Basic Appearanceof Ultrasound Structuresand Pitfalls

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/46008807
Basic Appearance of Ultrasound Structures and Pitfalls
Article in Physical Medicine and Rehabilitation Clinics of North America · August 2010
DOI: 10.1016/j.pmr.2010.04.002 · Source: PubMed
CITATIONS READS
13 22,175
4 authors, including:
Michael Fredericson Eugene Roh

Stanford University Stanford University
328 PUBLICATIONS 9,956 CITATIONS 21 PUBLICATIONS 42 CITATIONS
SEE PROFILE SEE PROFILE
Matthew Smuck
Stanford University
217 PUBLICATIONS 2,777 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
The relationship between body mass index and fluoroscopy time during intra-articular hip injections: a multicenter
cohort study View project
Ultrasound and carpal tunnel syndrome View project
All content following this page was uploaded by Michael Fredericson on 16 October 2017.
The user has requested enhancement of the downloaded file.

Basic Appearance of
U l t r a s o u n d S t r u c t u re s
a n d Pi t f a l l s
Shelley McDonald, MDa, Michael Fredericson, MD
b,
*,
Eugene Y. Roh, MDa, Matthew Smuck, MDb
KEYWORDS
Musculoskeletal ultrasound Diagnostic ultrasound
Imaging Pitfalls
The role of ultrasound in musculoskeletal imaging is expanding as technology

advances and clinicians become better educated about its clinical applications. The
main use of musculoskeletal ultrasound to physiatrists is to examine the soft tissues
of the body and to diagnose pathologic changes.1 Furthermore, ultrasound can be
used to assist clinicians in performing interventional procedures. However, to
successfully integrate this technology into their clinical practices, physicians must
be familiar with the normal and abnormal appearance of tissues. They also must
recognize the clinically relevant limitations and pitfalls associated with the use of
ultrasound.2
UNDERSTANDING MUSCULOSKELETAL ULTRASOUND
Ultrasound uses high-frequency sound waves to image the soft tissues, bones, and
nerves of the body. The ultrasound machine sends an electrical signal to the trans-
ducer, which is connected (via a cable) to the monitor and computer processing
unit. This system results in the production of sound waves that are transmitted from
the transducer to the soft tissues of the body through acoustic transmission gel.
The sound waves interact with the tissue interfaces and some reflect back toward
the transducer on the surface of the skin. The ultrasound image is produced from
this reflection, which converts sound waves to an electrical current.3 The ultrasound
machine then measures the amplitude of the returning electrical signal and records
its travel time to determine the depth of the reflected structure. As the machine
a
PM&R Residency Program, Department of Orthopaedic Surgery, Stanford University School of
Medicine, Stanford, CA 94063, USA
b
Division of PM&R, Department of Orthopaedic Surgery, Stanford University School of
Medicine, Stanford, CA 94063, USA
* Corresponding author. Orthopaedics & Sports Medicine, Stanford Center for Medicine, 450
Broadway Street, Redwood City, CA 94063.
E-mail address: mfred2@stanford.edu
Phys Med Rehabil Clin N Am 21 (2010) 461–479

doi:10.1016/j.pmr.2010.04.002 pmr.theclinics.com
1047-9651/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
462 McDonald et al
generates and records the amplitudes and travel times of the sound beams, it uses the
computer software to produce a two-dimensional image of the scanned structures.1
Transducer Selection
To produce an image of optimal quality, it is important to select the proper transducer
for the area of interest. A transducer is described by the range of sound wave frequen-
cies it can produce (MHz). Higher-frequency transducers produce higher-resolution
images, but at the expense of beam penetration, because higher-frequency sound
is more rapidly absorbed by the tissues. Lower-frequency transducers are more
capable of assessing deeper structures, but they have lower resolution.3 Transducers
also can be described as linear or curvilinear. Linear transducers produce a sound
wave that is propagated in a straight line perpendicular to the transducer surface
(Fig. 1). Such transducers are best for evaluating linear structures like tendons. Curvi-
linear transducers produce an arched beam and are less commonly used, but have
some advantages in evaluating deeper structures (Fig. 2).
Commonly used transducers in musculoskeletal ultrasound include the high-
frequency (15–7 MHz) small-footprint linear array transducer (hockey-stick transducer)
(Fig. 3), the high-frequency (17–5 MHz) linear transducer, and the low- to medium-
frequency (5–2 MHz) curvilinear array transducer. The examiner should choose the
highest-frequency transducer that can adequately image the target structure at the
appropriate depth. Because most musculoskeletal structures are superficial, it is often
best to use the high-frequency linear transducer, which can usually penetrate to 6 cm.1
Basic Scanning Techniques

For the transducer to produce an optimal image of the underlying tissue, it is important
to use enough acoustic transmission gel. After a thick layer of gel is applied to the
transducer, the examiner should begin by holding the transducer between the thumb
and fingers of their dominant hand, positioning the end of the transducer near the ulnar
side of the hand (Fig. 4). To maintain adequate pressure of the transducer on the skin
and prevent involuntary movement of the transducer, it is essential to securely stabi-
lize the transducer on the patient’s body, with either the heel of the imaging hand or the
small finger.
After the transducer is properly placed on the patient’s skin, a rectangular image is
produced on the monitor. The top of the image represents the tissues in contact with
Fig. 1. Linear transducers are best for evaluating linear structures like tendons.

Ultrasound Structures and Pitfalls 463
Fig. 2. Curvilinear transducers are used for evaluating deeper structures such as hip, pirifor-
mis muscle, and sciatic nerve.
the transducer; the bottom of the image displays the deeper structures. The left-to-
right orientation of the image can be altered using a button on the machine or by
rotating the transducer 180 (Fig. 5).3
The image on the screen can be further adjusted and optimized by changing the
sound-beam penetration using the depth controls. Selection of the proper transducer
is also critical in evaluating the depth of a structure (Fig. 6). There is an inverse relation
between the frequency of the transducer and its depth of penetration, such that
higher-frequency transducers are usually best to view superficial structures, whereas
lower-frequency transducers are used for deeper structures.1,4
The next step in imaging is adjusting the focal zone of the ultrasound beam. The
number of focal zones should be reduced to span the area of interest. The zone feature
is usually displayed on the side of the image as a series of cursors or symbols. The
depth and length of the focal zone position should match the position of the structure
Fig. 3. The small-footprint linear array transducer is also called a hockey-stick transducer
and has higher frequency compared with other transducers. This transducer is used for eval-
uating small superficial structures such as peripheral nerves because it has better image reso-
lution. It is not used for deeper structures because of its small field of view and limited
depth penetration.

464 McDonald et al
Fig. 4. Holding a transducer correctly is important to produce an optimal image of under-

lying tissue. The examiner is holding the transducer between the thumb and fingers and
is securely stabilizing the transducer on the patient’s body.
of interest (Fig. 7). The examiner may adjust the gain to either increase or decrease the
brightness of the echo image (Fig. 8).1
Advantages and Disadvantages of Musculoskeletal Ultrasound

Before integrating musculoskeletal ultrasound into practice, physicians must famil-
iarize themselves with the distinct advantages and disadvantages of this imaging
modality. When compared with other musculoskeletal imaging techniques (radiog-
raphy, computer tomography, and magnetic resonance imaging), ultrasound offers
numerous advantages. Perhaps the most important of these is that ultrasound offers
a hands-on, dynamic examination, allowing the clinician to image in real-time, while
interacting with the patient.5 The clinician can ask the patient for assistance during
the examination and may accurately localize painful areas by palpating with the trans-
ducer and seeking patient feedback.1 The sonographer can also ask the patient to
reproduce the abnormal or painful event while scanning dynamically.
Fig. 5. (A, B) Orientation of the image. The top of the image usually shows the shallow
structures and the bottom of the image, the deeper structures. The notch (arrow) of the
probe usually represents the left side of the image (asterisk), but an image can be inverted
by controls on the machine and it is important to confirm the side of the transducer with the
side of the image on the screen. During examinations it is important to be consistent. Many
find it helpful to align the left side of the image with the examiner’s left side.

Fig. 6. (A) Ultrasound machine control panel. Use depth button (D) to adjust the frequency
and optimize the view of the target structure only after selecting the correct transducer. For
example, selecting a higher-frequency transducer and a lower-depth setting is best for the
most superficial structures. F, focus button; G, gain knob. Depth of the structure (arrow) in
an image is usually seen at the side of the image. (B, C) Patellar tendon (PT), tibia (T).

466 McDonald et al
Fig. 7. (A, B) Adjustment of focal zone. The focal zone markers are usually located on the
side of the screen. The focal zone position should match the structure of interest. Focal
zone can be adjusted by using a mouse or a focal zone knob (asterisks and arrows).
Fig. 8. (A, B) Adjustment of gain. The examiner may adjust gain to increase or reduce image
brightness. Some machines have an automatic gain adjustment function in addition to gain
adjustment knobs. PT, patellar tendon; T, tibia.

Furthermore, ultrasound transmits no radiation to the patient or user, and thus may be
used in special populations, including pregnant women and those with metal implants or
other sources of imaging artifacts. Ultrasound can be of specific clinical use to physiat-
rists because it can be used to guide percutaneous interventions. It has the ability to
image soft tissues in real-time to improve safety and accuracy of needle placement.
There are also important limitations. One of the primary disadvantages of ultrasound
is that it is operator dependent and there is a steep learning curve. There is currently no
certification or accreditation process required to use musculoskeletal ultrasound, so
the accuracy of the examination is limited by the comfort level and skill of the exam-
iner. Numerous examinations must be performed to establish a reliable diagnostic
algorithm.6 For example, a study by Teefey and associates7 found that most errors
made while using ultrasound to diagnose and measure rotator cuff tears resulted
from failure of the examiner to recognize normal and abnormal structures as well as
errors caused by technical limitations inherent to the test.
The clinician must be familiar with the technical limitations associated with ultrasound.
Although ultrasound can provide exquisitely detailed pictures, it is not intended to image
large body areas or evaluate diffuse pain. The limited field of penetration and poorer reso-
lution at greater depths of the machine hinder its ability to evaluate deep body regions,
and inability to penetrate bone prevents visualization of intra-articular structures.1,4,6
For example, it is limited in evaluation of anterior and posterior deep hip pathologic condi-
tions, intercarpal joints, and ligaments in the wrist, or deep structures in the plantar mid-
foot.3,5 In addition, when examining the knee, deeper structures such as the menisci,
cartilaginous structures, and cruciate ligaments are not well visualized.6 Ultrasound is
also not the study of choice for imaging labral tears of the shoulder.
NORMAL AND ABNORMAL TISSUES

Describing Tissue Appearance
Musculoskeletal ultrasound can be used to identify muscles, tendons, ligaments,
nerves, and vessels at a resolution of less than 1 mm.2 These structures can be char-
acterized and described by their echogenicity. When there is a large difference in
impedance at the interface between tissues the sound beam is strongly reflected,
creating a bright echo on the image. This process is described as hyperechoic. If an
image displays no echo and is black, it is referred to as anechoic, and when a weak
or low echo is produced, it is termed hypoechoic (Fig. 9). When the echogenicity of
a structure appears equal to an adjacent structure, it can be described as isoechoic
or of equal echogenicity.3 In general, when interpreting musculoskeletal ultrasound,
a practical order of echogenicity is: bone/ligament/tendon/nerve/muscle.6
In addition to their echogenicity, tissues are also described by their echotexture,
which refers to their internal echo pattern. Echotexture varies based on whether
a structure is imaged longitudinally or transversely. For example, tendons exhibit
a fibrillar echotexture pattern when imaged longitudinally and a broom-end pattern
when imaged transversely. These patterns are descriptive of the compact arrange-
ment of hyperechoic collagen bundles within the tendons. Nerves show a fascicular
longitudinal and honeycomb transverse appearance because of the hypoechoic nerve
fascicles surrounded by hypoechoic connective tissue.2
Muscle
To optimally identify muscle by ultrasound, the examiner must be familiar with the
histologic appearance of the different types of muscle. Skeletal muscle is composed
of individual fibers, and a bundle of fibers composes a fasciculus. The fascicules are
visible as separate structures on ultrasound and are best identified as hypoechoic

468 McDonald et al
Fig. 9. Description of echogenicity. A bright echo on the image is referred to as hyperechoic

(straight arrow, bony surface). An image with no echo or black is referred as anechoic
(arrowhead, cartilage). An image with a low echo is referred as hypoechoic (bent arrow,
patellar tendon).
cylindrical structures separated by hyperechoic intervening connective tissue (the

perimysium).6 Longitudinally, muscles can be described as like a feather or veins on
a leaf, and when viewed transversely, they appear like a starry night (Fig. 10).2
During contraction of a muscle, the fibers shorten, causing an apparent increase in
muscle bulk. When the muscle is contracted, the fascicles have a thicker and more
hypoechoic appearance. In this contracted state partial thickness strain injuries can
be revealed and the full extent of a muscle tear can be evaluated.2,6 As with all struc-
tures, it is critical to compare the muscle of interest with the contralateral side when
evaluating for disease.
Additional muscle injuries that can be evaluated by ultrasound include muscle contu-
sions and hemorrhages that appear hyperechoic initially. As soft tissues hemorrhage and
begin to resorb, the hematoma becomes more echogenic, beginning at its periphery, and
a residual anechoic seroma or fluid collection may be present toward the center.3
Ultrasound can also evaluate a muscle hernia, which appears as a hypoechoic
nodule extending through a defect in the fascia. If the examiner suspects a muscle
hernia, he can directly palpate over the suspected site. This procedure allows the
hernia to be felt as an individual soft-tissue nodule that appears when the muscle
contracts.5 Application of focal pressure to the site while scanning can reveal reduc-
tion of the herniation, helping confirm the diagnosis.
Tendons
Tendons appear on ultrasound as dense, linear hyperechoic bands in a fibrillar pattern
when evaluated in the longitudinal axis. When viewed transversely, they appear as
hyperechoic with multiple hyperechoic foci or dots and display a broom-end echotex-
ture. Their hyperechoic appearance is caused by the specular reflections at the inter-
face between the fascicles and peritendineum (connective tissue containing blood
vessels and nerves) (Fig. 11).5 Because they are solid structures, tendons are normally
not compressible and do not show blood flow.
However, on color or power Doppler imaging, tendons may show increased blood
flow for several reasons. The increase could be seen in the setting of tendinosis, but it

Fig. 10. Muscle, lateral gastrocnemius and soleus. (A) At rest, the gastrocnemius (G) reveals
a hyperechoic veins-on-a-leaf appearance and the soleus (S) muscle deep to the aponeurosis
(arrows) appears hypoechoic. (B) During gastrocnemius muscle isometric contraction, the
angle between the aponeurosis and muscle fibers is greater (b) than the angle at rest (a).
(B) Muscle bulk is also increased during contraction.
Fig. 11. Longitudinal view of tendon. Longitudinal view reveals the linear fibrillar echo.
Transverse view would show a hyperechoic structure with multiple hypoechoic foci, the
so-called broom-end echotexture.

470 McDonald et al
should not necessarily always be equated with inflammation. For example, increased
blood flow is seen with Achilles tendinosis resulting from neovascularity and may
correlate with pain levels.9
Tendon abnormalities visible on ultrasound can range from tendinopathy to
complete tears. Tendinopathy can have numerous causative factors, including over-
use, external impingement, and age-related changes.8 Early tendinopathy appears
as tendon thickening. As it progresses, the normal fibrillar pattern of the tendon is
replaced with hypoechoic swelling without notable tendon fiber disruption.3,8 If the
clinician suspects a severe tendinopathy, they should perform a dynamic evaluation
to rule out a partial tear.
It is rare for a normal tendon to tear unless subject to an acute trauma. However, with
tendinopathy the tendon is weakened and tears are frequently observed. These risk
progression as a result of the weakened state. Also, a seemingly minor injury can
lead to complete disruption.8 Chronic tendon injuries resulting in tears can lead to
atrophy of the surrounding muscles, causing them to appear smaller and hyperechoic.
Ligaments
Ligaments are fibrous structures appearing similar to tendons. However, they are less
compact and are composed of a more diverse pattern of collagen bundles.2 Liga-
ments are usually well defined and easily visible on ultrasound examination. However,
when they occur as a focal thickening of a joint capsule, they may not be distinguish-
able as distinct structures. Ligaments display a hyperechoic, linear appearance on
ultrasound and are optimally evaluated when they are stretched (Fig. 12).5
Similar to tendons, ligaments appear fibrillar during longitudinal scanning and have
a broom-end appearance on transverse scans. However, ligaments can be distin-
guished from tendons by tracing them back to the bony structures to which they
attach.2
Ligamentous injuries can appear similar to tendon injuries. If the injury is low grade,
ligaments appear enlarged and hypoechoic with an otherwise normal echotexture.
Fig. 12. Ultrasound image of medial collateral ligament reveals the superficial ligament
(arrows) and meniscofemoral ligament (mf) and meniscotibial ligament (mt) attached to
the meniscus (asterisk).

Partial and full-thickness tears reveal fiber disruption. Partial and complete tears can
be differentiated using stress testing.2
Nerves
Peripheral nerves contain many nerve fibers grouped together in bundles called fasci-
cles enclosed by an endoneurium composed of connective tissue. Fascicles are sur-
rounded by a connective tissue sheath called the epineurium. The intrafascicular
epineurium (thin septae serving to further support the nerve bundles and their vascular
supply) extend inward from the epineurium.5
On ultrasound, when viewed longitudinally, nerves display a fascicular pattern with
uninterrupted hypoechoic bands (fascicles) surrounded by linear, interrupted hypere-
choic bands (the interfascicular epineurium). In the transverse field of view, nerves
may have a honeycomb appearance (Fig. 13). They are usually best viewed trans-
versely, when possible, to trace long nerve segments.2 Nerves and tendons can often
appear similar on ultrasound, but they can be differentiated in several ways. For
instance, tendons display a fibrillar pattern, whereas nerves have a fascicular pattern.
Furthermore, tendons are not usually compressible, and they show more active move-
ment on contraction of the adjacent muscles.5 It is also critical to evaluate tendons in
the long axis, dynamically and under stress. This strategy helps identify and localize
disruptions in the integrity of the tendon fibers.
Nerves can become entrapped at several specific anatomic sites, usually when they
traverse a confined space and are constrained by an osseous, ligamentous, or fibrous
structure. When entrapped, nerves appear hypoechoic and swollen just proximal to
the entrapment site.3 They appear compressed and show focal narrowing at the
site of entrapment. This focal narrowing is referred to as a notch sign.2
The dynamic capability of ultrasound can be helpful for evaluating nerve compres-
sions. The patient can give feedback regarding pain or other symptoms as transducer
pressure is applied.3 In peripheral nerve injuries, such as carpal tunnel syndrome, the
nerve has decreased mobility at the site of compression, and transducer pressure over
Fig. 13. Transverse view of the median nerve (MN) under the flexor retinaculum (black
arrowhead). Note the honeycomb appearance of the nerve. Compared with ligaments
and tendons, nerves are more compressible.

472 McDonald et al
the nerve at its entrapment site may reproduce symptoms and assist in guiding the
examination.
Vessels
Veins and arteries can be easily distinguished from other structures because they are
the only tissues that normally exhibit blood flow. They have a hypoechoic or anechoic
tubular appearance, are easily compressible, and display blood flow on Doppler
examination (Fig. 14). Identifying veins on ultrasound examination can facilitate the
location of nerves because they often follow a similar course in the body.2
Bones
Ultrasound provides limited views of bones. It can display vivid anatomic details of the
cortical surfaces of superficial bone.5 Bones appear with well-defined, linear, and
smooth hyperechoic borders. This hyperechoic appearance is caused by the high
reflectivity of the acoustic interface. Because nearly the entire sound beam is
reflected, ultrasound is unable to image beyond the bone surface or that of other calci-
fied structures, so the image beyond the interface appears black; this is referred to as
posterior acoustic shadowing.2 Because of this phenomenon, ultrasound can provide
information only about the superficial portion of bones (Fig. 15).
Although it is limited to evaluation of the superficial bone, ultrasound has high reso-
lution that allows for detection and evaluation of subtle cortical changes.
Although it is usually not the first-line imaging technique to diagnose acute bone
fractures, ultrasound can be useful for detecting fractures that are undetected on initial
radiographic examinations.10 An example is a fracture of the greater tuberosity of the
proximal humerus. Such a fracture is often not identified on a plain film because of
suboptimal patient positioning or technique.11 Other fractures visible on ultrasound
that are often missed on plain films include those of the scaphoid12–16 and tibia,
including a Segond fracture.17,18 In addition, in the foot and ankle numerous bones
may overlap and make radiographic diagnosis of fractures difficult. Usually, ultra-
sound more readily detects such fractures, including those of the cuboid,19,20 lateral
talar process,21 and anterior-superior calcaneal process.22 In addition, fractures and
Fig. 14. A vessel appears as a hypoechoic or anechoic tubular structure, is easily compress-
ible, and displays blood flow on Doppler examination.

Fig. 15. Bones appear as well-defined, linear, and smooth hyperechoic stuctures. The image
beyond the surface appears black because most sound beams are reflected back from the
bone surface. This process is referred to as posterior acoustic shadowing. Ultrasound can
be used to detect subtle cortical changes, including some fractures.
erosions of superficial bones, such as scaphoid fractures or Hill-Sachs deformities,

can be seen on ultrasound, but often are not visualized on plain radiographs.5
With an acute fracture, there is obvious discontinuity of the bone cortex with
a possible step-off deformity. There are focal breaks in the hyperechoic cortical
line, usually associated with a subperiosteal hematoma.10 An adjacent area of mixed
echogenicity hemorrhage also may be visible.
Irregularities of the normal smooth, echogenic surface of bone can indicate perios-
titis or a stress fracture.2 Ultrasound also may show soft-tissue swelling and local
hyperemia, but the fracture line is not usually visible. As the stress fracture heals, there
may be subtle calcified deposits over the bone, reflecting initial callus formation.10 A
stress fracture may initially appear as a local hypoechoic area adjacent to bone,
and may progress to a fracture deformity or hyperechoic callus formation.3
Joints
Joint anatomy varies extensively depending on the functional requirement of the joint.
Joints can be divided into 3 groups based on their anatomy: fibrous, cartilaginous, and
synovial.23 Synovial joints are the most common joints examined with ultrasound.
They are formed by articulating bone surfaces, fibrous capsules, and ligaments, and
other intra-articular structures (ligaments, menisci, labra, and fat pads) (Fig. 16).10
Ultrasound examination of joint surfaces reveals a homogeneously smooth hypoe-
choic smooth linear band (the hyaline cartilage).24,25 The joint capsule appears as
a hyperechoic line merging with the para-articular tissues.10 The deeper subchondral
bone is a regular, continuous, bright, hyperechoic line. Joints containing fibrocartilagi-
nous structures appear homogeneously hyperechoic and adherent to the bone or joint
capsule.26 Examples include the menisci in the knee, the labrum in the hip and

474 McDonald et al
Fig. 16. Joint. (A) Transverse view of the patella shows hyperechoic bone. The femur deep to
the patella is not visible because of shadowing. (B) The transverse view of the femur prox-
imal to patella reveals the lateral facet (Lf) of the trochlea, vastus medialis (vm), and hypo-
echoic cartilage (asterisk).
shoulder, and the triangular fibrocartilage in the wrist.5,10 However, because of their
deep structure and proximity to bone, fibrocartilaginous structures are usually not
well visualized by ultrasound.10
Because ultrasound is sensitive for detecting joint effusions, identification of intra-
articular effusions is one of the primary reasons ultrasound examination of joints is
requested.9,27,28 Radiographs are often inaccurate at diagnosing joint effusions in the
shoulder, wrist, and hip. Furthermore, it is often difficult to detect effusions of the wrist,
ankle, shoulder, and hip based on physical examination findings alone. Effusions can result
from trauma, mechanical causes, inflammation, infection, and neoplastic conditions.
Simple effusions appear on ultrasound as anechoic and compressible. Infection
should be suspected if fluid is complex with a heterogeneous appearance.28 Synovitis
appears as noncompressible, echogenic tissue within the joint. Enlarged bursae
usually contain simple, anechoic fluid, but they also may contain complex fluid,
appearing similar to joint effusions.2
Although ultrasound is extremely sensitive for the detection of intra-articular fluid, it
does not have the capability to distinguish between different types of fluid.29 For
example, a noninfected, nonhemorrhagic joint effusion could be completely anechoic
with no internal echoes, or it could contain several echogenic spots from fibrin, crys-
tals, and other debris.30
SONOGRAPHIC ARTIFACTS
In addition to recognizing the appearance of normal and abnormal tissues on muscu-

loskeletal ultrasound, it is also critical to be familiar with several artifacts common to
ultrasound.

Anisotropy
Anisotropy is likely the most common and most important artifact in musculoskeletal
ultrasound imaging, and failure to recognize it can be a major pitfall for the inexperi-
enced examiner. Normally, when a tendon is imaged perpendicular to the ultrasound
beam, it is hyperechoic and fibrillar. However, if the ultrasound beam is not angled at
90 , relative to the long axis of the structure, the normal hyperechoic appearance is
lost. As the angle is increased, the tendon becomes more hypoechoic. When this vari-
ation in ultrasound interaction with the fibrillar tissues occurs, it is termed anisotropy
(Fig. 17). Anisotropy usually involves tendons, ligaments, and occasionally muscle.3
Because tendinosis and tendon tears appear as dark and relatively hypoechoic, the
hyopechoic image created by anisotropy may be mistaken for disease, resulting in
a false-positive diagnosis.31,32 A common site for this mistake is within the supraspi-
natus tendon because of its coronal oblique course with angulation. To correct for
anisotropy, the transducer should be moved to maintain a position that is perpendic-
ular to the long axis of the tendon or ligament under examination.5 This position can be
accomplished by a tilting maneuver of the transducer. The examiner should also reex-
amine any area of abnormality to confirm that it did not result from anisotropy.
However, anisotropy can be beneficial in identification of hyperechoic soft tissues,
such as those in the ankle and wrist. If the transducer is angled more proximal or more
distal along the long axis of the tendon, it becomes hypoechoic, facilitating its distinc-
tion from the adjacent hyperechoic fat that does not show anisotropy. For example,
some ankle ligaments are often adjacent to hyperechoic fat, making them ordinarily
difficult to distinguish from each other. However, once the examiner identifies the
Fig. 17. (A, B) Anisotropy happens when beam angle is not perpendicular to a ligament or
tendon, causing the normally hyperechoic structure to appear hypoechoic. Anisotropy can
lead to a false-positive diagnosis such as the apparent quadriceps tendon tear in (A) (short
arrow). (B) The same tendon with a normal appearance (long arrow) after correcting the
transducer and beam position. To avoid an error from anisotropy, the examiner should care-
fully scan the abnormally hypoechoic area (short arrow) by rotating the probe in different
directions to determine if it appears normal from different angles (long arrow). P, patella.

476 McDonald et al
tendon, it is important to eliminate anisotropy to exclude disease. This procedure can

also be a useful adjunct at the carpal tunnel in distinguishing the flexor tendons from
the median nerve.
Shadowing
Another artifact in musculoskeletal ultrasound imaging is shadowing. Shadowing can
occur when the ultrasound beam is reflected, absorbed, or refracted (Fig. 18).33 The
image displays an anechoic area extending deep to the involved interface.
Surfaces that can produce shadowing include gas, some foreign bodies, and inter-
faces with bone or calcium. An object with a rough surface or small radius of curvature
displays a clean shadow, whereas an object with a smoother surface and larger radius
has a dirty shadow, a result of superimposed reverberation echoes.34 Refractile shad-
owing can occur at the edge of some structures like foreign bodies, or at the end of
a torn tendon.35
Posterior Acoustic Enhancement

An artifact that can occur when imaging some fluids or soft tissue tumors is posterior
acoustic enhancement or increased through transmission. This artifact can occur
when imaging fluids and peripheral nerve sheath tumors. In these situations, the sound
beam is less attenuated compared with the adjacent tissues. Thus, soft tissues deep
to a fluid collection appear hyperechoic compared with the surrounding soft tissues
(Fig. 19).33
Posterior Reverberation
An additional artifact to recognize on musculoskeletal ultrasound is posterior reverber-
ation. This artifact can occur when the surface of a surface is smooth and flat, such as
the surface of bone or a metal foreign object, and the sound beam reflects back and
forth between the smooth surface and the transducer, producing a series of linear
reflective echoes extending deep to the structure (Fig. 20).33 Because the reflective
echoes are deeper than the structure, the term ring-down artifact is also used.
Because of reverberation artifact, ultrasound is ideal for the evaluation of structures
overlying metal hardware because the artifact occurs deep to the hardware without
obscuring the superficial soft tissues.5
Fig. 18. Shadowing occurs when the ultrasound beam is reflected, absorbed, or refracted.
The image displays an anechoic area deep to the patella (P).

Fig. 19. Posterior acoustic enhancement. Soft tissues deep to a fluid collection (asterisk)
appear hyperechoic (arrows).
Beam Width Artifact

A final artifact with which to be familiar is the beam-width artifact. This artifact occurs
when the ultrasound beam is too wide compared with the object being imaged. For
example, when imaging a small calcification, the large beam width may eliminate
shadowing. This artifact can be reduced by adjusting the focal zone to match the
area of the object of interest.33
Fig. 20. Posterior reverberation happens when the sound beam reflects back and forth
between a smooth surface such as a metal needle and the transducer. It appears as a series
of linear reflective echoes. The ultrasound image shows the needle (arrows) and posterior
reverberation (arrowhead). It can be useful to locate the needle tip during an ultrasound-
guided injection.

478 McDonald et al
SUMMARY
Musculoskeletal ultrasound is emerging as a powerful diagnostic and clinical decision-

making tool for physicians. It can facilitate the identification of a variety of tissues and
aid in evaluation and treatment of musculoskeletal pathologies. Although ultrasound
provides numerous distinct advantages compared with other imaging techniques, it
also has several clinically important limitations. To successfully integrate this tech-
nology into their practices, it is critical that clinicians acquire an in-depth under-
standing of scanning techniques, an appearance of normal and abnormal tissues,
and pitfalls that may be associated with musculoskeletal ultrasound.
REFERENCES
1. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound:

Part 1. Fundamentals. PM R 2009;1(1):64–75.
2. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound:
Part 2. Clinical applications. PM R 2009;1(2):162–77.
3. Jacobson JA. Fundamentals of musculoskeletal ultrasound. Philadelphia: Saun-
ders Elsevier; 2007. p. 1–38.
4. Kremkau F. Diagnostic ultrasound. Principles and instruments. 6th edition. Phila-
delphia: WB Saunders; 2002. p. 428.
5. O’Neill J. Introduction to musculoskeletal ultrasound. In: O’Neill J, editor. Muscu-
loskeletal ultrasound. New York: Springer; 2008. p. 3–17.
6. Nofsinger C, Konin JD. Diagnostic ultrasound in sports medicine: current
concepts and advances. Sports Med Arthrosc 2009;17(1):25–30.
7. Teefey SA, Middleton WD, Yamaguchi K. Shoulder sonography: state of the art.
Radiol Clin North Am 1999;37:767–85.
8. Robinson P. Sonograhy of common tendon injuries. AJR Am J Roentgenol 2009;
193:607–18.
9. De Vos RJ, Weir A, Cobben LP, et al. The value of power Doppler ultrasonography
in Achilles tendinopathy: a prospective study. Am J Sports Med 2007;35(10):
1696–701.
10. Zamorani MP, Valle M. Bone and joint. In: Bianchi S, Martinoli C, editors. Ultra-
sound of the musculoskeletal system. Berlin: Springer; 2007. p. 137–85.
11. Patten RM, Mack LA, Wang KY, et al. Nondisplaced fractures of the greater tuber-
osity of the humerus: sonographic detection. Radiology 1992;182(1):201–4.
12. Hodgkinson DW, Nicholson DA, Stewart G, et al. Scaphoid fracture: a new
method of assessment. Clin Radiol 1993;48:398–401.
13. Munk B, Bovig L, Kroner K, et al. Ultrasound for diagnosis of scaphoid fracture.
J Hand Surg 2000;25:369–71.
14. Herneth AM, Sigmeth A, Bader TR, et al. Scaphoid fractures: evaluation with
high-spatial-resolution US initial results. Radiology 2001;220:231–5.
15. Haugher O, Bonnefoy O, Moinard M, et al. Occult fractures of the waist of the
scaphoid: early diagnosis by high spatial resolution sonography. AJR Am J
Roentgenol 2002;178:1239–45.
16. Senall JA, Failla JM, Bouffard JA, et al. Ultrasound for the early diagnosis of clin-
ically suspected scaphoid fracture. J Hand Surg 2004;29:400–5.
17. Boutry N, Lapegue F, Masi, et al. Ultrasonographic evaluation of normal
extrinsic and intrinsic carpal ligaments: preliminary experience. Skeletal Radiol
2005;34:513–21.
18. Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency
department. J Clin Ultrasound 2006;34:190–4.

19. Wang CL, Shieh JY, Wang TG, et al. Sonographic detection of occult fractures of
the foot and ankle. J Clin Ultrasound 1999;27:421–5.
20. Enns P, Pvlidis T, Stahl JP, et al. Sonographic detection of an isolated cuboid frac-
ture not visualized on plain radiographs. J Clin Ultrasound 2004;32:154–7.
21. Copercini M, Bonvin F, Martinoli C, et al. Sonographic diagnosis of a talar lateral
process fracture. J Ultrasound Med 2003;22:635–40.
22. Boutry N, Vanderhofstadt A, Peetrons P. Ultrasonography of anterosuperior
calcaneal process fracture: report of 2 cases. J Ultrasound Med 2006;22:307–11.
23. Erickson SJ. High-resolution imaging of the musculoskeletal system. Radiology
1997;23:405–6.
24. Martino F, De Serio A, Macarini L, et al. Ultrasonography versus computed
tomography in evaluation of the femoral-trochlear groove morphology: a pilot
study on healthy, young volunteers. Eur Radiol 1998;8:244–7.
25. Grassi W, Lamanna G, Farina A, et al. Sonographic imaging of normal and oste-
oarthritic cartilage. Semin Arthritis Rheum 1999;28:398–403.
26. Gerngross H, Sohn C. Ultrasound scanning for the diagnosis of meniscal lesions
of the knee joint. Arthroscopy 1992;8:105–10.
27. De Maeseneer M, Jacobson J, Jaovisidha S, et al. Elbow effusions: distribution of
joint fluid with flexion and extension and imaging implications. Invest Radiol 1998;
33:117–25.
28. Fessell D, Jacobson J, Habra G, et al. Using sonography to reveal and aspirate
joint effusions. AJR Am J Roentgenol 2000;174:1353–62.
29. Wilson DJ. Soft tissue and joint infection. Eur Radiol 2004;14:64–71.
30. Farina A, Filippucci E, Grassi W. Sonographic findings of the synovial fluid. Reu-
matismo 2002;54:261–5.
31. American Institute for Ultrasound in Medicine. AIUM technical bulletin (Trans-
ducer manipulation). J Ultrasound Med 1999;18:169–75.
32. Connolly D, Berman L, McNally E. The use of beam angulation to overcome
anisotropy when viewing human tendon with high frequency linear array ultra-
sound. Br J Radiol 2001;74:183–5.
33. Scanlan KA. Sonographic artifacts and their origins. Am J Roentgenol 1991;156:
1267–72.
34. Rubin JM, Adler RS, Bude RO, et al. Clean and dirty shadowing at US: a reap-
praisal. Radiology 1991;181:231–6.
35. Hartgerink P, Fessell DP, Jacobson JA, et al. Full- versus partial- thickness
Achilles tendon tears: sonographic accuracy and characterization in 26 cases
with surgical correlation. Radiology 2001;220:406–12.

View publication stats

Basic Appearanceof Ultrasound Structuresand Pitfalls

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Basic Appearanceof Ultrasound Structuresand Pitfalls

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Basic Appearance of Ultrasound Structures and Pitfalls

Michael Fredericson Eugene Roh

SEE PROFILE SEE PROFILE

Ultrasound and carpal tunnel syndrome View project

The user has requested enhancement of the downloaded file.

The role of ultrasound in musculoskeletal imaging is expanding as technology

UNDERSTANDING MUSCULOSKELETAL ULTRASOUND

Phys Med Rehabil Clin N Am 21 (2010) 461–479

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Basic Scanning Techniques

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Fig. 4. Holding a transducer correctly is important to produce an optimal image of under-

Advantages and Disadvantages of Musculoskeletal Ultrasound

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

NORMAL AND ABNORMAL TISSUES

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Fig. 9. Description of echogenicity. A bright echo on the image is referred to as hyperechoic

cylindrical structures separated by hyperechoic intervening connective tissue (the

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

erosions of superficial bones, such as scaphoid fractures or Hill-Sachs deformities,

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

In addition to recognizing the appearance of normal and abnormal tissues on muscu-

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

tendon, it is important to eliminate anisotropy to exclude disease. This procedure can

Posterior Acoustic Enhancement

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Beam Width Artifact

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Musculoskeletal ultrasound is emerging as a powerful diagnostic and clinical decision-

1. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound:

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

Downloaded from ClinicalKey.com at Stanford University December 07, 2016.

You might also like