglia may communicate with an adjacent joint or tendon the whole joint. Patients complain of chronic joint pain and
sheath but may also lie separately in the soft tissues. Ganglia swelling, with painful exacerbations due to bleeding. Histo-
are thought to result from focal myxomatous degeneration logically, PVNS is characterized by synovial inflammation
of collagenous tissue or from a communication with a joint with haemosiderin deposition, giant cell proliferation, col-
or tendon sheath. If there is communication with a joint, lagen and lipid-laden macrophages.
the lesion is usually referred to as a synovial cyst. In the
ankle and foot, ganglia most frequently arise on the dorsal IMAGING
aspect around the talonavicular joint or in the region of the When PVNS affects a joint there may be a focal mass or
sinus tarsi. Ganglia typically occur in the second to fourth diffuse joint involvement. Ultrasound demonstrates a non-
decades of life and present clinically as focal masses, often specific appearance with an effusion, synovial hypertrophy
Figure 28.12 GCTTS. Coronal T1-weighted MRI shows an interme-

diate signal mass in the interspace between the fourth and fifth
metatarsals. Areas of very low signal within the lesion are typical for
haemosiderin deposition.
Ganglion
FDL
a
Cuneiform
D
A P
P
b
Figure 28.11 Ganglion. Ultrasound shows an anechoic compress- 4 Metatarsal 5 Metatarsal

ible cystic structure with a duct (arrows) extending to the region of
the navicular cuneiform joint.
P
M L
D
and increased vascularity. Erosions may occur and eventu- b
ally there is joint destruction. Typically joint aspiration
reveals a bloodstained effusion. If PVNS is suspected then Figure 28.13 GCTTS (same patient as in Figure 28.11). Ultrasound
shows a low-echogenicity mass in the intermetatarsal space (arrow-
MRI should be performed, as this will show low-signal hae-
heads), with splaying of the metatarsal heads.
mosiderin deposition on all sequences.
PVNS can cause joint destruction and be locally aggres-
sive. Treatment primarily consists of resection of the lesion
or synovectomy. Studies have shown a recurrence rate of heterogeneous in texture. There is often minor vascularity
10–20% in focal disease and up to 50% in the diffuse form. on Doppler. The underlying tendon is usually not involved,
with normal excursion of the tendon on dynamic scanning
(Figs 28.12 and 28.13).
GIANT CELL TUMOUR OF THE TENDON SHEATH
The localized form of PVNS is called giant cell tumour of
PLANTAR FIBROMATOSIS (LEDDERHOSE DISEASE)
the tendon sheath (GCTTS). In this form, the disease pres-
ents as a slowly growing lobular mass. In the foot, the pero- The plantar fascia is a thin band of fascia extending from
neal and flexor tendon sheaths and the digits are most the inferior margin of the calcaneus to the plantar plates
commonly involved. GCTTS are usually small hypoechoic of the MTPJs and the bases of the proximal phalanges.
lobular masses most commonly found in the digits arising Plantar fibromatosis is a benign fibroblastic proliferative
from the tendon sheath. They may be homogeneous or disorder of the plantar fascia that usually manifests as a firm,
Figure 28.16 Epidermoid cyst. Well defined ovoid mass (arrow-

heads) in the subcutaneous tissues of the sole of the foot. The lesion
b contains internal echoes in keeping with keratin. There was no internal
Figure 28.14 Plantar fibromatosis. Extended field of view ultra- vascularity on Doppler.
sound showing two discrete plantar fibromas (arrowheads) pointing
at different signal characteristics. The origin of the plantar fascia is
clearly demonstrated (arrow). dermis. Histologically, they appear as a keratin-containing
cyst lined with epidermis. The epidermis nearly always arises
from the infundibulum of a hair follicle. Epidermoid cysts
are, therefore, most common in the hairy areas of the body,
such as the scalp, face and scrotum. Occurrence in the
extremities is less frequent, and usually due to traumatic
implantation of epidermal tissue. In the foot, the common-
est location is at the plantar or medial aspect of the first
metatarsal head. On ultrasound, epidermoid cysts are
usually well-circumscribed, ovoid, mildly echogenic masses
with occasional linear anechoic and/or echogenic reflec-
tions related to lamellation of keratin debris (Fig. 28.16).
There is usually increased through-transmission, with a
hypoechoic rim and no Doppler flow. A ruptured epider-
moid cyst, however, may have lobulated contours with
increased internal vascularity.
Figure 28.15 Plantar fibromatosis. Doppler interrogation reveals
disorganized vascularity throughout the lesion, which is commonly HAEMANGIOMAS AND VASCULAR
encountered. MALFORMATIONS
A haemangioma is a vascular anomaly characterized by
slowly growing mass. Typically, the lesion is painless. Patients increased cell turnover of endothelium, mast cells, fibro-
usually present between the ages of 30 and 50 years. Bilat- blasts and macrophages. The tumour is not present at birth
eral involvement is common. This condition is also discussed but usually becomes evident in the first few weeks of life, as
along with other disorders of the plantar fascia on page 282. a firm noncompressible mass. This is followed by a period
of proliferation when there is rapid growth, after which the
IMAGING lesion begins to involute. Up to 70% of cases resolve spon-
Plantar fibromatosis usually affects the central and medial taneously by 7 years of age. Some lesions however persist
portions of the plantar arch. The typical ultrasound appear- into adulthood.
ance is of a well-defined, hypoechoic fusiform mass arising Vascular malformations, on the other hand, are not true
from the plantar fascia adjacent to the plantar muscles in neoplastic lesions but are errors of vascular morphogenesis
the medial aspect of the foot (Figs 28.14 and 28.15). with a normal rate of endothelial turnover. They therefore
The lesion may decrease in size spontaneously. Most grow commensurately with the child. Sometimes they can
lesions are best left alone as incomplete excision or biopsy enlarge suddenly due to haemorrhage, infection or hor-
may result in aggressive transformation with local invasion monal changes at puberty. They are present at birth (unlike
of tissues. Surgery with wide excision is reserved for haemangiomas), although they may not become apparent
larger, painful lesions and those involving neurovascular until early adulthood. They can be subdivided according to
structures. main vessel type: capillary, venous, arterial and lymphatic,
often occurring in combination.
EPIDERMOID CYST (EPIDERMAL INCLUSION CYST) IMAGING
An epidermoid cyst occurs due to proliferation of keratin- Haemangiomas and vascular malformations have a variable
producing epidermal cells within a focal region of the appearance according to the predominant vessel type.
a b c d
Figure 28.17 Vascular malformation. Well-defined low echogenicity mass on the dorsum of the foot.
Haemangiomas often appear as well-defined compressible

solid echogenic or hypoechoic masses with cystic or serpigi-
nous areas representing dilated vessels. The presence of a
solid component can help distinguish haemangiomas from
arteriovenous malformations.
Key Point
It is important to distinguish low-flow haemangioma Figure 28.18 Neurofibroma. Small ovoid mass with dural tail at both
(capillary, venous, lymphatic or a combination) from ends (arrows) typical of a nerve sheath tumour.
high-flow (arteriovenous) lesions.
Capillary vascular malformations may demonstrate no sig-

nificant flow on Doppler. Venous malformations are com- is seen on Doppler imaging. Lesions larger than 5 cm with
prised of dilated slow-flowing vascular spaces and channels infiltrative margins and rapid growth should raise the suspi-
with no solid tissue component aside from septations. cion of malignancy.
Practice Tip MALIGNANT SOFT TISSUE TUMOURS
On compression and release of haemangioma there is slow The vast majority of soft tissue tumours of the foot and ankle
filling of the lesion. are benign, but it should be recognized that malignant
tumours can present as an indolent mass. The differential
for malignant soft tissue tumours is wide, including synovial
Lymphatic malformations have multiple lymphatic fluid- sarcoma, malignant fibrous histiocytoma, Kaposi sarcoma,
containing spaces with septations. Phleboliths appear as malignant melanoma and leiomyosarcoma.
echogenic foci with posterior acoustic enhancement. MRI
can be very helpful in the further evaluation of suspected
SYNOVIAL SARCOMA
haemangiomas or vascular malformations (Fig. 28.17).
Synovial sarcomas are the commonest soft tissue malignant
tumours occurring in the foot and ankle. Most patients
PERIPHERAL NERVE SHEATH TUMOURS
present between the ages of 15 and 40 years. The tumour
Peripheral nerve sheath tumours (PNSTs) are common in occurs primarily in the extraarticular areas of the extremi-
the ankle and foot. Schwannomas arise from the Schwann ties near tendon sheaths, bursae and the interosseous mem-
cells surrounding nerves, whereas neurofibromas arise form branes. Microscopically, these neoplasms appear similar to
the nerve fascicles. The latter tend to involve the smaller synovial tissue, which gives it its name. It is rarely intraarticu-
cutaneous nerves, as opposed to the larger nerves. Patients lar. Synovial sarcomas represent around 8% of all soft tissue
may present with a mass or with neural symptoms such as sarcomas. Three types are described: fibrous, epithelial and
pain or paraesthesia. poorly differentiated. Most have a biphasic appearance with
both fibrous and epithelial cells. Rarely, the tumour exhibits
IMAGING one monophasic form without exhibiting the other. Pain
The main imaging feature of a PNST is of a hypoechoic and tenderness are common presenting features. Two fea-
fusiform mass with a ‘dural tail’, the latter representing the tures that may lead to a mistaken diagnosis of a benign
entering or exiting nerve and adjacent vein (Fig. 28.18). lesion are slow growth (average time to diagnosis 2–4 years)
Schwannomas typically lie eccentrically in relation to the and small size at presentation. Calcification of the tumour
nerve, which may allow its differentiation from a neurofi- may be seen in 30% of cases. Tumours that exhibit calcifica-
broma. The neurovascular bundle is surrounded by fat so tion are associated with longer survival rates. Involvement
masses arising in this location may demonstrate a surround- of underlying bone may occur, with extrinsic erosion or
ing rim of fat, the ‘split fat’ sign. Usually, some vascularity periosteal reaction in up to 20% of synovial sarcomas.
IMAGING SYNOVITIS
In a study of the ultrasound appearances of synovial sarcoma,
Marzano et al. found that 66% of 35 cases revealed a focal, Synovium lines the joints of the foot as well as the bursae
nodular, round or lobulated, solid but hypoechoic soft and tendon sheaths. Several pathological processes affect
tissue mass suggestive of a more indolent, less aggressive the synovium, including primary synovial inflammatory dis-
process. Prominent heterogeneity with irregular margins orders, infections, degenerative and posttraumatic synovitis,
was demonstrated in 14% of the 35 cases. A complex appear- deposition diseases and tumours. The synovium responds in
ance was present in 20% of the 35 cases, with homogeneous a relatively predictable fashion when involved in acute
hypoechoic well-defined areas (indicating regions of haem- inflammatory processes: with hyperaemia, oedema and pro-
orrhage or necrosis) and heterogeneous, more hyperechoic liferation, termed synovitis. Usually there is an associated
areas with irregular margins (indicating cellular areas of effusion, with joint, bursal, or peritendinous fluid. Hyper-
aggressive viable tumour). Lesions are often deep-seated trophied synovium is ultimately responsible for the damage
and typically intimately related to tendons, tendon sheaths to the underlying cartilage and bone. As the synovitis
and bursae. becomes chronic the hyperaemia and proliferation subside
On Doppler there is usually increased neovascularity in and synovial fibrosis develops.
regions of viable tumour. Plain radiographs of synovial inflammation are usually
nonspecific, demonstrating only periarticular soft tissue
swelling. They are therefore insensitive to the early detec-
Practice Tip tion of synovitis in inflammatory arthropathy, when aggres-
sive therapy may be of greatest value in preventing
The vessels in malignant tumours have an irregular margin irreversible damage. MRI, with its multiplanar capabilities
and lack a muscle layer and therefore the pattern of and exquisite contrast resolution, is considered the gold
vascularity may suggest an aggressive neoplasm, typified by standard for evaluating synovitis. Compared with MRI, ultra-
a multiple branching pattern with stenoses, arteriovenous sound with power Doppler is considered at least as sensitive
shunts and small loops.
at demonstrating synovitis and effusions, but less sensitive
at detecting erosions. MRI also has the advantage of being
able to demonstrate subarticular marrow oedema, which is
In practice, a cautious approach to differentiating benign a good predictor of disease severity in inflammatory arthrop-
from malignant tumours should be taken as not all malig- athy. In everyday practice, ultrasound is an accessible, rapid
nant tumours have an anarchic pattern. Furthermore, and highly effective tool for confirming the presence of
necrotic lesions and low-grade neoplasms may not demon- synovitis, defining the extent of disease and assessing the
strate neovascularity and therefore the absence of flow does degree of severity, and is therefore often the first line of
not necessarily indicate benignity (Figs 28.19 and 28.20). investigation for suspected synovitis.
Synovial sarcoma is usually an intermediate or high-grade
lesion. Local staging with MRI and whole body staging with
IMAGING OF INFLAMMATORY SYNOVITIS
PET-CT should be performed. Treatment is with aggressive
wide surgical resection or amputation, combined with The European League Against Rheumatism (EULAR) has
chemotherapy. recommended standard views for scanning the foot for
Figure 28.19 Synovial sarcoma. Axial T2-fat saturated sequence Figure 28.20 Synovial sarcoma (same patient as figure 28.18).
shows a high signal mass (arrows) at the medial aspect of the foot Ultrasound shows a low echogenicity mass (arrows) with two small
within the tarsal tunnel. The image has been rotated clockwise to echogenic foci indicating calcification.
correspond to the ultrasound scan.
Synovitis
Figure 28.22 Hypervascular pannus. Longitudinal ultrasound shows

florid synovial hypertrophy with marked increased vascularity on
Doppler. There is an early erosion of the metatarsal head (arrows)
with hypervascular pannus within the erosion.
D Metatarsal
P A
b P
Figure 28.21 Erosion of fifth MTPJ. Longitudinal ultrasound shows in real-time, and has a recognized role in evaluating the
a well-defined erosion of the fifth metatarsal head (arrow) with associ- outcome of treatment. There are methodological difficul-
ated pannus (arrowheads). No significant flow is seen on Doppler. ties, however, in standardizing measurements and quantify-
ing the severity of disease, particularly if different observers
and equipment are used for follow-up studies. In practice
synovitis. Each MTPJ and intermetatarsal space should be a semiquantitative technique is recommended, grading
scanned longitudinally and transversely from the dorsal and each of the parameters of synovial hypertrophy, erosions
the plantar aspect. Scanning longitudinally from the dorsal and Doppler signal with a scoring system of 0–3; 0 (nil), 1
aspect is the most productive approach. When evaluating (few scattered vessels), 2 (more than a few vessels but less
for the presence of inflammatory synovitis, each MTPJ and than 50% of the involved synovium) and 3 (more than 50%)
interphalangeal joint should be scanned even if asymptom- (Fig. 28.22).
atic, as there may be subclinical disease. Each joint should
be evaluated for the presence or absence of synovial hyper-
OSTEOARTHRITIS
trophy, effusions, erosions and Doppler signal.
Effusions are typically anechoic intraarticular regions Osteoarthritis is a common finding in the ankle and foot,
with no flow on Doppler and can be displaced from the particularly in older patients. The classical findings of joint
region by compression. It should be recognized that small space loss and marginal osteophyte formation may be dem-
effusions are commonly seen in asymptomatic MTPJs, par- onstrated on ultrasound. Often there is associated synovitis
ticularly at the great toe, where considerable joint fluid may with synovial hypertrophy with increased vascularity and a
be asymptomatic. Runners in particular often have small joint effusion, particularly at the midfoot and first MTPJ.
MTPJ effusions or slightly thickened synovium, which can Therefore, the presence of synovitis in these regions does
be attributed to traumatic synovitis. not necessarily indicate an inflammatory arthropathy. The
In the absence of an effusion, synovial hypertrophy is entire clinical picture and blood tests may need to be con-
diagnosed by the presence of a layer of thickened, poorly sidered to differentiate between osteo-, rheumatoid and
compressible hypoechoic tissue (relative to the subcutane- crystal arthropathy (Figs 28.23 and 28.24).
ous fat) within the joint. Erosions are seen as intraarticular
discontinuities of the bone surface that are visible in two
BURSITIS
perpendicular planes. They are most commonly demon-
strated at the first and fifth metatarsal heads. Hypervascular Adventitial bursae may develop at sites where subcutaneous
pannus is usually seen within areas of active erosion. With tissue is exposed to high pressure and friction, usually over-
established quiescent inflammatory arthropathy, there may lying bony prominences or tendons. An adventitial bursa
be joint destruction with joint subluxation and erosions, but originates as a coalescence of preexisting small spaces in
no significant synovial hypertrophy or abnormal Doppler loose connective tissue. Eventually a well-defined fluid-filled
signal (Fig. 28.21). cavity is formed, which is lined by synovium-like columnar
The formation of new blood vessels, ‘angiogenesis’, is cells. In the forefoot, bursae occur in specific locations,
now established as a key factor in the formation and main- between the metatarsal heads and in the subcutaneous
tenance of synovial hypertrophy in inflammatory arthritis. tissues of the sole beneath the metatarsal heads. Bursal
Many novel therapies are directed at modulating angiogen- inflammation or bursitis can occur due to chronic trauma,
esis. Doppler ultrasound allows the assessment of vascularity infection or inflammatory arthritis.
Figure 28.23 Tarsometatarsal joint osteoarthritis. Longitudinal

image showing marginal osteophyte formation with synovial hyper-
a
trophy and increased vascularity.
Bursa
FHL
Metatarsal
Figure 28.24 First MTPJ osteoarthritis. Longitudinal image with fea-

P
tures similar to the ones in Fig 28.22. Note Doppler activity is only P A
grade 1. D
b
Figure 28.25 Adventitial bursa. Longitudinal scan shows a small

interstitial bursa (arrows) overlying the FHL tendon.
On ultrasound a bursa appears as a well-defined low-
echogenicity region that is compressible. Synovial hypertro-
phy may be present, giving rise to internal echoes and IMAGING FEATURES
internal vascularity (Fig. 28.25). Gout often presents with a nonspecific synovitis, synovial
thickening, an effusion and increased vascularity on
Doppler. Periarticular erosions may be evident. There may
GOUT
however be some features that are strongly suggestive of
Gout is a metabolic disorder characterized by hyperuricae- gout. The ‘double-contour’ sign or ‘urate icing’ is caused by
mia and deposition of monosodium urate crystals in the deposition of monosodium urate crystals on the surface of
joints and soft tissues. The acute phase of the disease is hyaline cartilage, giving an echogenic line on the surface of
characterized by recurrent attacks of synovitis. Typically the low-echogenicity articular cartilage (Fig. 28.26).
there is a rapid onset monoarthritis, with severe pain. The
interval between acute attacks of synovitis is highly variable, Practice Tip
ranging from a few days to several years. The first MTPJ is
affected in up to 50% of cases, but any joint may be involved. The double contour sign of gout is not subject to anisotropy,
The periarticular structures, such as bursae and tendons, and should persist regardless of the probe position.
may also become inflamed. Aspiration of joint fluid reveals
needle-like negatively birefringent crystals on polarized
microscopy. The serum urate may also be elevated. The ‘snowstorm’ appearance of the synovium/joint fluid is
The chronic phase is characterized by synovitis and peri- another characteristic sign of gout. This is due to multiple
articular erosions, with deposition of crystals in the joints, hyperechoic foci of variable size and shape within the effu-
bursae and tendons. Gouty tophi typically occur in the helix sion and synovial membrane, due to the echoes produced
of the ear, olecranon bursa and around the interphalangeal by the monosodium urate crystals (Fig. 28.27). Erosions
joints. Around 20% of patients with gout have renal stones typically are set away from the joint margin and have over-
and may develop interstitial nephropathy. hanging edges.
Figure 28.28 Cellulitis. Ultrasound demonstrates loss of normal fat

architecture with stranding and increased echogenicity.
Figure 28.26 Urate icing due to gout. Longitudinal ultrasound

shows synovitis (arrowheads) with a double contour (arrowhead) to
the metatarsal head due to urate crystal deposition over the articular
CELLULITIS
cartilage. Subcutaneous oedema may be due to fluid overload, vascu-
lar insufficiency, trauma or infection, and is characterized
by thickening and induration of the skin and subcutaneous
tissues. The presence of subcutaneous oedema is nonspe-
cific and cannot be differentiated from cellulitis by imaging
alone. On ultrasound there is loss of normal architecture
of the subcutaneous fat, with increased echogenicity and
poor penetration and with posterior acoustic shadowing.
Increased vascularity in the thickened tissues may be helpful
to differentiate the oedema of cellulitis from other causes,
such as fluid overload (Fig. 28.28).
ABSCESS
Simple fluid collections appear as focal anechoic regions
Figure 28.27 Snowstorm appearance of gout. Longitudinal ultra-
with posterior acoustic enhancement.
sound shows echogenic synovitis (arrows) with small foci of increased
echogenicity typical for gout. Practice Tip
Abscesses or collections of pus usually contain internal

Tophi are visualized as heterogeneous irregular masses particulate matter, which can move and swirl with
with a mixed hypoechoic and hyperechoic texture. When compression.
crystal density is high or when there is associated calcifica-
tion, acoustic shadowing occurs. An inflammatory anechoic
halo is a common finding. Internal septations may be present. There should be no
internal vascularity, but increased Doppler signal is typically
seen in the margins of the lesion.
Practice Tip
Tophi can be difficult to differentiate from rheumatoid Practice Tip

nodules; however, the latter usually appear more
homogeneous, better circumscribed and are usually not Inflammatory masses, or phlegmons, may be distinguished
associated with erosions. from abscesses by the presence of internal Doppler signal
(Figs 28.29 and 28.30).
INFECTION
Ultrasound may be useful in the evaluation of suspected soft REGIONAL PAIN SYNDROME
tissue infections of the foot. Its main role is in the detection
and delineation of soft tissue abscesses and synovitis, and for Posttraumatic regional pain syndrome or reflex sympathetic
guiding aspiration. dystrophy is a poorly understood condition characterized by
a
a
5 Metatarsal
4 Metatarsal P
M L
b D
Figure 28.29 Ulcer and phlegmon. Small sinus (arrowheads) on the

sole of the foot at the level of the metatarsal necks with an inflam- b
matory mass extending between the metatarsals (arrow).
Figure 28.30 Abscess. Longitudinal ultrasound shows a superficial
anechoic collection (arrow) in the dorsum of the foot with marked
vascularity in the wall. A gel stand-off (asterisks) has been used to
pain, hyperaesthesia and vasomotor disturbance. Eventually improve skin contact with the probe.
trophic skin changes and muscle atrophy may occur. Typi-
cally there is subcutaneous oedema with induration of the
skin, with increased vascularity on Doppler.
Kong A, Van Der Vliet A. Imaging of tibialis posterior dysfunction. Br
J Radiol 2008;81(970):826–36.
FURTHER READING Lee MH, Chung CB, Cho JH. Tibialis anterior tendon and extensor
Gregg J, Silberstein M, Schneider T, Marks P. Sonographic and MRI retinaculum: imaging in cadavers and patients with tendon tear. AJR
evaluation of the plantar plate: A prospective study. Eur Radiol Am J Roentgenol 2006;187(2):W161–8.
2006;16(12):2661–9. Mansour R, Teh J, Sharp RJ, Ostlere S. Ultrasound assessment of the
Gregg JM, Schneider T, Marks P. MR imaging and ultrasound of meta- spring ligament complex. Eur Radiol 2008;18(11):2670–5.
tarsalgia – the lesser metatarsals. Radiol Clin North Am 2008;46(6): Marzano L, Failoni S, Gallazzi M, Garbagna P. The role of diagnostic
1061–78, vi–vii. imaging in synovial sarcoma. Our experience. Radiol Med 2004;
Griffith JF, Chan DP, Kumta SM, et al. Does Doppler analysis of mus- 107(5-6):533–40.
culoskeletal soft-tissue tumours help predict tumour malignancy? Sharp RJ, Wade CM, Hennessy MS, Saxby TS. The role of MRI
Clin Radiol 2004;59(4):369–75. and ultrasound imaging in Morton’s neuroma and the effect of
Griffith JF, Wong TY, Wong SM, et al. Sonography of plantar fibroma- size of lesion on symptoms. J Bone Joint Surg Br 2003;85(7):
tosis. AJR Am J Roentgenol 2002;179(5):1167–72. 999–1005.
Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and Turner J, Wilde CH, Hughes KC. Ultrasound-guided retrieval of small
ankle, part 1: peroneal tendon disorders. Am J Sports Med 2009; foreign objects in subcutaneous tissue. Ann Emerg Med 1997;29(6):
37(3):614–25. 731–44.
PART 8
INTERVENTION
329
Musculoskeletal Intervention: 29
General Principles
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION FOREIGN BODY REMOVAL

Set Up BURSAL INJECTION
Treatment Rationale Overview
Corticosteroids and Their Side Effects Ultrasound Patterns of Bursal Disease
Local Anaesthetic Preparations JOINT INJECTION
General Principles of Ultrasound-Guided Large Joints
Injection Small Joints
Needle Techniques Children
SOFT TISSUE BIOPSY Synovial Biopsy
Important Principles CALCIUM BARBOTAGE
Biopsy Needles Overview
Technique Technique
INJECTIONS AROUND TENDONS GANGLION ASPIRATION
Tendon Sheath Injection Overview
Paratenon Injection Technique
Therapy Directed at the Tendon Itself:
Controlled Reinjury and Repair
Therapy Directed at the Tendon Itself:
Proliferant Therapy
Therapy Directed at Angiogenesis
anaesthetic into a presumed pain generator is an important

INTRODUCTION part of the clinical workup in musculoskeletal practice,
which cannot be replicated by systemic injection of thera-
The superficial location of many musculoskeletal structures peutic agents.
makes them readily amenable to injection therapy and
many unguided injections are carried out in the office or
ward setting. Large superficial structures are easily targeted, Key Point
although success will vary with the practitioner’s expertise.
It is generally accepted that many of these unguided injec- Guidance is important when the target is small, difficult to
feel clinically or landmarks are difficult to define. Accurate
tions will miss their target, but, despite this, patients not
localization is important when surgical decisions are based
infrequently report good responses. Good responses may on the patient’s response to local anaesthetic, when more
be due to local diffusion (in a non-contained space even a complex intervention is being considered or where patients
small-volume injection will spread quite widely) or systemic have failed to respond to unguided therapy.
absorption of the injected material. There is emerging
evidence, however, that clinical outcome is improved by
accurate injection, and image guidance, whether this is by
SETUP
X-ray fluoroscopy, CT ultrasound or MRI, plays an impor-
tant role in ensuring that diagnostic and therapeutic injec- In most cases, a complex setup is not required and most
tions reach their intended target. Accurate guidance of local injections can be carried out as an adjunct to the basic
331
332 PART 8 — INTERVENTION
Figure 29.2 The typical injected agents are local anaesthetic, either
long- or short-acting, and a corticosteroid preparation.
Figure 29.1 Standard interventional set-up tray. In the bottom left

corner, the two types of probe are visible. The hockey stick probe is
useful for injecting superficial structures, particularly joints. The larger is the pain generator provided the injection has been con-
linear array probe is covered by a sterile sheath. tained. There is no specific cellular inflammatory response
in most overuse injuries, although many other chemical
components of the ‘inflammatory’ cascade are present.
ultrasound examination. Syringes and needles that are Mucoid degeneration possibly augmented by a mechanical
found in most departments and wards are sufficient. Simple predisposition leads to repetitive injury and maladaptive
sterilization measures have kept the incidence of infection repair. Injection therapy in this group is aimed at inducing
very low. The routine use of a sterile probe cover is a matter more organized repair and relieving pain. Rehabilitation is
of personal preference or local policy. the most important component in managing overuse inju-
ries. This includes physical therapy, as well as analysis and
adjustment of technique and equipment if faulty. For
Key Point
patients who have undergone an unsuccessful rehabilitation
More rigorous sterility is mandatory when an implanted joint programme, interventional options include techniques
is being injected, in the presence of infection, where involving controlled breakdown and tissue repair with or
significant bleeding is expected or when it is anticipated that without augmentation by growth factor stimulation and
the needle will lie very close to the probe and risk rubbing techniques to reduce pathological neovascularization. A
against it. variety of methods of controlled reinjury have been advo-
cated and these will be discussed below. Although cortico-
steroids can sometimes be successful in this group of
For many injections, a standard footprint probe can be patients, the mechanism of action is less well understood.
used. If available, a smaller footprint probe, sometimes Their mechanism of action and rationale for use are better
referred to as a ‘hockey stick’ probe, can be used to bring understood in the truly inflammatory conditions such as
the puncture point closer to the target (Fig. 29.1). This is rheumatoid arthritis or tenosynovitis.
particularly helpful for very superficial structures such as
interphalangeal joints. CORTICOSTEROIDS AND THEIR SIDE EFFECTS
CORTICOSTEROID PREPARATIONS
TREATMENT RATIONALE
Corticosteroid preparations vary in their strength and effi-
cacy. Some of these differences are due to solubility and
Key Point composition, the latter related to chemical composition.
The composition also results in different particle sizes,
Broadly speaking, abnormalities of soft tissue commonly
which in turn has an influence on side effects. Hydrocorti-
encountered in musculoskeletal practice can be divided into
two main groups: inflammatory lesions and injuries that are
sone is generally considered the weakest of the preparations
the consequence of overuse or misuse. in general use. Triamcinolone and methylprednisolone are
intermediate in strength. The potency of dexamethasone
and betamethasone is fivefold that of methylprednisolone
Injection therapy in inflammatory lesions is aimed at reduc- or triamcinolone.
ing the inflammatory response and pain. The commonest
combination of injection therapy used is a mixture of corti- STEROID FLARE
costeroid and local anaesthetic (Fig. 29.2). The purpose of One of the most common complications occurring follow-
the local anaesthetic is to make the injection more comfort- ing steroid injection is steroid flare. This is an inflammatory
able and to assess the diagnostic response. Resolution of type reaction that comes on relatively quickly after the injec-
symptoms, albeit temporarily, confirms that the area injected tion and may last 2 to 3 days.
CHAPTER 29 — Musculoskeletal Intervention: General Principles 333
have been well described and tend to occur within several

Practice Tip days and up to the second week following injection. This
delayed onset helps to distinguish sepsis from postinjection
The features of steroid flare are similar to infection; however,
the relatively rapid onset occurring within hours usually steroid flair.
differentiates these two conditions.
HYPERGLYCAEMIA
Corticosteroid injection may lead to hyperglycaemia and
diabetics should be warned about potential changes in their
Steroid flare tends to occur in smaller joints rather than blood sugar readings. This effect may last several days.
larger ones, and it has been suggested that the long-term Rarely ketoacidosis may be precipitated.
response to injection is improved if steroid flare occurs.
There is no particular method of preventing this side effect, LOCAL ANAESTHETIC PREPARATIONS
although the prophylactic use of ice and analgesia may help
to offset its effects. DURATION OF ACTION
Lidocaine has a rapid onset of action and a duration of
SKIN CHANGES action of approximately 2–4 hours. Bupivacaine has a slower
Patients also need to be warned of the possibility of subcu- onset of action of approximately 10 to 15 min but is said to
taneous fat atrophy or skin depigmentation, particularly have a longer duration of action, but it may be no more
dark-skinned individuals. This is more common with super- than 6–8 hours. The relatively short duration of action of
ficial injections. There is some weak evidence that triam- lidocaine means that the diagnostic effect may be obscured
cinolone is a particular culprit and it is therefore suggested by the pain and anxiety related to the procedure itself. As
that this agent is not used for superficial injections or injec- previously outlined, an important role of the local anaes-
tions where there is a risk of the injected material tracking thetic component of the injectate is to assist with diagnosis
back along the needle. The adverse effect is thought to be and confirm that the patient’s symptoms do indeed emanate
due to a cytotoxic effect of the corticosteroid combined with from the structure being anaesthetized. A longer-acting
alterations of collagen and glycoaminoglycogen. Local vaso- agent has obvious advantages. It is important to ensure that
constriction may have an additive effect. The patient com- the patient understands that they need to test their symp-
plains of a palpable depression of the skin surface at the site toms following the injection, particularly in the initial
of injection. Other local effects on skin include depigmenta- several hours.
tion and atrophy. The effect may not occur immediately and
can resolve, albeit over several years.
Key Point
TENDON INJURY
It is well recognized that direct injection of corticosteroid A pain diary is a simple method of recording the response
into a tendon may precipitate tendon rupture. It is also and should be kept for several weeks.
suspected that injection around a damaged tendon carries
a similar risk. This poses a particular challenge to ultrasound-
guided injections for tenosynovitis, particularly those involv- The diagnostic component of a local anaesthetic is less
ing lower limb tendons. The sensitivity of modern ultrasound important in patients undergoing repeated injections
equipment is such that subtle abnormalities are frequently following previous successful therapy, although it is still
identified within the tendon in patients with predominant helpful to include some local anaesthetic to manage steroid
tenosynovitis. In such cases, it is becoming increasingly flare.
accepted that tendon sheath injections are not contraindi-
cated, but the patient should be warned of the potential CHONDROTOXICITY
risks, should avoid heavy-impact exercise or exertion and in Concern has been raised regarding toxic effects of intra
many cases the tendon should be immobilized in a cast or articular injections on articular cartilage. These have pre-
boot for several weeks to protect it. dominantly focused on local anaesthetics, particularly
bupivacaine, although corticosteroids have also been impli-
FLUSHING cated in the past. It does appear that repeated corticoste-
Facial flushing, facial redness and feelings of increased tem- roid injections can result in cartilage loss, although this
perature are not uncommonly experienced. They tend to occurs in a very small proportion of patients over a long
occur within hours of the injection and generally last for period of time. In vitro tests of bupivacaine have demon-
one day. It has been suggested that this is a histamine strated a cytotoxic effect on cartilage. Concern has been
response and antihistamines may be helpful in alleviating expressed over the use of this agent for intraarticular injec-
what can sometimes be an unpleasant side effect. tions, although its use as an intraarticular infusion following
joint surgery is a greater risk. Lidocaine has been shown to
SEPTIC ARTHRITIS be less toxic, although its duration of action is less than
Allergic reactions to corticosteroid injections are rare but bupivacaine and may therefore not be as useful an agent as
are occasionally encountered. The most significant compli- a diagnostic test. A suggested compromise is to use isomers
cation is septic arthritis. Fortunately the incidence of this of bupivacaine, ropivicaine or chirocaine, which are said to
complication is rare. There have been various reports but it be less toxic and have durations of action only slightly
is probably less than 1/1000 injections. Symptoms of sepsis shorter than bupivacaine.
GENERAL PRINCIPLES OF ULTRASOUND-GUIDED

INJECTION
Most ultrasound-guided procedures can be kept relatively
comfortable for the majority of patients. Unfortunately
some are intrinsically painful, but even in these careful
attention to detail can help minimize the trauma. Patients
do not like to see needles and it is important that they are
not flaunted. This is particularly important for children,
where even the use of the word ‘needle’ should be avoided.
Communication between the sonologist and assistant can be
limited to describing the colour of the needle required.
Once everything is made ready, the procedure should be
carried out as quickly and as efficiently as possible.
The patient should be in as comfortable a position as
possible, preferably one where they do not have to observe
the procedure. It is also important that the operator is com-
fortable and machine and couch heights should be adjusted
as appropriate. It is probably better to have the side being
injected closest to the operator so as not to have to stretch
over the patient, though of course this cannot be avoided if
both sides are being treated simultaneously. To begin, a
preliminary examination is carried out and a mark is placed
on the skin when the best puncture point and approach to
the lesion is found. It is sometimes helpful to use the blunt
end of a needle sheath to make the mark, as marking with Figure 29.3 A small circular mark has been made on the patient’s
a pen can be difficult in the presence of ultrasound gel. skin by gentle compression with the open end of a plastic needle
Alternatively two marks can be made at right angles to each cover. This can be made through local anaesthetic gel where it is
other away from the injection point out of any skin gel. This difficult to use skin markers. If necessary a line can also be drawn
is more appropriate for injection of larger structures. In indicating the initial needle direction.
addition, it is sometimes helpful to draw a line next to the
mark, giving the initial direction of approach for the needle
(Fig. 29.3).
Practice Tip
Thought should be given to the choice of puncture point and

needle track. In addition to the obvious desire to reach the
target without transgressing important structures, particularly a
nerves, there is also an advantage in choosing a course that
keeps the needle as parallel as possible to the ultrasound
probe.
Visualization of the needle is best under these circumstances b

(Fig. 29.4). If a parallel approach is not possible, the closest
alternative should be chosen. Beam steering or an asym-
metrical gel layer can be employed to optimize the ‘probe
to needle angle’ relationship.
Lidocaine is slightly acidic and may cause a stinging sensa-
tion that can be reduced by the addition of a small amount
c
of sodium bicarbonate. If the target is very superficial, with
experience, local anaesthetic is not required and can add
to the discomfort of the procedure. If local anaesthetic is to
be used, it is preferable to sterilize the skin and inject local
anaesthetic before drawing up the other injection agents or
Figure 29.4 Three needles have been inserted into gel. Needle a is
preparing a sterile probe. This gives some time for the local
inserted at a slight angle compared with needle b (arrow). The reflec-
anaesthetic to work before proceeding with the injection. A tivity of the latter is clearer. The discrepancy increases as depth
single puncture is recommended with local anaesthetic infil- increases. Needle c is specially formulated with a coating to increase
trated using the same needle that will be used for the actual ultrasound reflectivity. Although the needle is considerably more
injection. Exceptions are where a large needle is to be used, reflective, the additional expense in the majority of cases is not
such as for ganglion aspiration or in needle-phobic patients. necessary.
In these cases the skin is anaesthetized with the smallest the bevel, therefore for deep injections it is helpful to
available needle. counter this tendency by rotating the needle.
It is important to have an agreed local policy for patients
on anticoagulant therapy. For most superficial injections ‘OUT OF VIEW’ METHOD
when small bore needles are being employed, stable inter- For superficial small joints, there is not necessarily a need
national normalized ratio (INR) readings below 2.5 are to track the needle from skin to target. Instead, the probe
often accepted. When larger needles are required, for biop- is placed in the sagittal plane over the target joint such that
sies or where the injection is in an area where occult bleed- its midpoint is directly over the joint or its most distended
ing could be problematic, alternative arrangements should or effused part. The skin is punctured in the midpoint of
be made. Generally this involves converting the patient the long side of the probe (as opposed to the short side for
to heparin and omitting a dose the evening before the an in view approach), and directed deep and towards the
procedure. Obviously the final decision depends on the probe. If the initial position of the probe is chosen carefully
patient’s overall medical condition and risks from stopping enough and no proximal or distal angulation is applied to
anticoagulation. the needle, its tip should suddenly appear in the ultrasound
image within the joint. More recently, manufacturers have
been placing marks on the midpoint of the probes to facili-
NEEDLE TECHNIQUES
tate this. Short footprint probes also tend to be thinner,
In most cases, needles that are in general use in the depart- allowing the skin to be punctured closer to the target joint.
ment suffice. Some manufacturers produce coated needles,
which are undoubtedly easier to see; however, for most pro-
SOFT TISSUE BIOPSY
cedures the additional expense is debatable. For most pro-
cedures a 23 G needle is ample and it is useful to have a
IMPORTANT PRINCIPLES
selection of lengths available. There are two approaches
used to position needles under ultrasound guidance, A detailed discussion on the diagnosis of soft tissue masses
depending on the size and depth of the target. For deeper will be found in Chapter 31. The principal role of the ultra-
lesions, small targets and biopsies, amongst others, the sound of masses is to confirm the presence of a significant
needle is kept in view at all times. This is the in-view mass, to distinguish fluid from solid lesions, to identify tissue
approach. For superficial joint injections an out-of-view and compartment planes and to guide biopsy. Biopsy of
approach may be easier. musculoskeletal soft tissue masses follows similar principles
to the biopsy of other organs; however, there are several
‘IN VIEW’ METHOD aspects that are important when sarcoma is suspected.
For many procedures it is desirable to keep the needle in
view at all times until it safely reaches its target. For an in
view approach, the needle is aligned with the long axis of Key Point
the probe. The skin is punctured in the middle of one of
The prognosis of sarcoma is dependent on its local
the short sides of the probe at an appropriate distance from extent and in particular whether it is confined to a single
it depending on the size and depth of the target. As the anatomical compartment. It is therefore imperative that
needle is advanced, it quickly comes into view on one side the biopsy approach to a soft tissue lesion takes account
of the screen. The needle tip specifically must be identified of the compartment within which it is located and ensures
and tracked until it reaches its intended target. The shape that the track does not transgress adjacent spaces.
of the bevel must be visible to ensure that the tip and not
another part of the needle is being followed. To protect the
target, the bevel is kept upwards until the target is reached. It is mandatory to discuss the biopsy approach with the
Once within the target, the bevel is rotated to better posi- surgeon who will be carrying out the definitive surgery. This
tion the opening of the needle within the target joint, bursa is to ensure that the track can be excised through the surgi-
or sheath. cal approach to reduce the incidence of track recurrence
and, equally importantly, to ensure the biopsy does not
worsen the prognosis for the patient by spreading the
Key Point
tumour to another compartment. Some authors advocate
During the procedure, the probe should remain on the
the use of a soft tissue dye to help the surgeon identify the
target with the tip of the needle kept in view. If visualization biopsy track.
of the needle tip is lost, it should not be advanced further A particular advantage of using ultrasound guidance to
until it has been relocated. biopsy the soft tissues masses is that the internal structure
of the lesion can be assessed (Fig. 29.5). The preliminary
examination should note and avoid necrotic, fibrous or
To relocate a ‘lost’ needle tip, the probe is moved away from other atypical areas that may result in false-negative biopsy.
the target towards where the needle tip is felt to be. Once
the needle tip is located, the direction the probe had to be Practice Tip
moved to find it is noted. The probe is returned to the
target, the needle is retracted slightly and then moved in Targeting the biopsy towards more active or vascular areas
the opposite direction to bring it back into view. There is a of the tumour increases the likelihood of positive diagnosis.
tendency for needles to deflect away from the direction of
soft lesions. This system is also good for smaller and

superficial lesions.
TECHNIQUE
Once the skin and subcutaneous tissues have been satisfac-
torily anaesthetized, the needle is advanced under ultra-
sound guidance to the capsule of the lesion and this in turn
is infiltrated with local anaesthetic. If there is a suspicion
that the lesion is of neural origin, the anaesthetic needle is
gently moved to touch the periphery of the lesion to gauge
the patient’s response. If this is painful, the passage of a
biopsy needle is unlikely to be tolerated. The nerve can be
anaesthethized proximally; however, the risk of neural
injury still remains.
Once all these layers have been anaesthetized, the passage
of the biopsy needle itself should be relatively painless. Once
it is located within the lesion, the biopsy port is opened.
Practice Tip
Vibrating the needle slightly may assist in ensuring that a

reasonable core of tissue settles into the open port. Gentle
pressure can also be applied against the adjacent tissue prior
to the needle being triggered to improve the specimen.
Several cores should be obtained from different parts of the
Figure 29.5 Spring-loaded trucut-type biopsy needle with the port lesion to maximize the chance of a positive biopsy.
open inside a soft tissue tumour. It is vital that the approach is
selected bearing the subsequent surgical approach in mind.
INJECTIONS AROUND TENDONS

Solid areas can be differentiated from liquid or necrotic
ones. Important overlying soft tissue structures including OVERVIEW
vessels or nerves can be identified and avoided.
Biopsy should be avoided with aneurysms (obviously), AETIOLOGY
plantar fibroma and foreign body granuloma. The need for The aetiology of tendinosis is much debated. It is generally
biopsy should be carefully reviewed with neural tumours as agreed that there is an acceleration of the normal apop-
they are often painful and risk neural damage, and for fatty totic or ‘degenerative’ process. The cause of the accelera-
tumours due to difficulties with histological interpretation. tion is multifactorial, a combination of genetics, abnormal
Ultrasound can also be used for bone biopsy as long as the biomechanics and stress placed on the tendon by the
periosteum is involved, there is a cortical breach or there is nature of the patient’s sporting or occupational activity.
an associated soft tissue mass. In more complex cases, com- Abnormal ‘stress’ may be either an increased or decreased
bining ultrasound with fluoroscopy for bone biopsy can be load, as certain levels of use are required to maintain
very useful. tendon function. The term ‘overuse’ is beginning to be
superseded by the more apt term ‘misuse’. A variety of
other factors contribute to the susceptibility of a given
BIOPSY NEEDLES
tendon to injury. An anatomical predisposition such as a
Practice Tip valgus hindfoot or patella alta may combine with a biome-
chanical or training defect, such as a rapid increase in
Diagnostic yield is improved by the use of larger needles. running distance, change of racket grip or poor technique,
With automated core type needles, a 14 G port provides a to lead to tendinosis. Other factors may prevail, including
specimen significantly larger than an 18 G one. systemic disease (diabetes, renal disease and rheumatoid
arthritis) and drugs. Some tendons are also said to have
particular susceptibility to injury in certain locations due to
There are multiple designs of these needles, some with vascular watershed.
external and others with internal spring systems. A useful The biochemical pathway of accelerated apoptosis is
variant for small masses, particularly around the hands increasingly being studied. An increase in cytokines has
and feet, are systems that are capable of providing either a been detected in disordered tendons and animal studies
1 cm or 2 cm core, depending on how it is cocked. have confirmed that these predisposed tendon degenera-
Another type of soft tissue biopsy system takes a spiral tion histologically. Cytokines are known to play an impor-
sample as it is twisted into the mass and is useful in very tant role in oxidative stress-induced cellular apoptosis and
excessive apoptosis has been confirmed in abnormal rotator

cuff and patellar tendons. The activation of cytokines and TREATMENT OPTIONS
associated factors is said to result in the release of protein The first line of tendon therapy is conservative. The under-
kinases, oxygen free radicles and other apoptotic mediators, lying cause should be identified as far as possible and any
resulting in weakening of the collagen matrix and cell underlying biomechanical, technique or equipment faults
death. Interleukins, macrophage inhibitory and alpha rectified. Physical therapy, including lifestyle changes and
tumour necrosis factors have all been implicated in the eccentric loading programmes, is important and needs to
biochemical cascade. Other secretory factors such as vascu- be diligently followed. Intervention should only be consid-
lar endothelial growth factor are thought to underlie the ered if simpler measures fail.
angiogenesis associated with tendon degeneration and this A variety of ultrasound-guided therapies directed at the
in turn may stimulate the ingrowth of abnormal neural tendon have been described. The main groups are planned
structures (angioneurogenesis). Clinical studies have dem- reinjury and vessel ablation therapy. Planned reinjury gener-
onstrated a correlation between active Doppler signal within ally refers to dry needling, which may be accompanied by
a tendon and pain. What is also apparent is that there is some form of proliferant injection such as autologous blood
a lack of a true cellular inflammatory response such as or platelet-rich plasma (PRP). If angiogenesis is prominent,
might be seen with rheumatoid arthritis. Although this has therapies directed against new vessel formation are used,
led to criticism of the term ‘tendinitis’, it is clear that an including sclerotherapy, radiofrequency and high-volume
inflammatory biochemical mechanism is present in its injection.
broadest sense. If the tendon sheath is primarily involved, corticosteroid
injection is attempted for patients with no or very minimal
TERMINOLOGY associated tendon disease. Tendons that do not have a
A variety of terms have been suggested to describe tendon tendon sheath may have a paratenon which itself may
disease, although not all authors use them in the same way. become diseased, giving rise to the term paratenonopathy.
The term tendinosis or tendinopathy has been suggested to If paratenonopathy is present, stripping or distension pro-
replace tendinitis, reflecting the absence of a cell-mediated cedures are used. Surgery remains an option if all else fails.
inflammatory reaction in most cases. Mostly the two terms The principles of these different techniques will be dis-
are synonymous; occasionally tendinosis is used when symp- cussed in more detail.
toms are not present and tendinopathy when the tendon
changes are associated with symptoms.
TENDON SHEATH INJECTION
Tendinosis may be focal or generalized, fibre continuity
may be preserved or areas of delamination may be present.
Some tendons are sheet-like, supraspinatus and pectoralis Key Point
major are examples, and others are more cylindrical. Cylin-
Inflammatory tenosynovitis can be treated by corticosteroid
drical tendons may undergo partial or complete tears.
injection guided into the tendon sheath. Careful assessment
Full-thickness tears are self-explanatory; the term partial of the underlying tendon is important as, if the tendon is
thickness tear is used when there is interruption of the damaged, corticosteroid injection may increase the risk of
normal tendon fibres but the lesion does not involve the rupture.
entire tendon thickness. Some authors reserve the term
partial tear to mean an acute injury by whatever mecha-
nism the tendon fibres become disrupted. Under these cir- The recommended approach to specific tendon sheaths will
cumstances, the term focal degeneration or delamination be discussed in Chapter 30; however, certain general prin-
is reserved for fibre disruption that is the consequence of ciples do apply. As with other musculoskeletal structures, an
longer term misuse or overuse. In these cases there is often approach should be chosen that is free of other overlying
a preexisting tendinopathy. Other authors use the term structures, particularly vessels and nerves. Given the length
partial tear to mean all fibre disruptions regardless of of most tendon sheaths, this generally does not pose a
whether they are acute or chronic. Sheet-like tendons have problem. The approach to the tendon sheath can either be
thickness and width. The description of tendon tears must parallel with the tendon or perpendicular to it, i.e. either
be expanded appropriately to include an assessment of along its short or its long axis. There are advantages and
whether the tendon is partially or fully torn as before, but disadvantages to each of these; the principal determinant
also give an indication of the partial or full width of the will be whichever is the easier and is not obstructed by other
tear and its location within the sheet-like tendon. An structures.
example of such a description would be a 1 cm full- In all cases it is important to keep the needle tip in full
thickness partial width tear of the leading edge of view. If the bevel of the needle cannot be clearly seen, then
supraspinatus. it is out of the plane of the image and may be threatening
Pain in tendons that do not have a tendon sheath are the tendon or an adjacent structure. Some authors advocate
amongst the commonest causes of musculoskeletal presen- approaching with the needle bevel towards the tendon to
tation. Such tendons include the supraspinatus tendon, help protect it. Another useful tip, particularly for superfi-
common flexor and extensor origin, patellar and Achilles cial tendons, is to put a small bend in the needle at the
tendons. The Achilles and patellar tendons do not have a junction between the needle itself and its hub. This can be
tendon sheath but are instead surrounded by a paratenon. helpful to manoeuvre around elements of the patient’s
In some patients, symptoms arise from distension or thick- anatomy that would otherwise get in the way of a direct
ening of the paratenon. approach. An alternative is to attach a short length of tubing
THERAPY DIRECTED AT THE TENDON ITSELF:

CONTROLLED REINJURY AND REPAIR
Tendinopathy without associated tenosynovitis or paratenon-
opathy is one of the most difficult entities to treat. As has
been previously outlined, the first steps should be conserva-
tive and directed against identifying and alleviating the
cause whether it be biomechanical, a training or equipment
issue. Several ultrasound-guided techniques have been pro-
posed when conservative measures fail and surgical options
are considered too aggressive. These are divided into several
groups: controlled reinjury and repair with or without pro-
liferant therapy, therapies directed against abnormal vessel
formation and stem cell therapy. The evidence base for all
these therapies is poor. Much is based on anecdotal reports
of benefit in what are generally small to medium-sized
patient groups. Randomized controlled trials are sparse and
there is often poor documentation of previous or current
therapies. Despite this, percutaneous therapy provides a
Figure 29.6 Injected fluid surrounds the tendons on all sides, con- useful stopgap between rehabilitation and surgery. With
firming correct positioning of the needle within the sheath. careful planning, complications are relatively few. The risk
of tendon rupture should be explained to the patient;
however, these are most often seen with corticosteroid injec-
tion when the tendon is already significantly damaged or
between the syringe and the needle. This is also useful for when the tendon is insufficiently well protected.
superficial tendon sheaths in areas where the normal body Controlled reinjury and repair refers to a number of
contour may prevent correct angulation of the needle if the treatments aimed at reactivating the tendon repair pathway
syringe is attached. The presence of flexible tubing makes under controlled conditions and using a proper rehabilita-
manipulation of the needle easier. tion programme. Treatments include deep massage therapy,
In most cases the tendon sheath is being injected because extracorporeal shock-wave therapy and dry needling.
it is abnormal and fluid will usually be present, making can- Although there have been a number of studies of dry needle
nulation easier. If this is not the case, it is helpful to keep a therapy, there is no standardized method of performing it.
syringe of local anaesthetic attached to the needle as it is Typically it involves multiple insertions of usually an 18 G
advanced. Once the tendon sheath is breached, anaesthetic needle within the tendon. Needling the tendon in a direc-
can be injected to distend it. Once distended, the tip of the tion parallel to the long axis of its fibres is recommended
needle can be secured safely within it and the injection where possible. It is best carried out under ultrasound guid-
completed. During the injection, the injected material ance so that the most appropriate area of the damaged
should be seen to flow around the tendon and it may be tendon can be targeted.
helpful to examine the tendon in both planes to confirm
this (Fig. 29.6). Unless the tendon sheath is seen to distend
in this manner, it is not certain that the needle is correctly Key Point
positioned within it.
Most often, areas of maximal tendon damage and
neovascularization within the tendon are targeted by dry
PARATENON INJECTION needling to induce local bleeding.
The Achilles and patellar tendons do not have a tendon
sheath but are instead surrounded by a paratenon. The
changes of paratenonopathy around the Achilles tendon The amount of dry needling that is required is not known.
are characteristic. They are found posteriorly and on either Some define the number of needle passes, a time length or
side of the tendon but not anteriorly where there is no continuing until a little bleeding is seen to come back
paratenon. Various degrees of distension can be found with through the needle. Most patients tolerate dry needling
paratenonopathy: from very subtle changes to more florid reasonably well; however, in some it can be painful. Postpro-
distension. The finding may be localized to either the cedure, the patient should be given a dedicated rehabilita-
medial or lateral side. A particular variant occurs medially tion programme with the correct balance of protection and
due to friction between the plantaris tendon and the adja- activity. Differences in technique make evaluation of the
cent Achilles tendon. success of treatment between different operators difficult.
If the paratenon is distended, direct injection into it is
the preferred treatment. Most commonly a combination of THERAPY DIRECTED AT THE TENDON ITSELF:
local anaesthetic and saline is used. Corticosteroid should
PROLIFERANT THERAPY
be used with caution. Once cannulated, the injection will
be seen to fill the paratenon on three sides of the Achilles An advantage of dry needle therapy, as opposed to shock-
tendon. wave therapy, as a means of tendon reinjury is that placing
a needle within the damaged tendon gives the opportunity that ablating these vessels will improve symptoms and aid
to inject proliferants, or other agents, that may help with rehabilitation.
tendon regeneration by creating an improved chemical
environment as the tendon repairs. The most common
Key Point
agent used is the patient’s own (autologous) blood (AB).
Blood (AB) 1–2 mL is drawn from the patient. The tendon A variety of methods have been proposed to ablate vessels,
is dry needled as described above, and the blood is injected including direct injection with sclerosing agents,
into the damaged area. Autologous blood is cheap and does radiofrequency ablation and vessel compression by
not require any specialized kit or centrifuge. high-volume injection around the affected tendon.
PRP is also generated from the patient’s own blood. A
larger sample is taken and centrifuged to isolate the PRP.
This is then injected in the same manner as for autologous
blood following dry needling. These techniques have been applied to the Achilles and
patellar tendon and there is increased use around other
tendons, including the common flexor, common extensor
Key Point
tendons of the elbow and hamstring tendons.
The principal advantage of PRP over AB is that a Aetoxisclerol is one the most commonly used sclerosants.
concentrated specimen of what are thought to be the most It was initially pioneered by Alfredson and Ohlberg and very
important factors that stimulate fibroblasts is injected into good results were reported in observational studies. Two
the confined space of the tendon. different methods of sclerotherapy have been suggested.
In the first, the vessels are injected directly, as described
by the originators of the technique. A lateral approach to
One disadvantage is that the kits are expensive and a centri- the tendon is used and the needle is passed posterior to it
fuge is required; also not all PRP kits or formulations are to enter the vessels (Fig. 29.7). The main vessel trunks
the same. The quantity of platelets varies, as does their activa- outside the tendon can be selected and colour Doppler is
tion and ability to stimulate fibroblast proliferation in vitro. used to identify them. Once cannulated, the agent is injected
The use of PRP is based upon some promising basic science until flow within the vessel ceases. Several difficulties are
literature that demonstrates good stimulation of fibroblastic encountered with this method. As there are often many
activity in vivo. Animal studies also support a role for PRP vessels entering the tendon, the procedure can be time
over autologous blood; however, the procedure is a little consuming to obliterate each and every one. The passage
more time consuming and good outcome data is awaited. of the needle interferes with the colour Doppler signal and
Other proliferants include hypertonic 25–50% glucose makes small vessels difficult to cannulate. The needle and
and local anaesthetic, sometimes combined with sclerosants injected fluid can cause ablation of the vessel by compres-
such as phenol. Injecting these combinations is referred to sion alone, giving the false reassurance that the vessels have
as prolotherapy. It is most commonly used for ligament been sclerosed.
injuries but has also been used for tendon and muscle
injuries.
THERAPY DIRECTED AT ANGIOGENESIS

Another group of percutaneous procedures are those
directed against abnormal vessels that occur in patients with
chronic tendinopathy. Angioneogenesis is most likely driven
by hypoxia within the tendon, resulting in the secretion of
vascular growth factors along with other components of the
inflammatory chain. Vascular endothelial growth factor is
the most often implicated. Under normal circumstances,
few, if any, vessels are identified within the Achilles or patel-
lar tendons. In patients with chronic tendinopathy increased
vascularity becomes evident and in some cases can be
marked. The vessels usually arise from the anterior aspect
of the Achilles tendon and the posterior aspect of the patel-
lar tendon. An association between these vessels and symp-
toms has been demonstrated, leading to the hypothesis that
at least a proportion of the patient’s pain is due to the
ingrowth either of the vessels directly or nerves associated
with them. Histologically, the pattern of vascular ingrowth
is disorganized, often with abnormal trifurcation and blind-
ending channels. The demonstration of abnormal nerves Figure 29.7 A needle (arrow) has been inserted behind the patellar
histologically has been inconsistent. tendon, cannulating the abnormal vessels and forming part of an area
The relationship between the patient’s symptoms and the of focal tendinopathy. Once the bursa is cannulated, sclerosant is
degree of new vessel formation has led to the hypothesis injected to obliterate them.
The second technique is to foam the sclerosing agent by

mixing it with air and inject it along the anterior margin of
the Achilles or posterior margin of the patellar tendon
between the tendon and surrounding fat. Foaming is
achieved by connecting a syringe of sclerosant to a syringe
of air through a two-way tap. Passing the sclerosant repeat-
edly from syringe to syringe foams it up as it mixes with the
air. As the space where the vessels originate rather than the
vessels themselves are being targeted, the procedure is
quicker to carry out.
Whichever technique is preferred, several treatments are
required 2–3 weeks apart so it is a labour-intensive process.
Initial reports of success are good; however, although ran-
domized trials have been carried out, the numbers have not
been large and reproduction of good results by all practitio-
ners has not been a universal finding. Large-scale blinded
randomized trials have been lacking and the use of this
technique appears to be on the wane.
Vessels can also be ablated by compression from high-
volume injection around the tendon. This has also been Figure 29.8 Retained needle. The reflective mosquito forceps
reported as yielding very satisfactory pain relief in the short (arrow) has been inserted in place just below the retained needle. A
gentle upward movement of the forceps should show corresponding
term, although once again high-quality trials are lacking.
needle movement if they are in contact. The forceps is then opened,
The technique involves injecting fluid into the space elevated to the level of the needle and closed to grasp and remove it.
between the tendon and surrounding vessels. Various
volumes have been advocated, up to 50 or 60 mL. The
volume used can be titrated against patient tolerance and
care should be taken to identify low-musculotendinous junc- and some wood splinters can be removed by using ultra-
tions where the volumes required will be less. The injected sound guidance and a thin forceps.
combination is generally a mixture of local anaesthetic and
saline. The mode of action is unknown, but it is thought
that hydrostatic compression of abnormal blood vessels pos-
Key Point
sibly combined with disruption of adhesions.
Ultrasound-guided removal of foreign bodies can be
None of the above techniques have clearly emerged as considered if they are solid, will not disintegrate during
superior to the others and more importantly, none fit intui- retrieval, can be accessed at one end, via a reasonably
tively with what is felt to be the pathogenesis of tendi atraumatic approach, are linear rather than rounded and are
nopathy. A further group of therapies designed around not associated with an established granulomatous reaction.
reconstituting fibroblasts using stem cells has been advo-
cated. Clinical trials of such therapies are few and patient
numbers are small; nevertheless, they do offer an attractive Ideal for removal are fragments of needles more substantial
proposition for treating tendon disease at a basic cytological wood splinters and thorns. An approach is chosen to access
level. Such techniques also open the possibility of treating one end of the foreign body, preferably parallel to its long
tendon disease at its earliest stage. The principle is that stem axis. An anaesthetic needle is introduced and the area infil-
cells are injected into the affected part and image guidance, trated. Occasionally, the anaesthetic needle can be passed
and ultrasound in particular, has an important role in iden- over the foreign body itself, removing it by suction. Once
tifying the affected areas. the area is anaesthetized, a thin ‘mosquito’ forceps is passed
to the superior aspect of one end of the foreign body,
Key Point aligned with its long axis. Gentle downward pressure with
the forceps confirms contact (Fig. 29.8) by showing that the
Stem cells can be derived from a variety of sources and it is foreign body moves with the forceps. The forceps is then
apparent that there are some quite considerable differences opened sideways and the tip of the foreign body gripped
depending on the tissue of origin. and removed.
BURSAL INJECTION
Stem cells are easiest to retrieve from the subcutaneous fat,
but these are probably not as effective as cells isolated from
OVERVIEW
marrow.
Bursae are synovial-lined spaces located between bony or
soft tissue structures to facilitate movement between them.
FOREIGN BODY REMOVAL Synovial swelling and inflammation may cause pain directly
or secondary to impingement of the involved tissues. Bursal
Ultrasound is useful for detecting foreign material not injection is one of the commonest procedures carried out
visible on plain radiographs. Many metallic foreign bodies under ultrasound guidance. Typical procedures include
injection of the subacromial subdeltoid bursa, the trochan-

teric and subgluteus medius bursa and the intermetatarsal
bursa related to Morton’s neuroma/intermetatarsal bursa
complex. As bursae are generally quite large, cannulation
under ultrasound guidance is usually straightforward. The
general principles of consent, sterility and procedure prepa-
ration have already been covered. The typical combination
injected is once again a cocktail of a longer-acting local
anaesthetic and corticosteroid. Occasionally alcohol and
radiofrequency are used to treat Morton’s neuroma.
ULTRASOUND PATTERNS OF BURSAL DISEASE
Key Point
A number of different patterns of bursal disease have been

identified. In many cases there is a thin rind of thickened
bursal lining, which generally has decreased reflectivity with
respect to the connective tissue and fat surrounding the
bursa itself.
Figure 29.9 Following injection of the subacromial subdeltoid
bursa, fluid should be seen to surround the tendon with a typical
With this pattern, bursal distension is not marked and free bursal configuration.
fluid may either not be apparent or apparent only in the
most dependent areas of the bursa. This pattern is typical
of the commonest manifestation of subacromial subdeltoid material into the tendon may occur as the needle is removed.
bursitis. In this particular case, bursal thickening may be Whether this poses any more than a theoretical risk of
augmented by arm abduction and noting the behaviour of tendon rupture is unclear and there is little evidence to
the bursa adjacent to the coracoacromial ligament or the support the argument on either side. The techniques for
acromion. As the bursa impinges on these structures it may injecting specific bursae are discussed in Chapter 30.
become bunched up and more obvious. In many cases,
although not always, this coincides with pain. Thickening of
JOINT INJECTION
the subacromial subdeltoid bursa and bunching related to
movement may also be seen on the medial aspect of the
LARGE JOINTS
acromion, between the trapezius muscle and the supraspi-
natus musculotendinous junction. Injecting large joints is generally straightforward and a wide
The second pattern of bursal disease is more fluid-like. variety of approaches are possible. Generally the decision of
Care should be taken not to compress the probe too strongly where to puncture can be based on where the largest quan-
against the skin as a fluid-distended bursa is easily effaced. tity of fluid has accumulated, where the thickest synovium
Within the fluid, strands of synovial thickening may be seen. is located and where overlying soft tissues are going to cause
Doppler activity is usually more readily apparent with this the least problem.
pattern. When fluid distension of the bursa is marked, an
underlying inflammatory cause, such as rheumatoid arthri-
tis, should be considered. Other potential causes include Key Point
rice body bursitis. In some cases the bursa may appear
entirely normal to ultrasound interrogation, but when For large joint injection, an in view approach is used which
directs the needle along the long axis of the probe such
inspected directly at arthroscopy the wall may appear
that the needle stays in view throughout its course.
injected and friable. It should therefore be appreciated that
a normal appearance of the bursa on ultrasound does not
exclude bursal disease.
Like joints, bursae should distend easily as they are being As outlined above, the probe is positioned so that its distal,
injected and any resistance should be regarded with suspi- non-needle end will overlie the part of the joint being tar-
cion, the injection stopped and attempts made to confirm geted. The needle end of the probe will be directed towards
the location of the tip of the needle with respect to the sur- the puncture site such that the needle can be tracked along
rounding anatomy. In the early stages of the injection, its entire distance until it penetrates the joint.
nothing may be seen around the tip of the needle as the
injected material flows away from the needle tip. At the end
SMALL JOINTS
of the injection, if a reasonable volume has been used, the
distension should correspond to the normal shape of the Smaller joints are a greater challenge, particularly when
bursa (Fig. 29.9). For bursae around tendons, it is generally osteophyte formation is marked. In these circumstances,
considered that the needle should not transgress the tendon ultrasound offers significant advantages over other methods
as it approaches the bursa as backflow of the injected of image guidance in that the pathway through the
osteophytes is more readily apparent. This is particularly worthwhile seeking out areas of synovial thickening, as the
true for the small joints of the midfoot, fingers and toes. For diagnostic yield is often better if a synovial biopsy is carried
injecting small joints, an out of view approach is often pre- out rather than simple fluid aspiration. The principles of
ferred. The out of view approach relies on the proximity of ultrasound-guided synovial biopsy are similar to biopsy of a
the skin to the target being injected. soft tissue tumour. Larger-gauge needles are preferable to
ensure a good specimen; however, these can be difficult and
painful to insert as the capsule of an implanted joint is often
Key Point
thick and fibrous and resists passage of the needle. Care
For an out of view approach, the puncture point is midway should be taken to apply liberal local anaesthetic to the
along the longer side of a short footprint probe positioned capsule prior to the insertion of the biopsy needle. Although
over the area of maximal joint distension and the needle is it is preferential to use adequate analgesia to the skin and
directed towards the probe. joint capsule, it should be appreciated that…
Practice Tip
With a little practice, the tip of the needle will appear in the
centre of the joint. More recently, manufacturers have been …many local anaesthetics are bacteriostatic and
placing marks on the midpoint of the probes to facilitate consequently once the joint has been penetrated anaesthetic
this. Short footprint probes also tend to be thinner, allowing use should be limited.
the skin to be punctured closer to the target joint. As the
flexor and extensor tendons overlying many small joints are
also in the midline–sagittal plane, placing the probe along Practice Tip
their length also ensures that they will not be transgressed
during the injection. If the joint capsule proves resistant or painful, two tips to
help transgress it are to use an external cannula or to
advance the central part of the biopsy needle to make an
CHILDREN initial puncture.
In many cases aspirating a joint is easier than injecting it as

it presupposes that there is a joint effusion, which increases Cannulae tend to be much sharper than biopsy needles and
the size of the target. Aspiration is most frequently carried will more easily penetrate a thickened capsule. The cannula
out to exclude septic arthritis or to diagnose crystal arthrop- can be left in position, allowing multiple biopsies to be
athy. In patients who have undergone joint replacement, obtained via a single capsule puncture. If a coaxial system
aspiration or synovial biopsy is indicated where chronic is not available, another option is to place the tip of the
sepsis is suspected. biopsy needle on the capsule and then gently advance the
central portion as though a biopsy was about to be taken.
Key Point As this is a little smaller than the overall diameter of the
needle it creates an initial puncture through which the
In children aspiration needs to be carried out quickly to larger needle may more easily pass. Once the joint has been
ensure that the child does not become distressed so a penetrated, the needle should be directed to the point of
‘semiblind’ technique is recommended. maximum synovial thickening.
Thickened synovium is often rather friable and it is not
uncommon that the retrieved specimens are very frag-
This reduces the likelihood of them moving and making the mented. Use of a 14 G needle improves the diagnostic yield.
procedure very difficult to carry out. The principle of the
semiblind approach to large joints, such as the hip, is that
Practice Tip
ultrasound is used to identify the optimal puncture point
directly overlying the area of maximal joint distension, with It is also helpful to compress the needle against the
a perpendicular path to the joint free of important struc- thickened synovium while vibrating it slightly to try and get a
tures. This is followed by an unguided approach of the good specimen to embed itself in the biopsy port.
needle to the joint. The goal is to identify this point with
confidence such that aspiration can then be carried out
without the need for active image guidance. This technique When infection is suspected, multiple specimens should be
works well for larger joints such as the hip and shoulder, but obtained both for culture and histopathological assessment.
is more difficult for smaller joints where guidance under
direct vision is preferable. The specific technique for aspi-
Key Point
rating children’s hips will be described in Chapter 20.
For chronic infection around implanted joints, it is
SYNOVIAL BIOPSY recommended that multiple specimens are obtained
using different needles. This is to ensure that needle
Aspiration of fluid for culture in patients with acute septic contamination does not give rise to spurious results. Culture
arthritis is generally productive but this is less often the case should be carried out under enrichment to encourage the
in patients with chronic infection, particularly where the growth of low-virulent organisms.
joint has been implanted. In these patients it is also
CALCIUM BARBOTAGE (Fig. 29.13), aspiration is possible followed by fenestration

(disruption) of the surrounding wall. For more solid chalk-
like conglomerates, fenestration is the only option. For even
OVERVIEW
harder lesions, if the patient fails to respond to bursal injec-
Calcium deposition can occur in and around many tendons tion, surgery is often required.
but is most frequently associated with the rotator cuff and
the gluteal insertions. Not all require treatment as there is
TECHNIQUE
a well-recognized tendency for calcium deposits to reabsorb
spontaneously. Furthermore, not all calcium conglomerates Two aspiration techniques have been suggested using either
are symptomatic. a single needle to penetrate the calcium or a dual needle
The approach to ultrasound-guided management of approach. The two-needle technique uses one needle to
calcium deposits within tendons is similar regardless of their flush saline or local anaesthetic into the calcium and the
location. It depends firstly on whether the calcium per se is second needle for drainage. The single needle technique
causing symptoms or whether pain may be due to impinge- involves a clean puncture of the wall, such that the wall
ment of adjacent structures. A calcium conglomerate in the provides a reasonable seal around the needle. Local anaes-
supraspinatus tendon may cause symptoms of impingement thetic injected expands the conglomerate and washout is
on abduction because of the increased volume and reduced achieved as the lesion decompresses through the same
compliance within the tendon. Symptoms that are due to needle.
calcium shedding are typically severe, often mimicking
acute septic arthritis. Unless there is a clear history of acute
calcific tendinopathy or calcific bursitis, there is the option
to try an initial injection of local anaesthetic and corticoste-
roid into the adjacent bursa to see if this provides sufficient
relief without the patient having to undergo a somewhat
more uncomfortable barbotage procedure.
The procedure employed also depends on whether the
calcium is soft or hard. This is difficult to determine with
certainty on imaging. If plain films demonstrate trabecula-
tion then a solid conglomerate is confirmed. A cloudy or
milky appearance is more in keeping with a soft conglomer-
ate (Figs 29.10 and 29.11). Ultrasound can also assist with
this differentiation. If the calcified envelope is not too thick,
a liquefied, less reflected core might be seen. Dense calcifi-
cation will demonstrate a markedly reflective leading edge
and posterior acoustic shadowing (Fig. 29.12). It should be
appreciated, however, that both of these signs are present
in a conglomerate that has a more densely calcified shell Figure 29.11 More fluid-like milk of calcium. This is the easiest type
but a liquid or paste-like core. The final determination to aspirate.
of the nature of the conglomerate may not be realized
until the barbotage procedure itself when penetration
is attempted. If a liquefied or paste-like core is present
Figure 29.10 Ill-defined, speckled, increased intensity within the Figure 29.12 Dense leading edge of calcium conglomerate with
SST tendon. The lack of a posterior acoustic shadow suggests soft posterior acoustic shadowing suggesting more solid contents. In
calcium or milk of calcium. some patients the outer shell is calcified, obscuring soft matrix within.
Figure 29.13 Semi-solid aspirated calcium material. Compare with a

the more fluid contents in Figure 29.11.
The procedure begins by placing the patient in a comfort-

able position. In general a recumbent position is preferred
for patient comfort with the affected side close to the exam-
iners’ side. The arm is placed by the patient’s side in a palm
down position, resulting in a little external rotation and
greater access to the rotator cuff. The calcium is identified
and the optimal approach selected. The skin is sterilized,
draped and local anaesthetic injection is inserted onto the
skin. Under direct ultrasound guidance, a needle is passed
into the subacromial subdeltoid bursa and that is injected
with local anaesthetic. It is important to ensure that the
needle and syringe are free of air, as gas bubbles in the bursa
at this stage of the procedure may impair visualization when
the calcium is to be penetrated. Although many practitio-
ners also use a corticosteroid at some point during the
b
procedure, it is important not to inject it at this time, as the
particulate corticosteroid may also reduce visualization of Figure 29.14 (A) Calcification within the supraspinatus tendon fol-
the underlying tendon. lowing washout. Egg-shaped calcification remains, but the lesion is
Once the bursa is anaesthetized, the calcium conglomer- compressed. (B) The same calcification distended with local anaes-
ate is penetrated to its centre with a single puncture. At this thetic. Successive distension release cycles help to wash out the
point aspiration can be attempted and a cloudy, milky fluid calcium.
or toothpaste-like material may be retrieved. The syringe is
then exchanged for a low-volume 2 mL or 3 mL syringe half
filled with local anaesthetic. Air is cleared from the syringe point, the same needle can be used to make multiple pen-
prior to its attachment. Warming the local anaesthetic has etrations in the eggshell wall to disrupt it. The final step is
been suggested to improve its ability to dissolve calcium. to inject the subacromial subdeltoid bursa with a combina-
Once firmly attached, preferably with a Luer-lock attach- tion of longer-acting local anaesthetic and a corticosteroid
ment, the plunger is depressed until resistance is felt, then preparation. An exchange of needle is generally required
relaxed. Successive depression/relaxation cycles are used prior to bursal injection as the needle used for fenestration
until a small cloud of calcium crystal is ejected back into the usually becomes blocked. The patient should be given post-
syringe when the plunger is relaxed. With time, less resis- procedure advice, including warnings that any crystals shed
tance to injection will be encountered and more liquid into the bursa may be painful.
calcium is retrieved in exchange for the local anaesthetic.
Intermittent scanning during the procedure will show a GENERAL ASPECTS OF GANGLION
gradual breakdown of the internal structure of the conglom-
ASPIRATION
erate and crystals will be seen to swirl around within an
outer eggshell. With time, no further calcium will be
OVERVIEW
retrieved and in many cases the internal constituency of the
conglomerate will be seen to be more liquid. The ‘eggshell’ Ganglion cysts are fluid-filled structures contained within a
wall will be seen to distend and decompress as the plunger nonepithelialized connective tissue capsule. They arise most
of the syringe is pressed and retracted (Fig. 29.14). At this commonly due to mucoid degeneration of an adjacent
connective tissue structure. They are difficult to distinguish A compression bandage can be applied postaspiration,
from synovial cysts by imaging alone. Pathologically, synovial although once again the evidence that this reduces the rate
cysts have an epithelial lining and represent synovial of recurrence is scant.
fluid-filled extensions from an adjacent joint or bursa. Gan- In a high proportion of ganglia the fluid is highly viscous
glion cysts do not have a cellular lining and are usually filled and resistant to aspiration. In these circumstances it is
with a more viscous jelly-like material. Practically speaking, helpful to create a vacuum within the syringe to maintain
there is no particular reason to differentiate ganglia from suction while the viscous material is gradually aspirated.
synovial cysts that are causing pain by compression as both
need to be aspirated or removed. Differences largely reflect
the viscosity of the fluid contents. Essentially, synovial cysts Practice Tip
are usually of low viscosity and easy to aspirate, and ganglion
cysts contain a clear gelatinous fluid that is often viscous A simple vacuum system can be achieved in the ultrasound
room by attaching a 10 mL syringe once the needle has
and difficult to aspirate. Both may recur and there is no
penetrated the ganglion, extending the syringe plunger and
evidence to show that one or the other is more likely to do
placing a plastic needle cover in one of the gutters of the
so or is more likely to respond to concurrent corticosteroid syringe plunger to hold it open.
injection.
Ganglia can be found in any part of the musculoskeletal
system, although they are most frequently encountered near
joints. Common locations include the wrist, where they are This vacuum system now allows the needle to be held in the
related to the dorsal or, less commonly, the volar aspect of ganglion without tiring the operator. In addition, the needle
the scapholunate ligament, the finger/toe tendons, the can be manipulated throughout the length of the ganglion,
proximal tibiofibular joint and the foot, where they may arise even extending along the neck, as it is easier to manipulate
either in the hind- or midfoot. They have a typical multilocu- syringe and needle in one hand and probe in the other
lated appearance, which is due to one part of the ganglion without having to simultaneously aspirate. Patience is
folding over another, simulating a septum, although these required, but by using these techniques the majority of
are generally incomplete. In many cases a track can be seen viscous ganglia can be successfully aspirated.
extending towards the structure from which it originates.
FURTHER READING
TECHNIQUE Balint PV, Kane D, Hunter J, et al. Ultrasound guided versus conven-
tional joint and soft tissue fluid aspiration in rheumatology practice:
The approach to aspirating a ganglion or synovial cyst uses a pilot study. J Rheumatol 2002;29(10):2209–13.
principles similar to aspiration elsewhere. Where possible, Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injec-
the puncture is made where the skin comes closest to the tions in the treatment of subacromial bursitis. Am J Phys Med Rehabil
2006;85(1):31–5.
ganglion cyst, assuming that the path is clear of other struc-
Distefano V, Nixon JE. Steroid-induced skin changes following local
tures that may be injured. injection. Clin Orthop Relat Res 1972;87:254.
Farin PU, Räsänen H, Jaroma H, Harju A. Rotator cuff calcifications:
treatment with ultrasound-guided percutaneous needle aspiration
Practice Tip and lavage. Skeletal Radiol 1996;25(6):551–4.
Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-Guided Scle-
For dorsal wrist ganglia, wrist flexion may bring the ganglion rosis of Neovessels in Painful Chronic Patellar Tendinopathy. A Ran-
closer to the skin, making aspiration easier. The puncture domized Controlled Trial. Am J Sports Med 2006;34(11):1738–46.
point should also be selected to allow access to the neck of Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA. Intraarticular
the ganglion. Preliminary local anaesthetic injection with a foot and ankle injections to identify source of pain before arthrod-
esis. Am J Roentgenol 1996;167(3):669–73.
small-bore needle is helpful as puncture with a wide-bore
MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable Corticosteroid and
needle (ideal for ganglion aspiration) may be painful. Local Anesthetic Preparations: A Review for Radiologists. Radiology
2009;252(3):647–61.
Öhberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in
If the fluid can be easily aspirated then as much fluid as painful chronic Achilles tendinosis: Pilot study of a new treatment.
Br J Sports Med 2002;36:173–5.
possible should be removed. The wall of the ganglion or cyst Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity
is then fenestrated. It is common to inject a small quantity in human articular chondrocytes. J Bone Joint Surg 2008;
of corticosteroid, although the value of this is unproven. 90(5):986–91.
30 Specific Intervention Techniques
Eugene McNally
CHAPTER OUTLINE
SHOULDER INTERVENTION Trochanteric and Gluteal Bursa Injection

Subacromial Subdeltoid Bursa Injection Gluteus Minimus Bursa
Acromioclavicular Joint Sacroiliac Joint
Glenohumeral Joint Piriformis Syndrome and Ischiofemoral
Distension Arthrogram Impingement
Calcium Barbotage Ischial Bursa and Hamstring Origin
Biceps Tendon Sheath Injection KNEE INTERVENTION
Suprascapular Ganglion/Nerve Treatment Knee Joint Injection
Sternoclavicular Joint Injection Proximal Tibiofibular Joint
Coracoacromial Ligament Division Patellar Tendon
Long Thoracic Nerve Block Infrapatellar and Other Patellar Bursae
ELBOW INTERVENTION Hoffa’s Ganglion Aspiration
Tennis Elbow Semimembranosus Injection
Common Flexor Origin Pes Anserine Bursa
Elbow Joint Cruciate Ganglia
Interosseous Nerve Block Iliotibial Band Injection
WRIST INTERVENTION Biceps Femoris
Distal Radioulnar Joint Injection ANKLE INTERVENTION
Radiocarpal Joint Achilles and Peri-Achilles Intervention
Carpometacarpal and Scapho-Trapezio- Paratenon Injection
Trapezoid Joint Infections Plantaris Injection
Wrist Ganglion Achilles Dry Needle Autologous Blood and
Extensor Compartment 1: De Quervain’s Platelet-Rich Plasma Injection
Carpal Tunnel Volume Injection/Tendon Stripping
HAND INTERVENTION Pre-Achilles Bursa
Metacarpophalangeal and Interphalangeal Plantar Fascia
Joints Posteromedial Impingement
Flexor Tendon Sheath Flexor Hallucis Longus Tendon
Pulley Fibroma Tibialis Posterior Tendon Sheath Injection
PELVIS AND HIP INTERVENTION Peroneal Sheath Injection
Ilioinguinal Nerve Block Cuboidal Tunnel Injection
Lateral Cutaneous Nerve of Thigh Block Anterolateral Gutter
Adductor Origin Pubic Symphysis Tibiotalar Joint
Obturator Nerve Posterior Subtalar Joint
Hip Joint Injection MID- AND FOREFOOT INTERVENTION
Hip Joint Synovial Biopsy Intertarsal Joints
Aspiration of Paediatric Hip Effusions Metatarsophalangeal and Interphalangeal
Iliopsoas Bursa Injection Joint Injection
Tensor Fasciae Latae/Iliotibial Band Morton’s Neuroma Intermetatarsal Bursa
346
CHAPTER 30 — Specific Intervention Techniques 347
SHOULDER INTERVENTION
SUBACROMIAL SUBDELTOID BURSA INJECTION

PATIENT AND PROBE POSITION
Ultrasound-guided injections provide more reliable and
accurate needle placement which is particularly useful to
assess the diagnostic response to local anaesthethic in
patients with a poor response to a previous blind injection.
Guidance is also useful to ensure accurate medication place-
ment and in difficult cases such as obese and postoperative
patients. A quick wipe with a sterile swab followed by the
bursal injection allows the diagnostic examination to be
combined with a guided injection with little prolongation a
of the overall examination time. The standard shoulder
examination is with the patient seated and there is no need
to change position prior to bursal injection.
TECHNIQUE
Injection of the subacromial subdeltoid bursa is a com-
monly performed procedure. It is a large bursa and can be
accessed by a variety of routes. For a blind approach, the
most lateral and posterior margin of the acromion is pal-
pated and the needle inserted 1 cm below this, directed
upwards. There is a common misconception that if free
lateral side-to-side movement of the needle tip is possible, S
it must be in the bursa. It can be readily demonstrated with L M
ultrasound that side-to-side movement is possible whilst the I
needle is in subcutaneous fat.
Ultrasound-guided injections are generally from a supero b
lateral or anterior approach. A simple method is to place Figure 30.1 Superior approach to the subacromial subdeltoid
the probe in the same position as used to generate a coronal bursa. For a right shoulder injection from posterior, the probe is held
image of the cuff. From this position, the needle can in the ultrasonologist’s right hand. This approach is free of interfering
approach either from above the probe or from below. For probe cables. It does require a minimum of dexterity with the left hand
a right-handed operator, a left shoulder injection can be if the operator is right-handed.
carried out by holding the needle in the right hand and the
probe in the left hand, whilst the operator stands behind
the seated patient. The reverse is true for the right shoulder.
Key Point
A needle approach from above has the advantage of not
having the probe cable interfere with the needle (Fig. 30.1). It is important to ensure that, when a bursa is injected, it
An alternative is to place the probe axially in an anterior can be seen to distend cleanly and that the injectate flows
position until clear visualization of the supraspinatus tendon away easily from the needle tip.
and subacromial subdeltoid bursa is obtained. The skin is
punctured lateral to the probe and the needle directed
towards the bursa (Fig. 30.2). The overlying deltoid should been seen to lift temporarily
As long as the needle is kept in the same plane as the away from the bursa driven by the pressure of the injection.
probe it can be followed accurately until it reaches the When the injection is finished the muscle/tendon should
superficial surface of the supraspinatus tendon. It is impor- relax back into its normal location. If there is uncertainty
tant to be aware of the position of the bevel. Keeping the regarding the needle position within the bursa, this
bevel upwards allows easy passage of the needle into distension/relaxation appearance can be reproduced by
the bursa. Once transgressed, rotating the needle through giving a pulse injection. The plunger is pressed firmly and
180° places the needle fully within the space. A prelimi- the layers of the bursa should separate when plunger pres-
nary injection should demonstrate rapid flow of injected sure ceases; the two layers of bursa should return together.
material away from the needle tip. Focal accumulation If the needle tip is extrabursal, the tissue planes will separate
of injected fluid indicates incorrect positioning with on injection but will not recompress easily as the injected
the needle tip most commonly still lying on the deltoid fluid is not free to flow away from the injection site. Another
side of the bursa. Gentle advancement of the needle with useful tip for larger bursae is to place the probe over a dif-
a slight hooking action, to direct the needle under the ferent part of the bursa and confirm that fluid is flowing
reflective bursal surface, is usually adequate to ensure freely into it from the point of injection.
placement within the bursa and the injection can be The subacromial subdeltoid bursa is a large structure
completed. and can accommodate quite considerable volumes of fluid,
a a
A S
M L M L
P I
b b
Figure 30.2 Axial approach to the bursa. In this position, the needle Figure 30.3 A coronal approach to the ACJ is easier if there is joint
can be held in the right hand, which right-handed operators may find widening, effusion or offset.
more comfortable. The probe cable can be wrapped around the left
hand to prevent interference with the needle.
although a total injection dose of more than 10 mL is usually The probe is held in the coronal plane directly above the
not necessary. It is also useful to reexamine the bursal joint and moved immediately until the joint is seen close to
surface of the tendon following injection as the fluid intro- the lateral margin of the image. A point is marked on the
duced to the bursa may now demonstrate a bursal surface patient’s skin lateral to the probe, representing the punc-
partial tear not previously appreciated. ture point (Fig. 30.3).
If there is no malalignment or effusion, the joint is best
injected in the sagittal plane. This view is obtained by placing
ACROMIOCLAVICULAR JOINT
the probe, initially, medial to the joint and identifying the
Most shoulders are examined with the patient seated and bony reflective margin of the clavicle. The probe is then
there is no need to change position prior to injection. The moved laterally until the bony reflection disappears, indicat-
needle is targeted on the rounded, poorly reflective joint ing that the probe is now positioned directly over the joint
space. (Fig. 30.4). Further lateral movement brings the bony acro-
The acromioclavicular joint (ACJ) is easily identified in mion into view. The probe is returned to overlie the joint
the coronal plane. It is useful to make an initial assessment either anteriorly or posteriorly and the needle is inserted at
to determine whether there is any subluxation present, as 90° to it in the sagittal plane. In this position it is easily seen
there is commonly a slight offset between the end of the entering into the joint. Reversing needle and transducer is
clavicle and the acromion. The commonest situation is supe- equally effective. The ACJ is a rather small joint and is
rior displacement of the end of the clavicle. unlikely to accept more than 1–1.5 mL. It is therefore rec-
ommended that a low-volume syringe is used.
Practice Tip
GLENOHUMERAL JOINT
If ACJ subluxation is present, the lateral aspect of the joint is
open to an approach from the lateral side. If there is any joint Glenohumeral joint injection is indicated for patients
effusion projected above the joint, this too can be accessed undergoing MR arthrography, for local anaesthetic injec-
by a coronal approach from the lateral side. tion to diagnose indeterminate shoulder pain, to guide
treatment of glenohumeral arthropathy and to distend the
a a
S
P A
I
P
b
M L
Figure 30.4 This approach to the ACJ is used if the joint is not A
particularly distended or there is little acromioclavicular offset. The
joint is seen as an echo-poor space. There is excellent visualization
b
of the needle as it is inserted parallel to the probe. A coronal approach
to the ACJ is easier if there is joint widening, effusion or offset. Figure 30.5 Posterior approach to the glenohumeral joint with the
patient leaning forward with their head resting comfortably on pillows.
It is important not to puncture too far laterally as the curvature of the
humeral head may force the needle medially and into the labrum. The
shoulder in patients with adhesive capsulitis. As most shoul- target area in this case is the needle resting comfortably between
der dislocations are anterior and the structures of interest humeral head and labrum.
also lie anteriorly, a posterior approach for MR arthrogra-
phy is a good choice for reducing any extravasation or
artifact, which may subsequently impede interpretation of ensure it stays in-view and reaches the correct part of the
the study. joint. Alternatively, a medial puncture can be used and
A seated position with the operator standing behind the directed to a point lateral to the labrum, but generally there
patient is straightforward. It is helpful for the patient to have is less room to manoeuvre with this approach, unless there
some support, particularly during longer procedures such is an effusion. Care should be taken not to aim for the
as distension arthography. The patient can sit against a glenoid margin itself as a large labrum may displace the
raised examination couch and rest their head forward on needle posteriorly and prevent accurate placement into
some pillows. The arm of the side being injected can rest the joint. The intraarticular position of the needle can be
on the patient’s knee. Alternatively the patient may be confirmed by injecting a small amount of local anaesthetic.
placed in a semiprone position with the affected shoulder If the needle is correctly positioned, the injected local anaes-
uppermost. It is useful to rest the ipsilateral arm over a thetic will disappear into the joint and no resistance will be
bolster or pillow to maintain the semiprone position and felt. The arthrographic material or an antiinflammatory
optimize patient comfort. cocktail may then be injected. In the early stages of the
The needle is most frequently introduced lateral to the injection, distension of the posterior glenohumeral joint
ultrasound transducer and directed obliquely along a path recess is not evident. Towards the end of the glenohumeral
to where the humeral head slopes towards the posterior joint injection, if a sufficiently large volume of fluid has
labrum (Fig. 30.5). Once the skin is punctured, the needle been instilled, the posterior recess of the glenohumeral
should be directed in the same long axis as the probe to joint begins to distend and the posterior capsule is seen
displacing away from the humeral head. Colour-flow

Doppler can also show the injectate flowing way from the
needle tip.
DISTENSION ARTHROGRAM
In patients undergoing distension arthrography some modi-
fications to the above technique are necessary. The proce-
dure is carried out for patients with adhesive capsulitis or
frozen shoulder. It should be reserved for the later pain-free
but stiff phase of the condition as distension during the
acute, painful, inflammatory phase is less likely to be benefi-
cial. The principle of the procedure is that restriction of
motion is due to generalized joint contracture that can be
improved by stretching the capsule. Stretching is achieved
by injecting as high a volume as the patient can tolerate, up
to 40–50 mL.
A mixture of local anaesthetic (20 mL), normal saline a
and corticosteroid is prepared and a second syringe contain-
ing 20 mL of normal saline is made ready. Once the joint is
cannulated, a short flexible tube and a three-way connector
tap are attached to the needle. If the patient tolerates the
first 20 mL, the three-way tap is closed and a further filled
syringe is attached. The use of the three-way tap prevents
decompression of the joint as the syringes are being
exchanged. The aim is to inject a volume beyond joint
capacity in an effort to increase the volume within the joint
and thus improve the patient’s range of motion. Either the
patient’s tolerance will be reached or the capsule will
rupture. Any sudden reduction in resistance should be S
noted as further injection will not be helpful and may even M L
cause periarticular neural compression in the quadrilateral I
or spinoglenoid spaces.
Although much of the synovial and capsular thickening
in adhesive capsulitis is in the anterior interval and the axil- b
lary recess, it is unlikely that either of these two areas are
Figure 30.6 Barbotage is carried out with the patient recumbent
the ones that will rupture during the injection. More likely as this is a somewhat longer and possibly uncomfortable procedure.
that capsular rupture occurs posteriorly in the areas of In the ultrasound image, as much of the calcium as is feasible has
greatest weakness. been aspirated, leaving only a distensible eggshell. The last phase of
the procedure is to fenestrate the eggshell wall.
CALCIUM BARBOTAGE
Calcific tendinopathy is a relatively common and painful
disorder of the shoulder, which is due to the deposition of
calcium hydroxyapatite crystals. Calcific tendinopathy is not remains. This is then fenestrated and the bursa injected with
always symptomatic and barbotage is usually reserved for local anaesthetic and steroid.
patients who suffer acute pain as a result of crystal shedding
into the subacromial subdeltoid bursa and/or for patients
BICEPS TENDON SHEATH INJECTION
who are experiencing impingement related to the calcified
mass that has not responded to bursal steroid injection. Patients with anterior shoulder pain and tenderness overly-
Because barbotage may be painful, the examination is ing the proximal portion of the biceps tendon may benefit
best carried out with the patient supine and positioned with from guided injection into the biceps tendon sheath. It
the affected shoulder as near as possible to the edge of the could be argued that the easiest way to inject the biceps
examination couch (Fig. 30.6). This allows the arm to be tendon sheath is to carry out an injection into the glenohu-
lowered below the level of the couch, thus inducing a degree meral joint itself. The direct route into the biceps tendon
of extension and internal rotation. The operator sits at a sheath is preferred as not only does it place the injection
comfortable height at the level of the patient’s shoulder and where it is most likely to help, but also because of the pos-
preliminary examination identifies the easiest approach to sibility that communication between the glenohumeral joint
the calcium. The general principles of barbotage have been and biceps tendon sheath may be obstructed by synovial
described previously on page 343. Aspiration/washout is thickening in the anterior interval.
continued until the aspirated material is clear or nearly Patient positioning is the same as for the examination of
clear and only the eggshell margin of the conglomerate the biceps tendon with the hand placed palm upwards on
a a
$
0/
3
Figure 30.7 Fluid around the biceps tendon facilitates an approach

in the short axis. Under direct visualization, the needle is inserted to
the biceps tendon sheath.
the patient’s knee. The sheath can be approached along

either its short or its long axis. If fluid distension is present,
a short access approach from the lateral side is easiest (Fig.
30.7). For a long axis injection, a sagittal image of the
tendon in the groove is obtained (Fig. 30.8). A mark is
placed at the upper end of the probe identifying the punc-
ture point. The needle can be followed in-view as it runs
b
parallel to the probe and into the sheath.
Tenodesis can be carried out under ultrasound guidance Figure 30.8 The long-axis approach to the biceps tendon sheath
in patients who have anterior shoulder pain that is unre- from above. The puncture point should be sufficiently low so that the
sponsive to conservative measures where pain is felt to be needle passes below the subacromial subdeltoid bursa before enter-
due to a grossly attenuated biceps tendon. Ultrasound- ing the biceps tendon sheath. This is particularly important if a selec-
tive diagnostic procedure is being carried out.
guided biceps tenodesis is only recommended when all
other conservative measures have failed and surgical divi-
sion of the tendon is being considered in any case.
notch by a ganglion cyst. This is most commonly associated
SUPRASCAPULAR GANGLION/NERVE with posterosuperior impingement syndrome. A tear is
present in the posterosuperior labrum leading to the forma-
TREATMENT
tion of a ganglion. This passes in a posterior and medial
A treatable cause of infraspinatus muscle atrophy is com- direction until it reaches the notch, where it can expand
pression of the suprascapular nerve within the spinoglenoid and compress the suprascapular nerve.
a
a
A
L M
P
P
M L
b
A
Figure 30.10 In many patients the painful sternoclavicular joint
is due to osteoarthritis and fluid is present within the joint. As
b
the clavicle stands slightly proud of the sternum, a medial approach
Figure 30.9 Suprascapular nerve injection or rectus femoris (RF) is best.
ablation is carried out in a position similar to the approach to the
glenohumeral joint. The needle puncture is from the medial side and
directed towards the nerve that lies adjacent to the artery. In this
image, a little Doppler signal is evident helping to locate the supra-
scapular artery. at the medial margin of the image. The skin is marked at
the medial end of the probe representing the puncture
point. As usual, a small-volume syringe is used for small
The technique for ganglion aspiration has been described joints.
on page 344. An axial approach is employed for the spino-
glenoid notch. The probe is held in the axial plane over the
CORACOACROMIAL LIGAMENT DIVISION
ganglion. A medial sided puncture is best as this gives the
best opportunity for passing the needle along the neck once Division of the coracoacromial ligament (CAL) is often
the main ganglion has been satisfactorily aspirated (Fig. carried out as part of a surgical subacromial decompression
30.9). Neural injection can also be carried out for chronic procedure, although recently the need to do this has been
pain. Using Doppler is occasionally helpful as it may help questioned. There have been some reports on dividing this
visualize the adjacent suprascapular artery. The vessel is ligament under ultrasound guidance. A simple green needle
small, however, and in many cases its pulsation per se can be used to create multiple punctures at the same point
renders it easier to see than any Doppler signal it generates. in the ligament leading to its failure. This is a similar tech-
If anaesthetic injection is positive, radioablation may provide nique to biceps tenodesis.
longer-term relief.
LONG THORACIC NERVE BLOCK
STERNOCLAVICULAR JOINT INJECTION
The long thoracic nerve can be located approximately 5 cm
The principles for injecting the sternoclavicular joint are anterior to the lateral margin of the scapula in the midaxil-
similar to those for the ACJ. The medial clavicle usually lary line. It is quite superficial, overlying the serratus ante-
stands slightly proud of the underlying sternum, creating an rior muscle in the midaxillary line (Fig. 30.11). It is often
access to the joint from the medial side. Once again, the accompanied by a small artery that can help to locate it.
presence of joint effusion or synovial thickening facilitates There is another nerve that runs parallel to the long tho-
this further. The probe is held in the axial plane overlying racic nerve, but more posteriorly. This is the thoracodorsal
the joint (Fig. 30.10). It is moved laterally until the joint lies nerve.
ELBOW INTERVENTION
TENNIS ELBOW
The usual indication for injecting the common extensor
origin is recalcitrant tennis elbow. Several interventional
techniques have been described; the use of corticosteroid
injection has now largely given way to dry needle therapy,
which may or may not be combined with autologous blood
injection or platelet-rich plasma (PRP).
Two positions can be used, one with the patient seated
opposite (Fig. 30.12), the other with the patient recumbent
with the affected forearm flexed across their abdomen (Fig.
30.13). It is generally recommended that dry needling pro-
cedure is carried out as close to the long axis of the tendon
fibres as possible. The target is the most tendinopathic area,
particularly those showing areas of mucoid necrosis and
hypervascularity. The probe is held in the coronal plane
overlying the area to be treated. A puncture point is marked
on the patient’s skin distal to the probe. If a small footprint
c S
Figure 30.11 (A) The long thoracic nerve is located in the midaxillary L M
line overlying serratus anterior. In many patients, Doppler activity from I
the long-thoracic artery helps to identify the nerve. (B) It should not
be confused with the thoracodorsal nerve that lies closer to the lateral b
border of the scapula (outlined). (C) The needle lies close to the tip
of the long thoracic nerve separated from the underlying lungs and Figure 30.12 Long axis approach to the common extensor origin.
rib (outlined) by the serratus anterior muscle. The area of maximal tendinopathy and Doppler activity is targeted.
a a
L
D P
M
L
D P
M b
Figure 30.14 The common flexor origin can be accessed by having

b
the patient externally rotate their shoulder. As this can be uncomfort-
Figure 30.13 CEO injection. It is often more comfortable for the able to sustain, this procedure is also often carried out in the recum-
procedure to be carried out with the patient recumbent, particularly bent position.
if there is a fainting risk.
The approach is otherwise similar to the common extensor

probe is not available, care should be taken to ensure that origin technique described earlier (Fig. 30.15).
the probe is moved a little more proximally, so that the
proximal puncture point will be in the correct location
ELBOW JOINT
and not too distal to the target area. Local anaesthetic is
infiltrated along the outer epimyseum/paratenon of the The elbow joint can be injected diagnostically as part of an
common origin. Once anaesthetized, the needle is directed MR arthrogram. Saline arthrosonography can also be used
into the tendon and towards the bony origin. The general to detect radiographically occult osseous and cartilaginous
principles of dry needle therapy have already been described. loose bodies within the joint. Another common indication
There is a risk of tendon rupture following dry needling is to treat elbow arthropathy.
therapy that needs to be actively managed. It is important The patient may be seated with the palm on the couch,
that there is a planned rehabilitation programme under the with the elbow flexed at 90° and internally rotated. The
care of an appropriate specialist. This should be individually forearm is perpendicular to the examination table in
tailored to the needs of the patient and the degree of the so-called ‘crab position’ (Fig. 30.16). Alternatively the
tendon damage. patient can be recumbent with their forearm positioned
across their chest, either supine or decubitus (Fig. 30.17).
All of these positions expose the posterior joint to easy injec-
COMMON FLEXOR ORIGIN
tion. In children with a suspected diagnosis of septic arthri-
The rationale for ultrasound-guided therapy of the common tis, the child sits facing the mother on her lap with their
flexor origin is similar to its extensor counterpart. As has arms wrapped around the mother’s side. A nurse or assistant
been previously noted, the common flexor origin is more can stand behind the mother and hold the child’s hands to
fleshy than the extensor origin. A recumbent position is prevent excessive movement. This position allows access to
used and is especially good for nervous patients. The arm is the posterior aspect of the elbow joint for examination and
abducted exposing the common flexor origin (Fig. 30.14). aspiration.
a a
L
D P
M
Figure 30.15 Recumbent patient with shoulder abducted allowing

easy access to the common flexor origin.
P
The posterior joint space can be punctured in either the M L
long or the short axis. The short axis is the easiest, particu- A
larly if there is an effusion (Fig. 30.17). A posterolateral
approach into the posterior joint space is used. The ulnar
b
nerve posteromedially and the triceps tendon centrally
should be identified and avoided. If a posterolateral Figure 30.16 Posterior approach to the elbow joint with the patient
approach is not possible, a posteromedial approach can be sitting. The crab position should be used for easy access.
used if the ulnar nerve is safely identified. Once cannulation
has been achieved it is often helpful to move the probe to
visualize the olecranon fossa prior to injecting the joint.
This allows easy confirmation of joint filling and allows the passing between the two heads of the supinator muscle.
movement of suspected loose bodies, seen as mobile echo- Injection of the radial tunnel per se is not a common pro-
genic foci, to be observed. cedure but may be indicated in patients with symptoms
An alternative approach in adults is through the radio- suggesting isolated PIN compression. Compression may be
capitellar joint, which is palpated as a soft spot on the lateral due to a fibrous band at the proximal margin of the supina-
aspect of the flexed elbow. Another approach in adults is tor muscle or any mass. The rationale for injection therapy
just lateral to the olecranon process where a small groove in the absence of an identifiable cause is unclear, but it has
can be palpated between the olecranon and the humerus. been argued that corticosteroid injection dampens any
inflammatory response and breaks down adhesions that may
be present between the nerve and surrounding structures.
INTEROSSEOUS NERVE BLOCK
The approach to the radial tunnel is from the lateral side
The anterior interosseous nerve (AIN) is a branch of the through the brachioradialis muscle.
median nerve, arising close to where the nerve passes If injection around both interosseous nerves is required,
through the two heads of pronator teres. The posterior a more distal puncture point on the extensor aspect of the
interosseous nerve (PIN) is a branch of the radial nerve and forearm is chosen (Fig. 30.18). Within the forearm, the
reaches the posterior compartment of the forearm by nerves can be found on either side of the interosseous
a a
3,1
$,1
Figure 30.18 Occasionally, both interosseous nerves are injected

for diagnostic and pain control purposes. They can either be injected
separately or, more easily, a singular approach with posterior aspect
P can be used. The needle is passed into the posterior compartment
M L to infiltrate around the PIN and then advanced across the interosse-
A ous membrane to the region of the AIN.
Figure 30.17 A posterior approach to the elbow joint is easiest for

joint injection or aspiration. If the approach is on the ulnar side, the approach is used. The patient can either be seated opposite
ulnar nerve must be identified and avoided. the operator with the palm of the hand placed on the exami-
nation table or can be positioned prone with the arm above
the head, again with the palm of the hand on the table. The
latter is helpful in avoiding syncopal episodes, particularly
membrane. The AIN lies on the membrane itself but the in younger patients.
PIN is separated from it by the deep extensor muscle group. The probe is positioned in the axial plane over the DRUJ
Locating both nerves in a single image is possible in the that is identified by the characteristic rounded appearance
majority of patients and injection can be carried out with of the distal ulna (Fig. 30.19). The easiest approach is
the probe held in the axial plane. An imaginary line is ulnar to extensor compartments five. The needle is fol-
drawn between the two nerves and back projected to the lowed in-view until its tip encounters the dorsal aspect of
extensor skin surface. This is the puncture point that allows the ulnar head. Unless there is communication with the
both AIN and PIN to be injected via a single puncture. radiocarpal joint (RCJ), 2–3 mL is sufficient to fill this
small joint.
WRIST INTERVENTION
RADIOCARPAL JOINT
DISTAL RADIOULNAR JOINT INJECTION
A dorsal approach, radial to extensor compartment four,
Indications include distal radioulnar joint (DRUJ) arthropa- allows easy access to the joint (Fig. 30.20). The seated
thy or as a component of a wrist arthrography. A dorsal patient is positioned opposite the operator with their
a a
P
M L
3 A
/0
$ b
Figure 30.20 An axial approach is also used to approach the RCJ.

b The needle is passed radial to extensor compartment four. Identify
and avoid the PIN.
Figure 30.19 An axial approach to the DRUJ is easiest. Identify the
extensor compartments and pass either side of EC4 whichever
affords the best route.
WRIST GANGLION
forearm resting on the examination table in a pronated To aspirate a dorsal ganglion, the patient can either be
position. A rolled-up towel or pad may be positioned seated opposite the sonologist with the palm faced down on
beneath the wrist to allow slight wrist flexion. The RCJ gen- the examination couch, or lie prone with the wrist above
erally accepts 5 mL. their head. The latter position is preferred for nervous
patients or where there is a risk of fainting. As with ganglia
CARPOMETACARPAL AND SCAPHO-TRAPEZIO- elsewhere, the optimal puncture point is a combination of
where the ganglion comes closest to the skin surface, where
TRAPEZOID JOINT INFECTIONS
the line of the needle can continue into the neck of the
The patient is positioned with the ulnar border of the hand ganglia and where overlying structures, particularly nerves,
on the examination couch. If both sides are to be injected, can be avoided. For dorsal ganglia, flexing the wrist over a
a praying position can be employed (Fig. 30.21). A short rolled-up towel is helpful (Fig. 30.23). The general princi-
footprint probe is placed along the radial aspect at the base ples of ganglion aspiration have been described in the previ-
of the thumb and the scapho-trapezio-trapezoid (STT) and ous chapter. Converting a syringe into a suction device is
first carpometacarpal joint (CMCJ) identified. The position very helpful to achieve more complete aspiration of the
of the radial artery should be noted. An out-of-view approach ganglion.
is used with the puncture point at the midpoint of the probe
opposite the side of the radial nerve and extensor compart- EXTENSOR COMPARTMENT 1: DE QUERVAIN’S
ment one tendons. The two joints lie close together, sepa-
rated by a thin septum. If necessary, either joint can be The patient may either be seated opposite the operator with
injected depending on involvement. An alternative method their forearm extended on the examination table or lying
to inject the first CMCJ is through the thenar eminence with in the ‘superman’ position. Both allow access to the first
the probe held over the joint in the sagittal plane. For this compartment tendon sheath. Placing some support under
approach an in-view method is used (Fig. 30.22). the ulnar aspect of the wrist introduces a little ulnar
a a
A
b
D P
Figure 30.21 Out-of-view approach to first CMCJ. The radial nerve P
should be identified and the overlying tendons avoided. In this posi-
tion, bilateral injections can be carried out with ease.
b
Figure 30.22 Alternative approach to the first CMCJ. The opening

of the joint is identified in long axis. A distal puncture passes through
the muscles of the thenar eminence to reach the joint.
deviation, which helps straighten the course of the extensor

compartment one tendons. The transducer is orientated
along the long axis of the tendon sheath.
A puncture point is chosen either proximal or distal to wrist will determine whether the approach is best from distal
the transducer, whichever gives the best angle of approach to proximal or vice versa. The optimal line is as close to
to the extensor retinaculum (Fig. 30.24). Care should be parallel to the tendon and retinaculum as possible. To facili-
taken to indentify the radial nerve to avoid irritating it tate this, the puncture point is also a little distance from the
during the procedure. Under ultrasound guidance the retinaculum as, if made too close to it, the angle between
needle is advanced with infiltration of local anaesthetic to needle and retinaculum will make it difficult to completely
the tendon sheath. Rotating the needle so that the bevel traverse it.
points towards the tendon is a simple technique that will
reduce the risk of tendon puncture. The bevel can be
CARPAL TUNNEL
rotated once the sheath is penetrated to aid injection. Pre-
liminary injection is confirmed with the free flow of injec- The patient is seated opposite the operator with their
tate within the sheath and away from the needle. The forearm extended on the examination table in the supi-
injection should result in distension of the tendon sheath nated position. The standard injection point for a carpal
with filling on both sides of the tendon. If filling is limited tunnel injection is between the flexor carpi radialis tendon
to one side alone it is probable that the needle lies outside and the median nerve. The puncture point can initially
the tendon sheath. It should be noted that de Quervain’s be identified by placing the transducer in the transverse
is a sclerosing tenosynovitis so the tendon sheath may be plane to identify these two structures (Fig. 30.25). An out-
restricted in its capacity. of-view injection can be carried out or the transducer can
In many cases, the main focus of disease is in the first be rotated through 90° until its midpoint is centred over
extensor retinaculum and retinacular division may give the space between the flexor carpi radialis tendon and
symptomatic relief. If the retinaculum is to be disrupted, median nerve in the sagittal plane (Fig. 30.26). The punc-
a long axis approach with the needle in-view is used. An ture point is proximal to the transducer and the flexor
initial assessment of the shape of the patient’s hand and retinaculum.
a a
L
D P
M
Figure 30.24 Injection of the first extensor compartment. An angle

of approach is chosen so that the retinaculum (outlined) can be
divided if necessary.
P
M L
A
Figure 30.23 Dorsal ganglion aspiration. Wrist flexion helps to bring

the ganglion close to the skin surface. A wide-bore needle is used.
HAND INTERVENTION
METACARPOPHALANGEAL AND
INTERPHALANGEAL JOINTS a
The probe is placed in the sagittal plane over the extensor

tendon. The digital neurovascular bundle is located prior
to puncture, though it usually lies more towards the flexor
side and out of the route of the needle. An out-of-view
technique is used (Fig. 30.27). An alternative technique is
to rotate the probe about 45° from the sagittal plane and
use an in-view approach (Fig. 30.28). This may have advan-
tages in larger patients.
FLEXOR TENDON SHEATH

The approach to any of the flexor or extensor tendon com-
partments is similar. In general, an in-view approach is used
b
aiming for the sheath in either the long or short axis. If a
small footprint probe is not available, the larger footprint Figure 30.25 Out-of-view approach to the carpal tunnel. The target
probe can be moved so that the tendon sheath to be injected area is radial to the nerve deep to the flexor retinaculum.
a
a
A b
D P Figure 30.27 Out-of-view approach to the MCPJ of the hand. The

P joint is centralized under the sagittally positioned probe. The puncture
is at the midpoint of the probe and the needle appears in the target
b area.
Figure 30.26 Long axis approach to the carpal tunnel. The puncture
is made on the radial aspect of the nerve. The radial artery is palpated
and avoided. The needle tip lies under the flexor retinaculum (arrows).
is not in the middle of the probe, but over to one side and
closer to the needle puncture point.
PULLEY FIBROMA
Trigger finger is a condition caused by enlargement of the
A1 pulley. Percutaneous treatment includes corticosteroid
injection into the fibroma, which can be combined with an
attempt to divide the pulley using a cutting needle. The a
technique is similar to that used for disrupting the first
extensor compartment retinaculum. The patient places the
back of the hand on the examination couch and the short
footprint probe is placed in a sagittal position overlying the
fibroma. The skin can be punctured either proximal or
distal to the lesion. The choice depends on the fleshiness
of the patient’s hands/fingers, so some thought needs to be
given to the route that will give the easiest access to the long
axis of the fibroma, keeping the needle parallel to the
probe. It is also helpful to create a bend at the hub needle
P
junction and the creation of a second bend in the needle
D P
itself has also been suggested. The proximal puncture point
A
is at roughly the level of the distal palmar crease (Fig. 30.29).
An advantage of choosing a distal puncture point is that a
b
ring anaesthetic block can be used. The needle is then
passed through the pulley either bevel upwards or side on. Figure 30.28 Oblique approach to the metacarpophalangeal joint.
Several passes are carried out in an effort to divide the The puncture is distal and targeted towards the metacarpal head.
a a
A
D P
P
b A
L M
Figure 30.29 Injection of A1 pulley fibroma. In-plane approach with
P
proximal puncture. A small bend or several bends can be placed in
the needle to accommodate the shape of the hand and to facilitate
cutting if the fibroma is to be divided. b
Figure 30.30 The ilioinguinal nerve is located deep to the external

and internal oblique muscles and superficial to the transversus
abdominis. It is approached in the axial plane either from medial or
lateral.
pulley and release the triggering. Corticosteroid injection
may also be employed.
lateral side and the bevel of the needle tracked to the

PELVIS AND HIP INTERVENTION
nerve. Ideally, the injectate should completely surround
the nerve.
ILIOINGUINAL NERVE BLOCK
Injection around the ilioinguinal nerve is sometimes used
LATERAL CUTANEOUS NERVE OF THIGH BLOCK
as a means of differentiating causes of groin pain or as a
pain control technique following hernia repair. The nerve The lateral cutaneous nerve of the thigh is best located
is identified in the region of the anterior superior iliac close to the ASIS where it passes deep to the inguinal liga-
spine (ASIS). The lateral aspect of the probe is placed in ment. It may become entrapped at the ASIS, be injured as
axial plane on the ASIS. The medial end is rotated superi- part of a seat belt injury in a road traffic accident or become
orly until the three muscle layers of the anterior abdomi- symptomatic in diabetic neuropathy (meralgia paraesthet-
nal wall are located (Fig. 30.30). These are the obturator ica). To locate it, the probe is placed in the axial position
externus, obturator internus and transversus abdominis. with its lateral margin on the ASIS and the medial end is
The ilioinguinal nerve arises from the lumbar plexus, rotated downwards until it is aligned with the inguinal liga-
passes through the iliopsoas muscle and can be located in ment. The lateral cutaneous nerve is quite superficial,
the intermuscular fat plane between the obturator inter- passing just deep to the ligament immediately medial to
nus and transversus abdominis. It is often quite a small the ASIS (Fig. 30.31). It is a small structure but a surround-
structure but the tubal configuration can be confirmed by ing cuff of fat helps to locate it. Occasionally, it is easier to
following the nerve as it migrates towards the deep ring of identify a little more distally where it lies on the anterior
the inguinal canal. An in-view approach is used from the aspect of the sartorius muscle. Once identified, the probe
can be moved laterally to bring the puncture point on the

medial side of the probe closer to the nerve. An in-view
approach is used and the bevel of the needle tracked to
the nerve. Ideally the injectate should completely surround
the nerve.
ADDUCTOR ORIGIN PUBIC SYMPHYSIS

Injection into the symphysis or around the adductor origin
is best achieved with the patient lying in the supine position.
The symphysis can be injected from above using either an
in-view or out-of-view technique, or from the lateral side.
The in-view technique is preferred with the probe held
sagitally over the symphysis (Fig. 30.32). Moving the trans-
a ducer from side to side helps to identify the echogenic
landmark of the pubic bone and it becomes clear when the
transducer is positioned directly over the symphysis. Only
the uppermost aspect of the pubic symphysis is amenable to
injection but the needle can be seen to pass into the liquid
centre prior to injection. If the symphysis is to be injected
in conjunction with an adductor origin injection, an
approach from below can be used.
The adductor origin injection, or combined adductor
and symphyseal injection, is carried out from below. The
patient is supine in the frog-leg position (hip abducted and
externally rotated, knee flexed). The obvious palpable
muscle is the adductor longus. The probe is placed on it in
short axis, then rotated into its long axis on the anterome-
A dial aspect of the thigh. The probe is moved superiorly until
L M the rounded upper border of the adductor muscles gives
P way to a low-reflective triangular shaped tendon; this is the
common adductor tendon that is attached to the pubis. The
symphysis is adjacent on the medial side.
b
A small footprint probe allows a more proximal puncture
point. The point should be chosen distal to the probe, but
not so distal that the common tendon cannot be reached.
The needle should be directed into the tendon parallel to
the tendon fibres. Dry needling, autologous blood or PRP
injection are the most commonly performed procedures.
The sagittal approach to the pubic symphysis is similar. If
the probe is moved medially from the adductor origin, the
bony margin of the inferior pubic ramus disappears. The
probe now overlies the symphysis and the needle can be
directed into it.
OBTURATOR NERVE
Obturator nerve compression may underlie symptoms of
exercise-induced medial thigh pain or postexercise weak-
ness. Occasionally clinical examination may reveal an area
of medial sensory loss. Obturator nerve injury may arise
as a result of pelvic fractures, haematoma, osteitis pubis,
obturator hernia or as a consequence of fascial thickening
over adductor brevis. The neurovascular bundle is located
c
deep to pectineus, just below the superior pubic ramus
(Fig. 30.33).
Figure 30.31 The lateral cutaneous nerve of the thigh is located
close to the ASIS, just on its medial side, and deep to the
inguinal ligament. It is generally surrounded by a small cuff of echo- HIP JOINT INJECTION
genic fat that facilitates its location and it is also often accompanied
Several approaches to this large joint are possible and sagit-
by vessels. The approach to injecting around it is from the medial
side.
tal, axial, and any angle in between has been employed. The
axial method involves locating the characteristic rounded
A A
D P L M
P P
b
b
Figure 30.32 The adductor origin is usually approached below,
particularly if dry needle therapy is to be carried out. The patient is Figure 30.33 The obturator neurovascular bundle is identified just
placed in the frog-leg position and the probe placed in long axis below the superior pubic ramus deep to the pectineus muscle. An
overlying the tendon origin. The small footprint probe facilitates an approach from the medial side moves the puncture point further from
approach from inferiorly. If the probe is moved a little medially, the the femoral neurovascular bundle.
pubic symphysis comes into view. This can also be injected from
below or above.
HIP JOINT SYNOVIAL BIOPSY

anterior aspect of the femoral head and the adjacent ante-
rior acetabulum (Fig. 30.34). The puncture is lateral to the Synovial biopsy is a useful adjunct for the investigation of
probe, and uses and in-view approach, directing the needle complications following hip replacement and the resulting
towards the joint. Targeting the femoral head gives the best specimens are more likely to reflect the true microbiology
needle visualization as the needle track is parallel to the within an infected implant than simple aspiration. Two
probe. Targeting the head–neck junction offers the largest approaches are possible. One is where the probe is placed
space to aim for, though much of it is filled with intracap- axially, or a tilted axial plane aligned along the distended
sular fat. The femoral neurovascular bundle is medial and anterior joint space. The biopsy needle is inserted laterally
usually well out of any danger of injury, but it is important and directed across the anterior joint space lateral to medial.
to remember that the nerve is also lateral to the artery and An approach is chosen to avoid any obstruction from the
not as conspicuous. For the sagittal method, the probe is greater trochanter, and once this is achieved, access to the
placed along the femoral neck (Fig. 30.35). The puncture synovial space is good and there is no difficulty opening
is distal to the probe and the needle is directed towards the the port on a 2 cm port size 14 G spring-loaded type biopsy
anterior joint space, again using an in-view approach. In needle. A sagittal approach similar to that used for simple
practice a position between the true axial and sagittal is injection can also be employed; however, the plane is just
usually employed, with the probe position somewhat nearer lateral to the femoral neck, which allows the biopsy needle
the axial plane. to pass alongside the femoral neck and more fully into the
a a
A
A D P
L M P
P
b
b Figure 30.35 Long axis approach to the hip joint. The head–neck
junction makes a useful target area. In thin individuals, needle visu-
Figure 30.34 Axial approach to the hip joint. The apex of the joint
alization is helped by targeting a more proximal point overlying the
overlying the articular cartilage can be targeted. Alternatively, a target
apex of the articular cartilage.
point at the head–neck junction makes use of a slightly wider anterior
joint space in this location.
joint. Where possible several separate specimens should be transient synovitis, a self-limiting condition. A rarer, but
obtained, ideally using a different needle each time. This devastating, cause is septic arthritis and has been outlined
reduces the possibility of a false-positive result from instru- on page 221. These are difficult to differentiate by clinical
ment contamination. Restrained use of lignocaine local and radiological criteria alone. The cause of an effusion
anaesthetic is also recommended as it is bacteriostatic. cannot be determined by its ultrasound appearances and
clinical and laboratory parameters such as fever, peripheral
white cell count and erythrocyte sedimentation rate do not
ASPIRATION OF PAEDIATRIC HIP EFFUSIONS
always reliably predict hip sepsis. Delayed diagnosis of septic
A painful irritable hip is one of the commonest nontrau- arthritis can cause serious damage to the hip joint with rapid
matic acute paediatric presentations in orthopaedic prac- destruction of the femoral head, degenerative arthritis and
tice. Ultrasound is an important early diagnostic technique permanent deformity. Microscopic and microbiological
to detect a hip joint effusion and to guide aspiration to analysis of aspirated fluid is very much more accurate than
exclude sepsis. The commonest cause of the irritable hip is indirect blood evaluation and aspiration, when carried out
competently, is no more traumatic for the child than drawing

blood.
In children aspiration needs to be carried out quickly
to ensure that the child does not become distressed so a
‘semiblind’ technique is recommended. This reduces the
likelihood of the child moving and making the procedure
very difficult to carry out. The principle of the semiblind
approach to large joints is that ultrasound is used to identify
the optimal puncture point overlying the area of maximal
joint distension, with a perpendicular path to the joint free
of important structures. This is followed by an unguided
approach of the needle to the joint. The goal is to identify
this point with confidence such that the aspiration can then
be carried out quickly without the need for active image
guidance. The method for achieving this has been described a
in detail on page 223.
ILIOPSOAS BURSA INJECTION

Injection into the iliopsoas bursa has been used to treat
iliopsoas tendinopathy, bursitis, tendon impingement
against a prominent acetabular cup following hip replace-
ment and patients with a clinically suspected snapping ilio-
psoas tendon. An enlarged bursa, if present, is identified
lateral to the femoral neurovascular bundle. The proximity
of the bursa to the femoral artery means that cannulation
is best achieved by an axial approach, from the lateral side
using an in-view technique. The needle is passed deep and
medial until it reaches the bursa (Fig. 30.36). If there is no
fluid in the bursa or tendon sheath, the tendon itself
becomes the anatomical target point and the needle tip is
placed deep to it, but not so deep that it enters the joint.
TENSOR FASCIAE LATAE/ILIOTIBIAL BAND

The patient is decubitus affected side upwards, facing away A
from the operator. The probe is placed transversely over the L M
lateral aspect of the greater trochanter. The posterior P
margin of the iliotibial band (ITB) is located. The puncture
point is close to the posterior aspect of the probe and the
b
needle is followed in plane past the posterior margin of the
ligament until the space just deep to it is reached. A small Figure 30.36 Axial approach to the iliopsoas bursa. The puncture
volume of injectate is employed. In some patients symptoms is anterolateral, keeping the needle pathway some distance from the
emanate more proximally close to the origin of the ITB femoral neurovascular bundle. The needle is placed close to the
from the iliac crest. iliopsoas tendon, making sure to avoid entering the hip joint.
TROCHANTERIC AND GLUTEAL

minimus tendon inserts on the anterior facet and part of
BURSA INJECTION
the gluteus medius tendon on the posterior facet. There is
Perigluteal bursitis and gluteus enthesopathy is a common also a superior facet onto which the remainder of the
condition causing pain along the lateral aspect of the hip. gluteus medium tendon inserts. The subgluteus medius
Symptoms may be due to either subgluteal or trochanteric bursa lies deep to its tendon. The trochanteric bursa lies
bursitis, most commonly in association with tendinopathy of between the gluteus maximus and the femur, superficial and
the gluteus medius tendon. The trochanteric bursa is the more posterior to the gluteus medius insertion.
largest of the lateral hip bursae and lies posterior to the The rationale is that pain is related to gluteus medius
greater trochanter. The subgluteus minimus and medius enthesopathy associated with either trochanteric or subglu-
bursae lie more anterior and deep to the tendons of gluteus teus medius bursitis, or both. Whether it is possible to
minimis and medius respectively. differentiate these clinically is uncertain, but it has been
To evaluate this area, the patient is decubitus with the suggested that pain due to trochanteric bursitis is more
affected side upwards. The probe is placed transversely over typically posterior and distal to the maximal point of sub-
the proximal femur and moved proximally until a pointed gluteus medius pain, which is directly above or above and
bony prominence separating two facets is seen. The gluteus slightly posterolateral to the tip of the greater trochanter.
The presence of fluid allows a more secure diagnosis,

although in many cases low-grade bursal thickening only is
present and this may be difficult to detect, particularly in
larger patients. For this reason in many cases both bursae
are injected. If the gluteus medius tendon is torn, the two
bursae communicate.
If tenderness is maximal over the trochanteric bursa a
posterolateral injection is employed. The puncture is poste-
rior to an axially positioned probe and followed in-view
until it reaches the posterior aspect of the greater trochan-
ter near its upper aspect (Fig. 30.37). The needle is then
retracted slightly and anaesthetic injected. When correctly
positioned the bursa should be seen to distend. If tender-
ness is maximal over the subgluteus medius bursa, an
anterolateral approach is used (Fig. 30.38). The puncture
point is level with the anterior aspect of the probe and fol-
lowed in plane until it lies deep to the gluteus medius a
tendon. Once again the bursa can be seen to distend during
injection. The anterolateral approach to subgluteus medius
bursa can be extended to include the trochanteric bursa.
The upper aspect of the trochanteric bursa reaches the
lateral margin of the gluteus medius tendon as it inserts.
Following injection of the gluteus medius bursa, the needle
can be retracted and then advanced so that its tip lies just
lateral to the tendon and in the trochanteric bursa.
Following injections around the gluteal insertion, the
patient should be warned that, particularly for trochanteric
bursal injection, local anaesthetic might infiltrate around
the sciatic nerve, leading to transient numbness. The
patient should be warned to take care when standing to
avoid falls.
ALTERNATIVES
A long axis approach to the trochanteric bursa is also
straightforward. A long axis approach to the subgluteus
medius bursa is more difficult and in many cases results in
a transtendinous injection. It is generally thought that this
increases the risk of tendon rupture. Conversely a combina-
tion of a dry needle procedure to the tendon with bursal
injection has been advocated, suggesting that perforation of
the tendon itself is not particularly hazardous. It is also
argued that the more significant problem at the gluteal
insertion is gluteus medius enthesopathy or tendinopathy.
Dry needling procedures directed at the gluteus medius
tendon may be carried out instead of a corticosteroid injec-
tion into the adjacent bursa. There is suspicion but no L
compelling evidence that the combination of these proce- P A
dures leads to an increased risk of tendon rupture. M
GLUTEUS MINIMUS BURSA b
The gluteus minimus tendon inserts on the anterior facet Figure 30.37 Posterolateral approach to the trochanteric bursa.
of the greater trochanter. The facet is located as described This is a larger bursa. The bony contour of the posterolateral aspect
of the femur is targeted. The bursa lies just above it.
above. Both gluteus minimus and medius tendon should be
identified. An axial in-view approach is used to pass the
needle deep to the gluteus minimus tendon between it and
the greater trochanter. guidance is feasible via a posterior approach, though disad-
vantages include difficulty in confirming that the joint has
filled and less optimal visualization except in very thin indi-
SACROILIAC JOINT
viduals. Nevertheless, as sacroiliac pain is more common in
The majority of guided injections to the sacroiliac joint are pregnancy when radiation is to be avoided, ultrasound
carried out under fluoroscopic or CT guidance. Ultrasound offers another option.
sacral wing. At the level of the second sacral foramen, the

probe is moved approximately 5 cm lateral. A notch between
the sacral wing and iliac blade is observed, representing the
sacroiliac joint. The puncture is lateral to the probe and the
needle is directed in-view towards this notch.
PIRIFORMIS SYNDROME AND ISCHIOFEMORAL

IMPINGEMENT
Piriformis syndrome and ischiofemoral impingement are
uncommon. The aetiology of piriformis syndrome is poorly
understood, but occasionally the muscle is injected with
local anaesthetic and corticosteroid. The method of action
is also not well understood, but it is theorized that stretching
a the muscle fibres interrupts the pain gate and provides
symptomatic relief in this way. A temporary reduction in
symptoms may assist with physical therapy. Injection of the
muscle is relatively uncommon and is generally carried out
under CT control. In thin patients, the piriformis muscle is
easy to identify on ultrasound, providing an alternative
route.
Injecting the ischiofemoral fossa is also generally carried
out under CT control. Ultrasound offers some advantages
in that it is easier to identify and avoid the sciatic nerve that
overlies the space. The principal disadvantage is that, unless
the patient is very thin, the space is rather deep and it is
difficult to confirm accurate localization of the needle tip.
As would be expected, the space lies between the ischial
tuberosity and the femur. Placing the probe in an axial posi-
tion overlying the ischium and moving it slightly to the
lateral side reveals the quadratus femoris deep to the sciatic
nerve. If the probe is too high, the gemelli are in-view
posterior to the joint space. As the probe is moved lower,
the femoral neck disappears and the probe now overlies the
ischiofemoral space. The approach is most usually from the
lateral side. An in-view method is used, taking care to note
the position of the sciatic nerve and ensure that the needle
bypasses it and passes deep to quadratus femoris, into the
ischiofemoral space. In general, a local anaesthetic injection
is the principal diagnostic tool; however, it is usual to inject
corticosteroid as well. If the syndrome is due to ischiofe
L moral impingement secondary to a narrow space, it is not
P A particularly likely that this therapeutic cocktail will provide
M long-term relief.
b
ISCHIAL BURSA AND HAMSTRING ORIGIN
Figure 30.38 Anterolateral approach targeting the subgluteus The ischial bursa is injected in the axial plane as opposed
medius bursa. The gluteus medius tendon may be difficult to visualize to injection therapy to the hamstring origin, which is more
in large patients. It can be located first in long axis and the probe is often carried out in long axis, especially if dry needle
then rotated to reveal the oval-shaped, echo-poor tendon. An antero- therapy is to be carried out. The ischial bursa can be injected
lateral approach allows the needle to be placed deep to it just above either from medial or lateral (Fig. 30.39). An approach
the greater trochanter. from the medial side avoids the risk of any injury to the
sciatic nerve, which lies lateral to the hamstring origin, but
can be difficult in many individuals and especially in large
The procedure is carried out with the patient prone. The patients. A lateral approach is technically easier and is safe
joint lies at the level of the second sacral foramen. This in as long as the sciatic nerve is correctly identified and
turn is located by beginning with the probe centrally over avoided.
the L5 spinous process. It is then moved laterally to the The approach to the hamstring origin is like the adductor
affected side and passed distally until the sacral wing is origin. The probe is positioned in long axis and the punc-
encountered. Further distal movement identifies the first ture point is distal to it (Fig. 30.40). Once again, the sciatic
sacral foramen as a defect in the reflective contour of the nerve should be located in the axial plane. As it is turned
a a
P
P D
A
P Figure 30.40 Long axis approach to the hamstring origin. A distal

puncture point facilitates dry needling of the common tendon.
M L
A
Figure 30.39 The ischial bursa is ideally approached from the creating a space by first manually displacing the patella
medial side. Where this is not feasible, such as in larger individuals, medially. When ultrasound is available for guidance, such
a lateral approach is straightforward as long as the laterally positioned anatomical landmarks are no longer necessary and a
sciatic nerve is identified and avoided. more proximal puncture over the suprapatellar bursa is
employed. Preliminary examination determines whether
there is a joint effusion and whether the medial or lateral
aspects of the suprapatellar bursa are most prominent
(Fig. 30.41). Care should be taken to identify and avoid
sagittal, care should be taken not to allow it to drift laterally the tendinous insertions of the vastus medialis and vastus
and risk injuring the nerve. lateralis.
As in the hip, synovial biopsy is a better means of deter-
mining the microbiological content of an infected implant
KNEE INTERVENTION
when compared with simple fluid aspiration. In view of the
relative thinness of the synovium, biopsy is best achieved by
KNEE JOINT INJECTION
inserting the needle parallel to the area of synovium to be
Aspiration of a knee joint effusion, local anaesthetic injec- biopsied. Larger-gauge needles are preferable to ensure a
tion for diagnosis, corticosteroid therapy for arthropathy good specimen; however, these can be difficult and painful
and contrast injection for MRA are common indications for to insert as the capsule of an implanted joint is often rather
knee joint puncture. The joint is approached with the thick and fibrous and resists passage of the needle. Care
patient supine and the knee slightly flexed in a position of should be taken to apply liberal local anaesthetic to the
comfort. The suprapatellar bursa is large and, particularly capsule prior to the insertion of the biopsy needle. Although
when distended, is easily accessed from a variety of posi- it is preferential to use adequate analgesia to the skin and
tions. The classical blind approach describes cannulating joint capsule, it should be appreciated that many local
the joint at the level of the patella on the medial side by anaesthetics are bacteriostatic and consequently once the
the tip of the biopsy needle on the capsule and then gently
advance the central portion as though a biopsy was about
to be taken. As this is a little smaller than the overall diam-
eter of the needle it creates an initial puncture through
which the larger needle may more easily pass. Once the joint
has been penetrated, the needle should be directed to the
point of maximum synovial thickening.
Thickened synovium is often rather friable and it is not
uncommon that the retrieved specimens are very frag-
mented. Use of a 14 G needle or larger improves the diag-
nostic yield. It is also helpful to compress the needle against
the thickened synovium while vibrating it slightly to try and
get a good specimen to embed itself in the biopsy port.
When infection is suspected, multiple specimens should be
a obtained both for culture and histopathological assessment.
It has also been recommended that, particularly for chronic
infection around implanted joints, different needles are
used to obtain serial specimens. This is to ensure that needle
contamination does not give rise to spurious results. In the
case of implanted joints, culture should be carried out
under enrichment to encourage the growth of low-virulent
organisims.
PROXIMAL TIBIOFIBULAR JOINT

The patient is positioned lateral decubitus with affected
knee upwards. An axial or parasagittal orientation to the
probe posterolaterally identifies the superolateral aspect of
the joint. The puncture point is proximal to the probe and
the needle is directed distally and into the soft tissue trian-
gle that directs the needle towards the upper aspect of the
joint (Fig. 30.42). The joint will generally accept 2–3 mL.
PATELLAR TENDON
For patellar tendon therapy, the patient is generally supine
with the knee extended. The commonest procedure is dry
needle therapy to the proximal or distal tendon attachment.
$
The principles of dry needle therapy have been described
3'
on page 338. A sagittal in-view approach is used (Fig. 30.43).
3
The paratenon is anaesthetized and the needle inserted into
the tendon, targeting the area of greatest hypervascularity,
b keeping the needle as parallel to the tendon fibres as pos-
sible. Multiple passes are made, following which autologous
Figure 30.41 Aspiration, injection or synovial biopsy of the knee blood or PRP can be injected. In many cases, a series of 2–3
joint through a superolateral approach. The area where the joint is
procedures several weeks apart is thought to be more ben-
maximally distended is chosen. In most cases, this is superolateral
or superomedial.
eficial than a single treatment.
INFRAPATELLAR AND OTHER PATELLAR BURSAE

There are two superficial and one deep bursa located below
joint has been penetrated, where possible, anaesthetic use the patella. The prepatellar bursa lies anterior to the patella
should be limited. and proximal patellar tendon. The superficial infrapatellar
If the joint capsule proves to be resistant or painful, two bursa is located superficial to the tendon close to the tibial
tips to help transgress it are to use an external cannula, or attachment. It is uncommon that these bursae need to
to advance the central part of the biopsy needle to make an be injected and whatever approach is easiest can be
initial puncture. Cannulae tend to be much sharper than employed provided the skin is uninvolved. Care should
biopsy needles and will more easily penetrate a thickened be taken not to press the probe too hard so as to occlude
capsule. The cannula can be left in position, allowing mul- the bursal space.
tiple biopsies to be obtained via a single capsule puncture. The deep infrapatellar bursa lies deep to the tendon at
If a coaxial system is not available, another option is to place the anteroinferior margin of Hoffa’s fat pad. Injection here
a a
L
P D
M
b
A
Figure 30.42 The patient lies prone or decubitus for a proximal P D
tibiofibular joint injection. The head of the fibula is easily identified. A P
posterolateral approach from above allows access to the joint.
b
Figure 30.43 Long axis, dry-needle procedure of the patellar

tendon. The epimysium is anaesthetized and the needle procedure is
is more commonly indicated. The probe is placed trans- carried out along the long axis of the tendon.
versely across the patellar tendon and an in-view approach
is used to access it (Fig. 30.44). Notice should be taken of
whether the bursa is more prominent medially or laterally.
An appropriate puncture point is chosen some distance
SEMIMEMBRANOSUS INJECTION
from the probe to allow the needle to pass freely deep to
the tendon and into the bursa. For injecting the bursa around the tendon or the paratenon
an in-view axial approach is used. The probe is placed on
the posteromedial aspect of the knee identifying the tendon
HOFFA’S GANGLION ASPIRATION
which is followed to close to its insertion. Often it is easier
Hoffa’s ganglion is most often initially identified on MR to ask the patient to lie prone (Fig. 30.46). A medial punc-
imaging. The aetiology of the ganglion is not fully under- ture is used and the needle followed in-view until it reaches
stood. Possibilities include an origin from the anterior inter- the bursa or paratenon.
meniscal ligament or, more likely, arising from the anterior For direct tendon therapy such as dry needling, autolo-
cruciate ligament sheath. Hoffa’s ganglia are aspirated from gous blood or PRP injection, a long axis approach is recom-
anterior with the needle inserted adjacent to the patellar mended. The probe is rotated 90° along the long axis of the
tendon. A probe orientated in the axial plane overlying the tendon. An in-view approach is used with a proximal punc-
patellar tendon provides good visualization of Hoffa’s fat ture and the needle directed parallel to the tendon fibres.
pad (Fig. 30.45). The needle can them be inserted medially
or laterally depending on the position of the ganglion. As PES ANSERINE BURSA
the anterior cruciate ligament deviates towards the anterior
horn of the lateral meniscus, the ganglia tend to be more PATIENT AND PROBE POSITION
obvious on the lateral side and consequently a lateral The patient lies decubitus with the affected side down. The
approach is used. The principles of ganglion aspiration are unaffected knee is placed either in front or behind the side
discussed on page 344. to be injected. The pes anserine tendons are best identified
a a
A
L M
b P
Figure 30.44 The deep infrapatellar bursa is cannulated from either
medial or lateral side depending on which is more prominent. The b
probe is placed transverse and an in-view approach is used.
Figure 30.45 Hoffa’s ganglia can be difficult to visualize. If they are
large enough they are usually more apparent anterolaterally. A wide
bore needle is used to aspirate the viscous contents.
by locating the semitendinosus tendon; this has a very char-

acteristic configuration where it lies on the dorsal aspect
of semimembranosus. As it is traced distally, the smaller no definitive syndrome associated with them. If no other
gracilis and more muscular sartorius tendons are identified cause of pain is identified, aspiration of these ganglia is
and the three come together to form the pes anserine inser- frequently requested. A posterior approach is used for
tion. The pes anserine bursa tends to form around the aspiration. The patient lies prone on the examination
semitendinosus tendon. To inject it, an axial approach is couch. The probe is placed in an axial position over the
used with a puncture either on the anterior or posterior intercondylar notch. The popliteal vessels and tibial nerve
margin of the probe depending on where the bursa is most are identified and avoided. If the ganglion can be visualized
prominent and most easily accessed. Care should be taken a posteromedial or posterolateral approach can be used.
to identify all three tendons to prevent an inadvertent Once the neurovascular bundle is passed, the ganglion is
transgression. entered. In larger patients the ganglion may not be directly
visualized. Under these circumstances correlation with MRI
CRUCIATE GANGLIA is necessary to determine the best approach. The popliteal
vessels can be used as a landmark and the needle deliber-
PATIENT AND PROBE POSITION ately passed either medial or lateral to them as determined
Small cruciate ganglia are common and not necessarily by MRI (Fig. 30.47). Techniques of ganglion aspiration have
associated with symptoms. Even with large ganglia, there is been discussed on page 344.
a a
P
L M
A
P
b L M
A
Figure 30.46 Peritendinous injection of semimembranosus for
paratenonopathy is carried out by a posteromedial approach in the
axial plane. A long axis approach is used if dry needling procedure b
or volume injection is to be carried out.
Figure 30.47 The cruciate ganglia can be difficult to identify on
ultrasound, particularly in large patients. Careful planning using the
MRI examination is needed. The popliteal artery is an important land-
mark. Anterior cruciate ligament ganglia often lie more laterally and
a passageway between the lateral femoral condyle and the popliteal
ILIOTIBIAL BAND INJECTION artery is used.
The iliotibial band (ITB) is easiest to identify in long axis.

The probe is placed in a coronal position over the knee joint
laterally and the ITB identified as it inserts on Gerdy’s tuber-
cle of the tibia. It can then be traced proximally so that the positioned deep to the band without traversing it. An antero-
portion overlying the lateral femoral condyle, where it is lateral approach is also feasible. The lateral retinaculum is
most usually affected by friction syndrome, is identified. The a little thicker however. Care should be taken to identify the
injection, however, is best carried out in the axial position lateral recess of the joint to ensure that the bevel stops short
(Fig. 30.48). The probe is rotated 90° staying centred on the of this. An anterolateral approach makes it a little more
band, which measures approximately 2–2.5 cm anterior to difficult to avoid joint injection. A small volume of injectate
posterior and a few millimetres thick. Occasionally, it can is used.
be difficult to differentiate from the lateral retinaculum but
in most cases it is seen as a focal thickening of this
BICEPS FEMORIS
structure.
The injection is placed on its deep aspect via a postero- For injecting the biceps paratenon an in-view axial approach
lateral approach. An in-view approach is used with the punc- is used. The probe is placed on the posterolateral aspect
ture on the posterior aspect of the probe held in the axial of the knee identifying the tendon that is followed
position. The puncture point is close to the posterior aspect close to its insertion. An anterolateral puncture is used
of the transversely positioned probe and the needle is fol- and the needle followed until it reaches the bursa or
lowed past the posterior margin of the ligament until the paratenon (Fig. 30.49). Care should be taken to identify
space just deep to it is reached. It is important to choose a and avoid the common peroneal nerve on the posterior
puncture point that facilitates this angle of approach. Too margin of the tendon at the level of the myotendinous junc-
anterior a position makes it difficult for the needle to be tion (MTJ).
a a
L P
P A M L
M A
b b
Figure 30.48 Posterolateral approach to the ITB. The injection is Figure 30.49 Axial approach to the biceps similar to semimembra-
placed deep to the band (outlined). nosus injection. A posterolateral approach is used.
For direct tendon therapy such as dry needling, autolo- approach is used depending on where distension is maximal
gous blood or PRP, a long axis approach is recommended. (Fig. 30.50). During the injection, fluid should be seen to
The probe is rotated 90° along the long axis of the tendon. traverse around the posterior aspect of the tendon to fill the
An in-field approach is used with a proximal puncture and contralateral side.
the needle directed parallel to the tendon fibres.
PLANTARIS INJECTION
ANKLE INTERVENTION
Occasionally a friction syndrome can develop between the
plantaris tendon and the adjacent Achilles tendon. There is
ACHILLES AND PERI-ACHILLES INTERVENTION
signal alteration between the two which may be associated
The patient is best positioned prone as for the examination with increased Doppler activity (Fig. 30.51). The ultrasound
of the Achilles tendon itself. An axial approach from a appearances are similar to paratenonopathy, although the
medial or lateral puncture gives access to the paratenon, abnormality is localized to the medial aspect of the Achilles.
pre-Achilles space and tendon itself. A longitudinal approach A posteromedial approach is used. The probe is held in the
from posterior allows the tendon to be cannulated. Although transverse position at the same level as the needle so the
the medial lateral punctures are more versatile, care is needle can be tracked accurately from skin to bursa. A small-
needed to avoid the plantaris tendon and sural nerve gauge needle is used to pass between the Achilles tendon
respectively. and adjacent plantaris; a low-volume injection is used. Trans-
Interventional techniques around the Achilles tendon gression of either the Achilles or plantaris tendon should
include injection of the paratenon, pre-Achilles bursa, pre- be avoided to reduce the risk of tendon rupture.
Achilles space and tendon itself.
ACHILLES DRY NEEDLE AUTOLOGOUS BLOOD
PARATENON INJECTION AND PLATELET-RICH PLASMA INJECTION
The paratenon surrounds the tendon on three sides: poste- It is generally recommended that dry needling procedures
rior, medial and lateral. The true paratenon space is injected to the tendon itself are carried out as close to the long
for paratenonopathy. A posteromedial or posterolateral axis of the tendon fibres as possible. An approach from
a a
P P
M L L M
A A
b
b
Figure 30.51 Low-grade paratenonopathy and friction between
Figure 30.50 A markedly expanded paratenon allows easy access
plantaris and underlying Achilles. A posteromedial approach is used
from either side.
to inject around the plantaris tendon cannulating the space between
it and the underlying Achilles.
the posterior aspect facilitates this and allows all parts of the
tendon to be reached with ease. The probe is held in these cases the plantaris tendon and sural nerve need to be
the sagittal plane. A point is marked on the skin distal or identified to avoid injury. The Achilles insertion can also be
proximal to the probe. Local anaesthetic is infiltrated and targeted for dry needle therapy and proliferant injection
injected around the paratenon (Fig. 30.52). The needle is when chronic enthesopathy has not responded to conserva-
then passed into the area of maximal tendinopathy and tive treatment.
hypervascularity as close to the long axis of the tendon fibres
as possible. There is no standard technique for dry nee-
VOLUME INJECTION/TENDON STRIPPING
dling. Some operators continue for a time and others
by a number of passes. The entire area of tendinopathy The anterior space can be injected for chronic Achilles
should be treated. It is important that these techniques are tendinopathy. Large volumes of fluid are used to compress
carried out with a planned rehabilitation programme under abnormal vessels entering the tendon. The technique is
the care of an appropriate specialist. This should be indi- described on page 340. Doppler imaging confirms a signifi-
vidually tailored to the needs of the patient and the degree cant reduction in blood flow in the neovessels along the
of tendon damage. There is a risk of tendon rupture follow- ventral portion of the tendon. The technique is also said to
ing these procedures, which needs to be actively managed. disrupt adhesions that may have formed between the tendon
Dry needling techniques are often combined with either and surrounding structures. An axial approach is used with
paratenon injection or proliferate injection. Proliferants the puncture below the MTJ (Fig. 30.53). The sural nerve
can include autologous blood, sclerosing agents such as has to be identified and avoided with a lateral puncture;
hyperosmolar glucose or PRP. A long axis approach via the plantaris should similarly be avoided with a medial
medial or lateral tendon borders has been described. In puncture.
a a
Figure 30.53 The space between the anterior margin of the Achilles
b
and the underlying Kager’s fat pad is cannulated for high-volume
Figure 30.52 Long axis sagittal approach to the Achilles tendon. injection. Injected material strips the connected tissue plane between
these two structures, occluding the abnormal vessels that have
developed.
PRE-ACHILLES BURSA
For a pre-Achilles bursal injection, the ultrasound trans- (Fig. 30.56). The space just below, i.e. deep to the plantar
ducer is positioned in the axial plane directly over the distal fascia, is the target point. The difference between the two
Achilles tendon (Fig. 30.54). In this position an excellent approaches is principally whether the injected material is
view can be obtained of the needle approaching from the above or below the fascia. The deep location is preferred by
lateral side. The puncture needs to be sufficiently anterior some as it removes any risk of steroid induced fat pad
to the tendon to prevent penetrating it with the needle. The atrophy. Technically it is slightly more challenging, though
puncture point should also be kept low, particularly if the is probably more comfortable for the patient as the softer
degree of bursal distension is relatively minor. Preliminary skin on the medial foot is punctured rather than the thick
injection of a small quantity of local anaesthetic may be skin on the sole of the foot.
necessary to distend small bursae and confirm intrabursal A point of the medial aspect of the heel is chosen that is
positioning. The bursa easily accepts 5 mL but 2–3 mL is just beyond the calcaneal attachment of the plantar fascia,
usually sufficient. approximately 1.5 cm in depth. With practice this point can
be located relatively quickly. If necessary the probe can be
moved a little to the medial side to facilitate visualization of
PLANTAR FASCIA
the approaching needle, keeping it in a position transverse
The patient can be either prone or supine. A prone position to the plantar fascia (anatomical true coronal). The probe
similar to the Achilles tendon procedures is recommended. can then be rotated 90° to confirm that the needle lies close
Two methods for injecting around the plantar fascia are in to the calcaneal attachment. Once the needle tip is centrally
common use. The first uses a long axis approach and punc- positioned below the plantar fascia the injection is adminis-
ture on the sole of the foot (Fig. 30.55). The injection is tered. A low volume only is required.
deep to the fat pad superficial to the fascia. The second The same approach can be used for dry needle therapy
method places the probe in the short axis over the origin if this is to be used. Once the injection is complete, the
of the plantar fascia and the puncture takes place medially needle is withdrawn from beneath the fascia and tilted
a a
D
P A
P
P Figure 30.55 Approach to the plantar fascia through the fat pad.
M L The injection should be placed as deep as possible along the deep
surface of the plantar fascia. Corticosteroid injection into the fat pad
A
should be avoided.
Figure 30.54 Axial approach to the pre-Achilles bursa. The puncture

can be either medial or lateral depending on where the bursa is more used. The ligament lies deep to the tibialis posterior and
prominent.
flexor digitorum tendons which must be identified and
avoided. The probe is held in a tilted axial position and the
puncture is usually anterior, as long as it provides the best
approach to avoid the tendon (Fig. 30.57).
towards it. From this position the fascia can be entered and
dry needled along a short length close to the attachment.
FLEXOR HALLUCIS LONGUS TENDON
Most patients tolerate this quite well, but if painful, local
anaesthetic can be injected around the inferior calcaneal The flexor hallucis longus tendon is the deepest of the three
nerve. medial tendons, lying within its own fibroosseous tunnel
on the dorsal aspect of the os calcis. Tenosynovitis, tendi-
POSTEROMEDIAL IMPINGEMENT nopathy and thickening of the retinaculum leading to ste-
nosing tenosynovitis are amongst the several conditions
TECHNIQUE that can affect the tendon. The tibial nerve overlies the
Posteromedial impingement is due to chronic enthesopathy tendon and must be identified and avoided during injec-
within the tibiotalar ligament and most often follows an tion. For this reason, an approach from the posterolateral
eversion injury with distraction, though inversion with com- side with the probe positioned posteromedially is employed
pression can also lead to haemorrhage within the ligament. (Fig. 30.58).
Structural changes include disorganization of the normal The probe is first positioned in the axial plane on the
fibular structure, calcification and, in particular, increased lateral aspect of the Achilles tendon and the position of the
Doppler activity. The ultrasound findings correlate with sural nerve is noted. It may be helpful to place a small mark
local tenderness and pain. If conservative measures fail, dry on the skin overlying the nerve to ensure that it is not trans-
needle therapy with proliferant or prolotherapy is some- gressed during the puncture. The probe is then moved and
times employed. Corticosteroid injection has also been positioned again in the axial plane, but between the Achilles
a a
D
M L
P M
A P
L
b
Figure 30.56 Medial approach to the plantar fascia. The injection

b
can be placed on the deep surface with the needle passing beneath
the plantar fascia. A puncture point is chosen to place the injection Figure 30.57 Dry needle and injection therapy for posteromedial
as close as possible to the calcaneal attachment. impingement. A small footprint probe is used. The overlying medial
tendons need to be identified and avoided. An anterior approach
facilitates this.
tendon and tibialis posterior. The skin is punctured lateral

to the Achilles tendon, avoiding the sural nerve. As the the tendon sheath so that the puncture point is brought
needle is directed towards the flexor hallucis longus tendon, closer. The puncture point is at the end of the probe
it lies parallel to the probe position, affording good visual- and an in-view axial approach is used. The bevel of the
ization. The fibroosseous tunnel or sheath can be cannu- needle should be kept in-view until the tendon sheath is
lated and injected. Performing dry needle therapy on the pierced to ensure that the tendon itself is not punctured.
retinaculum is also feasible, although technically a more As for the other tendon sheath injections, the injected mate-
difficult manoeuvre. rial should be seen surrounding the tendon to confirm
correct positioning.
Occasionally injection around a pseudoarthrosis at the
TIBIALIS POSTERIOR TENDON SHEATH INJECTION
tendon insertion is indicated. This procedure should only
The patient can either lie supine with the ankle externally be carried out for painful pseudoarthrosis confirmed by
rotated or in a decubitus position with the affected side MR imaging demonstrating oedema in the adjacent bones.
downwards. The tendon sheath is most lax just below the It is regarded as a presurgical procedure that in some
medial malleolus where a small quantity of fluid often patients can obviate the need for surgical fixation. The
gathers. Fluid is usually even more prominent when teno patient should be warned, however, that rupture is
synovitis is present. The probe is placed in an axial or reported in a significant proportion of patients following
axial oblique plane at the level where this fluid is visualized corticosteroid injection into the pseudoarthrosis and, in
(Fig. 30.59). A small footprint probe is ideal if available; these incidences, surgery will be necessary to reattach the
otherwise the probe can be positioned slightly off centre to avulsed bone.
P
M L
A
TN
m Figure 30.59 A small footprint probe is used to identify fluid around

culu
etina the tibialis posterior tendon sheath. The point where the fluid comes
R FHL closest to the skin is used for puncture. The bevel of the needle is
kept in-view to avoid tendon injury.
Os Calcis
P
L M point closer. The best location is where the distended
A sheath is closest to the skin. A small-gauge needle is used to
minimize soft tissue trauma and, as with other relatively
superficial structures, it becomes the matter of operator
b
preference whether local anaesthetic is used or not. In
Figure 30.58 Injection around the flexor hallucis longus tendon is most cases the sheath can be quickly cannulated and the
from the lateral side with the probe placed medially to give best sting from unbuffered anaesthetic is often more painful
visualization of the needle. An approach from the lateral side avoids than the procedure itself. For nervous individuals, and
injuring the tibial nerve. The sural nerve should be identified prior to where a degree of needle manipulation is expected, local
the puncture. anaesthetic is used.
CUBOIDAL TUNNEL INJECTION

The cuboidal tunnel syndrome is tenosynovitis and enthe-
PERONEAL SHEATH INJECTION sopathy around the peroneus longus tendon as it passes
through the fibroosseous tunnel on the undersurface of the
TECHNIQUE cuboid (Fig. 30.61). The condition is said to occur more
As with the tibialis posterior tendon, a small quantity of commonly in road runners and needs to be differentiated
fluid often gathers in the submalleolar position. If disease from inflammatory changes around the knot of Henry
is present, the quantity of fluid is usually greater and the where the flexor digitorum and flexor hallucis longus
area of maximal fluid distension is targeted for cannula- tendons cross. Small volume injection is used in both of
tion. A direct in-view approach is used with the probe held these conditions once the tender area is identified. In the
axially (Fig. 30.60). Once again, a small footprint is ideal if case of injection around the knot of Henry, the medial and
available or a standard linear array can be positioned so lateral branches of the plantar nerve should be identified
that the sheath is close to one end, bringing the puncture to avoid puncture.
a a
L
S I
L
M
P A
M
b
b
Figure 30.61 The cuboidal tunnel can be cannulated from above.
Figure 30.60 A similar approach is used to inject the peroneal The needle is placed just below the retinaculum between it and the
sheath. Marked fluid distension in this case renders the injection underlying peroneus longus tendon.
straightforward. An anterior puncture and in-view approach is used.
ANTEROLATERAL GUTTER skin, is to place the patient supine with the hip and knee
flexed. An anterior sagittal approach provides a good view
TECHNIQUE of the anterior tibiotalar joint. The transducer is positioned
Chronic inflammatory changes may be present in the either medial or lateral to the dorsalis pedis artery and
anterolateral gutter following lateral ligament injury. The adjacent deep peroneal nerve. The extensor tendons are
anterior talofibular ligament becomes thickened and a located and avoided. A puncture point distal to the trans-
synovial reaction develops and becomes painful. Anterolat- ducer allows the needle to be directed into the anterior
eral gutter syndrome may be treated by injection into the tibiotalar joint beneath the anterior rim of the distal tibia
space. The author favours an out-of-view approach. The (Fig. 30.63).
probe is placed directly overlying the anterior talofibular
ligament, noting the position of the small overlying artery
POSTERIOR SUBTALAR JOINT
(Fig. 30.62). Either the probe can be moved so that the
artery does not underlie the central portion or an off- The joint should be initially assessed medially, laterally and
centre puncture point can be chosen. The needle is anteriorly to determine whether an obvious synovial recess
directed deep and towards the probe until its tip appears in presents itself. The anterior approach is through the poste-
the anterolateral gutter. This is also an ideal method of rior aspect of the sinus tarsi. In the absence of any fluid, a
injecting the tibiotalar joint, of which the anterolateral lateral approach is the most straightforward. The peroneal
gutter is part. tendons are followed into the submalleolar region until the
calcaneofibular ligament appears just below them. In this
position, the gap between the talus anteriorly and os calcis
TIBIOTALAR JOINT
posteriorly is identified (Fig. 30.64). It lies close to the ante-
The easist approach to the tibiotalar joint is via the antero- rior aspect of the tendon sheath. An anterolateral approach
lateral gutter, as described above. An alternative approach, is used with the needle passing anterior to the tendon
if this is not feasible due to infected or otherwise involved sheath into the joint.
a a
A
P D
P
b b
Figure 30.62 The easiest approach to the tibiotalar joint is through Figure 30.63 An alternative approach to the tibiotalar joint is in the
the anterolateral gutter. A small footprint probe overlies the anterior sagittal plane using an in-view appraoch. The probe is initially posi-
talofibular ligament. An out-of-view approach is used avoiding the tioned so that the anterior tendons and neurovascular bundle are
overlying vessels. avoided.
MID- AND FOREFOOT INTERVENTION

Joint injection with corticosteroid is indicated for local
inflammatory disease. In many patients, joint injection with
INTERTARSAL JOINTS
local anaesthetic is used to localize the source of the patient’s
symptoms to assist with surgical planning. For example, the The main indications are either symptomatic arthropathy
surgeon may need to know whether pain is arising from the or local anaesthetic injection to differentiate the source of
tibiotalar joint, the posterior subtalar joint or a combination symptoms. An out-of-view approach is recommended due to
of both. This will determine whether the patient has a tib- the superficial location of these joints, though an in-view
iotalar, subtalar or pan hindfoot fusion. In these instances, approach is also relatively easy. The target is the joint space
a fluoroscopic or CT injection is recommended as it is as deep as can be achieved around marginal osteophytes,
important to determine the precise location of the injected which are often present.
anaesthetic. In a high proportion of patients, the posterior The patient position is supine with the hip and knee
subtalar joint communicates with the tibiotalar joint and flexed. The probe is positioned in sagittal plane over the
this communication needs to be identified, as selective local symptomatic joint. This is identified using the patient’s
anaesthetic blockade is not feasible. It is easier to identify response to sonopalpation and recognizing any associated
communication between the two joints using fluoroscopy or synovitis and osteophyte formation. The centre of the probe
CT by including some iodinated contrast with the injected should be positioned over the joint space. Care should be
material. If ultrasound is to be used, a number of tricks help taken to ensure that the puncture point does not transgress
to determine whether communication is present. Firstly, a a tendon and the dorsalis pedis artery and deep peroneal
large-volume injection is attempted. This will help deter- nerves are identified and avoided. It is helpful to use a small
mine whether the overall joint capacity is large, and thus footprint probe if available. The position of the probe
communication between the subtalar joint and the tibiota- should be adjusted to take account of osteophyte formation.
lar joint more likely. Secondly, once the needle is positioned Once the probe is positioned over the joint an out-of-view
in the posterior subtalar joint and the injection begins, the approach is used (Fig. 30.65). A short needle is used to
probe can be moved and positioned over the anterior aspect puncture the skin at the midpoint of the probe. With careful
of the tibiotalar joint to see whether this too distends with planning the tip of the needle appears easily within the
injected fluid. joint. There is frequently intercommunication between the
a a
L
P A
D
M
P A
P
b b
Figure 30.64 The approach to the posterior subtalar joint is chal- Figure 30.65 The small joints of the foot are injected using, in this
lenging unless it is distended. The joint is identified deep to the case, an out-of-view approach. The needle tip appears in the joint if
peroneal tendons that need to be avoided during the injection. For osteophytosis is prominent; the probe can be rotated and an in-view
this reason an in-view approach is best. approach used.
navicular and cuneiform joints, allowing a larger-volume should be advised about steroid flare, which is most common
injection into this space. following small joint injection. Ice and analgesia is recom-
The probe can be placed in a transverse position along mended postprocedure to help alleviate this uncomfortable
the line of the joint. This method makes it easier to identify symptom.
the overlying tendons and ensure that the needle passes An alternative approach is to start with the probe in the
between them. It is somewhat more difficult to identify asso- sagittal plane, but rotate if 30–40° off the sagittal line (Fig.
ciated osteophytes. 30.67). An in-view approach is now possible as the head of
the probe is cast off the underlying tendon. This may be
METATARSOPHALANGEAL AND easier for beginners or where there is a bigger than usual
distance between skin and joint.
INTERPHALANGEAL JOINT INJECTION
An out-of-view approach is recommended due to the super-
MORTON’S NEUROMA INTERMETATARSAL BURSA
ficial position of these joints. The probe is placed in a sagit-
tal position along the line of the joint. This method makes Therapeutic management choices for symptomatic Mor-
it easier to identify the overlying tendons and ensure that ton’s neuroma and/or intermetatarsal bursitis include cor-
the needle passes between them. It is somewhat more dif- ticosteroid injection, ethanol injection or radiofrequency
ficult to identify associated osteophytes but these are less of ablation. All procedures have the same basic approach once
a problem with these joints. The patient position is supine the symptomatic intermetatarsal space is identified. If corti-
with the hip and knee flexed. The centre of the probe costeroid or ethanol injection is being used, differentiation
should be positioned over the joint space and, as with the between the different components of the complex is not
tarsometatarsal joints, it is helpful to use a short footprint particularly necessary. Corticosteroid injection is the most
probe. The interdigital neurovascular bundle should be straightforward. Many patients’ symptoms can be helped by
located. A short needle is used to puncture the skin at the a single injection whilst the underlying cause is identified
midpoint of the probe (Fig. 30.66). With careful planning and treated. In a proportion, a second injection is useful to
the tip of the needle appears within the joint. The patient supplement when treatment has been partially successful.
a a
Figure 30.66 Out-of-view approach to the metatarsophalangeal

joints.
D
L M
P
Figure 30.68 A puncture just above the skin crease between the
toes penetrates the soft area of skin. A needle approaching from the
dorsal side with the probe on the ventral side is slightly more difficult
to visualize, but with practice the procedure is straightforward.
a
Ethanol injected around a nerve produces chemical neu-
rolysis through dehydration and necrosis. It has been sug-
gested that alcohol injections are more successful than
corticosteroid for Morton’s neuroma but not everyone
agrees. A disadvantage is that multiple injections are
required: 3 or 4 are recommended at 2-week intervals. A
20% solution mixed with local anaesthetic is used. Radiofre-
quency ablation has also been described as a useful treat-
ment for this entity.
Whichever treatment is chosen, the technique for admin-
D
istering it is similar. The patient lies supine with the knee
A P
extended. The operator is seated at the end of the examina-
P
tion couch allowing easy access to the interspaces. The injec-
tion can be carried out with the needle and probe either on
b the same side of the interspace (dorsal or plantar) or the
Figure 30.67 Oblique in-view approach to the metatarsophalangeal needle and probe on opposite sides. Visualization of the
joints. A small footprint probe is rotated to expose the metatarsal needle is easiest when a same-side approach is used, as
head. At this angle, a puncture point will not traverse the overlying the angle of the needle is closer to being parallel to the
extensor tendon. probe. The skin on the dorsal aspect (Fig. 30.68) of the
recommended that beginners start with a same-side plantar

approach. Once experience is gained, none of the
approaches described above pose any great problems.
Whichever route is chosen, the webspace is gently sepa-
rated by the examiner’s fingers and the needle inserted.
Local anaesthetic to the skin is not particularly necessary
and may even make the procedure more painful for the
patient. If local anaesthetic is to be used, a single puncture
only is recommended, that is, local anaesthetic is injected,
the local anaesthetic syringe removed but the needle left in
place pending injection of the therapeutic agent. Some
authors suggest that local anaesthetic is required when
ethanol is being used. For radiofrequency ablation, a tibial
nerve block can be carried out at the ankle. The target point
a of the injection is the centre of the intermetatarsal neuroma/
bursa complex. Once the needle is identified in the centre
of the lesion, therapy can be delivered. Methylprednisolone
is preferred over triamcinolone for corticosteroid injection
as it may be associated with less subcutaneous fat atrophy.
Absolute alcohol is diluted to a 20% solution with bupiva-
caine. Most procedures are uncomplicated, but the patient
should be warned that increased symptoms can occur and
that ice and appropriate analgesia are recommended. Other
complications include subcutaneous fat atrophy related to
corticosteroid injection and occasional skin necrosis sec-
ondary to alcohol. Skin burning has also been described
with radiofrequency ablation. Puncture of an intertarsal
vein may occasionally lead to bruising.
P FURTHER READING
A P Balint PV, Kane D, Hunter J, et al. Ultrasound guided versus conven-
D tional joint and soft tissue fluid aspiration in rheumatology practice:
a pilot study. J Rheumatol 2002;29(10):2209–13.
Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injec-
b tions in the treatment of subacromial bursitis. Am J Phys Med Rehabil
2006;85(1):31–5.
Figure 30.69 A puncture-point below the skin fold. This is slightly Distefano V, Nixon JE. Steroid-induced skin changes following local
more uncomfortable for the patient; however, with the probe on the injection. Clin Orthop Relat Res 1972;87:254.
plantar aspect of the foot, needle visualization is easy. Farin PU, Räsänen H, Jaroma H, et al. Rotator cuff calcifications: treat-
ment with ultrasound-guided percutaneous needle aspiration and
lavage. Skeletal Radiol 1996;25(6):551–4.
Hoksrud A, Ohberg L, Alfredson H, et al. Ultrasound-Guided Sclerosis
of Neovessels in Painful Chronic Patellar Tendinopathy. A Random-
interspaces is a little softer than on the plantar aspect (Fig. ized Controlled Trial. Am J Sports Med 2006;34(11):1738–46.
Khoury NJ, el-Khoury GY, Saltzman CL, et al. Intraarticular foot and
30.69), consequently injecting on the dorsal side makes the ankle injections to identify source of pain before arthrodesis. Am J
procedure more comfortable for the patient. Conversely, Roentgenol 1996;167(3):669–73.
neuromas tend to project a little more to the plantar aspect MacMahon PJ, Eustace SJ, Kavanagh EC, et al. Injectable Corticosteroid
of the interspace and if the 2/3 interspace is particularly and Local Anesthetic Preparations: A Review for Radiologists. Radiol-
ogy 2009;252(3):647–61.
narrow, dorsal injection is more difficult. Same-side dorsal Piper SL, Hubert TK. Comparison of ropivacaine and bupivacaine
injection is also a little cumbersome due to the downslope toxicity in human articular chondrocytes. J Bone Joint Surg 2008;
of the dorsal aspect of the mid- and forefoot. It is therefore 90(5):986–91.
PART 9
GENERAL
385
Ultrasound of Soft 31
Tissue Masses
Simon J. Ostlere
CHAPTER OUTLINE
INTRODUCTION MYXOMA
LIPOMATOUS TUMOURS SYNOVIAL TUMOURS
Superficial Lipomatous Tumours Pigmented Villonodular Synovitis
Deep Lipomatous Tumours Synovial Osteochondromatosis
Other Benign Lipomatous Tumours Synovial Sarcomas
MUSCLE TUMOURS CYSTS
Muscle Hernias and Accessory Muscle Ganglia
FIBROUS TUMOURS Synovial Cysts
Benign Focal Lesions Perimeniscal and Paralabral Cysts
Malignant Fibrous Tumours Epidermal Inclusion Cyst
NEURAL TUMOURS Sarcoma
Benign Neural Tumours Other Malignant Tumours
Malignant Neural Tumours Haematoma
VASCULAR TUMOURS Myositis Ossificans
Benign Tumours Infections
Intermediate Malignant Vascular Tumours
Malignant Vascular Tumours
Soft tissue masses of the musculoskeletal system are In most peripheral and superficial lesions ultrasound
extremely common. The vast majority of lesions are benign provides all the information required.
and in many of these cases malignancy can be excluded
from the history and examination without resort to imaging.
Deep, large or diffuse lesions are best initially imaged with
MRI. Plain radiograph or CT occasionally gives additional
Key Point
useful information with regard to calcification or subtle
Because of the overwhelmingly high ratio of benign to involvement of the underlying bone. Ultrasound is an effec
malignant lesions there is often a delay in diagnosing the tive method for guiding percutaneous biopsy.
latter and early imaging is therefore recommended when the The clinician referring a patient with a suspected soft
nature of a mass is in doubt. tissue mass is usually asking one or more of the following
questions: (a) is there a lesion? (b) where is it? (c) what is
it? Ultrasound has been shown to be a highly sensitive tech
Any mass that is steadily increasing in size warrants urgent nique in the detection of soft tissue masses. A normal ultra
investigation. sound examination excludes a soft tissue mass with a high
Ultrasound and MRI are the principal techniques for degree of certainty. Although not often helpful in making
investigating soft tissue masses. As in other areas of muscu a precise diagnosis, ultrasound can readily differentiate
loskeletal imaging the two techniques are complementary solid from cystic lesions. Purely cystic lesions are benign
and both may be employed in any individual case. whereas a minority of solid or mixed lesions may turn out
387
388 PART 9 — GENERAL
to be malignant. Other ultrasound features such as lesion

morphology, calcification, compressibility, the presence and
type of vascularity and the pattern of internal echoes can all
help to narrow the differential diagnosis. MRI will provide
additional information with regard to tissue type in lipo
matous lesions, fibrous lesions and those containing haemo
siderin or other blood products. Cysts rarely require biopsy
but are often subjected to ultrasound-guided aspiration.
Small superficial solid lesions are suitable for excisional
biopsy. Larger or deeper lesions require staging with MRI
and, in most cases, preoperative biopsy, which can be per
formed under ultrasound control. Although ultrasound is
generally nonspecific, a confident diagnosis can commonly
be obtained by taking into consideration the clinical fea
tures along with the ultrasound appearances. This chapter
covers the role of ultrasound in the assessment of soft tissue
masses with emphasis on those conditions which exhibit Figure 31.1 Subcutaneous lipoma (arrows). The lesion is hypoechoic
specific ultrasound features. and contains linear striations. It is difficult to differentiate the lesion
from surrounding subcutaneous fat.
LIPOMATOUS TUMOURS
Lipomatous tumours range from the benign lipoma to

highly malignant forms of liposarcoma. Well-differentiated
liposarcomas do not metastasize but have the potential for
local recurrence and may rarely dedifferentiate. The term
‘atypical lipoma’ is sometimes used for the lowest grade of
liposarcoma to reflect the nonaggressive nature of these
lesions. Lipoblastoma is a benign tumour of childhood and
hibernoma is a benign tumour of brown fat. In general,
benign lipoma, its variants and well-differentiated liposarco
mas are seen as echogenic lesions on ultrasound in contrast
to most other soft tissue tumours. Although ultrasound may
be used to diagnose the simple subcutaneous lipoma, MRI
is considered superior for all other lesions on account of
the characteristic signal returned by fat. As deep-seated
lipoma cannot be differentiated from liposarcoma, all deep Figure 31.2 Large subcutaneous lipoma. The lesion measures
lesions should be imaged by MRI prior to surgery. nearly 10 cm in length but there are no sinister features.
Lipomatous tumours can be divided into those that are
confined to the superficial fat and those that lie deep to the
superficial muscle fascia. Superficial lesions are overwhelm
ingly benign and the vast majority of liposarcomas lie deep
to the fascia.
SUPERFICIAL LIPOMATOUS TUMOURS

The majority of lipomas are found in subcutaneous fat.
Lesions predominate in the trunk and proximal part of the
limbs, the shoulder girdle region being a particularly
common site for large lipoma. An ultrasound request is
usually prompted by the patient noticing an increase in the Figure 31.3 Subcutaneous lipoma. The lesion (arrows) contains
size of a lesion or the discovery of a new lump. Most super minor striations and is slightly hyperechoic when compared to the
ficial lipomas have characteristic features on ultrasound and adjacent fat.
do not require additional imaging or biopsy.
The lesion may rarely exhibit acoustic enhancement.

Key Point Lipoma size is very variable and lesions over 5 cm may be
seen, commonly around the shoulder (Fig. 31.2). The
A typical subcutaneous lipoma is an elliptical, well-defined, reflectivity is variable and depends, in part, on the site
compressible lesion containing short linear reflective of the lesion. Lesions of the head and neck have been
striations that run parallel to the skin surface (Fig. 31.1). described as being typically hyperechoic, whereas those in
the extremities tend to be more variable (Fig. 31.3). Doppler
CHAPTER 31 — Ultrasound of Soft Tissue Masses 389
signal is occasionally detectable. Lipomas may have an iden

tical echo structure to the surrounding normal subcutane
ous fat and the lesion may then be difficult to perceive on
ultrasound.
Practice Tip
One can still make a confident diagnosis of a lipoma when

there is a palpable superficial mass and no apparent
underlying abnormality on ultrasound.
Although superficial liposarcomas are rare, further imaging

and biopsy are required if there are suspicious features
such as excessive vascularity or rapid growth. Although
large benign lesions are quite common, lesions over 5 cm
a
are often subjected to further imaging as a precaution.
Superficial atypical lipoma (previously known as low grade
liposarcoma) are occasionally encountered within the sub
cutaneous fat, but are usually located deep to the muscle
fascia.
DEEP LIPOMATOUS TUMOURS

Deep-seated lipomas are uncommon compared with their
superficial counterparts and may occur in an intermuscular
or intramuscular position. b
Practice Tip
Deep lipomas tend to be hyperechoic relative to muscle

(Fig. 31.4).
Some intramuscular lipomas may have ill-defined borders

due to interdigitation of fat with the muscle fibres. This
feature is much better demonstrated on MRI and, when
present, suggests that the lesion is at the benign end of the c
spectrum. Most deep lesions are best imaged with MRI. Figure 31.4 Deep lipoma. (A) An intramuscular lipoma is seen as a
Deep-seated lipomas and atypical lipomas (previous known uniform hyperechoic lesion (arrows). (B) T1-weighted and (C) proton
as well-differentiated liposarcomas) may have similar ultra density fat suppression axial images through the chest wall in a differ-
sound features and MRI is therefore indicated. Although ent case. The lipoma is seen to lie deep within the muscle. The lesion
the detection of nonfatty tissue on MRI implies that the shows uniform signal suppression on the fat suppresses sequence.
lesion is not a simple lipoma atypical lipoma may also sup
press entirely on fat suppression sequences.
Nearly all liposarcomas of the extremities lie deep to the and more cellular tumour can vary, giving a spectrum of
superficial muscle fascia. The term liposarcoma covers a imaging appearances. Some tumours are almost purely
range of tumours with varying histological and imaging fea myxoid and give very uniform homogeneous features on
tures. The incidence peaks in the sixth and seventh decade imaging. On MRI these lesions are usually homogeneous
and the thigh is the commonest site. Well-differentiated and, without the benefit of ultrasound or intravenous con
liposarcoma is now termed atypical lipoma; it is at the most trast, could be misinterpreted as representing a cystic lesion.
benign end of the spectrum and is typically hyperechoic
relative to adjacent muscle (Fig. 31.5). The lesion has no
metastatic potential and the prognosis is excellent if exci Practice Tip
sion is complete. Neglected lesions will continue to grow
and are at small risk of dedifferentiating into a higher grade On ultrasound myxoid liposarcoma may resemble a cyst,
of sarcoma. Myxoid liposarcoma contains numerous lipo being uniformly hypoechoic, but on careful examination the
blasts and small plexiform vessels in a well-vascularized internal structure can be detected and internal vascularity can
myxomatous stroma that has a variable fat content. The usually be detected.
proportion of myxoid material, lipid-containing tumour
OTHER BENIGN LIPOMATOUS TUMOURS

There are several lipoma variants. Angiolipomas are prob
ably hamartomatous lesions. They typically present as a
small, sometimes painful, superficial mass in the young
adult. They are most commonly encountered in subcutane
ous fat of the arms and chest and are often multiple. On
ultrasound they are seen as small hyperechoic masses with
variable vascularity. Fibrolipoma describes a lipoma with
abundant fibrous strands. The lesions are hyperechoic and
cannot be distinguished from simple lipomas. Lipoblastoma
is a rare tumour of childhood, usually seen under the age
of 3 years. The tumour is typically lobulated, may contain
cystic areas and is hypovascular. Fat signal may or may not
Figure 31.5 Well-differentiated liposarcoma. Longitudinal scan
be seen on MRI or CT. On ultrasound the lesion has been
showing a mainly echogenic lesion. On Doppler imaging the lesion
shows modest hypervascularity.
described as uniformly echogenic and generally hypovascu
lar, although small amounts of flow may be seen on Doppler.
Hibernoma is a benign tumour of brown fat. It occurs chiefly
in the upper thorax in patients in their fourth and fifth
decade. Clinically it behaves in a manner similar to that of
simple lipomas. On MR the signal intensity of the lesion is
less high on T1-weighted images than that of lipoma, reflect
ing the smaller proportion of fat-containing cells. Hiberno
mas are more vascular than lipomas and will enhance
following contrast. The ultrasound appearances have been
described as showing a hyperechoic, vascular mass.
MUSCLE TUMOURS
Primary tumours of the muscle are rarely encountered in

the musculoskeletal system. Ultrasound features are gener
ally nonspecific. Ultrasound is useful in diagnosing acces
a b
sory muscles and muscle hernias, both of which may present
Figure 31.6 Myxoid liposarcoma. (A) The large lesion has a central as a mass. Leiomyomas are rare and are usually small cutane
hypoechoic component (*). Arrows mark the surface of the lesion. ous lesions that do not require imaging. Larger and deeper
(B) Axial STIR MRI shows the lesion consists of a fatty rim (arrows) hypervascular lesions, which may contain calcification, are
with a high signal myxoid centre (*). encountered. Leiomyosarcomas may be seen in the subcu
taneous tissue or in muscle. They probably arise from vessel
walls. Appearances are nonspecific and cannot be differenti
ated from other aggressive lesions. Central necrosis is a
However, in most cases of myxoid liposarcoma there is also common finding on ultrasound of intraabdominal lesions.
a lipomatous component (Fig. 31.6). Higher-grade liposar Angioleiomyoma is a relatively common superficial painful
comas such as round cell and pleomorphic types have no benign lesion that is very vascular and therefore may be
specific ultrasound features that will differentiate them confused with a haemangioma on ultrasound. It occurs pri
from other sarcomas. Tumours are often highly heteroge marily in middle age and is twice as common in females. On
neous on imaging. The lesion may be composed of large ultrasound the lesion appears as a well-defined hypoechoic,
areas of tumour of varying histological grade. The role of hypervascular mass. Rhabdomyomas are exceedingly rare
ultrasound in these deep-seated lesions is limited as the and in adults occur in the neck region.
tissue characteristics and the relationship of the tumour to
the surrounding structures are best appreciated on MRI.
MRI is a good method for confirming the lipomatous nature
of the tumour and provides a good estimate of the grade of Key Point
tumour and the fact that the goal for all lesions is complete
excision. Rhabdomyosarcoma is a tumour of childhood and young
adults and, although not uncommon, is rarely seen outside
the abdominal cavity and pelvis or head and neck region.
Key Point
Biopsy of lipomatous tumours rarely influences management Lesions in the extremities are usually intramuscular and
and can be safely omitted in most cases. occur in adolescence. Ultrasound features described in
bladder lesions are similar to other types of sarcoma,
Figure 31.8 Plantar fibromas. Small hypoechoic lesions (arrows) are

seen within the plantar fascia (arrowheads).
a
BENIGN FOCAL LESIONS
FIBROMA
In the musculoskeletal system, fibromas predominately arise
from the tendon sheaths of the fingers or thumbs. The
lesion affects young and middle-aged adults, predominantly
men. It is not known whether the lesion represents a neo
plasic or reactive process. On ultrasound a fibroma appears
as a well-defined hypoechoic mass closely related to the
tendon. Differentiating fibroma from a giant cell tumour is
impossible on ultrasound. On MRI the two lesions may also
have similar appearance, as fibrous tissue, seen in fibromas,
and haemosiderin, seen in giant cell tumours, are both
detected as low-signal on T2-weighted images.
b
Figure 31.7 Muscle hernia. (A) At rest, no lesion can be seen. FIBROMATOSIS
(B) Herniation through the fascia is demonstrated on contraction of
the muscle (arrows). Palmar and Plantar Fibromatoses
These two conditions result from fibrous proliferation of
the fascia. The condition may be bilateral and the plantar
showing variable echo pattern and cystic areas presumably and palmar versions may occur in the same patient. In the
representing necrosis. hand the patient may first notice a single nodule in the
palm. Progression is slow and unpredictable. Fibrous cords
extend from the lesion to the fingers, giving the character
MUSCLE HERNIAS AND ACCESSORY MUSCLE
istic feature of Dupuytren’s disease. Imaging is rarely
required. In the plantar version, the patient may present
Key Point with a lump, pain or both. The nodules may be solitary,
multiple and situated either medially or centrally within
A fascial defect may allow herniation of muscle, which may
only be palpable on contraction of the muscle or, in the the fascia. Unlike Dupuytren’s disease the clinical features
lower limb, on standing. are less specific and imaging is useful to confirm the
relationship of the lesion to the plantar fascia. On ultra
sound a typical plantar fibroma is seen as an elongated
hypoechoic, nonvascular lesion, which blends into the fascia
The nature of this lesion is easily determined on dynamic (Fig. 31.8). A mixed echo pattern can be seen in those
scanning. The herniated muscle is often hypoechoic, pre lesions larger than 1 cm in length. There is usually no or
sumably due to minor oedema secondary to recurrent her minimal flow detected on Doppler but the lesion can be
niation (Fig. 31.7). Accessory muscles, such as the accessory vascular (Fig. 31.9).
soleus at the ankle, may present as a mass and/or a neu
ropathy due to nerve compression. The true nature of the
Key Point
lesion is readily determined by ultrasound.
MRI will confirm the fibrous nature of plantar fibroma but is
rarely required as the ultrasound appearances are highly
FIBROUS TUMOURS specific.
There are three main types of tumours of fibrous origin:

benign focal fibrous tumours, diffuse fibromatous lesions Unlike fibromatosis seen at other sites (as discussed in this
(fibromatoses) and malignant fibrous lesions. In general chapter), plantar fibromatosis is not aggressive, although
fibrous lesions are hypoechoic lesions on ultrasound. recurrence following excision is common.
Figure 31.9 Plantar fibroma. There is focal widening of the plantar

fascia (arrows). Power Doppler demonstrates modest vascularity.
Figure 31.10 Elastofibroma of the posterior chest wall. The lesion

(arrows) is ill-defined and contains multiple striations.
NODULAR FASCIITIS
This is a relatively common reactive lesion of unknown
aetiology seen predominantly in young adults. The patient
presents with a rapidly growing solitary lump and some
tenderness. The lesion is usually situated in the subcutane
ous tissue but can occur in the intramuscular or intermus
cular positions. The lesion involves the upper limb in about
half the cases. Although the disease is self-limiting, most
lesions are excised on account of the alarming growth rate.
Histologically the lesion consists of immature fibroblasts in
a myxoid matrix. In the few reports in the literature the b
lesions have been described as well defined and mixed echo Figure 31.11 Fibromatosis. (A) A hypoechoic lesion is seen lying
genicity. The lesions do not enhance on MR or CT following deep to the pectoralis muscle (arrows). (B) Axial T2-weighted MRI
intravenous contrast. shows a low-signal intensity lesion (arrows).
ELASTOFIBROMA
Elastofibroma is a benign tumour of unknown aetiology oedematous, myxoid areas can result in mixed signal intensi
consisting of fibroblasts, collagen and thickened elastic ties. MRI is required to accurately assess the extent of the
fibres interspersed by fat. It is thought to be a reactive lesion disease for surgical planning. Ultrasound is less specific, the
rather than a neoplasm. By far the commonest site is lesion being seen as a hypoechoic or mildly heterogeneous
between the chest wall and the scapula. The condition may mass that may appear well defined or ill defined (Fig. 31.11).
be bilateral. On ultrasound the lesion may have a nonspe The lesion may be vascular on Doppler. If percutaneous
cific internal echo pattern, but usually the typical linear or biopsy is being considered then multiple samples are required
curvilinear hypoechoic strands against an echogenic back as differentiating fibromatosis from well-differentiated fibro
ground are seen, reflecting the interspersed fatty and fibro sarcoma may be difficult with a small quantity of material.
elastic components (Fig. 31.10). Recurrence following excision is common.
DEEP FIBROMATOSIS (DESMOID TUMOUR)

MALIGNANT FIBROUS TUMOURS
This locally aggressive fibrous lesion of unknown aetiology
affects the young adult. The muscles of the shoulder region, Fibrosarcomas are usually deep-seated lesions of the extrem
trunk and thigh are the commonest sites to be involved. ity or trunk, the thigh being the commonest site. Tumours
The patient presents with an ill-defined mass. Because of classified as malignant fibrous histiocytoma are now termed
the deep nature of the lesion MRI is often preferred as the undifferentiated pleomorphic sarcomas. The tumour is
primary investigation. Areas of low signal on all sequences usually intramuscular but is sometimes seen in the subcuta
reflect the abundant cellular and collagenous fibrous neous tissue. The thigh is the commonest site followed
tissue in the lesion, although variable amounts of more by the proximal arm. Ultrasound features of both these
malignant tumours are nonspecific and cannot be differen Neurofibromas may show a characteristic echogenic ring
tiated from many other types of sarcomas (as discussed in within the lesion or an echogenic centre. Most neurofibro
this chapter). mas are solitary. Multiple tumours are the hallmark of
neurofibromatosis type 1. Neurilemmomas, although rarely
multiple, may also be seen in neurofibromatosis. Neurilem
NEURAL TUMOURS momas, when long-standing, can cavitate and calcify, fea
tures that can readily be detected on ultrasound. The term
BENIGN NEURAL TUMOURS ancient schwannoma is sometimes used. Plexiform neurofi
broma is a diffuse abnormality of the nerve only seen in
BENIGN NERVE SHEATH TUMOUR neurofibromatosis. On ultrasound the tortuous mass of
The two main forms of benign neural tumours are derived expanded nerve fascicles appears as multiple nodules con
from the nerve sheath and are termed neurilemmoma taining echogenic foci.
(benign schwannoma) and neurofibroma. Although benign
neural tumours may have a nonspecific appearance on ultra NONNEOPLASTIC NEUROMAS
sound, there are often features present that will suggest the Traumatic neuromas represent disorganized neural bundles
diagnosis. Lesions are usually well defined, related to the that grow from the end of a severed nerve. They are com
neurovascular bundle, hypoechoic and may exhibit acoustic monly seen following amputations. On ultrasound they are
enhancement and variable blood flow on Doppler. In some hypoechoic lesions seen to arise from the free end of the
cases the tumour can clearly be seen to be arising from within nerve (Fig. 31.14A). Lesions are usually well demarcated,
a nerve, giving a characteristic appearance (Fig. 31.12). have a bulbous end and can be seen to be in continuity with
the nerve (Fig 31.14B,C). On MRI they have a heteroge
Key Point neous signal, often with a ring-like pattern.
Morton’s neuroma is a common reactive lesion that devel
Differentiating neurofibromas from neurilemmomas is not ops due to mucinous degeneration and fibrous prolifera
possible unless the tumour can be seen to lie eccentrically tion around interdigital nerves of the foot at the level or
within the nerve, as this feature is only seen in just distal to the metatarsal head. They are found at the
neurilemmomas (Fig. 31.13). interspace between the second and third or the third and
fourth toes and are much commoner in females. The lesions
are seen as well-defined hypoechoic round or disc-like
lesions lying between the bones and extending into the
plantar soft tissue. They are often related to intermetatarsal
bursitis. On ultrasound the lesions are best seen in the sagit
tal plane with the probe on the plantar surface of the foot,
with pressure being applied on the dorsal aspect of the web
space. Lesions usually measure between 0.5 and 1 cm in
diameter, and are hypoechoic and hypovascular (Fig. 31.15).
The relationship of the lesion to the digital nerve can often
be appreciated on ultrasound. Ultrasound-guided steroid
b a b
Figure 31.12 Neuroma. (A) The well-defined mainly hypoechoic Figure 31.13 Schwannoma. (A) Non-specific hypoechoic lesion,
lesion (arrows) is seen to be in continuity with the nerve (arrowheads). seen to be related to the sciatic nerve. (B) MRI confirms that the lesion
(B) Power Doppler demonstrates modest internal vascularity. (arrow) is lying eccentrically within the sciatic nerve (arrowheads).
a b c
Figure 31.14 Traumatic neuroma (arrows) in an above the knee amputation stump. (A) The lesion is mainly hypoechoic and is seen to be in
continuity with the severed tibial nerve (arrowheads). (B, C) Consecutive T1-weighted sagittal scans through the stump and showing the neuroma
(arrows) and the distal end of the severed tibial nerve (arrowheads).
benign nerve sheath tumour. Half the cases are associated

with neurofibromatosis type 1. The lesions do not have
any specific features, although they are generally larger
than neuromas, have a heterogeneous echo pattern and
have increased vascularity. As with their benign counterpart,
continuity of the tumour with the nerve may be demon
strated. Malignant peripheral nerve sheath tumours most
commonly occur in major nerves or plexuses. Calcification is
uncommon.
VASCULAR TUMOURS
BENIGN TUMOURS
HAEMANGIOMAS
Haemangiomas are common benign soft tissue lesions that
may occur in the skin, subcutaneous tissue or muscle. The
term is commonly used to include both true haemangiomas
and vascular malformations.
Figure 31.15 Morton’s neuroma. Sagittal scan between the meta-

tarsal heads. The neuroma is seen as a hypoechoic, disc-shaped
lesion (arrows). There is a small amount of fluid in the intermetatarsal
Key Point
bursa (arrowhead).
Haemangiomas are true neoplasms that grow in childhood
and involute, whereas vascular malformation represents
alcohol injections or radiofrequency ablation have been dysplastic vessels that do not undergo involution.
shown to be helpful.
Differentiating the two on imaging may be difficult. Dermal

MALIGNANT NEURAL TUMOURS
lesions do not require imaging. The lesions are probably
Malignant peripheral nerve sheath tumours arise de novo congenital and have little growth potential. Histologically
from normal nerves or from malignant transformation of a they may contain numerous capillaries, dilated vessels or a
Figure 31.17 Haemangioma. (A) No flow detected on compression.

(B) On release of compression positive flow can be seen as the
vessels fill with blood.
With typical clinical features where a lesion is seen to com

prise entirely of vessels, a confident diagnosis of haeman
gioma can be made on ultrasound. However, other highly
vascular lesions may mimic haemangioma and MRI should
b
be performed if the diagnosis is in doubt. MRI features,
Figure 31.16 Haemangioma. (A) The lesion is uniform and has an particularly the presence of intralesional fat, may be suffi
echogenicity similar to muscle. (B) Doppler demonstrates marked ciently specific to negate the need for biopsy. Plain films are
hypervascularity. also useful as phleboliths and involvement of the adjacent
bones may be seen. Analysis of the Doppler signal can be
helpful in differentiating haemangiomas from other vascu
lar tumours as the vessel density and peak arterial shift have
been shown to be greater in the former in most cases.
combination of both. The lesions may contain fat, which However, in practice, if there is any doubt as to the nature
surrounds the vessels. The clinical history may be character of the lesion, one should proceed to MRI and, if necessary,
istic with a soft tissue mass that fluctuates in size. There percutaneous biopsy.
may be a bluish tinge to the overlying skin in superficial
lesions. Patients, who are usually children or young adults, GLOMUS TUMOUR
present with a mass that may be painful. Ultrasound appear Glomus tumour is a small painful vascular lesion composed
ances are variable. When the lesion consists only of small of cells found in the glomus body. They are usually found
vessels it may be well defined, uniform, and often echogenic within the subcutaneous fat or muscle of the extremities
(Fig. 31.16). In other cases ultrasound will show a mixed with the subungual position at the hand being by far the
echo pattern with cystic serpiginous spaces representing commonest site. On ultrasound, glomus tumours are small
dilated vessels. Phleboliths, when present, will be seen as (<1 cm) hypoechoic, vascular lesions (Fig. 31.18). Deep
echogenic foci within the lesion. lesions may not be detected on palpation and the ultra
sound operator may have to rely on the fact that the lesion
is exquisitely tender to localize the lesion.
Key Point INTERMEDIATE MALIGNANT

VASCULAR TUMOURS
Colour flow Doppler is usually positive in haemangioma,
although slow flow may not be detected in some cavernous Haemangioendotheliomas are rare vascular tumours of
lesions. The lesions are often compressible as blood is intermediate malignancy. There are several histological
expelled from dilated vessels. On releasing the pressure, types, the two commonest being epithelioid and spindle
colour flow Doppler will be seen to be positive as the cell haemangioendotheliomas. Epithelioid haemangioen
vessels refill (Fig. 31.17). dotheliomas are found in adults and usually involve the
deep soft tissues of the extremities. They may be seen at
Figure 31.18 Glomus tumour of the finger. (A) The small round
hypoechoic lesion (arrow) causing erosion of the distal phalanx
b
(arrowheads). (B) Power Doppler demonstrates marked vascularity.
Figure 31.19 Solitary fibrous tumour (haemangiopericytoma).
(A) The lesion (arrows) is hypoechoic and contains some prominent
vascular channels (arrowheads). (B) The lesion is highly vascular, with
other locations, particularly the lung, liver and breast. On high flow seen in the vascular channels.
ultrasound the lesions contain cystic areas and may be
hyperechoic or hypoechoic. Arteriovenous shunting may be
demonstrated on Doppler imaging. Spindle cell haemangio
endotheliomas are superficial tumours of the extremity con radiation. On imaging, serpiginous vessels are seen, mainly
sisting of cavernous channels, which tend to be locally at the periphery of the mass.
multifocal but do not metastasize and may recur locally.
Imaging is rarely performed.
Solitary fibrous tumour is the more accepted term for MYXOMA
what was called haemangiopericytoma. This tumour is seen
in adults and is found in many anatomical locations. In the Myxomas are benign lesions that are usually intramuscular.
musculoskeletal system the tumour is usually found in the They have low cellularity and contain abundant myxoid
lower extremity. The lesion is well defined and highly vas ground substance, which accounts for the generally uniform
cular. On ultrasound the lesion is seen as a hypoechoic mass, appearance on imaging. On MRI myxomas are homoge
which may show acoustic enhancement. On Doppler the neous in nature and return a signal similar to that of a cyst.
lesion is highly vascular and spectral analysis may show intra They may have a relatively low attenuation on CT. On ultra
tumoral arteriovenous shunting (Fig. 31.19). Metastases sound they are seen as hypoechoic, well-defined lesions that
occur in the minority of patients. may contain small clefts and cysts. Colour flow Doppler
imaging is usually negative. Some sarcomas have a high-
myxoid content so, even if the ultrasound appearances are
MALIGNANT VASCULAR TUMOURS
typical of myxoma, further imaging and biopsy are usually
Angiosarcomas are rare tumours that can occur in the deep required. When multiple lesions with the typical imaging
soft tissues. More often they are cutaneous lesions of the features are seen in association with fibrous dysplasia of the
head and neck that do not require imaging. Deep lesions adjacent bone (Mazabraud’s syndrome) then biopsy is not
may be related to previous insult such as a foreign body or necessary (Fig. 31.20).
a b c
Figure 31.20 Multiple myxomas in the thigh associated with Mazabaud’s syndrome. (A) Typical lesion with multiple short linear echoes and
cleft-like cysts (arrow). (B) Two further intramuscular lesions (arrows) are seen in a neighbouring compartment. (C) STIR MRI coronal sequence
showing typical hyperintense myxoma (arrow). The abnormal heterogeneous signal in the adjacent femur represents fibrous dysplasia.
the lesion does not appear to be related to a synovial struc

ture. On ultrasound, the uncalcified component of the mass
SYNOVIAL TUMOURS
is hypoechoic and avascular. Calcification is very commonly
seen and when extensive will be the prominent feature
PIGMENTED VILLONODULAR SYNOVITIS
visible on ultrasound. Plain films are useful in establishing
Synovial tumours may arise from joints, tendon sheaths or the diagnosis. MRI is usually required, particularly when the
bursae. They are nearly always benign. The commonest lesion is arising from a joint.
synovial lesion that may present as a mass is pigmented vil
lonodular synovitis, a neoplastic condition of unknown aeti
SYNOVIAL SARCOMAS
ology. The diffuse form, which rarely occurs outside a joint,
usually presents as a monoarthropathy, but occasionally as Synovial sarcoma is one of the commonest sarcomas seen in
a soft tissue mass, particularly in superficial locations such young adults. The tumour tends to occur around joints,
as the ankle or foot. The knee is by far the commonest site. particularly the knee, ankle and foot. Occasionally the
MRI is the more appropriate investigation for joint-based lesion has an intraarticular location. They are usually
lesions as the intraarticular extent and bony involvement detected early on account of their superficial location, but
cannot be accurately assessed on ultrasound. In addition diagnosis may be delayed, as the vast majority of periarticu
MRI is more specific as the abnormal synovium contains lar masses are benign. Ultrasound appearances are often
haemosiderin that returns low-signal intensity on all nonspecific, but the diagnosis should be considered in any
sequences. The nodular form usually presents as a solitary solid periarticular mass. The lesions are often haemor
mass. The commonest lesion, termed giant cell tumour of rhagic, and may be mistaken for a benign cystic lesion
tendon sheath, is nearly always found related to the fingers (Fig. 31.23). Tumour calcification, which is particularly
or thumb. The lesion is hypoechoic or moderately hyper common in this lesion, will frequently be detected on ultra
echoic and is usually hypervascular (Fig. 31.21). The nodular sound (Fig. 31.24).
form may also arise from the joints, particularly the knee
(Fig. 31.22). As with the diffuse form, MRI is useful in nar
rowing the prebiopsy diagnosis by detecting the presence of CYSTS
haemosiderin in the lesion.
One of the most useful features of ultrasound is the ability
to differentiate cystic from solid lesions. Although ultra
SYNOVIAL OSTEOCHONDROMATOSIS
sound may not be able to make a specific diagnosis, a purely
Synovial osteochondromatosis is a neoplasm of the synovium cyst lesion can be assumed to be benign. Cysts are usually
that may occasionally present as a mass when it arises in anechoic, although they may contain some echoes that rep
superficial sites or in a bursa or tendon sheath. Occasionally resent particulate material.
Figure 31.22 Extended field of view sagittal ultrasound of the

nodular form of pigmented villonodular synovitis. The well-defined
hypoechoic lesion (arrows) is situated in Hoffa’s fat pad of the knee.
common nonneoplastic, nontraumatic cystic lesions are

ganglia, usually arising from ligaments and tendons, syno
vial cysts arising from the joint and distended bursae, and
meniscal or labral cysts. Cysts are therefore most commonly
found around joints, particularly in the periphery where
they are most readily palpable.
GANGLIA
A ganglion is thought to represent mucoid degeneration of
a fibrous structure, usually a tendon or ligament. Degenen
eration of a synovial cyst has also been postulated as a pos
sible mechanism as synovial lining can be detected in the
neck of some lesions. However, only a minority of ganglia
may be seen to communicate with the joint on arthrography.
With ultrasound, lesions may be seen to communicate with
a structure such as a tendon or joint capsule via a neck of
b
varying length and width. It is important to identify the neck
Figure 31.21 Giant cell tumour of the tendon sheath of the hand. of the lesion at the time of imaging, as at surgery this will
(A) The lesion is heterogeneous (arrows). (B) On MRI the lesion shows need to be excised along with the main body of the lesion
low-signal intensity representing haemosiderin (arrows). to prevent recurrence. If the origin of the lesion is not clear
or more anatomical detail is required then MRI may be
helpful. The commonest symptomatic ganglion is that
Practice Tip arising from the scapholunate ligament over the dorsum of
the wrist (Fig. 31.26). An occult ganglion at this site is not
With some cysts, such as an abscess or epidermal inclusion palpable but may cause pain. Ultrasound is a sensitive
cysts, the echoes may be so dense that the lesion may method for identifying these lesions; aspiration with or
appear solid on initial inspection. By palpating with the without an injection of corticosteroid under ultrasound
probe, the internal echoes can often be seen to move control may produce some symptomatic relief. In certain
randomly within the lesion, proving its cystic nature. locations, such as the tibial tunnel, cubital tunnel or Guyon’s
canal ganglia may cause signs and symptoms of neural
compression.
Cysts will exhibit acoustic enhancement (Fig. 31.25), Common peroneal nerve palsy due to an intraneural gan
although this sign may also occasionally be seen with some glion is a well-recognized entity that can be detected on
solid hypoechoic lesions. Cysts may have solid components ultrasound. The lesion arises from the proximal tibiofibular
such as synovial hypertrophy in synovial-lined cysts or joint and dissects along the anterior articular nerve to reach
inflammatory tissue in abscesses, and when these features the common peroneal nerve. MRI is usually performed to
predominate, the lesion can mimic a neoplasm. The most accurately assess the exent of the lesion. Ganglia of the
a a
Figure 31.23 Synovial sarcoma. (A) The lesion has a major cystic c
component and (B) a solid component showing internal vascularity
on Doppler. (C) Sagittal STIR MRI image showing a mixed solid and Figure 31.24 Synovial sarcoma of the knee. (A) Hypoechoic lesion
cystic lesion. containing echogenic foci representing calcification. (B) Radiograph
shows a focus of calcification within the lesion (arrow). (C) MRI proton
density fat-suppressed transverse image shows a soft tissue mass
within the medial recess (arrow).
Figure 31.25 Ganglion. Anechoic lesion with acoustic

enhancement.
cruciate ligaments of the knee can present as a loss of knee

flexion and the diagnosis is usually made on MRI. Ultra
sound is useful for guiding aspiration and steroid injection
and is discussed on page 344.
SYNOVIAL CYSTS
Bursal swellings and distended synovial cysts can usually be
diagnosed with confidence because of the typical anatomi
cal position of the lesions (Figs 31.27 and 31.28). As with
other cysts the degree of reflectivity depends on the nature
of the fluid within the lesion. Synovial hypertrophy is
common (Fig. 31.29) and when marked will result in a
largely solid mass that can mimic a neoplasm. Hypervascu
larity is often detected within the mass on colour Doppler,
particularly in patients with an inflammatory arthropathy.
c
PERIMENISCAL AND PARALABRAL CYSTS
Figure 31.26 Occult wrist ganglion. (A) Small multiloculated cyst
Periarticular cyst may occur as a result of a tear of the menis over the dorsum of the wrist. (B) A neck (arrows) is seen extending
cus of the knee or labrum of the shoulder or hip. Meniscal towards the scapholunate joint. (C) The lesion is seen to originate
cysts of the knee represent perimeniscal synovial fluid that from the scapholunate ligament (arrows).
communicates with the joint through a meniscal tear. On
ultrasound cysts are usually seen as hypoechoic lesions, but
may appear more echogenic. Meniscal cysts, particularly on denervation of infraspinatus may occur. The denervated
the medial side, may migrate along the tissue planes so that muscle will appear hyperechoic on ultrasound on account
the main body of the cyst may be remote from the meniscal of the fatty infiltration (Fig. 31.30).
tear. Paralabral cysts of the shoulder and hip are not pal
pable, but at the shoulder may be responsible for supra
EPIDERMAL INCLUSION CYST
scapular nerve palsy in the suprascapular notch with
resulting atrophy of the supraspinatus and infraspinatus These common cutaneous cysts are rarely imaged but can
muscles. If the cyst is positioned posteriorly then isolated cause confusion as the lesions contain considerable
Figure 31.29 Olecranon bursitis. The image demonstrates an

Figure 31.27 Baker’s (popliteal) cyst showing the typical configura-
anechoic fluid collection in the bursa overlying the olecranon (*) and
tion with the neck of the cyst situated between the medial head of
triceps (arrowheads). The synovium is hypertrophied and its surface
gastrocnemius and the semimembranosus tendon.
irregular (arrows).
Key Point
Typically sarcomas are large lesions in the deep tissues,

particularly in the lower limbs.
However, the appearances are very variable and they may

also present as a small superficial lesion mimicking a benign
a tumour.
Key Point
Typically sarcomas appear as heterogeneous, but overall

hypoechoic, vascular masses, often with well-defined
borders (Fig. 31.32).
Well-differentiated liposarcomas are an exception and

usually appear uniformly echogenic. Sarcomas often contain
areas of necrosis and there may be tumoral mineralization.
b
Highly necrotic tumours may appear more uniformly
Figure 31.28 Distension of the bicipitoradial bursa presenting as a hypoechoic. MRI should always be performed to locally
mass in the antecubital fossa. (A) Longitudinal and (B) transverse stage the tumour, with the exception of small superficial
images. A confident diagnosis can be made on account of the cystic lesions that may simply undergo wide excisional biopsy. MRI
nature of the lesion and the typical position between the brachialis (*) is more specific than ultrasound in providing a prebiopsy
and the biceps tendon (arrowheads).
diagnosis if there are specific signal characteristics to indi
cate the presence of fat or fibrous tissue.
echogenic material representing keratin and may mimic a Ultrasound is a convenient and easy tool for guiding per
solid lesion on ultrasound. However, the lack of demon cutaneous biopsy.
strable internal vascularity on Doppler and the presence
of acoustic enhancement are clues to the true diagnosis
(Fig. 31.31). Key Point
SARCOMA Before any biopsy is obtained there should be dialogue with

the tumour surgeon so that the biopsy track can be excised
Most soft-tissue sarcomas have a similar ultrasound at the time of surgery.
appearance.
Figure 31.31 Epidermal inclusion cyst. The image shows a superfi-

cial well-defined cyst containing multiple echoes.
a
Figure 31.32 High-grade liposarcoma. The lesion shows a deep-

seated nonspecific hypoechoic lesion (arrows).
Using ultrasound the needle can be placed with a high

degree of accuracy into the viable tumour. Ultrasound can
b
also ensure that the needle is not passed through the lesion,
thus risking contamination of adjacent compartments.
Identifying a recurrent tumour on follow-up examina
tions is challenging. MRI using fat suppression sequences is
a sensitive method, although relatively nonspecific as dif
ferentiating a recurrent tumour from postoperative change
and seroma may be difficult. Intravenous gadolinium will
increase the specificity when an abnormality is seen on the
unenhanced scan. Ultrasound has been shown to be an
accurate method for identifying recurrence and will readily
differentiate seroma from tumour. It is mainly used to
clarify the nature of a lesion seen on MRI or to assess a
suspected soft tissue recurrence adjacent to an endopros
thesis used for resection of a bone tumour (Fig. 31.33).
Guided biopsy of the suspect tissue can be performed at the
same time.
OTHER MALIGNANT TUMOURS

c
Soft tissue metastases are uncommon and have an appear
Figure 31.30 Paraglenoid cyst. (A) The cyst (arrows) is situated in ance similar to that of other malignant tumours. Primary
the supraglenoid notch impinging on the suprascapular nerve. Infra-
soft tissue lymphoma is also uncommon and is seen as a
spinatus is echogenic, indicating atrophy. (B, C) Axial T2-weighted
MRI. The cyst is seen posterior to the glenoid (arrow). There is early
hypoechoic ill-defined mass that may infiltrate along the
atrophy of the infraspinatus muscle (*). subcutaneous fat or tissue planes (Fig. 31.34).
Figure 31.33 Hypoechoic lesion lying adjacent to an endoprosthe-

sis (arrows) representing recurrent sarcoma.
Figure 31.34 Primary soft tissue lymphoma. Axial scan showing

extension of tumour (arrows) infiltrating along the tissue planes to
surround the sciatic nerve (arrowhead).
HAEMATOMA
Haematomas are usually not a diagnostic problem when
they are temporally related to a traumatic event and have
typical clinical features. However, a chronic haematoma may
present as a lump with the patient having no recall of a
single traumatic event.
Practice Tip c
The ultrasound features of haematoma are variable, ranging Figure 31.35 The spectrum of findings of a haematoma. (A) Uni-
from an anechoic structure in a completely liquefied formly echogenic lesion in an acute haematoma. (B) Mixed echo
haematoma to an echogenic mass consisting of a solid clot pattern in a subacute lesion. (C) Liquefied haematoma.
(Fig. 31.35).
Usually in the acute phase a mixed pattern is seen, reflect

ing partial liquefaction. Chronic haematomas are usually
entirely liquid and anechoic or contain low-level echoes
with or without septations. Fluid/fluid levels may be seen.
Differentiating haematoma from a necrotic sarcoma occa
sionally causes difficulty.
Practice Tip
Haematomas do not have internal Doppler signal.
MRI often helps in diagnosis as blood degradation products

show characteristic signal intensities. Chronic haematomas
may ossify. Haematomas related to muscle tears are dis
cussed in Chapter 33.
Pseudoaneurysm is a haematoma adjacent to a defect in
an artery. There is often a history of prior trauma, surgery
or vascular interventional procedure. The typical appear
ance is of a pulsatile mass of mixed echogenicity, depend
ing on the relative amounts of clot and fluid blood. On
a
Doppler a jet-like swirling pulsatile blood flow is seen enter
ing the lesion at the point of communication with the artery
(Fig. 31.36). Doppler ultrasound-guided compression and
ultrasound-guided injection of thrombin are useful non
surgical techniques in aneurysms complicating arterial
puncture.
MYOSITIS OSSIFICANS
Myositis ossificans is a benign lesion that is usually precipi
tated by a single, often trivial, traumatic event. The term
myositis ossificans is misleading as the lesion may occur in
the subcutaneous tissues and is not usually inflammatory.
Typically the lesion is seen in the young adult or adolescent
and presents as a painful, tender, ill-defined mass following
an episode of trauma. However, the lesion may occur in the
absence of any history of local trauma. The majority of cases
involve the limbs with the thigh being the commonest site.
Plain films are initially unhelpful but the appearance of
peripheral mineralization after about three weeks is highly
specific. Follow-up radiographs will show maturation with
ossification and usually a gradual regression. CT is also non b
specific until peripheral mineralization occurs. MRI typi Figure 31.36 Pseudoaneurysm. (A) There is a large, mainly
cally shows a zonal appearance reflecting the varying layers hypoechoic mass (arrows) in the groin lying close to the femoral artery
of cellular maturation seen at histology and, after a few (arrowheads). The patient had surgery in this region a few months
weeks, a low-signal intensity rim representing peripheral previously. (B) Colour flow Doppler shows a jet of blood entering the
mineralization. Peripheral enhancement may be seen mass via a small communication to the artery (arrow).
before mineralization occurs. Extensive oedema in the adja
cent muscle is typical. Ultrasound features also reflect the
histology. Initially the mass may have a nonspecific appear
ance with a hypoechoic or heterogenic pattern. As the rim matures the ultrasound beam is totally reflected
and no information is obtained from the centre of the
lesion. The differential diagnosis in the early stages is a soft
Key Point
tissue sarcoma and differentiation may be difficult on
The rim of myositis ossificans tends to be hyperechoic when imaging. Although myositis ossificans tends to show a zonal
compared with the centre and variable vascularity can be pattern with peripheral vascularity and frequently central
demonstrated on Doppler. Ultrasound is very sensitive in cystic areas, these features can also be seen in sarcomas.
identifying early peripheral mineralization, which will be seen Generally, if the plain film is normal, ultrasound is likely to
as a hyperechoic zone with eventual acoustic shadowing be nonspecific. The decision to biopsy is dependent on the
(Fig. 31.37). combined imaging and clinical features. The histology of
the central portion of early lesions may look alarming
Figure 31.37 Myositis ossificans. The rim of the lesion (arrows) is

highly echogenic, resulting in marked acoustic shadowing. No detail
can be seen from the centre of the lesion. The lesion is lying on the
surface of the bone (arrowheads).
Figure 31.39 Abscess. (A) Echogenic mass (arrows) with irregular

hypoechoic inflammatory superficial margin. (B) There is marked
a peripheral hypervascularity.
with immature cells and mitotic figures and an erroneous

diagnosis of malignancy may be made if sampling is inade
quate and the pathologist is unaware that myositis ossifi
cans is under consideration. The abnormal osteoid present
in myositis ossificans is different from tumoral osteoid
and careful histological assessment can usually distinguish
the two.
INFECTIONS
The commonest infective lesion to present as a mass is an
abscess. Often this arises from a known underlying lesion
such as osteomyelitis but abscesses may be confined to the
soft tissues. On ultrasound the cystic nature of the lesion
will usually be obvious (Fig. 31.38). The borders of the
lesion may be ill-defined and a hypoechoic rim representing
oedema may be seen surrounding the lesion. The rim of the
lesion is often hypervascular but no flow should be seen
b within the central portion of the abscess (Fig. 31.39). The
Figure 31.38 Tuberculous abscess. (A) The image shows a large echogenicity can vary. Abscesses containing thick pus and
hypoechoic cyst arising from the anterior chest wall. (B) MRI axial particulate matter may be echogenic. By gently fluctuating
STIR image showing that the lesion arises from an infected rib. the mass discrete echogenic foci can be seen to circulate
within the lesion, thus proving its cystic nature. It may be Bianchi S, Abdelwahab IF, Mazzola CG, et al. Sonographic examination
impossible to differentiate an abscess from a haematoma on of muscle herniation. J Ultrasound Med 1995;14(5):357–60.
Choong KK. Sonographic appearance of subcutaneous angiolipomas.
ultrasound criteria alone. Ultrasound is an excellent tool for J Ultrasound Med 2004;23(5):715–17.
guiding aspiration or drain insertion. A relatively large-bore Doyle AJ, Miller MV, French JG, et al. Ultrasound of soft-tissue masses:
needle may be required to successfully aspirate thick pus. pitfalls in interpretation. Australas Radiol 2000;44(3):275–80.
Soft tissue fungal infections may present as a solid inflam Gomez-Dermit V, Gallardo E, Landeras R, et al. Subcutaneous angi
oleiomyomas: gray-scale and color Doppler sonographic appear
matory mass. Fungal elements (fungal grains) may be seen
ances. J Clin Ultrasound 2006;34(2):50–4.
as multiple discrete echogenic foci surrounded by inflam Griffith JF, Wong TY, Wong SM, et al. Sonography of plantar fibroma
matory tissue in cases of mycetoma. A soft tissue abscess may tosis. AJR Am J Roentgenol 2002;179(5):1167–72.
be related to a foreign body. Ultrasound is an excellent Kuwano Y, Ishizaki K, Watanabe R, et al. Efficacy of diagnostic ultraso
technique for identifying foreign bodies, which are seen as nography of lipomas, epidermal cysts, and ganglions. Arch Dermatol
2009;145(7):761–4.
echogenic structures that can be easily identified against the Lee HS, Joo KB, Song HT, et al. Relationship between sonographic and
hypoechoic background of the surrounding inflammatory pathologic findings in epidermal inclusion cysts. J Clin Ultrasound
response. 2001;29(7):374–83.
Lee MH, Kim NR, Ryu JA, et al. Cyst-like solid tumors of the musculo
FURTHER READING skeletal system: an analysis of ultrasound findings. Skeletal Radiol
2010;39(10):981–6.
Abate M, Salini V, Rimondi E, et al. Post traumatic myositis ossificans: Lin J, Jacobson JA, Hayes CW, et al. Sonographic target sign in neuro
Sonographic findings. J Clin Ultrasound 2011;39(3):135–40. fibromas. J Ultrasound Med 1999;18(7):513–17.
Battaglia M, Vanel D, Pollastri P, et al. Imaging patterns in elastofi Quinn TJ, Jacobson JA, Craig JG, et al. Sonography of Morton’s neuro
broma dorsi. Eur J Radiol 2009;72(1):16–21. mas. AJR Am J Roentgenol 2000;174(6):1723–8.
Ultrasound Imaging of 32
Joint Disease
Karen J. Partington | Eugene McNally | Andrew J. Grainger
CHAPTER OUTLINE
INTRODUCTION Enthesitis
TECHNICAL ASPECTS OF ULTRASOUND Cartilage
PITFALLS AND LIMITATIONS Osteophyte
TECHNIQUES FOR SCANNING THE SMALL SOFT TISSUE ABNORMALITIES
JOINTS OF THE HANDS AND FEET Tenosynovitis
APPLICATION OF ULTRASOUND IN Rheumatoid Nodules
RHEUMATOLOGY Tophi
Synovitis CONCLUSION
Effusion
Erosions
joints and at bony prominences such as the malleoli, where

INTRODUCTION the skin surface does not allow adequate contact with larger
probes. Stand-off gel pads can prove useful to reduce the
Ultrasound machines with high-resolution probes are amount of near-field reverberation when examining super-
readily available in most radiology departments and are ficial structures; however, with modern probes these are
routinely used to assess both articular and periarticular dis- rarely necessary and the use of liberal amounts of ultra-
orders. They are also becoming commonplace in rheuma- sound jelly is usually all that may be required in practice.
tology departments, reflecting the important role they now
play in rheumatological disease. Ultrasound has many
advantages over other imaging techniques with the ability PITFALLS AND LIMITATIONS
to carry out rapid assessment of multiple joints at different
locations, undertake dynamic imaging and guide diagnostic Many of the pitfalls and limitations of ultrasound are
and therapeutic injections. This chapter focuses on the role dealt with elsewhere in this book. They include anisotropy
of ultrasound in joint disease and particularly rheumatologi- and beam edge artifact. However, when undertaking ultra-
cal conditions, the technical aspects of joint ultrasound sound of joint disease certain specific pitfalls should be
examination and the imaging findings. considered.
Excessive probe pressure can obliterate small quantities
of fluid, reduce the sensitivity for detection of blood flow
TECHNICAL ASPECTS OF ULTRASOUND and may obscure synovitis.
The development of higher-frequency transducers has

Practice Tip
allowed for improved resolution and, with the majority of
joints lying relatively superficially, linear array probes of If it proves difficult to maintain probe contact with the skin
frequencies of 10 MHz or higher can be effectively utilized. surface using minimal probe pressure, a thick application of
Curvilinear probes, although rarely required for musculosk- sonographic jelly may help.
eletal imaging, may be useful for examining deeper joints
such as the hip joint. Although transducer selection primar-
ily depends upon the frequency, the probe footprint (the Disadvantages compared to MRI include a small field of
surface area of the transducer in contact with the skin) view and difficulty in demonstrating cartilage and deep
should be considered. Small footprint probes can be easily joints in their entirety. Contrast-enhanced MRI provides a
manoeuvred to image small superficial structures, small better measure of capillary permeability and enhancement
407
characteristics, although the advent of 3-D ultrasound may It is essential to appreciate the normal sonographic
narrow this gap. At present, both ultrasound and MRI are anatomy of the small joints to be able to identify pathology
increasingly important in the diagnosis and management of (Fig. 32.1). Superficial and deep flexor tendons can be
early rheumatoid arthritis with no current clear winner as identified as they pass over the MCPJs into the flexor tendon
the imaging modality of choice. sheath of the fingers on the volar aspect of the joints.
Expertise is important in the interpretation of both ultra- Dynamic assessment with finger movement can help identify
sound and MRI; however, unlike with MRI, reevaluation of them individually. The tendons are maintained in place by
ultrasound requires the patient to be recalled. Thus stan- pulleys, seen as thin hypoechoic linear structures; the pulleys
dardization of ultrasound criteria and validation of training and other aspects of tendon pathology are discussed in
both of the radiologist and the rheumatologist who perform Chapter 15.
these studies are paramount. Several connective tissue structures such as the collateral
ligament, accessory collateral ligament and the volar plate
strengthen the flexor side of the MCPJs and IPJs and can
TECHNIQUES FOR SCANNING THE SMALL be identified on ultrasound. The proximal recess of the
JOINTS OF THE HANDS AND FEET joint is the area between the volar aspect of the metacarpal
neck and the joint capsule and contains intracapsular, but
While an all-inclusive examination of the small joints may extrasynovial, fat, allowing close approximation of the two
be desirable, this is daunting and time consuming and can layers of synovium.
be modified by omitting joints that are frequently unin-
volved, such as the distal interphalangeal joints (IPJs) and
thumbs in rheumatoid arthritis. Practice Tip
It is the authors’ routine to examine the index, middle,
It is important not to misdiagnose intracapsular fat as
ring and little fingers, although this may be adapted for
synovial thickening, particularly as the proximal recess is
specific clinical indications. Superficial structures such as where early and prominent synovial thickening may occur.
the tendon and tendon sheath are assessed prior to the joint
itself, where standard sagittal images form the basis of the
examination, with axial (metacarpophalangeal joint, MCPJ)
and coronal and axial (proximal interphalangeal joint, On the extensor surface of the joint the extensor tendon
PIPJ) images used as adjuncts. complex is identified. The joint line is evident and articular
cartilage may be seen, especially over the metacarpal heads.
An important recess to the MCP and IP joints is found over
Practice Tip
the dorsal aspect of the metacarpal or phalanx on the proxi-
Routine examination of the extensor aspect of the MCPJs, mal side of the joint that may contain synovitis or fluid and
followed by the extensor, ulnar and radial aspects of the should not be mistaken for a bursa or tenosynovitis.
IPJs, is performed.
Key Point
Coronal images of the IPJs are obtained by asking the
patient to hyperextend the metacarpophalangeal of the Under normal circumstances small quantities of fluid can be
finger being examined. present in the joint; however, this should not be thicker than
the joint capsule and should not extend outwith its recess.
Key Point
The radial aspect of the joint should be carefully scrutinized, Absolute measurements of normal joints remain undefined
as synovial hypertrophy and erosions are predominant at and most authors use the point of maximal joint distension
this site. for assessment of the joint; an increase in joint dimension
of more than 1 mm above normal is sufficient to suggest
When examining the extensor surfaces of the finger joints, abnormality.
it is commonplace to assess the dorsal aspects of the wrist
and associated tendons prior to turning to the palmar side.
Whether both the extensor and flexor sides need to be
Key Point
examined remains debatable; however, published literature
Realistically it is with increasing practice that operators gain
suggests that a significant proportion of synovitis would be an appreciation of the range of normal for the small joints.
overlooked if limited to one or the other, and it is the
authors’ practice to examine the flexor aspects of the MCP
and proximal IPJs at this time. Dynamic sonographic assess-
ment by moving the joint can be useful to facilitate the
detection of low-volume synovial thickening, which bunches APPLICATION OF ULTRASOUND IN
up in the proximal extensor recess on flexion. Articular RHEUMATOLOGY
cartilage over the metacarpal and phalangeal heads can be
more comprehensively demonstrated when the joint is Ultrasound can be used to assess involvement in areas
examined in flexion as well as extension. that are clinically occult as well as determine the precise
CHAPTER 32 — Ultrasound Imaging of Joint Disease 409
a c
A1 Pulley
Flexor Tendon
Patellar
Metacarpal
* Patellar
Metacarpal A P
P D P D
b
P d
A
Figure 32.1 Small joint anatomy. (A, B) Sagittal view of the flexor aspect of the MCPJ. The flexor tendons lie anterior to the joint
capsule. The volar plate, articular cartilage (*) and A1 pulley (arrow) are visible. (C, D) Sagittal view of the extensor surface of the middle
MCPJ. The normal articular cartilage (*) is seen clearly. There is a small amount of joint fluid present that can be seen in the dorsal joint recess
(arrows).
structures involved. Serial examinations can assess current

Practice Tip
activity and disease distribution, and monitor progression
or therapeutic response. Clinically occult synovial thickening is found more commonly
in the proximal interphalangeal joints (PIPJs) than in the distal
SYNOVITIS interphalangeal joints (DIPJs), and unless symptomatic the
DIPJs are not routinely examined in patients with rheumatoid
Synovitis is the earliest pathological abnormality in rheu- arthritis. The first ray of both hands and feet often contains
matoid arthritis and is responsible for the subsequent effusions, synovial thickening and osteophyte formation in the
bone and cartilage damage. The development of effective asymptomatic population, and findings here should be
biologic therapies for use in early inflammatory disease treated with caution.
has placed new demands upon imaging. There is increas-
ing evidence that ultrasound detects synovitis that is silent
to clinical examination. Apart from detecting clinically
occult diseases, ultrasound can also help distinguish
between patients with polyarthritis and those with oligoar- Doppler can be used to demonstrate synovial hyperae-
thritis, and can guide the clinician to a specific disease mia, and differentiate between hypervascular and fibrous
diagnosis. pannus. Optimization of Doppler settings such as pulse rep-
Definitions for synovitis on imaging have been pro- etition frequency (PRF) and colour gain allows detection of
duced by the Outcome Measures in Rheumatoid Arthritis low-velocity blood flow. While synovial hyperaemia can be
Clinical Trials (OMERACT) initiative, defining synovial observed using either colour or power Doppler imaging,
hypertrophy on ultrasound as hypoechoic tissue within power Doppler ultrasound has been shown to have improved
and involving the joint capsule that is nondisplaceable and sensitivity for synovial inflammation compared with colour
poorly compressible and that may exhibit Doppler signal Doppler. Detection of Doppler signal can be used as a
(Fig. 32.2). quantitative indication of synovial inflammation, with posi-
Synovitis in inflammatory disease tends to occur at char- tive signal being shown to correlate well with clinical disease
acteristic sites such as the radial or ulnar aspects of the activity within a joint. There is evidence that a reduction in
MCPJs or the suprapatellar pouch of the knee. Probe com- Doppler signal from the synovium can be used to assess
pression can be useful in differentiating synovitis from longitudinally a response to treatment. However, in practice
effusion with fluid displacing rather than deforming the there remains a degree of visual qualitative assessment of
probe. hyperaemia resulting in interoperator/observer variability,
a c
Metacarpal Metacarpal
Patellar Patellar
P P
P D P D
A A
b d
Figure 32.2 Synovitis in a patient with rheumatoid arthritis. (A, B) Synovitis (arrows) is seen in the dorsal aspect of the second MTP joint in
a patient with rheumatoid arthritis. (C, D) Power Doppler signal is demonstrated within the thickened synovium.
and standardization is required before the techniques the joint while scanning causes redistribution of any fluid
will find mainstream use in the assessment of disease into sonographically visible areas. The presence of an effu-
response. sion is a sensitive predictor of joint disease, but unfortu-
There are pitfalls when using Doppler techniques for nately is completely nonspecific. However, the exclusion of
imaging synovitis. False-positive Doppler signal may occur an effusion, particularly in the clinical setting of infection,
secondary to movement and noise artifact, resulting in is of particular importance, effectively excluding a septic
‘flash’ artifact. Increasing the PRF and reducing gain help arthritis.
to minimize movement artifact. In crystal deposition disease, and particularly acute gout,
brightly echogenic foci may be seen within the effusion
(Fig. 32.4). However, generally speaking the sonographic
Practice Tip appearance of the effusion cannot be used as a guide to
diagnosis.
Care must be taken in the application of probe pressure to
avoid compressing small vessels and obliterating power
Doppler signal. EROSIONS
The radiographic hallmark of inflammatory joint disease is
erosion of the bone and erosions are also seen on ultra-
Using liberal quantities of contact jelly can be used to mini- sound. The OMERACT definition of an erosion seen on
mize the pressure effect as many gel pads can be awkward ultrasound imaging is an intraarticular discontinuity of
and limit access to the lateral recesses of small joints. the bone surface that is visible in two perpendicular planes
(Fig. 32.5).
EFFUSION
Ultrasound is extremely sensitive in the detection of even
small amounts of joint fluid. Studies of the ankle and hip Key Point
in cadaveric specimens confirm that ultrasound can detect
an effusion as small as 1–2 mL. Synovial fluid is visualized Acute erosions generally have an irregular margin and a
as an anechoic or hypoechoic area within the joint capsule poorly defined base, which allows through transmission of
that is displaceable and compressible and does not exhibit sound, and they may be associated with synovitis.
Doppler signal (Fig. 32.3). Active or passive movement of
Metacarpal
Figure 32.3 Joint effusion. Hip joint effusion with simple anechoic A
fluid (*) within the hip joint. P D
Cuneiform
b P
Figure 32.4 Crystal deposition disease. Multiple echogenic foci

(arrows) are seen within synovitis at the tarsometatarsal joint in this
Severe erosive change leads to marked distortion of the patient with acute gout.
normal joint architecture and may be associated with joint
subluxation (Fig. 32.6). A potential pitfall for the ultra-
sound detection of erosions is the misinterpretation of
normal bone contours and vascular channels as erosions.
An example is the normal depression on the dorsal aspect Studies suggest that ultrasound examination can detect
of the head of the metacarpal. This has regular margins, 20% more erosions than conventional radiographs and
does not allow through transmission of sound and is not ultrasound is of particular use in detecting erosions in
associated with overlying synovitis (Fig. 32.7). The need to patients with early disease. However, there remains conflict-
visualize the erosion in two planes can help avoid this pitfall, ing evidence when ultrasound is compared to MRI for
as can comparison with the contralateral side. detecting early erosions. MRI has the advantage of being
In rheumatoid arthritis, erosions are most commonly able to demonstrate associated subchondral bone oedema
detected at the ulnar styloid process, radial aspect of the which cannot be assessed with ultrasound. Furthermore
second MCPJ and the ulnar aspect of the fifth MCPJ. certain aspects of some joints are difficult to access with
ultrasound such as the ulnar and radial aspects of the middle
and ring MCPJs.
Key Point
DIPJs are the least affected in rheumatoid arthritis, but more ENTHESITIS
erosions are detected here in seronegative arthritis along Inflammation of entheses where ligaments, tendons or
with entheseal changes and osteoarthritis.
joint capsules attach to bone (enthesitis) is a recognized
clinical, histopathological and imaging feature of spondylo-
arthropathy. Ultrasound detection of enthesitis is more sen-
In contrast, erosions in gout tend to be larger, more irregu- sitive and specific than clinical examination and can be a
lar and lie further away from the joint. However, there valuable tool in the diagnosis of early spondyloarthropathy.
remains no literature that has demonstrated the ability to The commonest sites of enthesitis are the plantar fascia,
confidently distinguish arthritis type from the morphology Achilles and patellar tendons. Tendinopathic change can
of an erosion using ultrasound. be seen with loss of the normal tendinous fibrillar pattern,
a c
* *
Patellar
Metacarpal
A
A
P D Metacarpal
P ML
P
b d
Figure 32.5 Erosion at MCPJ. Longitudinal (A, B) and transverse (C, D) images show an erosion (arrows) in the dorsal metacarpal head at
the metacarpal phalangeal joint in a patient with rheumatoid arthritis. There is synovitis and effusion in the joint (*).
Synovitis
Synovitis
Metacarpal
Patellar
P
P D
A
a b
Figure 32.6 Severe erosion and joint subluxation in rheumatoid arthritis. Synovitis, erosions (arrow) and joint subluxation of the MCPJ of a
patient with severe destructive arthropathy as a result of rheumatoid arthritis.
a a
*
Olecranon
Metacarpal
P Triceps
P D P
A P D
b b A
Figure 32.7 Pseudoerosion of the MCPJ. Sagittal image of the Figure 32.9 Olecranon bursitis. Fluid (*) is demonstrated within the
dorsum of the second MCPJ demonstrating a pseudoerosion (arrow), olecranon bursa on this longitudinal image.
due to the normal contour of the metacarpal.
entheseal insertions, seen as a break in the bone cortex

adjacent to the enthesis.
CARTILAGE
* Cartilage loss reflects irreversible joint destruction and con-
tributes to impaired joint function. Indirect signs of carti-
lage loss have traditionally been imaged with conventional
a radiography. Despite the increasing use of ultrasound in
early detection of bone erosions, few studies have directly
investigated the ability of ultrasound in the assessment of
Achilles Tendon cartilage, particularly in the small joints.
Normal hyaline cartilage can be shown as two hyper
echoic sharp, regular and continuous margins delimiting a
* homogeneous anechoic band (Fig. 32.1C,D). Cartilage
P damage can be seen as a spectrum, from surface irregulari-
P D
A
ties to full-thickness defects (Fig. 32.10). However, its use
b remains limited and at present sonographic imaging of car-
Figure 32.8 Achilles tendon enthesitis. The distal Achilles tendon is tilage loss generally remains within the realms of research
thickened and hypoechoic (*). At the insertion there is erosion (arrows) studies.
and enthesophyte (arrowhead). Ultrasound has an emerging role in the assessment of
crystal deposition disease. Chondrocalcinosis can be seen
on ultrasound as a dense echogenic material within the
articular cartilage.
hypoechoic change and increased tendon thickness or fusi-
form swelling, a common feature of soft tissue inflamma-
tion (Fig. 32.8). There may be involvement of adjacent Key Point
bursae (Fig. 32.9).
Changes seen at the bone surface of the enthesis com- The central location of the pyrophosphate calcification within
prise a combination of cortical bone breakage, erosion and the cartilage is in contrast to the characteristic appearance
of urate deposition in gout where the crystals are deposited
new bone proliferation. The most common sonographic
on the cartilage surface.
bony abnormality is enthesophyte formation seen as hyper-
echoic bone spurs forming at a tendinous insertion into
bone. These grow in the direction of the pull of the tendon
and are usually associated with inflammatory changes in the This appearance gives rise to the double contour sign, seen
surrounding soft tissues. Erosive changes may be present at as a bright reflection from the surface of the cartilage
*
Femoral Condyle
A
M I
P
b
Figure 32.10 Cartilage thinning of the trochlea groove of the knee.

Thinning of the cartilage (arrows) overlying the anterior aspect of the
femoral condyle. The normal cartilage thickness (*) can be seen in
comparison.
Trochlear
paralleling the subchondral bone. Occasionally articular
A
cartilage may give a bright interface with fluid simulating D P
the double contour sign. However, this only occurs when P
the cartilage surface parallels the probe face, enabling a b
true double contour sign to be distinguished (Fig. 32.11). Figure 32.11 Monosodium urate crystal deposition: double contour
sign in the elbow joint. Sagittal image of the volar aspect of the distal
humerus trochlea in a patient with chronic gout. There is a double
OSTEOPHYTE
contour sign with a hyperechoic line of crystal deposition (arrows) on
Sonographic-detected osteophytes have been found to be the cartilage surface. The subchondral bone is seen as a parallel line
related to pain in finger joints and are a key feature of (arrowheads). Note that the bright surface of the cartilage is still seen
osteoarthritis. Early osteophyte development is demon- as the cartilage curves away from the probe, distinguishing it from
artefact.
strated on ultrasound as an elevation of the bony cortex
(‘step-up lesion’) that eventually develops into an osteo-
phyte (Fig. 32.12). Conventional radiography remains the
standard imaging modality in the assessment of osteoarthri-
tis, although ultrasound has been shown to be more sensi-
SOFT TISSUE ABNORMALITIES
tive than radiography and MRI in the detection of finger
osteophytes. Ultrasound is valuable in the detection of early
TENOSYNOVITIS
osteoarthritis and, with the added ability to detect synovitis
and hyperaemia, may play a role in determining which Tenosynovitis is a common finding in patients with early
patients with mechanical arthritis have an inflammatory rheumatoid arthritis. The tendon, which may itself appear
element, guiding treatment options and monitoring normal, is surrounded by varying degrees of synovitis and
response. However, the relationship between pain and syno- effusion (Fig. 32.13). Although any tendon may be affected,
vitis in osteoarthritis is complex and a preliminary study has the extensor digitorum, flexor digitorum and particularly
shown that, while pain responds to treatment with intraar- extensor carpi ulnaris are most frequently involved. Bursitis
ticular corticosteroid in knee osteoarthritis, there is no sig- is also a frequent finding in rheumatoid arthritis and spon-
nificant effect on the extent of ultrasound-demonstrated dyloarthropathies with involvement of the retrocalcaneal,
synovitis. suprapatellar or intermetatarsal bursa. These findings are
Metacarpal
Proximal Phalanx
P
D P
A
b
Figure 32.12 Osteoarthritis of the metatarsophalangeal joint. Osteophytes (arrow) are seen arising from the metatarsal and proximal phalanx
at the edge of the articular cartilage with an associated joint effusion (*).
* *
Synovitis * *
Synovitis
Flexor Tendon
Flexor Tendon
A
D P
b P
A
ML
P
d
Figure 32.13 Tenosynovitis of the flexor tendon sheath. Longitudinal (A, B) and transverse section (C, D) of the flexor tendon overlying the
second MCPJ shows marked fluid (*) and frond-like synovial thickening within the flexor tendon sheath.
*
*
MT
MT
a c
b d
Figure 32.14 Rheumatoid subcutaneous nodule overlying the plantar aspect of the first metatarsal. Longitudinal image (A, B) overlying
the plantar aspect of the first metatarsophalangeal joint shows an ill-defined heterogeneous hypoechoic mass (arrows) with small fluid-filled
cavities (*) in the subcutaneous tissues overlying the metatarsal. Transverse image with power Doppler (C, D) demonstrates a small amount of
peripheral vascularity and fluid cavities (*).
not specific to rheumatological disorders and are discussed Ultrasound is the only imaging technique that has been fully
elsewhere. validated for tophus measurement and has been included
in the OMERACT outcome measures for gout.
RHEUMATOID NODULES
Rheumatoid nodules occur in 20–25% of patients with sero- CONCLUSION
positive rheumatoid arthritis and are the most common
extraarticular manifestation of rheumatoid arthritis. They Musculoskeletal ultrasound is now routine practice in the
are detected in the superficial soft tissues at pressure points, rheumatology clinic and a firm adjunct to clinical, biochem-
such as the extensor aspect of the elbow, calcaneus and ical and radiographic examination. With appropriate train-
fingers, and characteristically appear on ultrasound as het- ing many rheumatologists perform ultrasound in their
erogeneous hypoechoic masses with poor internal vascular- general clinic, both at initial consultation and routine assess-
ity and often containing fluid cavities (Fig. 32.14). The ment. In practice ultrasound allows detection of subclinical
lesion margins are often difficult to define precisely. synovitis, pre-radiographic erosion detection and may
Rheumatoid nodules are not exclusive to rheumatoid offer an alternative explanation for patients’ symptoms. Of
arthritis and similar histological and radiological lesions can patients referred with a suspected inflammatory arthropa-
sometimes occur in patients with systemic lupus erythema- thy, only one-third have appreciable synovitis on ultrasound,
tosus and ankylosing spondylitis. allowing a shift in therapeutic management away from
disease-modifying antirheumatic drug treatment.
Ultrasound may also have a role in treatment decisions
TOPHI
using synovial thickness, volume and reduction in synovial
The physics of ultrasound make it an ideal modality for the vascularity as markers for disease activity and response. Its
detection of crystalline material in soft tissues. Tophi are use for this purpose requires clearly defined quantitative
conglomerates of uric acid crystals that appear at ultrasound and reproducible measures to standardize treatment deci-
examination as hypoechoic to hyperechoic inhomogeneous sions. Validation trials, particularly looking at longer-term
material surrounded by a small anechoic rim (Fig. 32.15). outcome, are also required before this area of joint sonog-
The crystals within the tophi attenuate the ultrasound beam, raphy moves from the research environment into the clini-
frequently resulting in shadowing posterior to the lesion. cal practice.
FURTHER READING
Boutry N, Morel M, Flipo R-M, et al. Early rheumatoid arthritis: a review
of MRI and sonographic findings. AJR Am J Roentgenol 2007;189(6):
1502–9.
Dalbeth N, McQueen FM. Use of imaging to evaluate gout and other
crystal deposition disorders. Curr Opin Rheumatol 2009;21(2):
124–31.
de Miguel E, Muñoz-Fernández S, Castillo C, et al. Diagnostic accuracy
of enthesis ultrasound in the diagnosis of early spondyloarthritis.
Ann Rheum Dis 2011;70(3):434–9.
Kane D, Grassi W, Sturrock R, et al. Musculoskeletal ultrasound – a state
of the art review in rheumatology. Part 2: Clinical indications
for musculoskeletal ultrasound in rheumatology. Rheumatology
(Oxford) 2004;43(7):829-38.
a Keen HI, Wakefield RJ, Grainger AJ, et al. Can ultrasonography improve
on radiographic assessment in osteoarthritis of the hands? A com-
parison between radiographic and ultrasonographic detected pathol-
ogy. Ann Rheum Dis 2008;67(8):1116–20.
Rowbotham EL, Grainger AJ. Rheumatoid arthritis: ultrasound versus
MRI. AJR Am J Roentgenol 2011;197(3):541–6.
Spencer SP, Ganeshalingam S, Kelly S, et al. The role of ultrasound in
the diagnosis and follow-up of early inflammatory arthritis. Clin
Radiol 2012;67(1):15–23.
Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/
power Doppler ultrasound in rheumatology. Ann Rheum Dis
2008;67(2):143–9.
Wakefield RJ, Balint PV, Szkudlarek M, et al. Musculoskeletal ultra-
sound including definitions for ultrasonographic pathology. J Rheu-
matol 2005;32(12):2485–7.
Figure 32.15 Gouty tophus adjacent to the first metatarsophalan-

geal joint. Transverse image of the dorsal aspect of the first MCPJ
demonstrates a large gouty tophus (arrows) with central and posterior
acoustic shadowing due to crystal deposition (*).
PART 10
TRAUMA
419
Ultrasound of Muscle Injury
Philip J. O’Connor
33
CHAPTER OUTLINE
INTRODUCTION Early Remodelling Phase: Days 3–12

MUSCLE ANATOMY Late Remodelling Phase: Day 12 Onwards
ANATOMY OF COMMONLY INJURED SCANNING TECHNIQUES
MUSCLES GRADING MUSCLE TEARS
Quadriceps Anatomy HEALING
Hamstring Anatomy COMPLICATIONS
Calf Muscle Anatomy Myositis Ossificans
Pectoralis Major and Distal Biceps Anatomy Muscle Hernia
MECHANISMS OF MUSCLE INJURY Cysts
PATHOBIOLOGY OF MUSCLE INJURY
The Destructive Phase: Days 0–3
The history obtained with regards to muscle injury is impor-

INTRODUCTION tant as the appearances of haematoma and muscle tears vary
with time postinjury. The nature of the injury is also impor-
Muscle is probably one of the most difficult tissues in the tant in determining the exact sites that need to be most
musculoskeletal system to assess with ultrasound. There are carefully assessed. It is important for the examiner to dif-
a variety of reasons for this, including the complex anatomy ferentiate between direct contusion and indirect muscle
of the structures involved, the isotopic nature of muscle, the injury. These two mechanisms damage the muscle in differ-
different functional bundles present within muscles and ent sites; muscle ultrasound requires the examiner to focus
compartments, and the varied site and appearance of muscle the examination at the site of injury most frequently affected
lesions. and often with comparison to the contralateral side required
Once the examining sonographer appreciates the level of to demonstrate subtle changes.
difficulty involved, muscle ultrasound becomes a more
viable clinical tool. Increasing levels of exercise in the
Practice Tip
general population and an emphasis on imaging of sports-
related injuries in athletes has resulted in an increase in The presence of bruising is important; the site of muscle
requests for muscle ultrasound. Developments in ultra- damage frequently lies immediately proximal to the site of
sound technology have also resulted in the development of subcutaneous ecchymosis.
more mobile ultrasound services with many professional
clubs now employing diagnostic ultrasound as part of their
regular medical services. The sonologist should use the highest-frequency probe
to give sufficient depth of penetration to allow assessment
TECHNIQUE of the entire muscle under interrogation. In general high-
frequency linear array probes (for example, 7–13 MHz and
Key Point 5–17 MHz) can be used to assess muscle injury even in large
compartments such as the thigh or hamstring. This is
An ultrasound scan is part of a clinical assessment and achieved by a combination of lowering the frequency of the
therefore each examination should begin with a brief probe to give sufficient penetration and by using electronic
history and sometimes even a physical examination of the curvilinear field of view to give greater tissue coverage.
patient. Extended field of view scanning is useful in muscle ultra-
sound as it gives the examiner an appreciation of the overall
421
422 PART 10 — TRAUMA
muscle architecture and the degree of damage present. This The anatomy of the MTJ can be complicated and
is different to the use of extended field of view scanning in requires detailed assessment. Muscles with multiple heads
other areas where frequently it is only of value in demon- usually have more complex MTJ anatomy and are unfortu-
strating abnormalities for clinicians; in muscle ultrasound it nately the most commonly injured muscles requiring
helps with the grading and identification of muscle tears. imaging.
The focus of this chapter is limited to ultrasound imaging
of muscle injury. Inflammatory conditions of muscles are,
in the opinion of the author, best assessed with MRI and
have not been considered in this chapter. Practice Tip
The junction between a muscle and a tendon can be either

MUSCLE ANATOMY epimysial (at the periphery of the muscle) or via a central
aponeurosis with a gradual thickening of the aponeurosis/
Muscle has a hierarchical internal structure with hypoechoic epimyseum as the rounded tendon forms.
myofibrils separated by thin internal septa. This structure
produces the typical ultrasound appearances of muscle
tissue with hypoechoic tissue separated by thin hyperechoic
parallel lines. This parallel orientation of the myofibrils
renders muscle anisotropic, resulting in differing ultra-
sound properties dependent on the incident angle of the
ultrasound beam. In transverse this produces the classic
starry sky appearance with bright septa seen as dots within
the hypoechoic dark surrounding myofibrils (Fig. 33.1).
The echogenicity of the surrounding myofibrils varies with
probe angle, either accentuating or decreasing this appear-
ance. When examined in the longitudinal plane, muscle
anisotropy is easier to appreciate by angling the probe or
beam steering (Fig. 33.2). Within any single muscle there
are usually separate functional bundles, especially in large
muscles crossing two joints more prone to injury. This
results in fibres tracking in different directions within
muscles themselves, complicating even further the ultra-
sound assessment of muscle.
An understanding of myotendinous junction (MTJ)
anatomy is vital to successful imaging of muscles (Fig. 33.3).
Key Point
In young skeletally mature athletes, the MTJ represents the Figure 33.1 Transverse sonogram of the rectus femoris showing the
weak point in the kinetic chain most prone to injury. typical starry sky appearance of the muscle septa with the surround-
ing myofibrils.
a b c
Figure 33.2 Image of the gastrocnemius (G) and soleus (S) muscles of the calf. With no beam steering (A) the gastrocnemius is slightly
hypoechoic relative to soleus. Beam steering towards the feet accentuates this (B), whereas cranial beam steering (C) placed the gastrocnemius
fibres more parallel to the probe, rendering them virtually isoechoic to the soleus fibres.
CHAPTER 33 — Ultrasound of Muscle Injury 423
aponeurosis that lies on the deep surface of the muscle and

forms part of the quadriceps tendon. The most inferior
portion of vastus medialis lies directly adjacent to the
femoral shaft and as such is prone to contusion. This infe-
rior portion has a more horizontal fibre orientation and
inserts onto the medial retinaculum of the patella. This
portion of the muscle is sometimes referred to as vastus
medialis obliquus and is prone to injury during patellar
dislocation and contusion.
Rectus femoris arises from the two proximal tendons: the
direct (or sometimes called the straight) head and the indi-
rect (reflected) head. These merge 2 to 3 cm below their
origins to form the conjoint tendon. The direct head arises
from the anterior inferior iliac spine with the indirect head
arising from the iliac bone just posterior and inferior to the
direct head origin. The direct head forms the anterior
portion of the tendon and forms an anterior epimysial MTJ
terminating in the proximal thigh. The indirect head forms
the posterior portion of the conjoint tendon terminating in
a central aponeurosis within the muscle, which extends a
long way down the muscle. This central septum terminates
approximately 10 cm above the superior pole of the patella
and overlaps the distal rectus femoris MTJ. As a result it is
possible and indeed not unusual to have a proximal MTJ
injury in the distal thigh.
Practice Tip
Rectus femoris crosses two joints and contains a high

proportion of fast twitch fibres, which is why it is the
most commonly injury of the knee extensors during kicking
Figure 33.3 Extended field of view sonogram of the forearm dem- injuries.
onstrating the long-central MTJ (arrows) in a bipennate muscle.
This muscle also contains differing functional units with

unipennate direct and bipennate indirect components that
ANATOMY OF COMMONLY predispose to longitudinal splitting type of aponeurotic
injury most commonly seen in the central septum.
INJURED MUSCLES
QUADRICEPS ANATOMY HAMSTRING ANATOMY

The quadriceps muscle comprises four components, vastus
lateralis, vastus medialis, vastus intermedius and rectus Practice Tip
femoris. This muscle is responsible for knee extension and
is commonly injured during kicking. The vastus intermedius The hamstrings consist of three muscles, all of which cross
contains a high proportion of slow twitch fibres and, as it two joints with high proportions of fast twitch fibres. Like
rectus femoris, this combination makes them extremely prone
originates on the anterior femoral shaft, it only crosses one
to exercise-related injury. These muscles all arise from the
joint. As such it is rarely injured in exercise-related sprinting ischial tuberosity.
injury, though is prone to contusion, mainly as a result of
its close proximity to the femoral shaft. Vastus medialis and
lateralis also only cross one joint.
The vastus lateralis is the largest part of the quadriceps Key Point
femoris. It arises by a broad aponeurosis, which is attached
to the upper part of the intertrochanteric line and the The biceps femoris has two heads and is the most
upper half of the lateral lip of the linea aspera. The distal commonly injured hamstring muscle.
tendon forms from an aponeurosis on the deep surface of
the lower part of the muscle: this aponeurosis forms part
of the quadriceps tendon and inserts on the superolateral The semimembranosus muscle arises from the more ante-
border of the patella. rior and lateral portion of the ischial tuberosity and forms
The vastus medialis arises from the lower half of the a sheet-like (hence the name semimembranosus) epimysial
intertrochanteric line, the medial lip of the linea aspera and aponeurosis in the proximal thigh on the anterior aspect of
the tendons of the adductor group. Its fibres attach to an the semitendinosus muscle belly. This epimysial aponeurosis
has a configuration similar to the Nike tick. Semimembra- and distally forms the Achilles tendon via a long anterior
nosus muscle forms its distal tendon attaching via five sepa- epimysial junction. The soleus arises from two heads from
rate components to the medial condyle (the anterior, direct the proximal fibula and the adjacent deep fascia, forming
and inferior), a posterior oblique component that inserts the Achilles tendon with the gastrocnemius aponeurosis.
on the capsule and medial collateral ligament and an inser- The gastrocnemius and soleus aponeuroses fuse just as the
tion on the posterior joint capsule. Achilles tendon proper forms and, as such, differential
The semitendinosus and biceps femoris arise from a con- movement occurs in the plane between these muscles proxi-
joint tendon from the posterior and more medial aspect of mal to this level. It is important to remember this, as haema-
the ischial tuberosity. This tendon separates into its separate toma can track into this potential space following injury,
components 7–10 cm below its origin. The semitendinosus leading to an overestimation of tear size.
muscle belly arises from an epimysial proximal MTJ which
lies on the posterolateral aspect of the muscle anterior to Key Point
the sciatic nerve. Distally the semitendinosus forms a long
tendon (hence the name semitendinosus) that, in the distal Identification of the extent of actual muscle fibre damage
thigh, sits on top of the semimembranosus muscle belly around the MTJ is key to accurate grading.
looking a bit like a cherry on a bun!
MRI can be very helpful in grading the true extent of these

Practice Tip
tears by demonstrating the degree of muscle oedema
The configuration of the distal semitendinosus and present and identifying plantaris injury that can be difficult
semimembranosus is a useful landmark for the beginner to to diagnose on ultrasound.
help identify which hamstring is injured.
Key Point
Find the semitendinosus sitting on the semimembranosus Gastrocnemius is more commonly injured than soleus as a
distally, then track back up the thigh to the tear site to result of its higher proportion of fast twitch fibres and
confirm the exact location of the injury. The distal semiten- anatomy that crosses two joints.
dinosus tendon then forms one of the pes anserinus tendons
inserting on the tibia after having crossed the distal portion
of the medial collateral ligament of the knee. The pes anse- It is predominantly responsible for plantar flexion when
rinus translated means goose’s foot, as the three medial the knee is extended. Knee flexion reduces gastrocnemius
tendons adopt a configuration similar to a goose’s foot as movement with soleus responsible for a greater proportion
they cross the medial knee. The three tendons are sartorius, of plantar flexion in the flexed knee position.
gracilis and semitendinosus from anterior to posterior.
The biceps femoris muscle has a short and long head. Practice Tip
The long head arises from the posteromedial ischial tuberos-
ity; the short head arises from the linea aspera of the femur. As such forced plantar flexion injury on a flexed knee is the
The long head is more frequently injured than the short commonest mechanism for soleus injury.
head that only crosses one joint. However given their shared
function, combined injury of both these myotendinous units
is not unusual. The short head forms in the distal thigh, The plantaris muscle arises on the lateral aspect of the
forming a loosely connected conjoint distal biceps tendon distal femur and forms a short muscle belly in the proximal
approximately 5 cm above its fibular insertion. The biceps calf over the posterior aspect of the popliteal fossa. It then
tendon itself is bilaminar with long- and short-head compo- forms a long tendon that tracks lateral to medial in the
nents. Just above its insertion these pass on either side of fascial plane between the gastrocnemius and the soleus apo-
the distal lateral collateral ligament of the knee as they insert neuroses, to the medial side of the Achilles tendon. Its distal
onto the head of the fibula. This can give a somewhat con- insertion is variable, either fusing with the Achilles or
fusing appearance to the distal biceps that can be inadver- forming a separate tendon on the medial aspect of the Achil-
tently interpreted as tendinopathy, bursitis or even tears. les inserting on the calcaneus. A plantaris tendon can be
The adductor magnus muscle tendon sits just medial to found in the majority of, if not all, individuals, although the
the hamstring tendons and frequently connects to the semi- reported incidence of plantaris tendons is low, at only 15%.
membranosus tendon. This hamstring origin of adductor This low figure likely reflects the incidence of a separate
magnus has similar functions to the hamstrings and can be tendon on the medial aspect of the Achilles at its insertion.
injured as part of hamstring injury. It is, however, relatively The proximal muscle and the slip tendon extending between
unusual mainly because it has a lower proportion of fast the soleus and gastrocnemius aponeuroses are universally
twitch fibres and only crosses one joint. demonstrable with ultrasound to a greater or lesser extent.
CALF MUSCLE ANATOMY Practice Tip
The main muscle groups involved in calf muscle injuries are Plantaris injury is normally a tendon rupture and as such
gastrocnemius, soleus and plantaris. Gastrocnemius arises tends to occur in the slightly older athlete.
from two heads (medial and lateral) above the knee joint
An appreciation of plantaris anatomy is important as disrup-

THE DESTRUCTIVE PHASE: DAYS 0–3
tion of the tendon can result in haematoma between soleus
and gastrocnemius that can be misinterpreted as tears of The destructive phase involves haematoma formation at the
these muscles. There is a recognized association between site of physical fibre disruption (termed the central zone).
plantaris muscle belly injury and anterior cruciate ligament Around this central zone there is a destructive zone that
tears. extends for a short distance into the adjacent muscle
(2–3 mm each side of the central zone) where there is
PECTORALIS MAJOR AND DISTAL necrosis of the myofibrils associated with an inflammatory
reaction, phagocytosis of debris with sparing of the myofi-
BICEPS ANATOMY
bril basal lamina. There is also denervation of the muscle
Upper limb muscle injuries are relatively rare in sport and adjacent to the central zone, the size of which varies depen-
normally relate to explosive force injury. This is most com- dent on whether muscle innervation is predominant proxi-
monly seen in weightlifting training or contact sports. The mally (normally the case) or distally.
pectoralis major tendon arises from sternal and clavicular
heads forming a bilaminar tendon, which inserts on the
EARLY REMODELLING PHASE: DAYS 3–12
anterior humerus forming the anterior axillary fold. The
sternal head is the most common injury component of this Early healing changes are seen with gradual resorption of
muscle. the haematoma in the central zone associated with the for-
The distal biceps forms its tendon via a central myoten- mation of septa bridging the tear site and increased vascu-
dinous aponeurosis with imaging of this injury required to larization of the central zone. Septa form within the central
distinguish between mytotendinous junction injury (conser- zone haematoma.
vative management) and distal tendon disruption (which
can be managed surgically).
LATE REMODELLING PHASE: DAY 12 ONWARDS
After day 12, healing is occurring either by scar formation
MECHANISMS OF MUSCLE INJURY or myofibril regeneration. The junction either side of scar
formation is histologically identical to a normal MTJ and as
There are two mechanisms of muscle injury: exercise-related such represents a new point of weakness in the kinetic
injury and contusion. Exercise-related injury occurs during chain. Remodelling of both regenerated myofibrils and scar
overstretching or excessive contraction of a muscle. continues for approximately 9 months postinjury.
Key Point
SCANNING TECHNIQUES
Muscle is most vulnerable to damage when loaded in an
extended position, known as eccentric loading. It is most The elements of muscle injury that can be imaged are:
common in muscles that cross two joints with high
proportions of fast twitch fibres and multiple heads. • haematoma
• inflammatory reaction
• regeneration and scar
In skeletally mature athletes, the site of greatest weakness is • denervation change.
the MTJ, making an appreciation of the normal myotendi-
nous anatomy important for the examining sonologist. The approach to imaging varies with the clinical question
Comparison with the normal side can be extremely valuable posed. In general there are four clinical questions:
in the assessment of muscle injury both for detection of
subtle tears and for grading the length of MTJ involvement. 1. Is there a tear present? MRI gives an excellent assessment
Contusion results from direct (impact) trauma to the of muscle injury and is in general the modality of choice.
muscle fibres themselves and is characterized by fibre dis- Ultrasound can be used but only with caution and at the
ruption, oedema and haematoma formation that crossed right time.
anatomical boundaries. 2. How bad is the tear? MRI tends to overgrade muscle
injury. The MRI assessment of muscle architecture is
Key Point inferior to ultrasound and contralateral comparison is
not always possible. Ultrasound is dynamic and if
Muscle contusions heal faster than similar extent exercise- performed after 72 h can be very useful in assessment of
related injury and generally have a better prognosis. tear size.
3. Is it safe for the athlete to return to training or competi-
tion? The demonstration of bridging tissue across the
central zone of the tear is the key finding. Ultrasound
PATHOBIOLOGY OF MUSCLE INJURY gives an excellent assessment of the tear site and its
dynamic nature is of great value in showing tissue conti-
Following muscle fibre disruption there are three distinct nuity across a tear site.
phases: the destructive phase, the early remodelling and the 4. Has there been any complication? MRI is excellent at
late remodelling phase. demonstrating scar formation and denervation change
Figure 33.4 Acute grade 2 injury of the hamstrings with hyperechoic

20-minute-old haematoma (H) at the proximal MTJ of the biceps
femoris.
and is probably superior to ultrasound. Ultrasound is,

however, much more effective at demonstrating early cal-
cification in patients developing myositis ossificans (MO).
Haematoma is the most common imaged component of

muscle injury. It varies in its ultrasound appearances depen-
dent on its age; the timing of an ultrasound scan is vital.
b
Acute haematoma is hyperechoic relative to the echogenicity
of muscle (Fig. 33.4). As the haematoma matures it becomes Figure 33.5 Sonogram of the anterior thigh obtained 24 h postinjury
more hypoechoic. with a tear of the distal MTJ of the rectus femoris (RF). The
haematoma (H) is virtually isoechoic to the underlying vastus inter-
medius (VI).
Practice Tip
By 24 to 48 h haematoma is virtually isoechoic with the

adjacent muscle (Fig. 33.5). This is the most likely time for
the examining sonographer to miss muscle tears and
generally ultrasound at this time should be avoided. GRADING MUSCLE TEARS
Grading muscle tears with ultrasound is difficult.

By 72 h postinjury the haematoma is hypoechoic to the
adjacent muscle and is beginning to liquefy (Fig. 33.6). This Key Point
provides excellent contrast to the adjacent muscle and is
useful in providing contrast for assessing the true extent of The examiner needs to wait until 72 h postinjury to best
fibre disruption in a tear. visualize the tear extent.
By day 10, the haematoma will be virtually completely
liquefied and sonopalpation of the haematoma can be of
value in deciding whether a haematoma can be aspirated Virtually all muscle tears fall into grade 2; that is, 5–99%
(Fig. 33.7). involvement.
2. Mild grade 2 injury: 3–4 weeks recovery time. These tears

are characterized by relatively small amounts of muscle
damage. Focusing on the area of MTJ injury rather than
the size of the haematoma is important in grading the
severity (Fig. 33.10).
3. Severe grade 2 and grade 3 injury: 6–8 weeks recovery
time.
Some tears are quicker to heal than expected; this is

particularly the case with contusions which, unless the hae-
matoma is extremely large, usually behave as grade 1 injury.
Contusions are most commonly seen in the vasti of the
thigh.
Some tears are problematic and take longer to heal. Add
a week to the recovery time for hamstring tears, central
a septum injury in the rectus femoris, retears at scar sites and
tears of the proximal MTJ of soleus.
HEALING
The main findings at ultrasound are the demonstration of

bridging tissue across the tear site. This bridging tissue can
be either scar or regenerated muscle.
Practice Tip
Scar has a uniformly bright echogenicity with densely packed

internal echoes (Fig. 33.11).
b Regenerated muscle is hypoechoic and often where there is

Figure 33.6 Grade 2 muscle tear of the medial head of gastrocne-
good muscle regeneration the tear site can be difficult to
mius (G) imaged 4 days postinjury. There is liquification of the hae- demonstrate. Serial assessments of these tears and dynamic
matoma (h) with only a small solid haematoma remaining (arrows) scanning during contraction can be very useful in determin-
ing when there is tissue bridging the tear site.
Practice Tip
COMPLICATIONS
True grade 3 tears are unusual and are most commonly seen Denervation change is common adjacent to tear, especially
in contusion, with the classic bell clapper sign of muscle if there is scar formation. Ultrasound is relatively poor at
ends lying within the haematoma dividing the muscle demonstrating denervation change and is really best
(Fig. 33.8). reserved for gross pathology (Fig. 33.12). MRI is the tech-
nique of choice, though care must be taken not to confuse
denervation change with retearing. The demonstration of
The main role of imaging is to try and determine the extent fatty change in the oedematous muscle is the typical change
of fibre disruption regardless of the size of the haematoma. at MRI; this requires assessment of a T1-weighted image
Experience is required but in general the sonologist is alongside the T2-fat saturated or STIR images.
trying to place the tear within a spectrum of grade 2 injury,
from mild to severe.
MYOSITIS OSSIFICANS
When deciding on the recovery time of tears there are a
few simple rules based on the ultrasound findings: Clinically myositis ossificans (MO) presents as a patient with
failure to improve or clinically worsening symptoms and
1. No ultrasound abnormality. Rarely the sonologist can signs (pain and swelling) 2 weeks postinjury.
demonstrate loss of definition of the muscle fibres; this
normally requires comparison to the contralateral side
(Fig. 33.9). Ultrasound does not exclude grade 1 muscle Key Point
tears; patient should be able to return to play within 2
weeks. If this fails to occur, reassess the patient with MRI In general, after 2 weeks the vast majority of muscle tears
as the tear may be in an unusual deep muscle (this is will be improving clinically, regardless of the grade of injury.
especially the case around the hip and proximal thigh).
Figure 33.7 (A, B) Acute tear of the vastus intermedius with solid echogenic haematoma (H). 10 days postinjury (C, D) the haematoma has
liquefied and is now anechoic and freely mobile to sonopalpation.
Patients with MO develop an intense inflammatory reaction

around the tear site with hypervascularity and muscle
oedema.
Practice Tip
At MRI, changes of MO can look extremely aggressive

and mass-like and have, in the past, been misinterpreted
as tumour.
Sheets of heterotopic calcification are laid down at the

periphery of the haematoma and are the key to the early
diagnosis of this complication.
b
Figure 33.9 Grade 1 tear of the distal rectus femoris with loss of
Figure 33.8 Grade 3 tear of the vastus medialis with haematoma definition of the muscle fibres around the tip of the central septum
outlining the muscle ends, showing a typical bell clapper sign. (arrows).
Figure 33.10 (A, B) Extended field of view

of longitudinal scan of a 2-hour-old grade 2
tear of the medial head of gastrocnemius (G)
with hyperechoic haematoma (*) on the
superficial aspect of the soleus (S) aponeu-
rosis (arrows). (C) The advantages of MRI in
these cases where the haematoma (*) is
demonstrated as high signal with the muscle
a b c
oedema not seen on ultrasound (red arrows).
a
a
b
b
Figure 33.11 Longitudinal sonogram of a healed rectus femoris (RF)

tear with scar formation.
Figure 33.12 Longitudinal extended field of view scan of an old

grade 2 injury of the medial head of gastrocnemius. Adjacent to the
MTJ scar there is extensive fat atrophy with hyperechogenicity and
poor definition of the muscle fibres.
Key Point
Calcification within MO becomes visible at ultrasound by

about week 3 postinjury and at its earliest manifests as c
subtle hyperechogenic deposits around the haematoma.
These progress over time to form sheets of ossification

within the muscle. MRI and radiographs do not demon-
strate this ossificaction until around weeks 6–8 postinjury
(Fig. 33.13).
MUSCLE HERNIA
Muscle herniation is considered here although the majority d
of cases do not directly follow an identifiable muscle injury.
Figure 33.13 Patient with a contusion of the vastus inermedius.
More often patients present with a mass that is characteristi-
(A, B) A large haematoma with patchy increased echogenicity in
cally painless and more prominent on standing. Indeed, the the muscle margins around the haematoma 3 weeks postinjury. The
patient should be examined standing (or in whatever posi- edges of the muscle show marked hypervascularity on power Doppler
tion they report the mass as most prominent). The lower (C). By 10 weeks postinjury there has been resorption of much of the
limb is considerably more often involved than the upper haematoma with sheets of mature calcification in the surrounding
limb. Muscle hernias may be multiple, in which case the muscle (D, arrows)
becomes more prominent. A defect may be noted in

the adjacent fascia; this is more clearly seen with higher-
resolution equipment.
CYSTS
Muscle cysts can form at the site of tears. These persisting
fluid collections are rarely symptomatic in themselves,
though do represent a site of residual weakness with an
increased risk of retearing.
Key Point
• Muscle ultrasound is common.

• Muscle ultrasound is difficult with complex anatomy, injury
patterns and imaging abnormalities.
• Your approach to imaging muscle tears needs to vary
with the clinical question being addressed.
b
FURTHER READING
Figure 33.14 Muscle hernia. The patient is imaged standing. Notice
the defect in the fascia and the normal muscle passing through it. Bojsen-Moller J, Hansen P, Aagaard P, et al. Differential displacement
of the human soleus and medial gastrocnemius aponeuroses during
isometric plantar flexor contractions in vivo. J Appl Physiol
2004;97(5):1908–14.
Gyftopoulos S, Rosenberg ZS, Schweitzer ME, et al. Normal anatomy
possibility of a chronic compartment syndrome could be and strains of the deep musculotendinous junction of the proximal
considered, although this is uncommon. rectus femoris: MRI features. Am J Roentgenol 2008;190(3):
The ultrasound findings of muscle hernia are typical W182–6.
Helms CA, Fritz RC, Garvin GJ, et al. Plantaris muscle injury: evaluation
and allow a confident diagnosis. First and foremost, the with MR imaging. Radiology 1995;195(1):201–3.
palpable mass has ultrasound characteristics of normal Koulouris G, Connell D. Hamstring muscle complex: an imaging
muscle (Fig. 33.14). On standing (or straining) the mass review. Radiographics 2005;25(3):571–86.
Index
Page numbers followed by ‘f’ indicate figures, ‘t’ indicate tables, and ‘b’ indicate boxes.
A anconeus 60, 64f, 100 avulsion

abdominal masses 199–201 anconeus epitrochlearis 81–82 calcaneus 300f
abdominal muscles 187–188, 188f angioleiomyoma 390–391 hamstrings 214f
see also individual muscles angiolipoma 390 ischial tuberosity 184–186
abdominal wall 170, 170f anisotropy 28f lateral collateral ligament 246f
hernias 188, 188f, 199 ankle 253–268 patellar tendon 240
abductor digiti minimi (foot) 253–254 anatomy ulnar collateral ligament 159f
abductor digiti minimi (hand) 100–101, anterior 264–265, 293f axillary nerve 53–54
112, 137 lateral 258–262 impingement 45, 53–54
abductor hallucis 266 medial distal 254–255
abductor pollicis brevis 100, 111–112 medial proximal 253–254
abductor pollicis longus 100, 114–115 posterior 256–258 B
see also de Quervain’s tenosynovitis disorders Baker’s cyst 243–245, 244f, 401f
abscess 405f anterior 285–294 barbotage 343–344, 343f–344f, 350, 350f
foot/ankle 327, 328f lateral 295–300 supraspinatus tendinopathy 32
groin 200, 200f medial 301–314 Barlow manoeuvre 216
tubercular 405f posterior 269–284 Bassett’s lesion 85
acetabulum 169f interventions 373–380 Baxter’s neuropathy 253–254, 283, 313
labral cysts 194, 196f, 400 ligaments 262, 289–291, 298–300 biceps brachii 57, 60f
labral tears 194 tendons 258–262, 285–289 imaging 6f
Achilles bursa/bursitis 256–257, 277–278 see also foot short head 37
Achilles tendon 18, 238, 256–257, 256f, 259f annular ligament 74 tendon 4–6, 4f, 9, 17f, 37–39
interventions 373 anterior cruciate ligament tear 242 dislocation 37–38, 38f
dry needle therapy 373–374, 375f anterior interval 17f fluid around 351f
volume injection/tendon stripping 374, anterior process fracture 313–314 imaging 34f–35f, 65–67, 67f
375f anterior talofibular ligament injury 298– rupture 38, 88–89, 88f–89f
pathology 269–277 299, 299f subluxation 37, 38f–39f
enthesopathy 272–274, 274f, 413f anterior tibial artery 266 tendinopathy see bicipital tendinopathy
paratendinopathy 271–272, 273f anterior tibiofibular ligament 262, 263f tendon sheath injection 350–351, 351f
tears 274–277, 276f anterolateral gutter injection 379, 380f biceps, distal 425
tendinopathy 269–271, 270f–272f aponeurosis biceps femoris 175–176, 235, 236f, 424
xanthoma 270–271, 273f bicipital 68, 85f injection 372–373, 373f
postoperative 277 elbow 67f rupture 242
acromioclavicular joint 13 flexor-pronator 82 short head 175–176
dislocation 51, 52f apophysitis bicipital aponeurosis 68, 85f
erosive arthropathy 51 calcaneal see Sever’s disease bicipital tendinopathy 38–39, 40f–41f, 85,
geyser phenomenon 15, 52, 52f Iselin’s disease 297 87–88, 87f–88f
high-arc impingement 51–52 apoptosis 18, 336–337 bicipitoradial bursa 88f, 89
imaging 14f arcuate ligament 81–82 bifurcate ligament 266, 290
normal appearance 51–52 arm 57–58, 58f–60f biopsy
procedures 348, 348f–349f arthritis needles 336
subluxation 15, 51, 52f elbow, septic 94 soft tissue 335–336, 336f
acroosteolysis, post-traumatic 51 hand/wrist 132–134 synovial 342, 363–364
adductors hip, septic 221–222 bite injury 151
foot 266–267 ulnotrochlear 79b bone disease
thigh/hip 167, 168f, 189–190, 190f, see also osteoarthritis; rheumatoid foot/ankle 313–314
197–199 arthritis shoulder 48–50
injection 362, 363f arthropathy bony impingement 17, 18f
see also specific adductors shoulder boot-top injury 287–288
adductor digiti minimi 266 acromioclavicular joint 51 boutonniere deformity 160
adductor hallucis 267 sternoclavicular joint 17 bowstringing 154, 154f
adductor longus 167t, 190f arthroplasty, hip 193, 204f–205f boxer’s knuckle 160
injury 190, 190f, 198f aspiration brachial artery 58f
adductor magnus 424 dorsal ganglion 136f brachial nerve 60
adductor pollicis 100–101 elbow 58–60, 91 brachial plexus 52–53
adhesive capsulitis 9, 41–42, 50 hip, child 221–223, 223f–224f brachialis 57–58, 60f, 62f
aetoxisclerol 339 shoulder brachioradialis 62f, 64f, 100
anatomical snuffbox 102 calcific tendinopathy 32 bursa
anatomy glenoid labrum cyst 50 Achilles see Achilles bursa/bursitis
elbow joint 58–69 atrophic tendinopathy 302–304 ankle 311
shoulder 3–15 atrophy, skeletal muscle 25–26, 53, 54f, 82f fluid 33–35, 34f
upper limb 57–69, 58f–60f see also individual muscles injection 340–341, 341f
433
434 INDEX
knee 243–245 common extensor origin 58, 60, 62f–63f elbow joint
injection 369–370, 371f injection 73f anatomy 58–69
see also specific bursae; and bursitis tendinopathy 60, 70–71, 71f–72f effusion 58–60
bursitis common flexor origin 63, 64f injection 354–355, 355f–356f
Achilles see Achilles bursa/bursitis injection 354, 354f–355f interventions 353–356
cubital 89 tendinopathy 70, 78, 79f pathology
foot/ankle 325–326, 326f common peroneal nerve 234–235, 248–249 anterior 87–90
iliopsoas 195, 197f palsy 249, 398–400 lateral 70–77
ischiogluteal 214 coracoacromial arch 16 medial 78–86
knee 243–245, 244f coracoacromial ligament (CAL) 3, 7, 10–11, posterior 91–95
olecranon 91, 91f–92f 15, 36–37 synovitis 93–95, 93f–95f
pes anserinus 245, 245f imaging 37f endometriosis 201, 202f–203f
retrocalcaneal 277 impingement 36–37, 37f enthesitis 411–413, 413f
subacromial subdeltoid 16–17 injection 352 enthesopathy
bursal fluid 34f–35f, 36–37 coracobrachialis 57 Achilles tendon 272–274, 274f, 413f
bursal thickening 35–36, 36f tendon 6 elbow 70–71
subgluteus medius 178–179, 178f coracohumeral ligament 3 shoulder 17, 18f, 25f–26f, 28f, 38f
trochanteric 179–180, 179f tears 37 tibialis anterior 286, 287f
coracoid process 6, 8f see also tendinopathy
corticosteroids 332–333 epicondylalgia of common extensor
C adverse effects origin 70–71
calcaneal nerves 253–254 flushing 333 epidermal inclusion cysts 400–401, 402f
inferior 253–254, 283, 313 hyperglycaemia 333 epidermoid cysts 322, 322f
medial 313 septic arthritis 333 epigastric vessels 179f, 181f, 183f
calcaneocuboid ligament 266 skin changes 333 erosions, bony
calcaneofibular ligament 262, 264f tendon injury 333 hand/wrist 134, 134f
injury 298–299 preparations 332 imaging 410–411, 412f
calcaneonavicular ligament 255f steroid flare 332–333 erosive arthropathy of acromioclavicular
calcaneus (os calcis) 253–254, 257 crab position 58, 68, 68f joint 51
avulsion 300f crepitus 102 extensors
fractures 291f, 314 crossover syndrome see proximal intersection elbow 58, 60, 62f–63f, 70–71, 71f–73f
calcific tendinopathy 31–32, 31f–32f, syndrome fingers 147–149
302–304 cruciate ganglia, injection 371, 372f forearm 100, 100f
calcification cubital bursitis 89 hand/wrist 101–108, 357–358
cartilage see chondrocalcinosis cubital tunnel 81–82 see also extensor tendons
gluteal tendons 180, 180f cuboid 255 extensor carpi radialis brevis 60, 64f, 70,
hand/wrist 134 cuboidal tunnel injection 378, 379f 100, 114–115
rotator cuff 31–32, 31f–32f cuneiforms 255, 264–266, 265f extensor carpi radialis longus 64f, 100,
calcium barbotage see barbotage cysts 397–406, 400f 114–115
calf 229–231, 237f Baker’s 243–245, 244f, 401f extensor carpi ulnaris 64f, 100, 105f–106f
muscles of 424–425 dorsal ganglion 101 instability 122–123, 123f–124f, 134
canal of Nuck 201, 202f epidermal inclusion 400–401, 402f tenosynovitis 123, 123f–124f
carpal boss 120 epidermoid 322, 322f extensor digiti minimi 64f, 100, 104
carpal tunnel 101, 109–110 glenoid labrum 50 extensor digitorum (foot) 238, 261–262,
content 131–132 labral 194, 196f, 400 267
injection 358, 359f–360f meniscal 246, 246f–247f, 400 injury 288–289
carpal tunnel syndrome 77, 129–132 muscle 431 extensor digitorum (hand/wrist) 60, 64f,
carpometacarpal (CMC) joints 111–112, paraglenoid 402f 100, 104, 137–139, 139f
143, 163f synovial see synovial cysts extensor hallucis longus 238, 264
injection 357, 358f injury 287–288
cartilage extensor indicis 100, 106f
elbow 74–75 D extensor pollicis brevis 100, 114–115
hand/wrist 133–134 de Quervain’s tenosynovitis 101, 113–114, see also de Quervain’s tenosynovitis
imaging 413–414, 414f 114f–115f extensor pollicis longus 100
knee 249 injection 357–358, 359f tenosynovitis 115–116, 116f
cellulitis, foot/ankle 327, 327f deep peroneal nerve entrapment 293 extensor retinaculum 113t
children deltoid 57–58 extensor tendons
elbow problems 58–60, 74, 74f, 94 tears 46 fingers 147–149, 160–161
hip problems 216–226 desmoid tumour 392, 392f hand/wrist 104–105, 133f
developmental dysplasia 216–221 developmental dysplasia of hip see hip, injury 116f
irritable hip 221–224 developmental dysplasia external impingement syndrome see painful
Meyer dysplasia 225 digits see fingers; toes arc syndrome
Perthes’ disease 224–225 dislocation
slipped upper femoral epiphysis 225, acromioclavicular joint 51, 52f
226f biceps brachii tendon 37–38, 38f F
joint injection 342 distal intersection syndrome 115 fasciitis, plantar 279–281, 281f
chondrocalcinosis, wrist 135f distal radioulnar joint injection 356, 357f fat pads
chondromalacia 95 distal tarsal tunnel syndrome 313 Hoffa’s 243
radial head 71 distension arthrography 350 pre-Achilles 256–257
chondrotoxicity of local anaesthetics 333 dorsal hood injury 161, 162f femoral artery 171
circumflex humeral artery 12 Dupuytren’s contracture 156, 157f pseudoaneurysm 201, 201f
cobra position 67–68 femoral canal 185t, 186f
collateral ligaments femoral hernia 184–187, 187f, 199
elbow 60–61, 63f, 71, 73f E femoral nerve 171
hand, injury 159–160 effusion fluid see fluid compression 202–203
Colles’ fracture 115 elastofibroma 392, 392f femoral vein 186f
INDEX 435
femoroacetabular impingement 191 hand/wrist 133, 163 foot 320, 320f–321f

femur hip 193–194, 194f knee 249
condyle 414f aspiration 364–365 suprascapular 351–352, 352f
head 168–169, 169f, 179–180 child with irritable hip 221, 222f wrist 125–126, 134–136, 345t
head epiphysis imaging 410, 411f carpal tunnel 131
in Perthes’ disease 224–225, 225f knee 247–248 dorsal 103–104, 108, 120, 121f,
slipped 225, 226f shoulder 135–136, 136f
fibrocartilage lesions, hand/wrist 126–127, glenohumeral joint 50–51, 50f injection 357, 359f
127f–128f rotator cuff tear 33–35, 34f palmar 135f, 136
fibrolipoma 390 flushing, corticosteroid-induced 333 gastrocnemius 233–234, 237–238, 257, 422f
fibrolipomatous hamartoma 137, 138f foot injury 424
fibroma 391 adductors 266–267 tears 276–277, 427f, 429f–430f
finger pulley 154–158, 155f–156f effusion 292f gemelli 173, 174f
injection 360–361, 361f flat 302 Gerdy’s tubercle 172, 236
plantar 282–283, 282f–283f forefoot see forefoot geyser phenomenon 15, 52, 52f
fibromatosis 391 fractures 290, 291f giant cell tumour of tendon sheath
deep 392, 392f hindfoot 261f forefoot 321, 321f
palmar/plantar 391, 392f imaging 408 hand 398f
fibrous tumours 391–393 interphalangeal joints see interphalangeal wrist 139, 139f
malignant 392–393 joints, foot GIRD phenomenon 50
fibular collateral ligament 235 metacarpophalangeal joints see glenohumeral joint 3, 4f, 12f
fine needle aspiration cytology (FNAC) metacarpophalangeal (MCP) joints, effusion 50–51, 50f
200 foot subluxation 15, 50–51
fingers 143–149 midfoot see midfoot glenohumeral ligaments 50
extensors 147–149, 160–161 see also ankle middle 7–8
fibroma 154–158, 155f–156f forearm 99–112 superior 7
injection 360–361, 361f forefoot 267–268, 315–328 glenoid labrum 12f, 50
flexors 144–147, 150–153 imaging 315–316 glomus tumour 395, 396f
tendon rupture 152–153, 153f injury 316–318 gluteal bursa injection 365–366, 366f
tenosynovitis 151, 151f–152f foreign body 316, 316f gluteal tendinopathy 178–180
ganglia 154–158 Freiberg’s infraction 318, 318f gluteus maximus 172
pulleys 144–147, 153–158 plantar plate injury 316–317, 317f gluteus medius
injury 154 sesamoiditis 317–318, 318f tear 179f
flat foot (ples planus) 302 stress fracture 316, 317f tendinosis 173f, 178f, 180f, 208f
flexors interventions 380–383 gluteus minimus
elbow 63, 64f, 70, 78, 79f malignant soft tissue tumours 323–324 bursa, injection 366
fingers 144–147 synovial sarcoma 323–324, 323f tendon 172f
forearm 99–100, 99f masses 318–323 golfer’s elbow 70, 78, 79f
hand/wrist 108–111 epidermoid cyst 322, 322f gout
see also flexor tendons ganglia and synovial cysts 320, foot/ankle 326–327, 327f
flexor carpi radialis 63, 66f, 99–101 320f–321f imaging 411f
tenosynovitis 116–117, 117f giant cell tumour of tendon sheath 321, knee 248f
flexor carpi ulnaris 63, 66f, 69, 81–82, 321f gouty tophi 416, 417f
99–101, 106f haemangiomas and vascular gracilis 168f, 190f, 232–233
tendinopathy 123–125, 125f malformations 322–323, 322f Graf’s method, developmental dysplasia of
flexor digiti minimi 100–101, 112 Morton’s neuroma 268f, 319–320, hip 218–219, 218f–219f
flexor digiti minimi brevis 267 319f–320f greater trochanter pain syndrome 177
flexor digitorum brevis 258 peripheral nerve sheath tumours 323 greater tuberosity fractures 48, 49f
flexor digitorum longus 253–254 pigmented villonodular groin
pathology 307 synovitis 320–321 abscess 200, 200f
flexor digitorum profundus 63, 66f, 99–101, plantar fibromatosis 282–283, 282f– anatomy 177
129, 150 283f, 321–322 chronic pain 191–192, 191f–192f
flexor digitorum superficialis 66f, 99–101, see also ankle disorders 177–215
129, 150 foreign body female, soft tissue masses 201, 202f
flexor hallucis brevis 267 forefoot 316, 316f Guyon’s canal 109–110
flexor hallucis longus 254, 255f, 266f removal 340, 340f Guyon’s canal syndrome 125–126, 126f
injection 376–377, 378f fractures
pathology 307–309 elbow 95
sclerosis and friction foot/ankle 290, 291f, 300, 313–314, 316, H
syndrome 308–309 317f haemangioendothelioma 395–396
tenosynovitis 308 hand/wrist 115, 119–120, 120f, 128 haemangioma 394–395, 395f
flexor pollicis brevis 111–112, 267 shoulder 48, 49f forefoot 322–323, 322f
flexor pollicis longus 101, 108, 111–112, see also avulsion; and individual fractures haemarthrosis of knee joint 248f
129 Freiberg’s infraction 318, 318f haematoma 403–404, 403f, 426, 430f
flexor profundus tear 152–153, 153f Frohse’s ligament 75–76, 76f groin 201
flexor retinaculum 109, 129 frozen shoulder see adhesive capsulitis muscle injury and 187–188
in carpal tunnel syndrome 131, 131f Haglund’s disease 269, 274, 275f
flexor tendon sheath injection 359–360 hammer syndrome 126
flexor tendons G hamstrings 173f, 174–176, 175f
fingers 144–147, 150–153 Galeazzi fracture-dislocation 126 anatomy 423–424
hand/wrist 101, 108, 131 gamekeeper’s thumb 158 avulsion 214f
flexor-pronator aponeurosis 82 ganglion (ganglion cysts) 398–400, 400f injury 426f
flexor-pronator sprain 70, 78 ankle 312f origin, injection 367–368, 368f
fluid (joint effusion fluid) aspiration 344–345 tears 182–183
elbow 58–60, 93–95, 93f–95f fingers 154–158, 158f tendinopathy 182–183
foot/ankle 292f, 324–327, 325f pulley 158 tendinosis 215f
436 INDEX
hand iliotibial band 173t, 236, 237f subluxation see subluxation

anatomy 143–149 injection 365, 372, 373f ultrasound imaging 407–417
disorders 150–164 iliotibial band friction syndrome 242–243 see also individual joints
interventions 359–361 iliotibial snapping 173, 178–179, 181f jumper’s knee 239–240
small joints 163–164, 163f–164f impingement
imaging 408, 409f ankle 278–279, 280f, 291–292, 291f–292f,
heel pad syndrome 279 310 K
heel toeing 4 elbow, posteromedial 95 Kager’s fat triangle 256–257
hernias femoroacetabular 191 karate chop position 143
abdominal wall 188, 188f, 199 shoulder 17–18 Kiloh-Nevin syndrome 84–85
femoral 184–187, 187f, 199 acromioclavicular joint 51–52 knee
inguinal see inguinal hernia axillary nerve 45, 53–54 anatomy 229–238
midline 199f bony 17, 18f anterior 229–231
muscle 391f, 430–431, 431f coracoacromial ligament 36–37, 37f anterolateral 236–237, 237f
spigelian 188, 188f, 199 posterosuperior 49–50 medial 231–233, 233f
sports 199 SICK scapula 17–18 posterior 233–235, 234f
herniography 183 subcoracoid 43 posterolateral 235, 235f
Hill-Sachs lesions 48–49, 49f supraspinatus tendon 15, 33, 37f bursae 243–245
hindfoot 261f incisional hernia 188, 188f ganglia 249
see also ankle infections 405–406 injection 368–369, 369f
hip 167–176 see also abscess; septic arthritis interventions 368–373
adductors see adductors, thigh/hip infraglenoid tubercle 57–58 ligaments 231–232, 232f, 245–246
anterior 168–170, 207–215 infrapatellar bursa 243, 243f menisci 246–247
bursa and bursitis 172, 179–180, 179f injection 369–370 nerve supply 248–249
children 216–226 infraspinatus 3, 4f, 11–12, 11f–12f, 16, 17f pathology 239–250
aspiration 364–365 atrophy 53, 54f vascular supply 249–250
conditions other than developmental imaging 9f, 11f knot of Henry 266f, 267, 307
dysplasia 225–226 tears 43–44, 44f
irritable hip 221–224 inguinal canal 177, 178f–180f
Meyer dysplasia 225 inguinal hernia 177, 180–182, 181f–184f, L
Perthes’ disease 224–225, 225f 199, 199f labral cysts 194, 196f, 400
slipped upper femoral epiphysis 225, postoperative evaluation 182–183, lacerations see tears
226f 185f–186f lateral antebrachial nerve 85
developmental dysplasia 216–221 inguinal lymphadenopathy 199–200, 200f lateral collateral ligaments
dynamic examination 219, 220f inguinal ring, deep/internal 178–179 ankle see lateral ligament complex
epidemiology 216 injections elbow 71
Graf angles vs. coverage needle techniques 335 knee 239, 246f
measurements 218–219, 218f–219f set-up 331–332, 332f see also specific ligaments
imaging 217–218, 217f ultrasound-guided 334–335, 334f lateral cutaneous nerve of thigh 170, 170f
older infants 219–220 see also specific sites and substances compression 203
screening programmes 220–221 internal epigastric artery 199 injection 361–362, 362f
ultrasound in 216–217 interosseous bursa 87f, 89 lateral ligament complex (lateral collateral
vs. instability 216 interosseous muscles ligaments of ankle) 298–300, 298f
extraarticular pathology 194–199 foot 267 lateral ulnar collateral ligament 61, 63f, 69,
greater trochanter pain syndrome 177 hand 100–101, 111 72–74
injection 362–363, 364f interosseous nerve injection 355–356, 356f latissimus dorsi 57
interventions 361–368 interphalangeal joints (IPJs) 147, 147f–148f Leash of Henry 61–62, 75–76
intraarticular pathology 193–194 foot 268 Ledderhose disease 282–283, 282f–283f,
lateral 171–173, 178–179, 207–215 distal 150, 153–154 321–322
Morel-Lavallée effusions 178–179, 181f injection 359, 360f, 381, 382f leiomyosarcoma 390–391
posterior 173, 193–206 hand, proximal 152–154 lidocaine 334–335
prosthesis 193, 204f–205f imaging 408 ligaments
snapping 173, 178–179, 181f, 194–195 intertarsal joint injection 380–381, 381f ankle 262, 289–291, 298–300
hockey stick probe 332, 332f interventions/therapy 346–383 knee 245–246
Hoffa’s fat pad 243 see also specific procedures and areas wrist, injury 127–128
Hoffa’s ganglion, injection 370, 371f intraarticular bodies 248f, 248t see also specific areas and ligaments
hook of hamate 126, 129 irritable hip 221–224 linea semilunaris 199
housemaid’s knee 243 ischial bursa, injection 367–368, 368f lipoblastoma 390
humeral head 10f, 16 ischial tuberosity 173f lipoma
bony irregularity 48 avulsion 184–186 hand/wrist 131, 132f, 139–140, 140f
hypertrophic tendinopathy 302–304 ischiofemoral fossa 174f inguinal 186f
hypothenar eminence 111–112 ischiofemoral impingement, injection 367 preperitoneal 184f
hypothenar muscles 100–101 ischiogluteal bursitis 214 lipomatous tumours 388–390
Iselin’s disease 297 deep 389–390, 389f–390f
superficial 388–389, 388f
I liposarcoma 389, 390f, 401, 402f
iliacus 169f–171f J myxoid 389, 390f
ilioinguinal nerve 170, 170f jersey finger 152–153 Lisfranc ligament 290–291
inflammation 191 jogger’s foot 313 Lister’s tubercle 101, 115
injection 361, 361f joints local anaesthetics 333
iliopsoas 169f, 171f aspiration see aspiration adverse effects, chondrotoxicity 333
snapping 194–195 dislocation see dislocation duration of action 333
tendinopathy 203–204 effusion fluid see fluid long plantar ligament 267, 279
tendon 169, 194–195 hand 163–164, 163f–164f long thoracic nerve
iliopsoas bursa 195, 197f injection 341–342 compression 53
injection 365, 365f midfoot 292 location 352, 353f
INDEX 437
loose bodies Morton’s neuroma 268f, 319–320, 319f– Ortolani manoeuvre 216
elbow 68, 93–94, 94f, 354 320f, 393–394, 394f os acromiale 51
hip 194, 195f injection 381–383, 382f–383f os calcis see calcaneus
knee 244f Moulder’s click 319t os peroneum syndrome 296f
lumbrical muscles 100–101, 267 muscle os trigonum 254
lunate 103–104, 106f abdominal 187–188, 188f os trigonum syndrome 278–279, 280f
lymphadenopathy, inguinal 199–200, striated see skeletal muscle Osborne’s ligament 64–65, 69, 81–82
200f see also individual muscles absence of 83
lymphoma, soft tissue 403f musculocutaneous nerve 57, 60f, 85 laxity 83f
musculoskeletal interventions 331–345 Osgood-Schlatter’s disease 239–241, 241f
set-up 331–332, 332f ossification in muscle see myositis ossificans
M treatment rationale 332 osteitis pubis 177, 191–192
macrodystrophia lipomatosa 137 see also specific procedures osteoarthritis
magnetic resonance imaging (MRI) myositis ossificans 404–405, 405f, 427–430 foot/ankle 325, 326f
ankle 273f, 275f, 321f myxoid liposarcoma 389, 390f hand/wrist 115, 415f
elbow 64f, 87f, 89f myxoma 396, 397f osteochondritis dissecans 74–75, 75f
hand 155f osteochondroma, knee 249f–250f
hip 220f osteochondromatosis, synovial 397
inguinal hernia 183–184 N hip 194, 195f
knee 372f navicular 255 infrapatellar bursa 243f
shoulder 45f, 54f accessory, insertional tendinopathy 305– osteophytes 414, 415f
wrist 128f 306, 306f–307f ovary, round ligament varicosities 201, 203f
mallet finger 160–161 stress fracture 290
masses, soft tissue 387–406 naviculocuneiform joint 265–266, 265f
cysts see cysts needles P
fibrous tumours 391–393 biopsy 336 paediatrics see children
foot/ankle 318–323 techniques 335 painful arc syndrome 3, 16
groin 199–201 nerve entrapment/compression see palm, anatomy 111
female 201, 202f neuropathies, compression and palmar fibromatosis 391
hand/wrist 120, 134–140 entrapment palmaris longus 99–101
lipomatous tumours 388–390 nerve tumours (incl. nerve sheath pampiniform plexus 199
muscle tumours 390–391 tumours) 393–394, 393f Panner’s disease 74
myxoma 396, 397f benign 393–394 pannus, hand/wrist 122
neural tumours 393–394 foot/ankle 323 paraglenoid cyst 402f
synovial tumours 397 hand/wrist 137, 137f paratendinopathy, Achilles 271–272, 273f
vascular tumours 394–396 knee area 248–249, 249f–250f injection 338
see also individual tumours malignant 394 paratenon injection 373, 374f
Mazabraud’s syndrome 396 see also individual tumours paratenonitis 239–240
medial antebrachial nerve 57, 85 nerves see individual nerves pars reflexa 174–175
medial collateral ligament 231–232 neurilemmoma (schwannoma, Parsonage-Turner syndrome 53
tear 245, 245f neurinoma) 393, 393f partial articular supraspinatus tendon
medial ligament disease 309–311 hand/wrist 137 avulsion see rim-rent tears
medial malleolus 253, 254f knee area 249f patellar ligament/tendon 18, 229, 230f,
bursa 311 neurofibroma 239–240, 240f
medial meniscus foot/ankle 322f avulsion 240
elbow 61 hand/wrist 137b, 137f injection 369, 370f
knee 232 neurogenic tumours 136–137, 137f rupture 240, 240f, 276f
median nerve 57, 68, 101, 110 neuroma 393, 393f tendinopathy 239–240, 240f
compression 68, 83–85, 85f, 129–131, hand/wrist 132f patellofemoral ligaments 231, 232f
130f Morton’s see Morton’s neuroma pectineus 168–169
meniscus non-neoplastic 393–394, 394f pectoralis muscle
cysts 246, 246f–247f, 400 neuropathies, compression and entrapment imaging 45f–46f
medial 61 (pressure palsies) 100 pectoralis major 6, 45–46, 46f
tear 246, 246f elbow 81 injury 425
meralgia paresthetica 203 foot/ankle 253–254, 283, 292–293, pectoralis minor 46
metacarpophalangeal (MCP) joints 311–313 tendon injury 46
foot 267–268 hand/wrist 120, 125–126, 129–132 peripheral nerve sheath tumours 323
osteoarthritis 326f hip 202–203 peroneal sheath injection 378, 379f
hand 143, 153–154, 155t shoulder 52–54 peroneal tendons (brevis and
injection 359, 360f see also individual nerves longus) 295–298
injury 158–159 nodular fasciitis 392 instability 297–298
osteoarthritis 415f notch sign 129–132, 130f tears 296–297, 297f
pseudoerosion 413f tendinopathy 296–297, 296f–297f
imaging 408, 409f tenosynovitis 295–296, 296f
metatarsophalangeal joint injection 381, O peroneus brevis 258, 261, 261f
382f oarsman’s forearm see proximal intersection enthesis 297
Meyer dysplasia 225 syndrome peroneus longus 258, 267
midcarpal joint 106, 164f oblique abdominal muscles 187–188, 188f peroneus quartus 261–262
midfoot obturator nerve 167 Perthes’ disease 224–225, 225f
dorsal 265–266 injection 362, 363f pes anserinus 176f, 233, 234f
interventions 380–383 O’Donoghue’s triad 245 bursa, injection 370–371
joint disease 292 olecranon, stress fracture 95 bursitis 245, 245f
plantar 266–267 olecranon bursa/bursitis 69, 91, 91f–92f, pigmented villonodular synovitis 320–321,
see also ankle 401f 397, 398f
midline hernia 199f imaging 413f piriformis syndrome 213–214
Morel-Lavallée effusions 178–179, 181f opponens digiti minimi 100–101, 112 injection 367
438 INDEX
pisiform 129 radial tunnel syndrome 76b scapula

pisiform-triquetral joint 110 radiocapitellar joint 74, 74f infraglenoid tubercle 57–58
pisohamate ligament 110–111 compression 79 sick 17–18
pisometacarpal ligament 110–111 radiocarpal joint 106, 164f scapulothoracic dyskinesia 17–18
plantar fascia and fasciitis 258, 259f–260f, injection 356–357, 357f schwannoma see neurilemmoma
279–281, 281f radiocarpal ligaments 105f sciatic nerve 173, 213–214, 234–235
injection 371, 375–376, 377f radiolunotriquetral ligament 106–108, screening, developmental dysplasia of hip
injury 282 107f–108f 220–221
pathology 279 radioscaphocapitate ligament 106–107, semimembranosus 174–175, 232–233, 237f,
treatment 283–284 108f 423–424
plantar fibromatosis 282–283, 282f–283f, rectus abdominis 179f–180f, 188f injection 370, 372f
321–322, 324f, 391, 392f rectus femoris 170–171, 171f, 422f tendon 242, 242f
plantar plate 267, 267f tears 196, 426f, 429f–430f semimembranosus-gastrocnemius
injury 316–317, 317f regional pain syndrome 327–328 bursa 243–245
plantaris 237–238, 257, 257f, 424 retinacula semitendinosus 174–176, 175f–176f,
injection 373, 374f elbow 81, 83 232–233, 424
tendon 278 foot/ankle 261, 262f, 264–265, 286f, rupture 242f
Popeye sign 38, 88 297–298, 298f sentinel ganglion 20–21, 22f
popliteal artery 249 hand/wrist 101–102, 104, 108–110, septic arthritis
popliteal vein 250 113–114, 114f, 129 corticosteroid-induced 333
popliteus 235, 236f, 237–238 retro-Achilles bursa/bursitis 277–278 elbow 94
posterior ankle impingement 278–279, retrocalcaneal bursitis 277 hip 221–222
280f rhabdomyoma 390–391 sesamoiditis 317–318, 318f
posterior interosseous nerve 64f, 75–76, 76f, rheumatoid arthritis Sever’s disease 269, 278
100 hand/wrist 122, 134 shoulder
see also radial nerve imaging 408–414, 412f anatomy and technique 3–15
posterior subtalar joint injection 379–380, shoulder 34–35, 51 bone disease 48–50
381f synovitis see synovitis distension arthrography 350
posteromedial impingement syndrome 95 rheumatoid nodules 416, 416f dynamic assessment 13–14
injection 376, 377f rim-rent tears 10, 20–21, 22f impingement see impingement, shoulder
posterosuperior impingement 49–50 rotator cable 18 injection 348–350, 349f
pre-Achilles bursa injection 375, 376f rotator cuff interventions 347–352
pre-Achilles fat pad 256–257 arthropathy 19–20 rotator cuff tears see rotator cuff tears
prehernia complex 182 rupture 49 ultrasound 5f
prepatellar bursa 243, 244f tears see tears, rotator cuff SICK scapula 17–18
pronator quadratus 101, 110 tendinopathy 30–31, 31f sidewinder position 65–67
atrophy 82f tendons 16, 17f, 33–47 Sindig-Larsen-Johansson syndrome 241,
pronator syndrome 83 rotator interval 6–7, 7f, 39–42 241f
pronator teres 66f, 83, 83b, 85f, 101 anatomy 39–40 sinus tarsi 262, 264f
prosthesis, hip 193, 204f–205f tears 40, 41f skeletal muscle
proximal intersection syndrome 102, rugby finger 152 accessory 137–139
114–115, 115f–116f runner’s foot 307 anatomy 422, 422f–423f
proximal tarsal tunnel syndrome 313 runner’s knee 242–243 atrophy 25–26
pseudoaneurysm 404f rupture cysts 431
femoral artery 201, 201f biceps brachii 38, 88–89, 88f–89f healing 427, 430f
psoas see iliopsoas finger tendons hernia 391f, 430–431, 431f
pubalgia 191–192, 191f–192f, 197 extensors 161 injury 421–431
pubic symphysis see symphysis pubis flexors 152–153, 153f complications 427–431, 430f
pulled elbow 74, 74f patellar tendon 240, 240f healing 427
pulleys quadriceps tendon 242f mechanisms of 425
foot/toes 267 rotator cuff 49 pathobiology 425
hand/fingers 144–147, 153–158, 360–361, subscapularis 39f, 42f scanning techniques 425–426
361f tibialis anterior 286–287, 288f see also tears
pump bump phenomenon (Haglund’s tibialis posterior 306, 307f tumours 390–391
disease) 269, 274, 275f triceps 92–93, 92f–93f see also specific areas and muscles
slipped upper femoral epiphysis 225,
226f
Q S snapping hip 173, 178–179, 181f, 194–195
quadratus plantae 267 sacroiliac joint injection 366–367 soft tissues
quadriceps 170–171, 171f, 195–197 sagittal band injury 161 abnormalities 414–416
anatomy 423 saphenous vein 258f biopsy see biopsy
tendon 230, 230f, 241–242 sarcoma 401–402, 403f masses see masses
rupture 242f synovial 397, 399f soleus 237–238, 257, 278, 278f, 422f, 424
tears 241 sartorius 170, 170f–171f, 195–197, 198f, solitary fibrous tumour 396, 396f
tendinopathy 241f 232–233 sonopalpation 14, 24t, 82
quadrilateral space 12 SASD bursa see subacromial subdeltoid spigelian hernia 188, 188f, 199
quadrilateral space syndrome 53–54 (SASD) bursa spinoglenoid notch 12f, 44f, 53
sausage digit 151 cyst 45f, 53f
scaphoid 103–104, 109 sports hernia 199
R fracture 119–120, 120f sprains
radial collateral ligament 60–61, 63f, 71, scapholunate advanced collapse wrist ankle 262, 289, 298–300
73f (SLAC) 115 elbow 78
radial head, chondromalacia 71 scapholunate ligament 117, 117f thumb 158
radial nerve 57–58, 61–62, 61f–62f, 64f, 76f, injury 117–119, 117f–119f wrist 119–120
100 scapholunotriquetral joint 108 spring ligament 255, 255f
compression 75–77 scaphotrapeziotrapezoid joint 143 Stener lesion 158f, 159b, 160f
INDEX 439
sternoclavicular joint 51–52 hand/wrist 132–133, 133f–134f, 163 tendinosis 337

arthropathy 17 hip 194 biceps 38–39
injection 352, 352f transient 221 definition 150–151
steroid flare 332–333 imaging 409–410, 410f flexor carpi radialis 117
steroids see corticosteroids knee 247–248, 247f flexor carpi ulnaris 125f
stitch granuloma 186f pigmented villonodular 320–321 gluteus medius 173f, 178f, 180f, 208f
stress fractures, foot/ankle 290, 316, 317f hamstring 215f
Struthers’ arcade 82 tendon sheath 151
Struthers’ ligament 68, 83 T giant cell tumour of 139, 139f
subacromial subdeltoid (SASD) bursa 4, 6f, talonavicular joint 265–266, 265f, 290f inflammation of synovial lining see
7–8, 10–11, 11f, 16, 33 ligament 290 tenosynovitis
bursitis 16–17 talus 262, 263f, 265–266, 265f injection 337–338, 338f
fluid 33–35, 34f–35f tarsal coalition 313 tendons
injection 347–348, 347f–348f tarsal tunnel syndrome 311–313, 312f ankle 258–262, 285–289
thickening 35–36, 36f tarsometatarsal joints 265–266, 265f fingers
ultrasound 33–36 osteoarthritis 326f rupture 152–153, 153f
subcoracoid impingement 43 tears tenosynovitis 151, 151f–152f
subgluteus medius bursa/bursitis 178–179, ankle injection 336–340
178f Achilles tendon 274–277, 276f anti-angiogenesis 339–340, 339f
subluxation tibialis anterior 288f dry needle therapy 338
acromioclavicular joint 15, 51, 52f coracohumeral ligament 37 proliferant therapy 338–339
biceps tendon 37, 38f–39f deltoid muscle 46 rotator cuff 16, 17f, 33–47
glenohumeral joint 15, 50–51 grading of 426–427 wrist 113–117, 122–125
imaging 412f infraspinatus 43–44, 44f tears 134
tibialis posterior 306–307 medial collateral ligament 245, 245f tennis elbow 60, 70–71
triceps muscle 93 patellar tendon 240, 240f injection 352, 353f–354f
subscapularis 3, 4f, 7–8, 8f, 16, 17f, 37 pectoralis muscle 46f tennis leg 276–277
disease 42–43, 42f peroneal tendons 296–297, 297f, tenodesis 351
imaging 8f quadriceps tendon 241 tenosynovitis
recess 51 rotator cuff 16–21, 49 fingers
rupture 39f, 42f concealed interstitial extensors 161f
tears 43, 43f delamination 20–21 flexors 151, 151f–152f
tendinopathy 43 diagnosis 22–24 foot/ankle 285–286, 286f, 302, 302f–303f,
superficial peroneal nerve 266 dynamic assessment 13–14 308
compression 292–293 free edge 18–21, 20f–21f, 23f peroneal tendons 295–296, 296f
superficialis tendon 150 full-thickness 19–21, 19f, 26f hand/wrist 131, 152f
Superman position 101 linear 19 De Quervain’s 101, 113–114, 114f–
supinator 100 midportion 20f, 24f–25f 115f,, 357–358, 359f
supracondylar process 68, 83, 85f partial 19f, 26f–27f, 29f–30f extensors 115–116, 116f, 123–126,
suprascapular ganglion injection 351–352, retraction 19–20, 21f 123f–124f
352f rim-rent 10, 20–21, 22f flexors 116–117, 117f
suprascapular nerve 53 size, location and muscle atrophy 25–26 rheumatoid arthritis 134
supraspinatus 3, 4f, 7, 9f–10f, 13, 13f–14f, 16 small 25f imaging 414–416, 415f
atrophy 13f ultrasound 21 tensor fascia lata 172
footprint lesions 48–49 rotator interval 40, 41f injection 365
imaging 9f, 13f–14f, 34f SLAP 17 muscle hypertrophy 182
tears see tears, rotator cuff subscapularis 43, 43f tendinopathy 180–182, 182f
tendinopathy 30–31, 31f tibialis posterior tendon 302 teres major 57–58
tendon 8–11, 9f, 13f, 16–32, 17f trapezius muscle 46 teres minor 11–12, 12f, 16, 17f, 57
calcification 31–32, 31f–32f ulnar collateral ligament 80f tears 45
impingement 15, 33, 37f tendinopathy thenar eminence 111–112
sural nerve 258, 258f ankle thigh, adductors see adductors,
surgery see specific procedures and areas Achilles 269–271, 270f–272f thigh/hip
symphysis pubis 189–192, 189f peroneal 296–297, 296f–297f Thompson’s manoeuvre 70t
injection 192, 363f tibialis anterior 285–286, 286f–287f thoracodorsal nerve
symphysitis pubis 167, 168f tibialis posterior 301–302 compression 53
syndesmosis injury 289 atrophic 302–304 location 352
synovial biopsy 342 calcific 31–32, 31f–32f, 302–304 thumb
hip 363–364 elbow 70–71 base of 143–144, 144f
synovial cysts 110, 400, 401f common extensor origin 60, 70–71, gamekeeper’s 158
foot 320, 320f–321f 71f–72f, injury 158–159
synovial osteochondromatosis see common flexor origin 70, 78, 79f tibial enthesis 229–230
osteochondromatosis hand/wrist 123–125, 125f tibial nerve 248–249, 255f, 266f, 311
synovial plica/flange 71, 73f hip tibialis anterior 238, 264, 265f, 285
synovial sarcoma 323–324, 323f gluteal 178–179 tendon injury 285
synovial sheath see tendon sheath hamstring 182–183 tibialis posterior 253–255
synovial tumours 397 iliopsoas 203–204 rupture 306, 307f
osteochondromatosis see tensor fascia lata 180–182, 182f subluxation 306–307
osteochondromatosis, synovial hypertrophic 302–304 tendon 301–307
pigmented villonodular synovitis 320–321, injection 338 injection 377, 378f
397, 398f knee 239–240, 240f tears 302
sarcoma 388f–389f, 397 shoulder 16–20, 26f–28f, 48 tendinopathy 301–304
synovitis bicipital 38–39, 40f–41f, 85, 87–88, tenosynovitis 302, 302f–303f
elbow 93–95, 93f–95f 87f–88f tibiocalcaneal ligament 255, 255f
foot/ankle 324–327, 325f supraspinatus 30–31, 31f pathology 309–311
440 INDEX
tibiofibular joint, proximal, injection 369, triquetral 103–104, 106f vascular malformations, forefoot 322–323,
370f fractures 128 322f
tibionavicular ligament 255, 255f trochanter, greater 177 vascular tumours 394–396
pathology 309–311 trochanteric bursa 172, 179–180 glomus tumour 395, 396f
tibiospring ligament 255, 255f–256f inflammation 179–180, 179f haemangioendothelioma 395–396
pathology 310–311, 311f–312f injection 365–366, 366f haemangioma 394–395
tibiotalar joint 255 tubercular abscess 405f malignant 396
injection 379, 380f tuberculous dactylitis 151 solitary fibrous tumour 396, 396f
tibiotalar ligament 254, 255f tumoural calcinosis 179–180 vastus intermedius 170–171, 171f
Tinel’s sign 77b, 81–82, 136, 312 tumours tears 428f
toes neurogenic 136–137, 137f vastus lateralis 170–171, 423
Morton’s neuroma see Morton’s see also masses, soft tissue; and specific tendon 230–231, 231f
neuroma tumour types vastus medialis 170–171, 423
turf toe 317f turf toe 317f tears 429f
transversalis fascia, bulging 182 volar plate injury 159–160, 160f
transverse intercarpal ligaments 107f–108f
transversus abdominis 177, 188f U
trapezius 16 ulnar collateral ligament 63, 65f–66f, 105 W
tears 46 injury 143, 158–159, 158f–159f Wartenberg’s disease 77, 120
trauma/injury pathology 78–80, 80f Welch lesions 48
acroosteolysis following 51 ulnar nerve 61f, 64–65, 66f, 100–101, 106f, wrist 99–112
foot/ankle 282, 298–299, 316–318 125 anatomy and techniques 101–112
hand/wrist 116f, 127–128, 158–159 compression 81–83, 81f–84f, 125–126 disorders 129–140
muscle 421–431 dislocation 84f radial 113–121
see also specific trauma and areas ulnolunate ligament 105f–106f, 128 ulnar 122–128
triangular fibrocartilage tears 126–127, ulnotriquetral ligament 105f–106f, 127, 128f ganglion see ganglion (ganglion cysts),
127f–128f ultrasound wrist
triceps 57–58, 61f, 100 pitfalls and limitations 407–408 interventions 356–358
insertion 59f technical aspects 407
rupture 92–93, 92f–93f see also specific areas
subluxation 93 umbilical hernia 188 X
tendon 58 xanthoma
tendinopathy 92–93, 92f–93f Achilles tendon 270–271, 273f
trigger finger 154–158, 156f V plantar fascia 283
injection 360–361, 361f Valsalva manoeuvre 179, 179t, 199f
tripezium 143 varicocele 185f

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Practical Musculoskeletal Ultrasound

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PRACTICAL

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First edition 2005

Video Contents vii

PART 1 SHOULDER PART 5 HIP

19 Disorders of the Groin and Hip:

20 Disorders of the Groin and Hip:

6 Disorders of the Elbow: Lateral 70

7 Disorders of the Elbow: Medial 78 PART 6 KNEE

26 Disorders of the Ankle and Foot: Lateral 295

30 Specific Intervention Techniques 346 Index 433

PART 1 SHOULDER PART 2 ELBOW

Mid substance supraspinatus tendon tear axial PART 3 WRIST

PART 7 ANKLE Retro-malleolar peroneus brevis tendon tear

Cannulatingsubacromial subdeltoid bursa

Double Mulder’s click Cuff tear visualised during injection

Inflamed intermetatarsal bursa in rheumatoid arthritis Hip joint injection

Injecting Morton’s neuomai Forceps on FB prior to retrieval

Soft tissue biopsy

Hifz-ur-Rahman Aniq MBBS FRCR Philip J. O’Connor MRCP FRCR

Michel Court-Payen MD PhD Karen J. Partington MRCS FRCR

A acetabulum/acetabular component EDT extensor digitorum tendons

L/R length/radius PIPJ proximal interphalangeal joint

O oblique TT tibial tuberosity

OVERVIEW Standard Position 6: Supraspinatus Muscle

cause. Impingement is a clinical diagnosis, whereby pain

The cuff tendons, particularly supraspinatus, should be

STANDARD POSITION 3: SUBSCAPULARIS

lies between subscapularis and deltoid, and fluid frequently

similar, the two positions do not result in an identical con­

bursa should also be traced medially to the lateral margin

posterior labrum can be readily identified in thin patients.

STANDARD POSITION 6: SUPRASPINATUS

DYNAMIC SHOULDER ASSESSMENT

Dynamic assessment of the shoulder is most often used

can be observed during this movement. Changes in tissue

in the same position as is used to assess infraspinatus. The

INTRODUCTION A TEAR IS DETECTED: REPORTING SIZE,

Patients with external impingement syndrome, painful

it must be appreciated that not all rotator cuff tears are

THE AETIOLOGY OF SHOULDER

As with tendinopathy elsewhere in the body, a combination

diseased tendons in the body, prominent increased vascular­

THE ROTATOR CABLE

supraspinatus remaining intact or as involving the midpor­

FULL-THICKNESS TEAR PATTERNS, LOCATION

Infraspinatus Supraspinatus Subscapularis

Figure 2.8 Leading-edge tear with retraction. Difficult to see on

Figure 2.6 Schematic diagram of a linear supraspinatus tear involv-

Figure 2.9 Crescent tear with retraction.

Figure 2.10 Large U- or V-shaped tear with retraction.

arthroscopist to see as they only become visible if the tendon

An important landmark is the biceps tendon just proximal to

It will either be in close contact with the biceps/anterior

If the size of the gap increases and/or the leading edge

The dynamic examination involves both gentle movements of

The probe position used to evaluate the suprapinatus

Key Point Detecting partial thickness tears and tendinopathy is more

Figure 2.30 Extensive, ill-defined calcification almost completely

anaesthetic injection into the bursa. Fortunately, as has been

may become more solidly calcified and occasionally even

SUBACROMIAL SUBDELTOID BURSITIS Rotator Interval Tear

SUBACROMIAL SUBDELTOID BURSITIS ULTRASOUND APPEARANCES

Figure 3.1 Coronal image of supraspinatus. The probe has been

similar, the two positions do not result in an identical con

diseased tendons in the body, prominent increased vascular

supraspinatus remaining intact or as involving the midpor

Humerus Lat H more difficult joints to examine comprehensively with ultra