MUSCULOSKLETAL ULTRASOUND

Musculoskeletal ultrasound is a musculoskeletal imaging technique which

adds a different and complimentary dimension of imaging evaluation to the
traditional modalities of plain radiography, computerized tomography (CT), and
magnetic resonance imaging (MRI).
Recognized advantages of the modality include the ready availability of
ultrasound equipment, the relatively low cost of the procedure compared with
advanced imaging such as CT and MRI, and that the exam uses non-ionizing
radiation.
Other advantages of the modality include an ability to image patients with
a contraindication to MRI (e.g., patients with some types of pacemakers) and that
ultrasound experiences much less artifact when imaging patients with surgical
hardware.
Musculoskeletal ultrasound also allows dynamic evaluation of patients,
which can improve radiologic interpretation of the clinical relevance of findings
seen in a static image (e.g. shoulder impingement).
Standard high-frequency ultrasound probes also resolve finer imaging
detail than many types of clinical musculoskeletal MRI. The axial resolution of a
10 MHz probe is 150 um. A 1.5T MRI scanner with a field of view of 12 x 6 cm
and a matrix of 256 x 256 pixels, with a slice thickness of 0.5 cm has a resolution
of 469 x 469 um.1
Despite its many strengths, however, musculoskeletal ultrasound also has
some limitations in the the complete evaluation of musculoskeletal disorders.
Radiography and CT provide much better evaluation of mineralization and the
spatial relationship of fractures. MRI is invaluable for assessment of bone
marrow, bone tumors, and for evaluation of joints and muscles that aren't
accessible to high resolution ultrasound probes (e.g. the spine, the sacroiliac
joints, the cruciate ligaments). Musculoskeletal ultrasound also encounters its own
set of artifacts, such as anisotropy, and requires a solid knowledge base and
background in ultrasound technique for safe and accurate results.1

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 Indications for MSK ultrasound include but are not limited to:
A. Pain or dysfunction.
B. Soft tissue or bone injury.
C. Tendon or ligament pathology.
D. Arthritis, synovitis, or crystal deposition disease.
E. Intra-articular bodies.
F. Joint effusion.
G. Nerve entrapment, injury, neuropathy, masses, or subluxation.
H. Evaluation of soft tissue masses, swelling, or fluid collections.
I. Detection of foreign bodies in the superficial soft tissues.
J. Planning and guiding an invasive procedure.
K. Congenital or developmental anomalies.
L. Postoperative or postprocedural evaluation.

MUSCULOSKLETAL ULTRASOUND OF THE KNEE

Ultrasound of the knee allows high resolution imaging of superficial

knee anatomy while simultaneously allowing dynamic evaluation of some of the
tendons and ligaments. Knee ultrasound is somewhat limited compared with
ultrasound examinations of other joints because the cruciate ligaments and the
entirety of the meniscus is usually difficult to visualize.
In contrast with the hip, the knee joint is easily accessible to clinical
examination. However, very small effusions or synovitic proliferations which are
missed clinically can often be demonstrated by US. Small amounts of effusion can
be detected in the suprapatellar longitudinal and transverse scans in neutral
position when pressure is exerted on the suprapatellar and parapatellar pouch by
tightening of the quadriceps muscle.
An important indication for musculoskeletal US is the examination of
pathological processes of the popliteal region. Popliteal cysts (Baker's cysts) are
fluid accumulation in the bursa of the gastrocnemius or semimembranosus
muscles. Frequently those cysts communicate with the joint space. To confirm the
diagnosis of a popliteal cyst this comma shaped extension has to be visualised
sonographically in the posterior transverse scan between the medial head of

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gastrocnemius and semimembranosus tendon. Popliteal cysts can extend far into
thigh and calf muscles and US allows precise definition of their shape and size. A
rupture of a popliteal cyst, which may clinically mimic a deep vein thrombosis, is
easily identified by US.
Loose joint bodies in the knee can be detected sonographically in the
suprapatellar pouch and in the infrapatellar and popliteal regions. However, the
failure to detect a loose body in the knee or any other joint can never rule out its
presence.

Ultrasound detectable pathology

1. Suprapatellar and parapatellar pouch:
Synovial proliferation
Synovial folds
Effusion
2. Quadriceps tendon:
Tear (partial or complete)
3. Femoropatellar joint:
Irregular contours
Bony lesions (erosions, osteophytes)
4. Popliteal sulcus:
Bursitis
Synovial proliferation
5. Patellar ligament:
Tear (partial/complete)
6. Deep infrapatellar bursa:
Bursitis
7. Subcutaneous prepatellar bursa:
Bursitis
8. Tuberosity of tibia:
Irregular bony contour (Mb. Osgood-Schlatter)
Infrapatellar bursitis
9. Ligaments:
Tear/lesion

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 10. Meniscus (lateral/medial):
Lesion
Cyst
11. Popliteal fossa:
Popliteal cyst (volume, echogenicity signs of leakage)
Compression of vessels

Specifications for a Knee Examination

An ultrasound examination of the knee is divided into 4 quadrants. The
examination may involve a complete assessment of 1 or more of the 4 quadrants
of the knee described below or may be focused on a specific structure depending
on the clinical presentation.

Anterior knee
Knee is flexed 20-30 degrees (flexion of the knee tightens the extensor
tendons, decreasing the chance of anisotropy occuring in a lax tendon):
1. Transverse and longitudinal images of the quadriceps tendon from its
myotendinous junctions to its attachment on the superior patella (rectus
femoris myotendinous junction is more cranial than the vastus junctions).
2. Evaluate the suprapatellar and parapatellar joint recesses.
o suprapatellar fat pad
o prefemoral fat pad
o small amounts of synovial fluid may preferentially locate to the
parapatellar joint recess
3. Evaluate the femoral trochlea
o best examined in full knee flexion
o useful for examination of the trochlear cartilage
4. Evaluate the patellar retinacula
5. Evaluate the medial patellar articular facet (lateral facet not visible on
ultrasound)
6. Evaluate the patellar tendon and patellar bursa
o prepatellar bursa normally not visible
o infrapatellar bursa

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 small amount of fluid in the deep infrapatellar bursa is
normal
normally no fluid in the superficial infrapatellar bursa

Lateral knee
Knee is flexed 20-30 degrees:
1. Evaluate the distal iliotibial band in long axis (located between anterior
and middle third of the lateral knee).
2. Evaluate the lateral collateral ligament in long axis.
o may detect para-articular ganglia
3. May see lateral meniscal pathology (e.g. meniscal cyst)
o extreme knee flexion may bring out a meniscal abnormality

Medial knee
Knee is flexed 20-30 degrees, with external rotation:
1. Evaluate medial collateral ligament and pes anserinus tendons in long axis
o valgus stress may be useful to examine the ligament

Posterior knee
Often examined with patient prone and knee extended, thereby gaining
access to the dynamic fat-filled popliteal fossa:
1. Evaluate the medial tendons in short axis (medial to lateral):
o sartorius
o gracilis
o semitendinosus
2. Moving even more medially, evaluate the semimembranosus-
gastrocnemius bursa in short axis
o a popliteal cyst (Baker's cyst) arises between these tendons
3. Evaluate the popliteal neurovascular bundle and intercondylar fossa in
short axis.
4. Evaluate the posterolateral corner and biceps femoris in short and long
axis.
5. Evaluate the peroneal nerve

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 o start with the common peroneal nerve branching off the sciatic nerve
above the knee
o follow it around the fibular head

Pathology
A number of knee abnormalities can be identified on ultrasound,
including:
patellar tendinosis / patellar tendon tear
quadriceps tendon tear
prepatellar bursitis
infrapatellar bursitis
popliteal cyst (Baker cyst)

Transverse suprapatella region:

RF: Rectus Femoris VI: Vastus

Transverse scan plane for the quadriceps intermedius

VL: Vastus Lateralis VM: Vastus

Medialis

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 Longitudinal suprapatella region
Suprapatella scan plane showing the suprapatella bursa and
quadriceps tendon.

To avoid loss of contact, use plenty of

Prepatella scan plane
thick gel or a standoff.

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 The infrapatella tendon.
Infrapatella scan plane
Also called the patella ligament.

The insertion of the infrapatella tendon Transverse Infrapatella tendon. Note

onto the tibial tuberosity. Note: The how wide it is, to then have an
normal physiological amount of fluid understanding of the area you need to
along the underside of the tendon. examine in longitudinal.

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 Pes anserinus scan plane.
Remember the Pes Anserine tendons as
The Pes Anserine bursa and tendon (sargent) SGT:
insertion are medial to the Infrapatella
tendon on the tibia, adjacent to the MCL Sartorius, Gracilis and semi-Tendinosis.
insertion.

The medial collateral ligament (green)

Medial knee joint scan plane. directly overlying the medial meniscus
(purple).

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 Assess the Lateral collateral ligament,
Ilio-Tibial band insertion and peripheral
Lateral knee joint scan plane. margins of the lateral meniscus. Unlike
the medial side, the LCL is separated
from the meniscus by a thin issue plane.

Rotate the probe off the lcl with the toe

Ilio-Tibial Band.
of the probe angled slightly posteriorly.

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 Medial aspect of the popliteal fossa
Popliteal fossa scan plane showing the
semimembranosis/gastrocnemius plane.

Confirm both arterial and venous flow

and exclude a popliteal artery
Ultrasound of the Popliteal vein and
aneurysm. If a Popliteal aneurysm is
artery in transverse.
discovered, always extend the
examination to the other leg and the
Without and with compression to exclude
abdomen. There is a risk of bilateral
DVT.
and high association with aortic
aneurysm

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 Experience with Ultrasound of the Knee Joint at Mulago Hospital, Uganda

E. Wakamuke, M. Kawooya, E. Kiguli Malwadde, Z. Muyinda

Mulago Hospital, Kampala Uganda

Background: The knee is prone to various pathology. Mulago Hospital records of

2001/2002 show that an average of 432 patients with knee joint disorders are seen
in orthopaedic and rheumatology outpatient clinics out of a total of 5400 patients
annually. For a long time the only mode of radiological investigation for these
patients has been x-rays of the knee joints and this meant that limited information
was got about the soft tissue component of the knee. Advances in technology with
high frequency transducers, power Doppler ultrasound and extended field of view
function have facilitated the progressive development of musculoskeletal
sonography (MS). In developing countries like Uganda, where advanced imaging
modalities like MRI are unaffordable and not readily available, ultrasound U/S
serves as an efficient substitute in trained hands. This study was aimed at
describing the sonographic pattern of knee joint pathology at Mulago Hospital in
patients with knee joint symptoms.
Methods: A cross sectional descriptive study of the sonographic pattern of knee
joint pathology was performed at Mulago Hospital from July 2004 February
2005. A total of 107 consecutive patients referred to the Radiology department
with knee joint pathology were studied. The patients socio-demographic data,
clinical history and physical examination were recorded. Sonography of the knees
was done using U/S machines [ATL-HDI 1500, Sonoace [Medison] SA8800 &
SA9900] with high frequency linear transducers (7-12 MHz) The sonographic
appearance of joint fluid, synovitis , loose bodies, bursae and cysts, tendon,
menisci and ligament pathology were recorded. The data was entered in the
computer using Epi-data soft ware and analysed using the SPSS version 10.
Results: A total of 107 patients had their knee joints evaluated with U/S. The age
range was from 2 months to 80 years. The mean age was 38.0 and median 36
years. The commonest presenting symptoms were painful swelling of the knee
55(51.4%), pain 39 (36.4%), swelling and inability to move were 6 (5.6%).
Sonographic features revealed osteoarthrosis was the most frequent 22(59.5%),
loose bodies were 7 (18.9%) and fractures 2(5.4%).

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Conclusion: U/S can ably evaluate the pathology of menisci, ligaments, tendons
and muscles. The majority of the knee joint pathology disorders were as a result of
the degenerative disease. In view of the fact that MRI is not readily available and
is expensive, U/S goes a long way in contributing to the diagnoses of knee joint
pathology in a low resourced countries like Uganda.

Introduction
Using U/S as a clinical investigative tool started in 1950s. However, its
application in imaging of MS remained underutilized till 1980s1,2. Soft tissue
pathology of the knee represents one of the more common, yet perplexing,
musculoskeletal disorders presenting at Mulago Hospital. Knee pain and related
symptoms may come as a result of damage to one or more of the soft tissue
structures that stabilize and cushion the knee joint, including the ligaments,
muscles, tendons, and menisci. Mulago Hospital records of 2001/2002 show that
an average of 432 patients with knee joint disorders were seen in orthopaedic and
rheumatology outpatient clinics out of a total of 5400 patients annually. In a
country with a population of 26 million people, it contributes significantly to the
burden of disease. The only mode of examination for these patients has been x-
rays of the knee and this meant that little information was got about the soft tissue
component of the knee. Yet U/S of the knee joint can yield a lot more information
on the bursae, tendons, muscles, ligaments menisci and joint space pathologies.
In this study, the sonographic pattern of knee joint pathology at Mulago Hospital
was reviewed.

Patients and Methods

A cross sectional descriptive study of the sonographic pattern of knee joint
pathology was performed at Mulago Hospital. This was done from July 2004
February 2005. One hundred and seven consecutive patients referred to the
Radiology department with knee joint symptoms were recruited. The patients
socio-demographic data, clinical history and physical examination findings were
recorded. Sonography of the knee joints was done using U/S machines [ATL-HDI
1500, Sonoace [Medison] SA8800 & SA9900] with high frequency linear

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transducers (7-12 MHz) The knee was examined in four positions: Anteriorly,
posteriorly or popliteal fossa, laterally and medially. The sonographic appearance
of joint fluid, synovitis, loose bodies, bursae and cysts, tendon, mensci and
ligament pathology was recorded. For each position, transverse and longitudinal
views were done. Joint effusions were readily detectable by US as anaechoic area
bounded by the joint capsule. A simple effusion was anaechoic. Diffuse increase
in echogenicity suggested infection or haemoarthrosis. Simple bursitis was
depicted as anechoic fluid, with or without septa (fig 1A). In chronic bursitis, there
was bursal thickening seen as a band of moderate echogenicity. With
complications like infection or haemorrhage internal echoes were detected in the
fluid (fig 1B). Synovitis was demonstrated as diffuse nodular thickening of the
joint or bursal margins, or as nodular thickened folds of synovium within an
effusion and occasionally, flow was visible on a power Doppler examination, (fig
2A). In some cases synovial pannus would be mistaken for fluid. Graded
compression was used to distinguishing between these two entities. Loose bodies
detection was dependent on demonstrating a focal echogenic structure, completely
separated from other structures, lying within the joint space, (fig 3A). Meniscal
cysts were shown as anaechoic fluid collections characteristically lying at the
margin of the knee joint underlying the meniscus. They gave a characteristic
appearance of an ice cream cone, (fig 4Ai). Meniscal tears were recorded as
discrete hypoechoic clefts coursing in the oblique fashion through a hyperechoic
triangular meniscus. Meniscitis were seen as hypoechoic triangular menisci.

Baker's cysts were seen to arise from the semimembranosus bursa and protrude
posteriorly to overlie the gastrocnemius muscle. The simple cysts were uniformly
anaechoic while internal echoes were in the complex cysts. In rupture of Bakers
cysts there was abnormal and irregular hypoechoic or anechoic areas at the distal
aspect of the cyst. Larger fluid collections extended distally and were located
superficial to the medial gastrocnemius muscle. The double wall of the Bakers
cyst was noted. Residual irregularity or hyperechoic scar tissue at the distal aspect
of a Baker's cyst indicated a remote rupture. Ruptured Bakers cysts were
differentiated from deep venous thrombosis by Doppler studies. Tendon

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pathology was also evaluated. Full-thickness tears appeared as echopoor focal
defects in the fibre bundles, or as focal contour deformities, particularly when
local pressure was applied with the transducer. Tendon calcification was shown as
focal brightly hyperechoic area with variable degrees of posterior shadowing.
Focal tendon swelling coupled with decreased echogenicity was reported as
tendinosis. Tenosynovitis was shown as thickening of the tendon sheath or a
hypoechoic rim around the tendon due to fluid or synovitis. Sonographic features
of Osgood-Schlatter disease were demonstrated as cortical discontinuity of the
tibial tuberosity associated with tendonitis of the patella ligament. The
sonographic appearance of ligaments of the knee is similar to tendons
characterized by parallel echogenic fibre bundles. Ligament tears were
demonstrated as interrupted echogenic fibrillar pattern by hypoechoic granulation
tissue when completely torn, or have focal internal hypoechoic areas with partial
tears. Injury to the medial collateral ligament was also detected as a thickened
heterogeneously hypoechoic band. Muscle tears were also seen. The partial
thickness tears in the muscle were recognized as a discontinuity in the pinnate
pattern or hypoechoic areas within the muscle. Lipomas were shown as
hyperechoic masses with posterior attenuation within the muscle fibre without
distorting architectural pattern, while calcifications were small hyperechoic
structures with or without acoustic shadow. Haematomas and tumours had almost
similar appearances with variable echogenicities.

Colour Doppler was used to distinguish viability of the tumour by demonstrating

flow from the haematomas which had no flow. All the above sonographic features
were demonstrated by at least 2 radiologists. The data was then entered in a
precoded questionnaire which was then transferred into the computer using Epi-
data soft ware and analysed using the SPSS version 10.

Results
A total of 107 patients with knee complaints were recruited in the study. Their
ages ranged from 2 months to 80 years. The mean age was 38.0 and median 36
years. The peak age was in the 31-40 years age group which accounted for 30

15
(28.0%) cases. Females were 61 (57%) were while 46 (43%) were males. The a
male: female ratio was 1:1.4. A painful swollen knee was the commonest
presenting complaint by 51.4%. Pain alone was the second commonest symptom
36.4%. Out of the 107 patients seen 51 (47.7%) of them were office workers,
43(40.2%) were manual labourers and 13 (12.1%) were children and students.
Thirty eight (35.5%) of patients were referred with a suspicion of osteoarthritis,
12 (11.2%) patients were suspected to have knee effusions and eight (7.5%) cases
had diagnoses of ligament tears. The clinical diagnoses of haemothrosis, meniscal
tears and pyogenic arthritis each were recorded in 6 (5.6%) cases. Post traumatic
arthritis was diagnosed in 5 (4.7%) cases. The rest of the cases 24.3% had various
diagnoses including Bakers cyst, meniscal cyst, loose bodies and Osgood-
Schlatters disease. One patient had no diagnosis The pathology was unilateral in
91 patients while 18 patients had pathology in both knees. This means that a total
of 125 knees were scanned. Ninety five patients (89.8%) scanned had pathology
in the knee joints while 12 patients (11.2%) had normal knee joints. Out of all
patients scanned, normal knee joints were seen in those below 40 years while
those above this group all the knee joints had pathology. A total of 85 cases were
diagnosed with ultrasound as abnormal, 50 of which had normal x-ray findings.
Knee joint space pathology: In the knee joint space, it was found that
osteoarthrosis was commonest 22(20.6%), followed by loose bodies 7(6.5%),
arthritis 6(5.6%) and fracture (1.9%). The above sonographic pathology was
correlated with age, sex, and occupation. Osteoarthrosis was common above 40
years, while loose bodies were more prevalent in the younger less than 40 years.
Overall, more females were affected than males. Fifteen 15(14%) female had
osteoarthritis compared to 7(6.5%) males. However, occupation does not seem to
pause a risk in the development of knee joint diseases, except in osteoarthrosis
where there were 13(12.2%) manual labourers compared to 9(8.4%) office
workers. Significantly students and children were not found to have any knee joint
space pathology.
Bursal sonopathology: The suprapatella bursa was affected in 25 (23.2%) cases.
Sixteen (14.8%) were simple effusions while the 9(13.3%) depicted internal
echoes. This was observed in pyogenic arthritis and hemoarthrosis. These 2

16
conditions were confirmed on aspiration. Bakers cysts were demonstrated in 39
(36.2%) of cases and 14(13.0%) were regarded as complicated due to the presence
of internal echoes. Four (3.7%) cases were documented for the pes anserinus and
three 3(2.8%) infrapatellar bursitis. Of all Bakers cysts diagnosed, 32 (80%)
occurred in patients aged above 30 years of age. Two peaks were observed at 31-
40 years and 51-60 years age groups. There was no case of Bakers cysts recorded
under 10 years of age. One subcutaneous cyst was recorded in the popliteal fossa
in 0-10 age group. More females with Bakers cyst 30(75%) than males 9(22.5)
were recorded with female: male ratio of 3:1. There was no significant difference
between the office workers 19 cases (47.5%) and manual labourers 20(50%). The
majority of the suprapatella effusions 21(84%) were seen in cases above 30 years
of age. The peak was noted at 31-40 years age group with 11 (44%) cases. Only 4
cases (16%) were recorded below 20 years of age. Majority of the cases with
bursitis of the supraprapatella bursa 34 (97.1%) were above 20 years. Two peaks
were recorded 21-30 years age group 10(28.6%) and 51-60 years age group
8(22.9%) cases.
Meniscal pathology: Two patients (1.9%) had menical cysts, 4 (2.8%) meniscitis
and 1 (0.9%) meniscal tear.
Ligaments, tendons and muscles pathology: Sonographic evaluation of the
ligaments of the knee\ showed that 3 (2.8%) had tears, 6(5.6%) had ligamentitis
and 1 (0.9%) had tumor. Two (1.9%) of the patients had Osgood-Schlatters
disease. One (0.9%) case of tendon tear was demonstrated. In the quadriceps
muscle, 3 (2.7%) cases had partial thickness tears, 2(1.8%) haematomas, 1(0.9%)
lipoma and another 1(0.9%) dystrophic calcification .

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 Figure 1A Figure-1B
Figure 1A is a simple effusion shows anechoic fluid in the suprapatella bursa. Fig
1B shows fluid in the suprapatella bursa with internal echoes.

Figure 2A Figure 2B
Fig 2A shows a markedly thickened suprapatella bursa. At colour Doppler
imaging there is increased blood flow which is in keeping with suprapatella
bursitis & fig 2B iIllustrates pannus in the suprapatella bursa in patient with
osteoarthritis of the knee

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 Fig 3A Fig 3B
Figure 3A. Loose bodies in the Bakers cyst with posterior acoustic shadowing.
Figure 3B. Ill definition of the left anterior femoral hyaline cartilage. The right
knee is normal

Fig 4Ai Fig 4A ii

Fig 4Ai, demonstrate impalpable meniscal cyst in the base of the menisci & ii
shows a blood vessel.

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 Fig 4B
Fig 4B: show an ill-defined mixed echogenicity medial meniscus but
predominantly hypoechoic, a crushed meniscus. The arrows are pointing at the
small tears within the meniscus.

Discussion
Ultrasound is an established modality in the diagnosis of knee disorders. In our
series of 107 patients who had U/S of their knees, more females presented for U/S
of the knee than males. This may explained by the statistics of the Uganda
population and housing census of September 2002, where the females 51.1 %3. At
the same time, it is known that a number of women present with arthropathies
following pregnancy, obesity and post-menopausal osteoporosis4.

Knee joint pain and swelling were found to be the commonest clinical
presentations. This was similar to what was observed by Verena T. Valley et al5.
However, we noted that clinical examination alone or attempted blind joint
aspiration could not reliably provide diagnosis. For this reason sonography was
employed and more information was obtained.

We observed that office workers 51(47.7%) had more knee disorders compared to
the manual labourers 43(40.2%). There was a high prevalence of knee disorders
among individuals of working age compared to children and students 13 (12.1%).

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It supports the findings of the prospective case-control study that surgically
treated meniscal injury is associated with sporting activities especially soccer and
rugby and with occupational kneeling and squatting6. In Uganda, rugby and
soccer sports are dominated by the elite group who are also office workers. The
children and students contributed only 12.1% of the total cases seen which is
inversely proportional to the rest of the population of Uganda. Zero to fourteen
years contributes 50.6% of the Ugandan population according to Uganda Housing
and population census 20023. Most of the knee disorders increase with increasing
age.

A spectrum of knee U/S findings were demonstrated. Although we found

degenerative osteoarthrosis occurred in patients of 40 years and above, this
differed from skimmer and Sherger7 who reported that it is usually uncommon in
the age group 41-50. However Uganda has a relatively young age population than
in developed countries. In cases of patients less than 40 years who had knee
osteoarhrosis, there was previous traumatic injury to the knees 5-10 years before
the onset of knee symptoms. U/S was able to detect early degenerative processes
where plain radiographs were reportedly normal.

In septic arthritis, the fluid frequently had a hypoechoic appearance with internal
echoes (particulate appearance)8. All patients with septic arthritis had knee
arthrotomy to confirm the diagnosis. The effusions associated with chronic
inflammatory arthritic conditions, such as rheumatoid arthritis (RA), were often
difficult to differentiate from acute infective arthritis. One sonographic sign of
infection versus a rheumatoid joint is a marked increase in intra-articular fluid
without a concomitant increase in synovial thickness. The amount of joint
effusion is proportionate to the amount of synovial thickening with flaring in
rheumatoid arthritis8. However, septic arthritis cannot be ruled out based solely on
the sonographic appearance9,10. One case reported in this study had rheumatoid
arthritis with positive radiographic features, U/S as well as a positive rheumatoid
factor. Synovial hypertrophy or pannus, are most commonly seen in inflammatory
arthritis, but can also be found in chronic infections (tuberculosis, brucellosis,
Lyme disease, or fungal infection) 8.

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The suprapatellar effusions were seen in 25(23.3%) cases. Ultrasound has a high
accuracy for identification and characterization of joint effusions11,12. Ptasnik13
observed that the presence of increased flow on color or power Doppler imaging
or tenderness during transducer palpation are indicative of an inflammatory state
consistent with true bursitis. Infrapatellar bursitis was reported in 3 (2.8%) cases.
Infrapatellar bursitis, "clergyman's knee," has been reported to be due to kneeling
in the upright posture. It was characteristically noted that more females got the
bursitis compared to males. This could be due to the fact that in most of our
communities, females kneel when greeting or when performing most of the
activities at home. The synonym suggests that this condition is common among
the clergy.

Studies done by Ward et14 al have shown that identification of fluid between the
semimembranosus and medial gastrocnemius tendons in communication with a
posterior knee cyst indicates Baker's cyst with 100% accuracy. In this study, these
features were demonstrated in all cases where the Bakers cyst was found. Among
the complicated cysts, 2(1.9%) had pus which was confirmed at aspiration and
later arthrotomy was done. The knee fluid aspirate in adults cultured
staphylococcus aureus while in a neonate the cultures grew Escherichia coli. One
(0.9%) case of a subcutaneous popliteal cyst mimicked Bakers cyst clinically.
Sonography has been found useful in differentiating between deep venous
thrombosis and ruptured Bakers cyst15. We saw one patient with a ruptured
Bakers cyst. Rupture of a Baker's cyst frequently presents with the sudden onset
of pain in the calf. In addition to this, the sonographic findings
mimic DVT, however Doppler study of the popliteal vein was normal in this case.

Rasmussen16 found out that in acute tendonitis, the tendon appeared swollen and
hypoechoic with loss of the fibrillar structure which correlated with our study
findings. Calcifications may be seen in chronic cases. Two cases (1.9%) of
Osgood- Schlatter disease were recorded in this study. One of the patient was 16
years a boy and the other 18 years, a girl. Literature shows that the disease
predominates in adolescence between 11 and 15 years old 16. In the study done by
De Flaviis et al15 found out that the boys are affected more frequently than girls.

22
Both our patients had a history of participation in sports and a rapid growth spurt
as reported in literature. The condition is bilateral in 25% of patients. The cause of
the condition is thought to be traumatic in origin, resulting in avulsion of
fragments of cartilage and bone from the tibial tuberosity17. Three (2.7%) cases
had partial tears of the quadriceps tendon. Two (1.9%) haematomas cases were
associated with the tears. Our observations at U/S were similar to those described
by Zeiss et al19 and Bianchi et al18.

When haematoma distorts the normal tendon architecture it allows identification

of these injuries as reported by Takebayashi et al20. Typical U/S appearances of
ligament tears were demonstrated in 3 (2.7%) cases as described in literature21.

Meniscal cysts were identified in 3 (2.7%) cases. Literature reveals an underlying

meniscal tear can be identified in some patients, communicating with the meniscal
cyst23. In our documentation, there were no sonographically detected meniscal
cysts co-existing with tears. Various authors indicate the incidence of meniscal
24.
cysts varies from 1 to 20 % Three (2.9%) cases of meniscal tears which were
recorded in this study were a result from a fall on the knee. Reports reveal that
majority of patients with meniscal tears are in their 20s23. One patient was in the
second decade and the other two were in the fourth and fifth decades respectively.
Because the meniscus has such important functions in load bearing and stability of
the knee, loss of this structure in the young is associated with significant
degenerative changes which may be depicted on U/S in addition to meniscal
pathology

Conclusion
The majority of patients at Mulago Hospital with knee pathology have
degenerative disease. Ultrasound provides very useful information on the status of
menisci, ligaments, tendons and muscles in low resourced country like Uganda
where MRI is expensive and accessible only to a few. Knee recesses are best
evaluated by US due to its ability to characterize masses as either fluid or solid.
Application of Doppler study is imperative in cases of suspected ruptured cysts to
differentiate them from DVT. Though U/S has its technical limitations, provides

23
useful diagnostic information which is relevant to subsequent patient
management.

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