Pictorial Essay

An Illustrated Tutorial of Musculoskeletal Sonography:

Part 1, Introduction and General Principles
John Lin 1, David P. Fessell, Jon A. Jacobson, William J. Weadock, Curtis W. Hayes

usculoskeletal sonography is a
rapidly evolving technique that is
gaining popularity for the evaluation and treatment of joint and soft-tissue diseases. Inherent advantages of sonography

include accessibility, quick scan time, low

cost, multiplanar capability, and the ability to
perform dynamic real-time imaging with contralateral comparison. Advances in technology
with higher frequency transducers, power

Doppler sonography, and extended field-ofview function have facilitated the progressive
development of sonography [13].
One notable drawback of sonography is operator-dependency; the quality and consistency

Fig. 1.36-year-old asymptomatic man.

A and B, Longitudinal (A) and transverse (B) sonograms reveal normal supraspinatus tendon (white arrows). Note hyperechoic cortex of humerus
(black arrows), including cortex (arrowheads) of greater tuberosity (GT) in A.
Deltoid muscle (D) is overlying supraspinatus tendon. m = medial, a = anterior.
C, Transverse sonogram reveals normal peroneus brevis (white arrowheads)
and peroneus longus (black arrowheads) tendons. Note border between peroneus tendons (arrows) and peroneus brevis muscle (PB). a = anterior, p =
posterior, F = fibula.

C
Received December 8, 1999; accepted after revision February 10, 2000.
1

All authors: Department of Radiology, The University of Michigan Medical Center, 1500 E. Medical Center Dr., TC 2910, Ann Arbor, MI 48109-0326. Address correspondence to J. Lin.

AJR 2000;175:637645 0361803X/00/1753637 American Roentgen Ray Society

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Lin et al.
of sonographic studies rely on the expertise of
the examiner. Other limitations include a long
learning curve and a physician timeintensive
examination, particularly for beginners. Musculoskeletal sonography is a widely accepted
and available tool in Europe and other parts of
the world, in which it is often the principal
technique performed for many clinical indications. However, in the United States, sonography is relatively underused because of the wide
availability of MR imaging and the small number of training programs offering instruction
and experience in musculoskeletal sonography.
Additionally, physicians, including radiologists, are often unaware of the potential applications of sonography for the assessment of
joint and soft-tissue disease. Sonography offers
a cost-effective alternative for imaging musculoskeletal disorders in many situations [13].
We discuss basic principles, advanced imaging functions, scan artifacts, and general
characteristics of key musculoskeletal structures. Subsequent articles will feature abnormalities pertaining to specific joints, and the
final installment will focus on musculoskeletal tumors, sonographically guided interventions, and miscellaneous topics. Our intent is
to review current accepted clinical applications of musculoskeletal sonography and
generate interest in what we believe to be an
underused technique. We hope to inspire
physicians to consider musculoskeletal
sonography as a viable, and frequently primary, option in the assessment of joint and
soft-tissue disorders.

C
Fig. 2.30-year-old woman without symptoms. Longitudinal sonogram reveals normal ulnar collateral ligament (black arrows) of elbow. Note medial epicondyle
(M and white arrows) and proximal ulna (U and arrowheads). d = distal.

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Fig. 3.60-year-old man with muscle herniation caused by remote trauma.

A, Longitudinal sonogram of anterolateral lower extremity, in region of focal bulge, reveals herniation of anterior
tibial muscle (white arrows) through defect in fascia (black arrows).
B, Longitudinal split-screen sonogram obtained in same location as A shows minimal motion of anterior tibial
muscle with dynamic imaging between dorsiflexion (left-sided image) and plantar flexion (right-sided image).
Note muscle herniation (solid arrows), fascia (open arrows), and small subfascial fluid collection (asterisk).
C, Longitudinal split-screen sonogram shows comparison of muscle echotexture between scarred, herniated
symptomatic leg (left-sided image) and normal contralateral asymptomatic leg (right-sided image). Note fascia
(open arrows) and muscle herniation (solid arrows).

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Principles of Musculoskeletal Sonography

General Principles

When performing musculoskeletal sonography, the proper equipment is essential to

facilitate optimal image quality and diagnostic examinations. In general, the structures
examined will be superficial; therefore, highfrequency ( 712 MHz) linear array transducers are usually the most appropriate
choice. The high resolution attainable allows
detailed anatomic depiction of pertinent
structures [1]. Proper positioning of the patient is of paramount importance in obtaining
high-quality studies. Different sonographic
techniques have been described, with the
universal goal of optimizing the visualization
of structures of interest.

and orientation of the nerve but can usually

be identified by the nerve distribution.
On sonography, the bone cortex appears
as an echogenic surface with posterior shadowing (Fig. 1). Only the superficial surface
of the bone can be consistently evaluated on
sonography. Radiographically occult fractures can be detected on sonography, seen as
a step off cortical disruption [1, 7] (Fig. 5).

A thin hypoechoic rim paralleling the

echogenic articular cortical surface represents hyaline cartilage (Figs. 1 and 6). Ongoing research on the potential clinical
applications of sonography of fibrocartilage
is promising. Sonography may play a more
significant role in the assessment of labral
and meniscal lesions as technology continues to improve [1] (Figs. 7 and 8).

Musculoskeletal Structure Characteristics

In this section, we describe the sonographic characteristics of key musculoskeletal structures.

The evaluation of tendon abnormality is
the most common clinical indication for
musculoskeletal sonography. Whether the
tendon is in the shoulder, wrist, or ankle, the
sonographic appearance of a normal tendon
is fairly uniform. On sonography, tendons
should have a fibrillar pattern of parallel hyperechoic lines in the longitudinal plane and
a hyperechoic round-to-ovoid shape in the
transverse plane [4] (Fig. 1).
Ligaments have an appearance similar to
tendons but are static stabilizers connecting
bone to bone. Ligaments can be differentiated
from tendons by noting their more compact
fibrillar, hyperechoic pattern [1]. Superficial
ligaments, such as the anterior talofibular ligament or elbow ulnar collateral ligament (Fig.
2), are readily visualized. Deeper internal ligaments, such as the anterior cruciate ligament,
are more difficult to consistently identify.
Normal skeletal muscle shows low- to
mid-level echogenicity with hyperechoic fascial planes [1] (Fig. 1). Partial and complete
tears can be characterized on sonography,
and the degree of retraction, if any, can be
accurately measured. Dynamic imaging with
contraction of the affected muscle can sometimes better illustrate the abnormality and
provide functional information (Fig. 3).
Larger peripheral nerves can also be accurately identified on sonography [5]. Normal
peripheral nerves typically appear as
echogenic fascicular structures and tend to
be slightly less echogenic than tendons or
ligaments [6] (Fig. 4). This appearance is
somewhat variable depending on the location

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B
Fig. 4.32-year-old asymptomatic man.
A and B, Transverse (A) and longitudinal (B) sonograms of carpal tunnel of wrist show normal appearance of median nerve (black arrows) and flexor tendons (white arrows). r = radial, u = ulnar, p = proximal, d = distal.

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Lin et al.
Calcifications typically exhibit increased
echogenicity with associated posterior acoustic shadowing (Fig. 9). However, the presence
of shadowing depends on the size of the calcification [8]. When calcification is present
within the substance of a tendon, it commonly represents calcific tendonitis (Fig. 10).
Examination

Although sonography is operator-dependent, the interaction between the examiner

and the patient is invaluable. Additional clinical history about the precise location and
character of symptoms, direct feedback
about tenderness with probe palpation, and
positions or movements that elicit or aggravate symptoms can assist in the accurate interpretation of findings.
The flexibility and dynamic capability of
sonography allow a targeted examination, specific for each individual. Dynamic imaging
can readily reveal certain transient conditions

related to specific positions or movements,

which can be absent during static examination
[2] (Fig. 11).
Compression from applying transducer
pressure under real-time visualization can reveal important information about the composition of underlying structures and allows
increased conspicuity or detection of abnormalities that may be otherwise hidden [2]
(Fig. 12).
Contralateral comparison is easily performed in the musculoskeletal system; it distinguishes significant findings from normal
variants and occasionally reveals unsuspected abnormalities, which can be crucial to
the treatment of a patient (Figs. 13 and 14).
Technical Features

Fig. 5.36-year-old woman with patellar fracture. Longitudinal sonogram shows mildly displaced fracture of patella
(arrows) that was not revealed on radiographs of knee. p = proximal, d = distal.

Fig. 6.80-year-old woman with rotator cuff tear. Transverse sonogram reveals small full-thickness tear (curved arrows) in distal supraspinatus tendon. Note hypoechoic hyaline articular cartilage (black arrowheads) of humeral
head. Fluid present within defect of supraspinatus tear accentuates echogenicity at surface of hyaline cartilage
(white arrowhead ). a = anterior, p = posterior.

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Color and power Doppler sonography features show the degree of vascularity associated with inflammatory processes and solid
masses. Power Doppler sonography can be
used to characterize musculoskeletal inflammation in cellulitis, abscess, synovitis, myositis, and bursitis [9] (Fig. 15).
The split-screen function that is available
on most sonography units can expand the
field of view to approximately double the
width or can be used for side-by-side comparisons (Figs. 13 and 14). The extended
field-of-view function, available on the
Sonoline Allegra sonographic unit (Siemens
Medical Systems, Iselin, NJ), can display
very large continuous sections of anatomy,

Fig. 7.37-year-old man with shoulder pain. Transverse sonogram of posterior glenohumeral joint shows
normal posterior glenoid labrum (arrows). Note glenoid (G) and humeral head (H). Pain was caused by
torn rotator cuff tendon (not shown).

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Fig. 8.18-year-old woman with contralateral hip pain.Principles

Longitudi- of Musculoskeletal Sonography
nal sonogram of asymptomatic left hip shows normal anterior acetabular labrum (arrows). Note acetabulum (A) and femoral head (F).

preserving spatial resolution without distorting structural relationships [10, 11] (Fig. 16).
Recent innovative functions such as threedimensional imaging (Fig. 17) and tissue
harmonics (Fig. 18) may provide further improvement in the diagnostic effectiveness of
sonography. The role of these functions in
the assessment of musculoskeletal disorders
is currently under investigation [3].

Fig. 9.27-year-old woman with dermatomyositis. Transverse sonogram of medial

upper arm in region of several small nontender palpable nodules shows several
subcutaneous echogenic foci (arrows)
with distal shadowing (arrowheads) that
represent superficial calcifications.

Artifact

Anisotropy is an important artifact that can

affect the image and should be considered
when examining any musculoskeletal soft-tissue structure. This finding is most obvious with
tendons and ligaments, caused by the highly

Fig. 10.21-year-old man with calcific tendonitis of Achilles tendon.

A and B, Longitudinal (A) and transverse (B) sonograms of Achilles tendon at distal insertion reveal extensive calcifications (white arrows) within tendon, consistent with calcific tendonitis. Note distal shadowing (arrowheads), and note superoposterior aspect of calcaneus (C and black arrows) in A. p = proximal, d = distal, m = medial, l = lateral.

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Lin et al.

B
Fig. 11.50-year-old man with intermittent ulnar nerve subluxation.
AC, Transverse dynamic sonograms of cubital tunnel region reveal transient dislocation of ulnar nerve (black arrows) out of cubital tunnel (white
arrowheads) with progressive flexion. Note medial epicondyle (white arrows) and origin of common flexor tendons (black arrowheads), which
appear hypoechoic because of anisotropy artifact (see Figs. 17 and 18).
v = volar.

Fig. 12.64-year-old man with rotator cuff tear. Splitscreen image shows complete full-thickness tear of
distal supraspinatus tendon. Manual compression
(COMP) of transducer (right-sided image) reveals volume loss (solid arrows) and bursal contour deformity
(arrowheads) confirming diagnosis of full-thickness
tear. Note echogenic debris (open arrows) present in
tear defect. Secondary sonographic findings of fullthickness rotator cuff tear will be discussed in part 2,
Upper Extremity.

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Fig. 13.48-year-old woman with left Achilles tendinosis. Longitudinal split-screen image compares abnormal focally thickened left Achilles tendon (white
arrowheads, left-sided image), consistent with tendinosis, with asymptomatic normal-caliber right AchilAJR:175,
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les tendon (black arrowheads
, right-sided
image).2000

Principles of Musculoskeletal Sonography

Fig. 14.36-year-old man with right brachial muscle atrophy.
Split-screen image compares severely atrophied right brachial
muscle (arrows) at anterior aspect of elbow with normal appearance of left brachial muscle (arrowheads). Note capitellum (C)
and radial head (R). Contralateral comparison provides internal
control, particularly for difficult or unsuspected findings.

Fig. 15.56-year-old woman with rheumatoid arthritis.

A, Longitudinal sonogram of radial aspect of left wrist shows hypoechoic periarticular lesions consistent with synovial hyperplasia and pannus (black arrows). Note abductor pollicis longus tendon (black arrowheads), distal radius (white arrows), and scaphoid (white arrowheads). d = distal, p = proximal.
B, Longitudinal power Doppler sonogram obtained in same location as A shows markedly increased flow consistent with inflammation.

Fig. 16.68-year-old woman with large hematoma caused by falling. Longitudinal

extended field-of-view sonogram of anterior aspect of right leg reveals large pretibial
hematoma (black arrowheads), which measured 10 cm in length. Extended field-ofview function allows full coverage of this lesion. Note tibial cortex (arrows). Mirrorimage artifact (white arrowheads) is present. p = proximal, d = distal.

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Fig. 17.66-year-old woman with left shoulder pain. Three-dimensional image of intact
long head of biceps tendon with joint effusion extending into bicipital tendon sheath shows
three standard orthogonal planes: axial (solid arrowhead ), coronal (straight arrow ), and
sagittal (open arrowhead). Oblique plane (curved arrow ) was chosen by sonographer. Clinical use of this function for musculoskeletal sonography is under investigation.

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Lin et al.

Fig. 18.62-year-old man with left shoulder pain. L = lesser tuberosity, G = greater tuberosity.
A, Standard transverse sonogram of long head of biceps tendon is poorly visualized because of deep location of biceps tendon caused by large body habitus of patient.
Note bicipital groove (arrowheads).
B, Transverse sonogram with tissue harmonics function reveals intact long head of biceps tendon (arrows) discretely in bicipital groove (arrowheads).

Fig. 19.36-year-old asymptomatic man. L = lesser tuberosity, G = greater tuberosity.

A, Transverse sonogram shows normal long head of biceps tendon (arrows).
B, Transverse sonogram obtained at same location as A shows effect of anisotropy with artifactual hypoechogenicity in expected location of tendon (arrows).

ordered, parallel pattern of collagen fibers that

shows the greatest degree of reflectivity when
examined perpendicular to the ultrasound
beam. Anisotropy occurs when the ultrasound
beam is not perpendicular to the fibrillar structure of the tendon, resulting in the absence of

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specular reflectors and an artifactual hypoechoic to anechoic appearance [4] (Figs. 19 and
20). The sonographer should be aware of
proper transducer position and may need to
manipulate the heeltoe and foreaft angulation of the probe to avoid this artifact [12].

When a tendon has a curving course, the effects

of anisotropy cannot be entirely eliminated.
Each separate portion of the tendon must be examined individually, and the evaluation of tendon integrity should be primarily determined
during real-time scanning.

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Principles of Musculoskeletal Sonography

Fig. 20.49-year-old asymptomatic man.

A, Transverse sonogram of normal Achilles tendon (arrowheads) is echogenic except for slightly hypoechoic area relative to pre-Achilles fat.
B, Transverse sonogram obtained at same location as A shows effect of anisotropy with artifactual hypoechogenicity in expected location of tendon (arrows).

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