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MUSCULOSKELETAL ULTRASOUND-

a diagnostic AND therapeutic toolKelly Williams, DO

Northeastern Rehab AssociatesScranton, PA

OBJECTIVES

WHY ultrasound is advantageous as a diagnostic tool

WHAT types of pathologies USD can and cannot be useful in diagnosing

WHAT types of injections USD is used to guide

WHAT types of injections USD is NOT useful for

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INTRO

Linear Transducer (15‐6MHz)Higher ResolutionLower Depth

Curvilinear Transducer (52MHz)Higher DepthLower Resolution

ADVANTAGES OF USD

Nazarian 2008 Increased safety

Decreased discomfort

Increased resolution

Real‐time dynamic imaging

Doppler

Flexible evaluation: symmetry, length of structure

Guided therapeutic interventions

“one‐stop shopping”

Disadvantage: operator dependence! steep learning curve!

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DIAGNOSTIC ULTRASOUND +/‐

POSITIVE:

MUSCLE‐TENDON

EXTRA‐articularLIGAMENTS

NERVE (size‐dependent)

DYNAMIC CONDITIONS

NEGATIVE:

JOINT

INTRA‐articularLIGAMENTS, CARTILAGE

SPINE

*habitus

SHOULDER

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Pathology

Tendon (cuff, bicep)‐ tear, tendinosis

Dinnes et al‐USD (95%) and MRI (89%) highly sensitive for full‐thickness tears, but USD (67%) more sensitive than MRI (44%) for partial thickness tears

Lenza et al (Cochrane)‐MRI, MRA, USD all sensitive for full tears, USD possibly less for partial

Bursitis, tenosynovitis

Glenohumeral Joint effusion, paralabral cyst

AC Joint osteoarthritis, separation

Dynamic impingement

***MRI Needed: labral tear, GHJ

INTERVENTIONS: subacromial, glenohumeral, ACJ injections, calcium barbotage, guide PRP into tear

SupraspinatusTears

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Postsurgical Shoulder

SubscapularisTear s/pTSR

Deltoid Dehiscence s/pTSR

Atrophy

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PROCEDURE‐ Subacromial

AJUM 2010; 13(2)

Melbourne Radiology

essr.org

PROCEDURE‐ AC Joint

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PROCEDURE‐ Calcium BarbotagePROCEDURE‐Calcium Barbotage

ELBOW/ HAND

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Pathology

Tendon‐ epicondylitis, tendon tear (incl bicep, tricep), wrist tenosynovitis, dynamic (tricep)

Ligament‐ ulnar/radial/annular, +/‐wrist

Joint‐ Elbow effusion, wrist ganglion cyst

Nerve‐Ulnar/Radial/Median

***MRI Needed: intraarticular abnormalities

INTERVENTIONS: elbow joint, tennis elbow (inj, PRP, tenotomy), carpal tunnel, small joint, trigger finger, tendonitis

Lateral Epicondylosis& Partial Tear

0.56cm 0.67cm

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Distal Biceps Tendon Tear

Ulnar Neuropathy at Elbow

NORMAL

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Ulnar Nerve SubluxationUlnar Nerve Subluxation

ULTRASOUND FOREARM/RADIAL NERVE

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ULTRASOUND RADIAL NERVE

BR

B

ULTRASOUND MEDIAN NERVE

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HIP

Pathology

Anterior: effusion, some signs of OA, iliopsoas tendinosis/ bursitis, rectus abnormalities, etc

Medial: Adductor tendinosis/ tear

Lateral: Gluteus Medius/Minimus tendinosis/tear

Posterior: +/‐piriformis thickening, hamstring tendinosis/ tear

Dynamic: snapping hip, femoroacetabular impingement

Limited: Sciatic and femoral nerves

***MRI Needed: intraarticular abnormalities (labrum); X‐Ray for OA

INTERVENTIONS: hip joint, trochanteric (inj, PRP, tenotomy), iliopsoasbursa, piriformis, lateral femoral cutaneous nerve block

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PROCEDURE‐ Hip Joint

Anterior Recess Femoroacetabular Joint

PROCEDURE‐ Trochanteric Bursa

GMed

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PROCEDURE‐ Hamstring Tenotomy

KNEE

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Pathology

EXTRAarticular

Effusion, signs of OA, Baker’s cyst

Patellar and quad tendinitis, ‐osis, tear; retinaculum

MCL, LCL

+/‐Peroneal nerve entrapment

Limited: meniscus (perameniscal cyst)

***MRI Needed: INTRAarticular

meniscus, ACL/PCL; X‐ray for OA

INTERVENTIONS: aspiration

PATELLAR TENDINOSIS

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KNEE EFFUSION / ASPIRATION

FOOT / ANKLE

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Pathology

Effusion, signs of OA

Ligaments (ATFL, CFL, PTFL, Detoid, etc)

Tendons (Achilles, peroneal, T‐D‐H), Plantar Fascia

Dynamic: peroneal tendon subluxation, ligament integrity

Morton neuroma

Limited: “tarsal tunnel”

***MRI Needed: intraarticular abnormalities

INTERVENTIONS: joint, tendon (PRP, tenotomy)

MORTON NEUROMA

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SPINE

Uses

LACK OF DIAGNOSTIC VALUE*

Interventional:

SI Joint

Caudal ESI 

Cervical facets

Occipital nerve block

Intercostal Nerve Blocks

Advanced‐ epidurals

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SI Joint INJECTION

CAUDAL ESI

JUM 2003

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SUMMARY

Diagnostic: improved resolution, but limited by depth and limited to extra‐articular pathologies, and learning curve

Therapeutic: improved safety, particularly useful for guiding medications into otherwise non‐visualizablepathology (nerve, tendon), developing use in interventional spine care

QUESTIONS???

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BIBLIOGRAPHY

Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System, 1st ed. 2007. Springer-VerlagBerlin Heidelburg.

Dinnes et al. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7(29)

Lenza et al. Magnetic resonance imaging, magnetic resonance artthrography, and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. The Cochrane Database 24 Sept 2013; Issue 9.

Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. Amer J Roentgenology 2008;190: 1621-1626.