The Role of Ultrasound in Sports Medicine

Ciavarra, Gina A.; Adler, Ronald S.

doi:10.1007/978-3-319-14307-1_5

Gina A. Ciavarra MD⁴ &
Ronald S. Adler MD⁴

2516 Accesses

Abstract

The use of ultrasound in musculoskeletal imaging and, in particular, sports medicine has dramatically increased with the technical advances of the last 20 years. These improvements allow detailed evaluation of the structures of the musculoskeletal system including tendons, ligaments, muscles, nerves, joints, cartilage, and bursae. In addition to its wide availability, portability, and lower cost, the greatest advantages of ultrasound, particularly in the musculoskeletal system, are the ability to perform dynamic imaging as well as the opportunity to interact with the patient and correlate symptoms with sonographic findings. The real-time nature of ultrasound provides a unique evaluation of structures in their dynamic state, thereby identifying pathology that may be demonstrated only when the patient performs certain motions.

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POCUS in Sports Medicine

Evolution of Sports Ultrasound

Musculoskeletal Ultrasound

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5.1 Introduction

With advances in ultrasound technology over the last 20 years, the utilization of ultrasound in musculoskeletal imaging and, in particular, sports medicine has dramatically increased. The development of high-frequency transducers has allowed for improved in-plane resolution that is equivalent to and in some cases may exceed that of magnetic resonance imaging (MRI) (Erickson 1997; Jacobson 2002). These improvements have allowed for the more detailed evaluation of the structures of the musculoskeletal system including tendons, ligaments, muscles, nerves, joints, cartilage, and bursae. Both MRI and ultrasound have been shown to have similar efficacy in the assessment of tendon pathology (Bryant et al. 2002; Chang et al. 2002; Davies et al. 1991; Teefey et al. 2000a, b, c, 2004) and other structures in the musculoskeletal system; however, each modality has certain advantages over the other, and they are best used as complementary tools to better serve the needs of the patient (Adler and Finzel 2005; Jacobson 1999). For example, MRI provides a broader assessment of a joint and is particularly useful when the clinical picture may be uncertain. It also allows for the evaluation of structures that cannot be assessed by ultrasound due to inability of the ultrasound beam to penetrate past bone. This is true for the assessment of the bone (beyond the cortical surface) and certain intra-articular structures such as cartilage, fibrocartilage, or ligaments (e.g., the anterior cruciate ligament in the knee). Please refer to the chapter on the use of MRI in sports medicine for further discussion of MRI and its utility in evaluating pathology in the musculoskeletal system.

On the other hand, ultrasound is especially useful when a targeted assessment of a particular structure is requested. Ultrasound has certain distinct advantages over MRI. In addition to its wide availability, portability, and lower cost, the greatest advantages of ultrasound, particularly in the musculoskeletal system, are the ability to perform dynamic imaging as well as the opportunity to interact with the patient and correlate symptoms with the findings at examination. Because MRI is a static examination, some pathology may be missed as routine MRI examinations are performed with the patient in a specific position. Ultrasound allows for dynamic evaluation of structures and can identify pathology that may be demonstrated only when the patient performs certain motions. For example, ulnar nerve subluxation is produced with the elbow joint in flexion; however, standard MRI examinations are performed with the arm in extension, thus limiting the ability of the radiologist to identify the condition. A dynamic ultrasound examination that assesses the nerve through the dynamic range of flexion and extension can identify nerve subluxation.

Some of the pathology identified during the course of imaging may not be associated with patient symptoms. By interacting with the patient, it is possible to determine whether the identified pain is the cause of the patient’s pain or simply an incidental finding.

5.2 Ultrasound of Normal Structures in the Musculoskeletal System

Virtually the entire spectrum of structures within the musculoskeletal system are visible with ultrasound imaging, although some structures may be more readily assessed, and assessed in their entirety, than others. The normal sonographic appearance of tendons is hyperechoic with a fibrillar pattern (Fig. 5.1) which is due to the visualization of the individual tendon fibers that comprise the tendon (Martinoli et al. 1993). This normal appearance is generated when the ultrasound beam is perpendicular to the ultrasound beam. If the beam is positioned at an angle of less than or greater than 90°, the tendon will appear artifactually hypoechoic, mimicking pathology. This characteristic of tendons is known as anisotropy (Fig. 5.2) (Crass et al. 1988). It is the dense, linear arrangement of the fibers that produces anisotropy. As the tendon is imaged at increasing or decreasing angles relative to the perpendicular, it becomes progressively hypoechoic.

Normal muscle appears hypoechoic with internal hyperechoic septations representing the perimysium that surrounds the bundles of muscle fibers (Fig. 5.3) (van Holsbeeck and Introcaso 2001). Muscles can present a characteristic multipennate appearance when viewed in long axis. Ligaments are typically hyperechoic and demonstrate a fibrillar structure similar to that of tendons (Fig. 5.4); however, the individual fibers are more tightly packed. Like tendons, ligaments demonstrate anisotropy when the ultrasound beam is not perpendicular to the structure. When surrounded by echogenic fat, ligaments may appear relatively hypoechoic (Jacobson 2002).

Peripheral nerves demonstrate a fascicular pattern with hypoechoic nerve fascicles surrounded by a hyperechoic connective tissue known as the epineurium (Fig. 5.5) (Silvestri et al. 1995). Only the surface (cortex) of the bone is visible with ultrasound. The cortex is smooth and hyperechoic with posterior acoustic shadowing (Fig. 5.6) (Jacobson 2002).

There are two types of cartilage within the musculoskeletal system, hyaline cartilage that lines the articular surfaces of the joints and fibrocartilage that comprises the labrum of the shoulder and hip and the menisci of the knee. Hyaline cartilage is hypoechoic (Fig. 5.7), while the normal fibrocartilage is hyperechoic (Fig. 5.8) (Kazam et al. 2011; Lee and Bouffard 2001).

5.3 Ultrasound of Pathology in the Musculoskeletal System

5.3.1 Tendons

The pathology of tendons includes tendinosis or tendinopathy, partial tearing, and full-thickness tearing as well as the development of calcific deposits as seen in calcific tendinitis. Tendinosis manifests as abnormalities of both tendon morphology and echogenicity (Adler and Sofka 2003; Kainberger et al. 1990; Sell et al. 1996). There may be hypoechoic linear regions of diminished echogenicity as well as mucoid degeneration manifested by more globular regions of decreased echogenicity (Fig. 5.9). The tendon may be enlarged. In addition, areas of dystrophic calcification or ossification may also be seen (Adler and Finzel 2005).

Tears appear as discretely marginated defects within the tendon involving a portion of the tendon width (partial tear) (Fig. 5.10) or the entire width (full-thickness tear). The defects are well defined and hypoechoic or anechoic in appearance. Because tears and tendinosis can both appear hypoechoic, secondary signs may be necessary in differentiating these two entities (to be discussed later in this chapter) (Teefey et al. 2000a, b, c; Wiener and Seitz 1993).

Occasionally, areas of dystrophic calcification or ossification may develop within a tendon. These calcifications present as linear or globular foci of increased echogenicity with variable degrees of posterior acoustic shadowing (Fig. 5.11) (Adler and Finzel 2005; Farin and Jaroma 1995). The calcification represents deposits of calcium hydroxyapatite.

5.3.2 Muscles

Abnormalities of the muscle in the setting of sports medicine may result from direct or indirect injury. Indirect injury may be caused by stretching of the muscle fibers during muscle contraction or may be due to excessive stretch alone (Speer et al. 1993). There are three grades of injury that may result in this setting. Grade 1 refers to muscle strain without frank tissue disruption. Grade 2 refers to partial-thickness tearing of the muscle. Grade 3 refers to a full-thickness tear of the muscle (Palmer et al. 1999). These types of injuries typically occur at the myotendinous junction and affect muscles that traverse two joints such as the hamstring muscles in the thigh or the gastrocnemius muscle in the calf (Garrett 1996).

Acute muscle injury may be associated with hemorrhage that appears hyperechoic (Fig. 5.12) in the acute setting (Blankenbaker and Tuite 2010; Lee and Healy 2004). Over time, the hematoma becomes more hypoechoic in appearance. Most frequently, hematomas are heterogeneous in appearance with areas of increased and decreased echogenicity (Lee and Healy 2004). Diffuse muscle edema also appears hyperechoic (Adler and Garofalo 2009). Partial tears manifest as incomplete disruption (Fig. 5.12) of the muscle fibers, while complete disruption of the muscle fibers reflects a full-thickness tear (Peetrons 2002). Over time, the muscles may develop granulation tissue that displays vascularity on color or power Doppler flow imaging.

A special subtype of injury occurs when hemorrhage occurs between the deep surface of the subcutaneous fat and the subjacent musculature due to a shear injury, most frequently at the level of the hip. This is known as a Morel-Lavallee lesion (Mellado and Bencardino 2005). On ultrasound, these lesions are heterogeneous in the early stages, with irregular margins. Chronic lesions are smoother in contour and more homogeneous. They may contain hypoechoic or anechoic fluid and may contain echogenic globules of fat (Fig. 5.13). No flow should be demonstrated with color or power Doppler interrogation (Mukherjee et al. 2007; Neal et al. 2008; Parra et al. 1997).

Occasionally, following trauma, the injured muscle may ossify. This appears as a region of increased echogenicity that may show posterior acoustic shadowing (Fig. 5.14). Ultrasound may demonstrate early mineralization before changes are visible on plain radiography (Tyler and Saifuddin 2010).

Finally, a previously injured muscle or a muscle with an injury to its nerve supply may atrophy. This results in decreased muscle volume and increased echogenicity of the affected muscle (Fig. 5.15). Atrophy may also occur in the setting of chronic tear of the associated tendon (Peetrons 2002).

5.3.3 Bones

As previously mentioned, the normal cortex of the bone is smooth and hyperechoic with posterior acoustic shadowing. In the setting of an acute fracture, there is focal discontinuity of the cortex (Fig. 5.16) with or without an associated cortical step-off (Crag et al. 1999). The sonographic appearance of stress fractures includes periosteal reaction with hyperemia on color or power Doppler interrogation. There may hypoechoic periosseous fluid and/or hemorrhage and possible cortical discontinuity (Bodner et al. 2005; Drakonaki and Garbi 2010). Patients will typically report point tenderness with transducer pressure. The presence of modular increased echogenic soft tissue about the fracture site represents callous formation.

5.3.4 Ligaments

Abnormalities of the ligaments include partial and complete tears. Partial tears appear as areas of decreased echogenicity within a thickened ligament with some fibers remaining in continuity. A complete tear manifests as disruption of the ligament fibers or replacement of the fibers by heterogeneous, hypoechoic tissue representing fluid and/or hemorrhage and residual ligament (Fig. 5.17). Occasionally, a hyperechoic fleck of bone can be seen in the setting of an avulsion fracture. Remote sprains are characterized by thickening and enlargement of the ligament possibly associated with focal ossification (Peetrons et al. 2004). Scar remodeling or granulation tissue may appear as hypervascular soft tissue at the site of the tear.

5.3.5 Nerves

Abnormalities of the nerves may be caused by entrapment secondary to ligamentous or fibro-osseous structures or secondary to mass effect from anomalous muscles, tumors, or fluid collections. Alternatively, abnormal motion of a nerve can result in nerve pathology as seen in ulnar nerve subluxation. The abnormal nerve appears enlarged and hypoechoic with loss of the normal fascicular pattern (Fig. 5.18) (Bianchi 2008; Jacobson et al. 2010; Kermarrec et al. 2010). In the setting of a localized nerve injury, a posttraumatic neuroma may form. These appear as discrete hypoechoic nodules.

5.4 Shoulder Ultrasound

5.4.1 Rotator Cuff

The shoulder is the most frequently evaluated joint with sonography. The routine shoulder examination includes the assessment of the rotator cuff tendons (supraspinatus, infraspinatus subscapularis, teres minor), long head of the biceps brachii, and the acromioclavicular joint as well as the performance of dynamic maneuvers to assess for subacromial impingement (Jacobson 2013a). The most commonly affected tendon is the supraspinatus tendon. Pathology of the tendons ranges from tendinosis to full-thickness, full-width tears.

Tendinosis manifests as focal or diffuse decreased echogenicity of the tendon with possible enlargement of the affected tendon (Fig. 5.19) (Adler and Sofka 2003; Kainberger et al. 1990; Sell et al. 1996). Partial tears appear as focal hypoechoic or anechoic defects within the tendon that involve only the bursal or articular surface of the tendon (Fig. 5.20) (Jacobson et al. 2004; van Holsbeeck et al. 1995). Partial tears may also be intrasubstance or interstitial, not extending to the articular or bursal surfaces.

The most commonly encountered partial, articular surface tear involves the anterior supraspinatus tendon distally at its insertion on the greater tuberosity (Fig. 5.20) (Schaeffeler et al. 2011; Tuite et al. 1998). Cortical irregularity or enthesopathic change involving the greater tuberosity may be present related to chronic rotator cuff degeneration (Fig. 5.21). This will not be present in the setting of an acute tear of an otherwise normal tendon or a tear involving the more proximal non-insertional tendon fibers (Jacobson et al. 2004; Wohlwend et al. 1998). In the setting of a partial, articular surface tear, the superficial surface of the tendon may maintain its normal convexity on ultrasound, without associated volume loss (Fig. 5.20) (Jacobson 2013a).

A special subtype of partial articular surface tear involving the most distal, insertional fibers of either the infraspinatus or supraspinatus is known as a rim-rent tear or PASTA lesion when it involves the supraspinatus (partial articular-sided supraspinatus tendon avulsion) (Fig. 5.22). This more frequently affects younger patients, such as athletes (Tuite et al. 1998; Vinson et al. 2007).

Like partial articular surface tears, bursal surface tears also appear hypoechoic or anechoic; however, these tears occur along the more superficial aspect of the tendon (Fig. 5.23) (Jacobson et al. 2004). Tears extending from the bursal surface through the tendon footprint to the greater tuberosity are still considered bursal surface tears (Jacobson 2013a).

Since tendon tears and tendinosis both may appear hypoechoic, secondary findings will be helpful in differentiating these entities. Indirect signs of a tear include diminished thickness of the tendon. In addition, the hypoechoic tear tends to be a more focal and well-defined defect, rather than the ill-defined hypoechoic areas seen in tendinosis (Teefey et al. 2000a, b, c; Wiener and Seitz 1993). The cartilage interface sign may assist in the diagnosis of partial articular surface tears. This finding occurs when the tear contacts the hypoechoic hyaline cartilage along the humeral head, appearing as a hyperechoic curvilinear interface between the tear and the cartilage (Fig. 5.24) (Bouffard et al. 1993). Secondary signs of bursal surface partial tears include tendon thinning and herniation of the subacromial–subdeltoid bursa and peribursal fat into the defect with resultant loss in the normal convexity of the tendon (Fig. 5.25) (Bouffard et al. 1993; Thain and Adler 1999; Wiener and Seitz 1993). Tears may be accentuated in real time by direct compression with the transducer. This maneuver may be helpful when complex material fills the tear or in differentiating partial from full-thickness tears.

Tendinosis and tears of the subscapularis tendon are less common than supraspinatus tears. Partial- and full-thickness tears have similar sonographic appearances as tears of the supraspinatus and infraspinatus tendon. The more common type of tear involves the superior fibers of the subscapularis associated with a tear of the anterior fibers of the supraspinatus. In the setting of a partial-thickness subscapularis tear, the long head biceps brachii tendon may subluxate or dislocate into the substance of the tear (Fig. 5.26). Full-thickness tears of the subscapularis may allow the biceps brachii tendon to dislocate into the glenohumeral joint (Fig. 5.27) (Farin and Jaroma 1996; Morag et al. 2011; Thain and Adler 1999). The multipennate nature of the subscapularis tendon seen in short axis should not be confused with tendon pathology.

5.4.2 Biceps

Biceps tendinosis appears diffusely hypoechoic on ultrasound (Fig. 5.28) (Adler and Sofka 2003; Kainberger et al. 1990; Sell et al. 1996). The biceps tendon may be enlarged, and there may be associated calcification manifesting as echogenic foci with posterior acoustic shadowing (Adler and Finzel 2005). Small calcifications may not shadow and may just appear as discrete echogenic foci. Partial or complete disruption of the tendon may occur. Additionally, linear regions of decreased echogenicity may also be present reflecting interstitial split tears (Thain and Adler 1999). As mentioned above, the biceps tendon may subluxate or dislocate secondary to partial- or full-thickness tears of the subscapularis tendon (Figs. 5.26 and 5.27). The biceps tendon may be perched on the lesser tuberosity in the setting of subluxation or translate more medially in the setting of a full-thickness subscapularis tear. In dynamic ultrasound imaging, placing the shoulder in external rotation can accentuate subluxation and dislocation of the biceps tendon (Farin et al. 1995a). Complete rupture of the biceps tendon results in an empty sheath (Fig. 5.29) (Thain and Adler 1999). Although a trace amount of fluid may normally be seen adjacent to the biceps tendon, when a greater amount of fluid is seen surrounding a focal segment of the tendon, this suggests tenosynovitis (Jacobson 2013a). These findings can be further confirmed with the use of power Doppler that will demonstrate hyperemia in the setting of inflammation as seen in tendinitis and tenosynovitis (Fig. 5.30) (Thoirs et al. 2008). Normal tendons and synovium about the shoulder should demonstrate minimal or no flow with power Doppler interrogation. A branch of the anterior humeral circumflex artery adjacent to the biceps tendon will cause a focus of blood flow on power Doppler imaging that should not be confused with tenosynovitis (Fig. 5.31) (Thain and Adler 1999). Because the biceps tendon sheath communicates with the glenohumeral joint, the joint should be assessed for an effusion so as not to mistake biceps tenosynovitis for normal decompression of joint fluid into the tendon sheath (Zubler et al. 2011).

5.4.3 Calcific Tendinitis

Calcific tendinitis develops due to the deposition of calcium hydroxyapatite in the rotator cuff tendons. The supraspinatus is by far the most frequently affected tendon (80 %); however, the other rotator cuff tendons may also be affected (Bianchi and Martinoli 2007; Bosworth 1941; Mole et al. 1997). It is thought to be the result of local hypoxia within the tendon that results in metaplasia of the tendon and resultant calcification (Uhthoff and Sarkar 1989). Areas of calcification may appear as linear echogenic foci with posterior acoustic shadowing or more globular areas of echogenicity without shadowing (Fig. 5.32). These latter calcifications are typically more symptomatic and associated with hyperemia on power Doppler interrogation (Chiou et al. 2002). These calcifications may be treated with ultrasound-guided aspiration that will be discussed later in this chapter (Farin et al. 1995b; Howard et al. 1993).

5.4.4 Impingement

Impingement syndromes in the shoulder are readily evaluated with dynamic ultrasound imaging. Impingement occurs when the acromiohumeral interval through which the supraspinatus tendon passes is narrowed. This may be due to a thickened coracoacromial ligament, an acromioclavicular joint arthrosis, or a subacromial spur (Farin et al. 1990). On ultrasound, the supraspinatus tendon and subacromial–subdeltoid bursa become entrapped between the greater tuberosity and the structures of the coracoacromial arch (Farin et al. 1990). As the arm is abducted, there may be “bunching” of the supraspinatus tendon and subacromial–subdeltoid bursa as these structures attempt to pass under the coracoacromial arch (Fig. 5.33). There may also be pooling of fluid within the bursa with subacromial–subdeltoid bursitis (Farin et al. 1990). Abnormalities of the supraspinatus tendon may be seen in association with impingement including tendinosis and tears. Similar findings can be seen in subcoracoid impingement where there is narrowing of the coracohumeral interval, resulting in the entrapment of the subscapularis tendon during internal rotation of the shoulder (Troelsen et al. 2007).

5.4.5 Glenoid Labrum

As previously described, the normal glenoid labrum, composed of fibrocartilage, is hyperechoic (Fig. 5.34). The labrum attaches to the adjacent glenoid and appears as a triangular structure (Talijanovic et al. 2000). Degeneration of the labrum appears as diffuse hypoechogenicity, while a tear appears as a discrete hypoechoic or anechoic defect (Tirman et al. 1994). While a portion of the posterior labrum can be visualized when scanning the infraspinatus tendon and the posterior joint recess, the anterior labrum is difficult to assess due to overlying structures. Therefore, MRI with or without intra-articular gadolinium should be considered to evaluate the labrum.

A paralabral cyst is a fluid collection that may develop when fluid from the glenohumeral joint extends through a labral tear into the surrounding tissues (Hashimoto et al. 1994). Around the shoulder, this may result in compression of the suprascapular nerve within the suprascapular or the spinoglenoid notch (Fehrman et al. 1995; Tirman et al. 1994; Tung et al. 2000). The cysts appear as round, anechoic sometimes multiloculated collections that can contain echogenic debris (Fig. 5.35). A communication through the associated labral tear may also be demonstrated. There may be associated atrophy of the infraspinatus or supraspinatus and infraspinatus muscles in the region of the spinoglenoid notch or suprascapular notch cysts, respectively (Fig. 5.36). These cysts may be aspirated under ultrasound guidance (see Sect. 5.10.1) often producing thick, clear material, although the cysts can recur if the underlying labral tear is not repaired.

5.4.6 Fractures

Fractures of the greater tuberosity can be diagnosed during evaluation of the shoulder following trauma. Nondisplaced fractures may be missed at plain radiography. Fractures appear as a focal disruption of the echogenic cortex with an associated step-off (Fig. 5.37) (Patten et al. 1992). There will typically be point tenderness on exam over the fracture site.

5.4.7 Pectoralis Major

Although not routinely evaluated during a shoulder ultrasound examination, the pectoralis major muscle and tendon may be assessed as directed by the patient’s clinical history or symptoms. The normal pectoralis major muscle has three heads, the clavicular, sternal, and abdominal heads. The tendons converge into a single tendon unit to insert on the bicipital groove of the humeral shaft, just lateral to the biceps tendon. The insertion extends over 5 cm in craniocaudal dimension (Rehman and Robinson 2005). Injury of the pectoralis muscle has become more common in high-performance athletes and is seen almost exclusively in men (Weaver et al. 2005). Injuries to the pectoralis include avulsion injuries at the tendon insertion with or without osseous avulsion or injury to the myotendinous junction or muscle belly (Miller 2003). As in the rotator cuff, injuries may be partial or full thickness. The most common injuries are partial tears involving both the sternal and clavicular heads (Connell et al. 1999; Lee et al. 2000). Injuries manifest as hypoechoic or anechoic regions within the tendon, at the myotendinous junction, or within the muscle belly with disruption of the tendon and/or muscle fibers (Fig. 5.38). Retraction indicates a full-thickness tear. There may be associated hematoma that can be hypoechoic or anechoic (Weaver et al. 2005). There may be edema within the more proximal muscle bellies. Dynamic examination may accentuate the site of the tear.

5.5 Elbow Ultrasound

5.5.1 Biceps Brachii

Because many of the ligaments and tendons of the elbow are relatively superficial in location, they are readily evaluated with ultrasound. Evaluation of the distal biceps, however, can be difficult due to its oblique course, anisotropy, and the deeper location of the insertion on the radial tuberosity. Provocative maneuvers and dynamic imaging may be used to better visualize the insertion and to eliminate anisotropy (Fig. 5.39) (Chew and Giuffrè 2005; Miller and Adler 2000). Injuries of the biceps tendon typically occur 1–2 cm proximal to the insertion on the radial tuberosity. Tears can be complete or partial and may be associated with pre-existing tendinosis due to relative hypovascularity of the tendon in this region (Chew and Giuffrè 2005; Vardakas et al. 2001). Mechanical impingement between the radial tuberosity and proximal ulna during pronation may also predispose to biceps tendon tears (Fig. 5.40) (Chew and Giuffrè 2005; Seiler et al. 1995). There may be associated bicipitoradial bursitis manifesting as a hypoechoic fluid collection that may contain internal debris or echoes that insinuates between the insertional fibers of the biceps tendon and the adjacent radial tuberosity (Fig. 5.41) (Sofka and Adler 2004).

With partial tears, there is thickening of and decreased echogenicity within the tendon (Fig. 5.42). This may be difficult to differentiate from tendinosis. There may also be attenuation of the distal tendon in the setting of partial tearing. Tendon retraction will be absent. Dynamic imaging can help elucidate partial tears from tendinosis and nonretracted full-thickness tears (Chew and Giuffrè 2005; Hayter and Adler 2012; Kalume et al. 2009). With full-thickness tears, there will be complete disruption of the tendon fibers with a hypoechoic defect. There may be surrounding edema or hemorrhage in the acute setting (Fig. 5.43). If there is tearing of the bicipital aponeurosis, there will be proximal retraction of the tendon into the arm. This usually occurs in the setting of a single, forceful traumatic injury. Ultrasound may be used to locate the retracted tendon stump (Chew and Giuffrè 2005; Hayter and Adler 2012; Miller and Adler 2000).

5.5.2 Triceps Brachii

Triceps injury may result from direction impaction or tendon avulsion from the olecranon. Tears may be partial or complete, and there may be pre-existing tendinosis or enthesopathy (Fig. 5.44), or there may be associated olecranon bursitis. Tears appear as hypoechoic or anechoic defects in the tendon involving some (partial) or all (complete) of the tendon fibers (Fig. 5.45). There may be tendon retraction in full-thickness tears, and a linear focus of increased echogenicity reflecting an osseous fragment may be present in the setting of bone avulsion (Fig. 5.46). Tendinosis appears as tendon enlargement with decreased echogenicity of the tendon fibers without disruption (Downey et al. 2011; Hayter and Adler 2012; Jacobson 2013b).

5.5.3 Common Flexor and Extensor Tendons

The origins of the flexor and extensor tendons of the hand and wrist originate from the medial and lateral epicondyles, respectively. Disorders of the tendons including tendinosis and tearing are the sequelae of acute, traumatic, and chronic overuse injuries (Hayter and Adler 2012). The term lateral epicondylitis or “tennis elbow” refers to pathology of the common extensor tendons. Although acute or chronic inflammation is lacking, the term epicondylitis continues to be used. The underlying pathology involves tendinosis and tearing of the tendons (Nirschl and Pettrone 1979; Potter et al. 1995). At ultrasound, the tendons appear enlarged and hypoechoic (Connell et al. 2000). There may be foci of internal calcification within the tendon and enthesopathic change at the lateral epicondyle (Hayter and Adler 2012). With power Doppler interrogation, there may be increased vascularity (Tran and Chow 2007). The most commonly and severely affected tendon is the extensor carpi radialis brevis. In the setting of tears, there is partial- or full-thickness discontinuity of the tendon fibers (Fig. 5.47) (Levin et al. 2005).

Medial epicondylitis or “golfer’s elbow” refers to tendinopathy of the common flexor origin. This entity is much less common than lateral epicondylitis and is most frequently seen in overhead, throwing athletes such as baseball pitchers (Kaplan and Potter 2004). The findings of medial epicondylitis are similar to those of lateral epicondylitis (Fig. 5.48) (Kijowski and De Smet 2005; Miller et al. 2002). Ultrasound is useful in assessing both the findings of medial epicondylitis and concomitant pathology of the medial collateral ligament and the ulnar nerve that will be further described below (Martin and Schweitzer 1998).

5.5.4 Medial (Ulnar) Collateral Ligament and Lateral (Radial) Collateral Ligament Complex

The primary stabilizer of the medial elbow against valgus instability is the medial collateral ligament (MCL), composed of anterior, posterior, and transverse/oblique bundles (Morrey and An 1983). The anterior bundle is the most functionally important and frequently evaluated component of the MCL complex, extending from the undersurface of the medial humeral epicondyle to the sublime tubercle of the ulna (Hayter and Adler 2012). This segment of the MCL is the most commonly injured ligament in the elbow and may be injured acutely, or more commonly, as a result of chronic overuse as seen in overhead throwing athletes (Jobe and Nuber 1986). The normal appearance of the anterior bundle of the MCL is a smooth, hyperechoic band of tissue (Fig. 5.49). Due to anisotropy, the ligament may appear hypoechoic (Jacobson et al. 2003; Ward et al. 2003). Sprains of the ligament appear as decreased echogenicity with loss of the normal band-like appearance of the ligament. Partial- and full-thickness tears appear as hypoechoic or anechoic areas of discontinuity in the ligament fibers (Fig. 5.49). In the setting of hemorrhage, it may be difficult to distinguish partial- and full-thickness tears (Miller et al. 2004). Dynamic imaging is helpful in these situations by exerting valgus stress on the elbow in partial flexion and assessing for separation of the torn fibers as well as widening of the medial joint line. The contralateral side may be imaged concurrently to assess for asymmetry (De Smet et al. 2002; Nazarian et al. 2003). In the setting of chronic MCL pathology due to overuse in overhead athletes, the ligament may be thickened and hypoechoic or may become remodeled and elongated due to the repetitive stress (De Smet et al. 2002; Nazarian et al. 2003). In the chronic setting, there may be associated signs of valgus extension overload or posteromedial impingement that can be seen in the throwing athlete. These include common flexor tendinopathy, medial joint line osteophytes, intra-articular bodies, or ulnar neuropathy. Due to increased compressive forces on the lateral joint line, there may be associated radiocapitellar arthritis (Gaary et al. 1997; Hayter and Adler 2012; Kijowski et al. 2005; Wilson et al. 1983).

The lateral collateral ligament complex is composed of the radial collateral ligament (RCL), the lateral ulnar collateral ligament (LUCL), and the annular ligament. The LUCL is the most important stabilizer against varus stress and posterolateral rotatory instability (Olsen et al. 1996). The LUCL originates from the posterior aspect of the lateral humeral epicondyle and curves around the posterior aspect of the radial head to insert on the supinator crest of the ulna. The RCL originates at the lateral humeral epicondyle and inserts along the annular ligament (Hayter and Adler 2012). The RCL and common extensor origin may be difficult to separate when both structures are normal. The normal ligaments should be echogenic and band-like in appearance (Fig. 5.50) (Jacobson 2013b).

The LUCL may be injured acutely following varus extension injury or a traumatic elbow dislocation, such as after a fall on an outstretched hand (Nestor et al. 1992). The ligament may also be injured iatrogenically following overaggressive debridement of the common extensor tendon for the treatment of lateral epicondylitis. In addition, severe cases of lateral epicondylitis may extend into and involve the lateral collateral ligament complex. Disruption of the LUCL results in posterolateral rotatory instability with posterior subluxation of the radial head with respect to the capitellum (O’Driscoll et al. 1992; Walz et al. 2010). Like the UCL, tears of the lateral ligamentous structures manifest as areas of decreased echogenicity with partial or complete disruption of the ligament fibers (Fig. 5.51).

5.5.5 Ulnar Neuropathy

The ulnar nerve traverses the posterior elbow within the cubital tunnel. The cubital retinaculum forms the roof of this tunnel, keeping the nerve within the tunnel through the range of motion of the elbow. Localized ulnar neuropathy at the elbow is known as cubital tunnel syndrome (Hayter and Adler 2012). Causes of ulnar neuropathy include acute trauma, chronic repetitive injury during elbow flexion, ulnar nerve subluxation/dislocation, or the presence of an anconeus epitrochlearis muscle, an anatomic variant present in up to 23 % of the population (Husarik et al. 2009; Jacobson 2013b). With ulnar neuritis, the nerve is abnormally enlarged and diffusely decreased in echogenicity with loss of the normal fascicular pattern (Fig. 5.52) (Hayter and Adler 2012). A cross-sectional area of greater than 9 mm² is considered abnormal (Thoirs et al. 2008). Measurements, however, are not well established for the ulnar nerve.

The role of ultrasound is to evaluate for a potentially treatable cause of ulnar neuritis, to assess for subluxation or dislocation, and to provide guidance for therapeutic injection. Although frequently no cause of compression is seen, other causes besides an anconeus epitrochlearis include synovitis, soft tissue masses, and findings related to valgus extension overload as seen in the throwing athlete, including osteophytes and joint bodies (Wilson et al. 1983).

The advantage of ultrasound over MRI is the ability to perform dynamic imaging. This is particularly important in evaluating for ulnar nerve subluxation where the nerve abnormally dislocates medially over the medial epicondyle during flexion (Fig. 5.53) and “snapping triceps” where the medial head of the triceps subluxates medially during flexion, resulting in medial dislocation of the ulnar nerve. This latter entity has been described in weight lifters (Husarik et al. 2009; Jacobson et al. 2010; O’Driscoll et al. 1991; Okamoto et al. 2000).

5.5.6 Olecranon Bursitis

In addition to bicipitoradial bursitis, olecranon bursitis is readily assessed with ultrasound. In the athlete, this is frequently secondary to trauma. The collapsed bursa is not easily identified; however, in the setting of olecranon bursitis, there will be distension of the bursa with anechoic or hypoechoic fluid that may contain internal debris (Fig. 5.54). If the fluid is more hyperechoic, a hemorrhagic bursitis should be considered (Jacobson 2013b).

5.6 Wrist and Hand (Including Finger) Ultrasound

Ultrasound is an ideal modality for the evaluation of sports-related injuries in the hand and wrist because of the development of high-frequency transducers and the superficial location of the structures (Teefey et al. 2000a, b, c). In addition, dynamic imaging may be performed to identify abnormalities of tendon motion or joint instability.

5.6.1 Scapholunate Ligament

The dorsal component of the scapholunate ligament is the more clinically relevant portion of the ligament and an important stabilizer of the carpus. The dorsal fibers are readily assessed with sonography appearing as a hyperechoic, fibrillar band. Tears appear as focal disruptions of the normal hyperechoic ligament with a focal area of decreased echogenicity (Jacobson et al. 2002). In the setting of chronic, repetitive injury, the ligament may be abnormally thickened and hypoechoic (Jacobson et al. 2002; Renoux et al. 2009). There may be associated widening of the scapholunate interval that may be accentuated with clenching of the fist. A ganglion cyst (Fig. 5.55) may also develop adjacent to the tear with fluid decompressing from the joint through a tear (Cardinal et al. 1994). This may cause compression of the distal portion of the posterior interosseous nerve.

5.6.2 Scaphoid Fracture

Fractures of the scaphoid may also be diagnosed with ultrasound with a fairly high degree of accuracy (Herneth et al. 2001). Findings include focal areas of periosteal reaction and cortical disruption or step-off (Herneth et al. 2001).

5.6.3 Extensor Tendons

Abnormalities of the tendons can be readily assessed with ultrasound including tenosynovitis, tendinosis, and tendon tears. Tenosynovitis refers to distension of the sheath surrounding a tendon with fluid and/or soft tissue (Fig. 5.56). The fluid may be anechoic or more heterogeneous and complex due to synovial hypertrophy, hemorrhage, or debris (Daenen et al. 2004; Teefey et al. 2000a, b, c). In the setting of synovial hypertrophy, there may be hyperemia as demonstrated in color or power Doppler interrogation (Fig. 5.56) (Breidahl et al. 1998; Teefey et al. 2000a, b, c).

Tendinosis manifests as focal or diffuse enlargement of the affected tendon with areas of decreased echogenicity (Fig. 5.56). Foci of calcification may be present (Daenen et al. 2004). Tendon rupture may be partial or complete and appears as a fluid-filled cleft within the affected tendon with disruption of the normal fibers (Fig. 5.57) (Daenen et al. 2004). The fluid may be anechoic or hypoechoic and complex in the setting of hemorrhage due to acute injury. With complete rupture, there may be retraction and separation of the torn ends of the tendon (Daenen et al. 2004).

De Quervain’s tenosynovitis is a common disorder that describes tendinosis and tenosynovitis of the first extensor compartment of the wrist that includes the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. It is frequently seen due to chronic repetitive stress and overuse in athletes, such as tennis players (Daenen et al. 2004). At sonography, there will be tendinosis of the APL and EPB tendons with tendon enlargement and decreased echogenicity with loss of the normal fibrillar pattern. There may be linear foci of decreased echogenicity reflecting interstitial microtears (Daenen et al. 2004). There will be distension of the tendon sheath with anechoic or hypoechoic fluid (Fig. 5.58) (Daenen et al. 2004). This is often accompanied by thickening of the corresponding extensor retinaculum.

The extensor hood stabilizes the extensor tendons of the hand at the level of the metacarpophalangeal (MCP) joints, maintaining them in place through the range of motion during flexion and extension (Kichouh et al. 2011). The sagittal bands are the most important stabilizing structures of the extensor hood (Clavero et al. 2003; Drapé et al. 1994; Scott 2000; Young and Rayan 2000). Ruptures of the sagittal bands can occur following trauma to the MCP joint as seen in “boxer knuckle.” This can result in subluxation or dislocation of the extensor tendon at the level of the MCP joint (Kichouh et al. 2011). On short-axis sonographic imaging, the normal sagittal bands appear as linear hyperechoic bands along both sides of the extensor tendon at the level of the MCP joint (Fig. 5.59) (Kichouh et al. 2011). Injury to the sagittal bands may appear as focal disruption of the normal hyperechoic band and/or focal hypoechoic thickening (Fig. 5.59) (Kichouh et al. 2011). There may be subluxation of the extensor tendon due to the injury. There may also be associated injuries to the extensor tendon itself (Kichouh et al. 2011).

5.6.4 Flexor Tendons

Abnormalities of the flexor tendons of the wrist and hand are similar to those affecting the extensor tendons, including tenosynovitis, tendinosis, and tendon tears. The sonographic findings of flexor tendon pathology are similar to those previously described in the extensor tendons (Fig. 5.60).

5.6.5 Triangular Fibrocartilage

The normal triangular fibrocartilage complex (TFCC) is a hyperechoic structure extending from the base of the ulnar styloid process to the radius. The deeper, radial attachment may be more difficult to see, although utilizing a lower-frequency transducer may help (Chiou et al. 1998; Jacobson 2013c; Taljanovic et al. 2011). The ulnar attachment of the TFCC is located subjacent to the extensor carpi ulnaris tendon. Tears of the TFCC appear as areas of hypoechogenicity, typically linear, or areas of thinning of the TFCC (Fig. 5.61) (Keogh et al. 2004).

5.6.6 Ulnar Collateral Ligament of the Thumb

Injury to the ulnar collateral ligament (UCL) of the thumb is known as gamekeeper’s thumb or skier’s thumb (Moschilla and Breidahl 2002). The normal ulnar collateral ligament of the thumb appears as a hyperechoic fibrillar band along the ulnar aspect of the metacarpophalangeal joint of the thumb (Fig. 5.62). The ligament is located deep to the adductor aponeurosis that appears as a smooth, thin echogenic band. Tears of the UCL appear as partial or complete hypoechoic disruptions with loss of the normal ligament architecture (Fig. 5.62). The ligament may also appear enlarged and hypoechoic (Ebrahim et al. 2006; Jacobson 2013c; Moschilla and Breidahl 2002). The torn ligament may be proximally retracted appearing as a round hypoechoic mass adjacent to the metacarpal head (Hergan et al. 1995). There may be an associated hyperechoic avulsion fragment from the base of the proximal phalanx that remains attached to the torn ligament (Fig. 5.62) (Moschilla and Breidahl 2002).

A subtype of gamekeeper’s thumb is a Stener lesion that is defined as a full-thickness and displaced tear of the UCL. A Stener lesion is present when the torn, retracted UCL displaces superficial to the adductor aponeurosis (Ebrahim et al. 2006). This distinction is clinically relevant as Stener lesions are usually treated with surgery (O’Callaghan et al. 1994). Sonographic images demonstrate a nodular focus of tissue of mixed echogenicity at the level of the metacarpal head reflecting the proximally retracted UCL. The retracted ligament is displaced superficial to the adductor aponeurosis that becomes distorted and bulges with a convex surface due to the overlying retracted ligament (Fig. 5.63) (Ebrahim et al. 2006). The appearance has been referred to as a yo-yo on a string (Ebrahim et al. 2006).

Dynamic imaging with slight valgus stress placed on the MCP joint may help elucidate complete, nonretracted tears from partial tears (Jacobson 2013c).

5.6.7 Finger Pulleys

Ultrasound may also be used to evaluate the pulley system of the fingers (Boutry et al. 2005). The pulleys help to stabilize the flexor tendons during finger flexion and prevent subluxation or bowing (Boutry et al. 2005). The normal pulley (Fig. 5.64) appears as a linear hyperechoic band located superficial to the flexor tendon, although it may appear relatively hypoechoic adjacent to fat (Boutry et al. 2005; Martinoli et al. 2000). They may demonstrate anisotropy (Boutry et al. 2005). The A2 pulley located along the proximal phalanx is the most commonly injured pulley. This injury is typically seen in rock climbers but may be seen in other athletes such as football players (Moschilla and Breidahl 2002). Ultrasound shows focal hypoechoic disruption of the normal hyperechoic pulley. There may be thickening of and diffuse hypoechogenicity within the injured pulley. There will be volar displacement of the flexor tendon that becomes more pronounced during finger flexion known as bowstringing (Fig. 5.64) (Jacobson 2013c; Klausner et al. 2002; Martinoli et al. 2000; Moschilla and Breidahl 2002).

5.6.8 Carpal Tunnel

The carpal tunnel may also be assessed sonographically. Carpal tunnel syndrome is an entrapment neuropathy of the median nerve within the fibro-osseous carpal tunnel (Sernik et al. 2008). Anything that results in decreased size of the tunnel or increase in the tunnel contents may result in compression of the median nerve. These include tenosynovitis of the flexor tendons, masses, or trauma although frequently a cause is not found (Chen and Liang 1997; Duncan et al. 1999).

On imaging, there is enlargement of the median nerve within the carpal tunnel with decreased echogenicity and loss of the normal honeycomb appearance. Enlargement of the nerve of greater than 12 mm² is considered abnormal (Fig. 5.65) (Chen et al. 1997; Klauser et al. 2009). Values between 10 and 12 mm² are indeterminate. There may be flattening of the nerve with bowing of the overlying flexor retinaculum (Chen et al. 1997).

5.6.9 Ganglia of the Wrist and Hand

Ganglion cysts frequently occur in the hand and wrist and may be evaluated sonographically. Most commonly, they occur along the dorsal aspect of the wrist, superficial to the scapholunate ligament (Fig. 5.66) (Bianchi et al. 1994a). Along the volar aspect of the wrist, ganglion cysts commonly occur between the radial artery and flexor carpi radialis tendon (Fig. 5.67) (Bianchi et al. 1994a). Within the fingers, ganglia may occur as retinacular cysts related to the A1 or A2 pulleys. Ultrasound may be used to guide aspiration and therapeutic injection with corticosteroid as a treatment for ganglion cysts (Breidahl and Adler 1996).

5.7 Hip and Thigh Ultrasound

5.7.1 Snapping Hip Syndrome

Snapping hip syndrome is an abnormal snapping or clicking sensation associated with certain hip motions. It is frequently seen in young, athletic adults and is more common in women. There may be pain associated with the snapping sensation (Deslandes et al. 2008). The syndrome can be further subdivided into intra-articular causes, including labral tears, chondral abnormalities, or joint bodies (Fig. 5.68), and extra-articular causes. The extra-articular causes may involve the iliopsoas tendon anteriorly (internal snapping hip) or the iliotibial band and gluteus maximus tendons laterally (external snapping hip) (Choi et al. 2002; Pelsser et al. 2001; Schaberg et al. 1984). Although there may be bursitis and tendinopathy associated with the affected tendons, frequently these findings are absent, and the only abnormality is the pathologic motion of the tendons. The kinematic nature of snapping hip limits the utility of MRI in these patients, making dynamic ultrasound critical to the diagnosis of snapping hip syndromes (Pfirrmann et al. 2008).

Under normal circumstances, the psoas muscle glides laterally, rolling over the medial border of the iliacus muscle. With internal snapping hip, during abduction/flexion/external rotation, the iliopsoas tendon moves abruptly over the iliacus muscle, which becomes entrapped between the tendon and the iliopectineal eminence. As the hip returns to the neutral position, the tendon “snaps” over the muscle onto the subjacent pubic bone (Fig. 5.69) (Deslandes et al. 2008). The tendon may also abruptly flip over the femoral vessels during abduction/flexion/external rotation (Fig. 5.70). In addition to the findings at dynamic imaging, there may be iliopsoas tendinosis with enlargement and decreased echogenicity of the tendon with fluid distension of the bursa (Pelsser et al. 2001).

In the setting of external snapping hip, either the posterior margin of the proximal iliotibial band or the anterior margin of the gluteus maximus tendon snaps over the greater trochanter as the hip moves from flexion to extension. There may be thickening of and decreased echogenicity within the iliotibial band or gluteus maximus tendon, and there may be associated greater trochanteric bursitis (Fig. 5.71) (Pelsser et al. 2001).

5.7.2 Calcific Tendinitis Around the Hip

Although calcific tendinitis and bursitis occur much more frequently in the rotator cuff, tendons about the hip may also be affected, including the gluteus maximus, gluteus medius, and rectus femoris tendons, as well as the greater trochanteric bursa. Imaging findings are similar to those in the rotator cuff with echogenic foci demonstrating posterior acoustic shadowing and possible hyperemia with power Doppler interrogation (Fig. 5.72). As in the rotator cuff, percutaneous aspiration with ultrasound guidance may be employed for treatment (Chiou et al. 2002; Farin et al. 1995b; Howard et al. 1993).

5.7.3 Labral Pathology and Femoroacetabular Impingement

Although traditionally evaluated on MRI, the labrum of the hip can be visualized with ultrasound. It appears as a hyperechoic, triangular structure attached to the anterior rim of the acetabulum (Cho et al. 2000). Tearing of the labrum is suggested by a hypoechoic cleft through the base of the labrum (Fig. 5.73), absence of the labrum, abnormal morphology of the labrum, or paralabral cyst formation (Fig. 5.74) (Troelsen et al. 2007). There are limitations of ultrasound evaluation of the hip labrum due to the depth of the structure and a limited acoustic window (Troelsen et al. 2007, 2009).

Femoroacetabular impingement (FAI) may also be assessed with ultrasound. FAI results from morphologic abnormalities of the proximal femur and/or acetabular rim resulting in abnormal contact between these structures. This may result in labral pathology, premature cartilage loss, and osteoarthrosis (Ganz et al. 2003). In cam-type FAI, there is an abnormal osseous protuberance at the femoral head/neck junction that abuts against the acetabular rim resulting in early cartilage and labral pathology (Buck et al. 2011; Ganz et al. 2008). With sonography, the osseous contour deformity (Fig. 5.75) may be documented as well as potential labral pathology (Buck et al. 2011; Cho et al. 2000). Dynamic imaging allows direct observation of the osseous protuberance along the femoral head/junction abutting the labrum and acetabular rim.

5.7.4 Proximal Hamstring and Quadriceps Injuries

The hamstring and quadriceps muscles and tendons are prone to the same pathology as other muscles and tendons throughout the body. The tendons are prone to tendinopathy that appears as decreased echogenicity and tendon enlargement. There may also be associated dystrophic calcification or ossification (Adler and Finzel 2005). Partial- and full-thickness tears of the tendons may occur with or without distal retraction of the tendons (Fig. 5.76). Injuries to the hamstring tendons may involve the entire hamstring complex or selectively involve the semimembranosus tendon along the lateral border of the ischium or the conjoint tendon posteromedially, composed of the biceps femoris and semitendinosus tendons (Fig. 5.77) (Koulouris and Connell 2005).

Injuries to the muscles may also occur. There are three grades of muscle injury. Grade 1 refers to muscle strain without frank tissue disruption. Grade 2 refers to partial-thickness tearing of the muscle (Fig. 5.78). Grade 3 refers to a full-thickness tear of the muscle (Palmer et al. 1999). These types of injuries typically occur at the myotendinous junction and affect muscles that traverse two joints such as the hamstring muscles and the rectus femoris (Garrett 1996).

In the setting of chronic tendinopathy of the hamstrings, cortical irregularity and pitting may occur at the tendon origin along the ischial tuberosity (Koulouris and Connell 2005; Linklater et al. 2010).

The rectus femoris is the most commonly injured muscle of the quadriceps muscle group. Injuries to the tendon may occur at the origin at the anterior inferior iliac spine. Because the rectus femoris crosses two joints, it is prone to myotendinous junction injuries. These injuries manifest as regions of decreased echogenicity along the central myotendinous aponeurosis within the substance of the muscle (Bianchi et al. 2006). More severe injuries will result in partial or complete disruption of the muscle fibers, appearing as hypoechoic defects that may contain more hyperechoic hemorrhage in the acute setting (Fig. 5.79) (Douis et al. 2011). Infiltrative hemorrhage or edema will make the muscle appear swollen and more echogenic.

Direct impaction of the muscle may result in an intramuscular hematoma, appearing as a hyperechoic ill-defined region initially and becoming more hypoechoic over time (Lee and Healy 2004). This may be complicated by heterotopic ossification in the healing stages (Fleckenstein and Shellock 1991). While strain injuries more frequently involve superficial muscles, direct impact injuries more frequently affect the deeper muscles. Thus, in the thigh, the vastus intermedius muscle that is located immediately adjacent to the femur is the most frequently injured in the setting of direct trauma (Stoller 2007a). Mature myositis ossificans appears sonographically as an echogenic focus or foci with posterior acoustic shadowing within the previously injured muscle (Fig. 5.80) (Abate et al. 2011). In the early phases of injury, painful intramuscular hematomas may be treated with ultrasound-guided aspiration that will be discussed later (Lee and Healy 2004).

5.7.5 Adductor Muscles and Sports Hernia

Injuries of the adductor muscle group most frequently involve the adductor longus at the pubis. These types of injuries most frequently occur in high-level, elite athletes (Shortt et al. 2008). A subtype of injury occurring in this patient population is the “sports hernia” or athletic pubalgia. This involves tendinosis and/or partial tearing of the adductor longus origin with associated pathology of the common aponeurosis between the adductor longus and rectus abdominis. The spectrum of athletic pubalgia also includes pathology of the symphysis pubis including osteitis pubis and parasymphyseal stress injuries (Robinson et al. 2011; Shortt et al. 2008; Zoga et al. 2008). At ultrasound imaging, the adductor longus tendon may be thickened and hypoechoic. A hypoechoic or anechoic cleft may be seen undermining the tendon origin in partial tearing (Fig. 5.81) (Campbell 2013). In complete tearing, the tendon will be retracted distally and a surrounding hematoma of mixed echogenicity may be present in the acute setting (Campbell 2013). Pathology of the symphysis pubis as seen in symphyseal degeneration may include bony irregularity or productive change with adjacent soft tissue calcification (Campbell 2013). Ultrasound is frequently used to guide for therapeutic injections into the symphysis (Campbell 2013).

5.7.6 Abductor and Gluteus Muscles

Historically, lateral hip pain was frequently believed to be the result of trochanteric bursitis. It is now believed that the underlying pathology is most commonly related to tendinopathy of the gluteus medius and minimus tendons, with associated bursitis only rarely present (Kong et al. 2007; Westacott et al. 2011). The complex of symptoms including lateral hip pain, point tenderness over the greater trochanter, and weakness of hip abduction has been termed greater trochanteric pain syndrome (Kong et al. 2007). Other causes of greater trochanteric pain syndrome include hip arthrosis, stress injuries, and referred pain from the spine (Klausner et al. 2013). Although gluteal tendinopathy is most frequently seen in middle-aged women, tendinopathy and tears of these tendons can also be seen in athletes. Ultrasound is useful in the diagnosis of gluteal tendon pathology and may assist in guiding treatment of symptoms, including image-guided therapeutic injections (Klausner et al. 2013). At imaging, the tendons may appear thickened and heterogeneous with hypoechoic areas (Fig. 5.82). Tears manifest as attenuation of the tendons with partial- or full-thickness anechoic defects. Tears most frequently affect the deep fibers of the tendon, specifically the gluteus medius tendon (Klausner et al. 2013), or hypoechoic distension of the bursa may also be present. The individual facets of the greater trochanter may also be identified with ultrasound that allows for precise determination of the affected tendon (Kong et al. 2007). The abductor tendons are a common site of calcific tendinosis and are amenable to percutaneous treatment. It should be noted that multiple bursae exist about the hip abductors. Ultrasound can be valuable in individually targeting these bursae.

5.8 Knee and Calf Ultrasound

5.8.1 Quadriceps Tendon

Anterior knee pain is a frequent problem in athletes. Because the quadriceps and patellar tendons are superficial structures, they are amenable to evaluation with sonography (Friedman et al. 2003). Sonographic findings of tendinosis demonstrate an enlarged tendon with hypoechoic areas without discontinuity of the tendon fibers (Fig. 5.83). Dystrophic calcifications may also be present (Friedman et al. 2003; Pfirrmann et al. 2008). With power or color Doppler interrogation, there may be hyperemia. Regions of hyperemia frequently correspond to symptomatic areas of point tenderness in the patient. Similar to tears involving other tendons, tears of the quadriceps tendon appear as hypoechoic or anechoic defects (Fig. 5.84) involving portions of the tendon (partial thickness) or the entire width of the tendon (full thickness) (La et al. 2003). With full-thickness tears at the tendon insertion, there may be an associated avulsion fracture of the patella appearing as a curvilinear echogenic focus (Fig. 5.85) attached to the torn tendon fibers (Bianchi et al. 2011; Friedman et al. 2003). In cases where hematoma in the tendon gap may be confused with an incomplete tear, dynamic assessment of the tendon in extension and flexion can help identify the edges of the torn tendon (Friedman et al. 2003). These maneuvers will also be useful in subacute and chronic injuries when granulation tissue and fibrous scar tissue fill the gap between the torn fibers, mimicking a partial tear (La et al. 2003).

5.8.2 Patellar Tendon

Patellar tendon pathology is similar to that seen in the quadriceps tendon. The patellar tendon, however, is more prone to injuries, particularly in the young, athletic population (Miller 2013). In patellar tendinopathy, the tendon will appear enlarged and heterogeneous in echotexture with areas of decreased echogenicity. The fibers, nevertheless, remain in continuity. This entity has been referred to as jumper’s knee (Khan et al. 1996). Focal hypoechoic or anechoic defects reflect tears that may involve a portion of the tendon or the full width and thickness of the tendon (Fig. 5.86) (Friedman et al. 2003). With power or color Doppler evaluation, there will be increased vascularity and hyperemia that again corresponds to the more symptomatic area in the patient (Fig. 5.87) (Hoksrud et al. 2008). Dynamic imaging may also be used to accentuate tendon retraction in the setting of a full-thickness tear with gentle flexion of the knee (Friedman et al. 2003).

5.8.3 Iliotibial Band

The iliotibial band friction syndrome is a commonly seen entity in sports medicine. It is most frequently seen in runners, particularly long-distance runners; however, it is also seen in other athletes, especially those who engage in activities involving repetitive knee flexion and extension, such as rowers, cyclists, and football players (Bonaldi et al. 1998). In this disorder, repetitive flexion and extension at the knee result in chronic friction between the iliotibial band (ITB) and the lateral femoral condyle. This results in abnormalities of the ITB and development of ill-defined edema or adventitial bursa formation deep to the ITB (Muhle et al. 1999). At ultrasound, the ITB will be thickened and hypoechoic. Within the intervening fat between the ITB and the lateral femoral condyle, there may be ill-defined hypoechoic edema or a more well-defined anechoic fluid collection reflecting adventitial bursa formation (Fig. 5.88) (Bonaldi et al. 1998).

5.8.4 Medial Collateral Ligament and Other Knee Ligaments

Although the anterior and posterior cruciate ligaments are far better evaluated with magnetic resonance imaging due to their intra-articular location, the superficial ligaments of the knee may be assessed sonographically. The ligaments most amenable to ultrasound evaluation are the medial and lateral collateral ligaments (De Maeseneer et al. 2002). Injuries of the medial collateral ligament (MCL) vary in appearance based on the severity of the injury (Fig. 5.89). Low-grade injuries manifest as periligamentous fluid without fiber disruption. Higher-grade injuries include partial or complete fiber disruption with associated hypoechoic or anechoic fluid separating the torn fibers. Remote injuries result in thickening of the ligament with or without associated calcification (Friedman et al. 2001) Dynamic imaging with gentle valgus stress may be utilized to accentuate the gap between the torn fibers (Lee et al. 1996).

The lateral collateral ligament, an important part of the posterolateral corner complex, may also be evaluated sonographically (Sekiya et al. 2010). The injured ligament will be thickened and hypoechoic or may be discontinuous (Sekiya et al. 2010).

5.8.5 Meniscal Pathology

While comprehensive evaluation of the menisci is limited due to their intra-articular location, ultrasound is capable of diagnosing some tears, particularly those located at the periphery or posterior aspect of the meniscus (Azzoni and Cabitza 2002; Wareluk and Szopinski 2012). The normal meniscus appears as a homogeneous, hyperechoic triangular structure (Grobbelaar and Bouffard 2000). Tears of the menisci present as linear hypoechoic or anechoic clefts within the substance of the meniscus (Friedman et al. 2003). Parameniscal cysts may also be identified with sonography. They appear as hypoechoic or anechoic fluid collections closely apposed to the meniscus. They may be of varying size (Seymour and Lloyd 1998). Often cysts contain varying amounts of internal echogenic debris and may mimic a solid lesion (Fig. 5.90) (Friedman et al. 2003). A communication between the cyst and a meniscal tear may be, but is not always, demonstrated with ultrasound. MRI remains the preferred imaging modality for meniscal evaluation (Azzoni and Cabitza 2002; Friedman et al. 2003).

5.8.6 Gastrocnemius and Plantaris Muscles

Within the calf, one of the most commonly injured muscles is the medial head of the gastrocnemius at the myotendinous junction. This entity has been termed “tennis leg” (Bianchi et al. 1998). Although this more frequently occurs in middle-aged persons involved in sports activities, these injuries may also occur in high-level athletes (Bianchi et al. 1998). Ultrasound is well suited to diagnose tears of the gastrocnemius. In addition, ultrasound is also useful in excluding other disorders that may clinically mimic gastrocnemius tears such as plantaris muscle tears (see below), deep vein thrombosis, ruptured popliteal cysts, or Achilles tendon pathology (Bianchi et al. 1998; Jamadar et al. 2002). The sonographic appearance varies based upon the severity of the injury. On imaging, tears appear as ill-defined hypoechoic areas at the myotendinous junction with varying degrees of muscle fiber disruption (Fig. 5.91). There may be increased echogenicity within the surrounding, intact muscle due to edema (Bianchi et al. 1998; Kwak et al. 2006). Complete tears result in tendon retraction (Bianchi et al. 1998).

The plantaris muscle courses from the lateral femoral condyle between the medial gastrocnemius and soleus muscles, inserting medial to the Achilles along the posterior calcaneus (Jamadar et al. 2002). Tears of the plantaris are less frequent than medial gastrocnemius tears and may simulate clinically injury to the latter muscle (Bianchi et al. 1998). Tears of the plantaris typically occur at the level of the mid-calf. Sonographic evaluation demonstrates discontinuity of the tendon with a surrounding hypoechoic fluid collection located between the medial gastrocnemius and soleus muscles (Fig. 5.92). The fluid collection resulting from a plantaris tear is typically located more proximally within the calf compared to the fluid accumulating following a medial gastrocnemius tear (Khy et al. 2012).

5.8.7 Stress Fractures

Stress fractures of the lower extremity are common in athletes and have increased in frequency in recent years (Khy et al. 2012). These fractures may occur in the femur, tibia, fibula, tarsal bones, and metatarsal bones. MRI is the modality of choice for the diagnosis of stress injuries as its sensitivity and specificity are greater than other modalities in all phases of stress injury, including early injury when plain radiographs may be normal (Khy et al. 2012). Ultrasound has recently been proven useful in the diagnosis of stress fractures in the aforementioned osseous structures where the cortical surface is visible sonographically, such as the anterior tibia (Khy et al. 2012). Sonographic imaging of stress fractures reveals hypoechoic periosteal thickening with a small adjacent hypoechoic fluid collection and soft tissue edema (Fig. 5.93). Hyperemia with color or power Doppler interrogation is also present. Occasionally a focal disruption of the hyperechoic cortex is present. As the healing process progresses, hyperechoic callous formation develops at the fracture site (Bodner et al. 2005; Khy et al. 2012).

5.9 Foot and Ankle Ultrasound

5.9.1 Achilles Tendon

The Achilles tendon is readily examined with ultrasound due to its superficial location. In addition, extended field-of-view imaging allows the entire tendon to be rapidly assessed from the myotendinous junction to the enthesis by extending the range over which the information may be displayed. This technique provides a panoramic image of the tendon to illustrate bony and soft tissue landmarks as well as the relationship of any pathology to the surrounding tissues (Fig. 5.94) (Adler and Finzel 2005; Barbarie et al. 1998). Ultrasound may also be used to assess the peritendinous tissues including the paratenon and the retrocalcaneal bursa.

The pathology of the Achilles includes tendinosis, partial-thickness tearing, and full-thickness tearing. Tendinosis of the Achilles manifests as focal or diffuse, fusiform enlargement of the tendon with areas of decreased echogenicity (Fig. 5.95) (Aström et al. 1996). In addition, hyperemia with power or color Doppler interrogation may be present in the setting of tendinosis due to neovascularity. This finding, not present in a normal tendon, correlates directly with the site of the patient’s symptoms (Fig. 5.96) (Richards et al. 2005). Enlargement of the tendon, greater than 6 mm, is considered abnormal (Bleakney et al. 2007).

Partial-thickness tears appear as focal hypoechoic or anechoic regions within the tendon that involve only some of the tendon fibers. These tears are usually superimposed on a background of tendinosis. Tears may be intrasubstance or extend to a surface (Fig. 5.97) (Bleakney et al. 2007). Enlargement of the tendon, greater than 10 mm, with marked intrasubstance abnormality suggests a partial-thickness tear (Aström et al. 1996).

Full-thickness tears are defined as complete disruption of the Achilles tendon fibers. These most frequently occur approximately 2–6 cm proximal to the enthesis in the critical zone of the tendon, corresponding to a zone of diminished vascularity (Hartgerink et al. 2001). There may be intervening hemorrhage between the torn edges of the tendon. There may also be herniation of adjacent echogenic fat into the gap (Fig. 5.98) (Jacobson et al. 2005). There may be retraction of the torn edges. The use of dynamic ultrasound in the setting of full-thickness tears allows the Achilles tendon to be quickly assessed in both neutral and plantar flexion to assess how closely approximated the torn edges are to determine if the patient may be treated conservatively. One caveat in the evaluation of full-thickness tears is that the plantaris tendon frequently remains intact and may mimic a partial-thickness tear. Thus it is important to track the plantaris in its entirety (Alfredson 2011).

The Achilles tendon does not have a true tendon sheath; however, inflammation of the surrounding tissues may occur resulting in paratenonitis. This manifests as hypoechoic soft tissue swelling surrounding the tendon (Calleja and Connell 2010). Retrocalcaneal or retro-Achilles bursitis may also be present in the setting of Achilles pathology with anechoic fluid distension along the deep or superficial surfaces of the tendon (Fig. 5.99) (Calleja and Connell 2010).

5.9.2 Medial Flexor Tendons

The medial flexor tendons of the ankle include the posterior tibialis (PT), flexor digitorum longus, and flexor hallucis longus. The most frequently encountered pathology involves the posterior tibialis tendon. Tenosynovitis appears as hypoechoic or anechoic fluid distension of the tendon sheath. There may be associated synovial hypertrophy within the fluid that appears more hyperechoic (Fig. 5.100). A small volume of fluid within the PT tendon sheath is normal; however, a volume greater than 5.8 mm indicates PT tendon pathology (Chen and Liang 1997).

Power Doppler can be used to differentiate complex fluid from hypoechoic synovial thickening. The presence of hyperemia with power Doppler imaging indicates the presence of synovial thickening (Breidahl et al. 1998). In the competitive athlete, tenosynovitis is most frequently mechanical or traumatic.

As previously described in other tendons, tendinosis manifests as enlargement of the affected tendon with hypoechoic areas without fiber disruption (Premkumar et al. 2002). The tendon is most frequently abnormal at the level of the medial malleolus (Premkumar et al. 2002). Partial-thickness tears present as hypoechoic or anechoic regions of disruption of the tendon fibers (Kong and Van Der Vliet 2008). A variant of partial tearing of PT tendon is the longitudinal or intrasubstance split tear which results in the appearance of two separate tendon bundles with intervening anechoic or hypoechoic fluid. The tear may be completely intrasubstance or may extend to the tendon surfaces (Fig. 5.101) (Miller et al. 1996). Full-thickness tears involve the entire width of the tendon with retraction of the torn edges and interposed fluid and/or hemorrhage (Miller et al. 1996).

Dynamic sonographic imaging is useful in assessing for posterior tibial tendon subluxation or dislocation that may occur following prior injury to the flexor retinaculum. Because the abnormal motion may be present only following certain ankle motions, this pathology may be missed on static MRI (Prato et al. 2004).

The flexor digitorum longus and flexor hallucis longus tendons are less frequently injured; however, they should be routinely evaluated during a medial ankle examination in an athlete. Flexor hallucis longus (FHL) injuries have been reported in both elite ballet dancers and other athletes involved in running, climbing, or other activities that involve abrupt changes in direction during activity (Sammarco and Cooper 1998). While tears of the tendon may display sonographic appearances similar to other tendon tears, FHL pathology more frequently manifests as tendinosis and tenosynovitis. FHL pathology may also be seen in the setting of posterior impingement due to the presence of a large accessory ossicle posterior to the talus, the os trigonum (Fig. 5.102). This occurs with repetitive, extreme plantar flexion of the ankle (Michelson and Dunn 2005; Sammarco and Cooper 1998). Dynamic evaluation of the FHL may demonstrate impingement. Impingement may also be seen with synovitis in the posterior recess of the tibiotalar joint.

5.9.3 Peroneal Tendons

The pathology of the peroneal tendons is similar to that seen in the medial ankle tendons. This most frequently occurs at the level of the lateral malleolus due to friction of the tendons against the adjacent bone. Tendinosis appears as hypoechoic enlargement of the affected tendon without fiber disruption (Grant et al. 2005). Partial tearing results in hypoechoic or anechoic regions involving a portion of the tendon, while complete tearing involves the entire width of the tendon. Longitudinal split tears may also affect either of the peroneal tendons; however, the peroneus brevis is more frequently affected due to its interposition between the peroneus longus tendon and the fibula (Fig. 5.103) (Grant et al. 2005). While tears of the peroneal tendons more frequently occur at the level of the lateral malleolus, the peroneus longus tendon may tear more distally in association with a fracture of an os peroneum, an intratendinous ossicle normally found within the tendon (Brigido et al. 2005). Separation of the fragments of the ossicle of greater than 6 mm indicates fracture rather than a bipartite os peroneum, which is a normal anatomic variant. The former also indicates full-thickness tearing of the peroneus longus (Brigido et al. 2005).

Tenosynovitis may also involve the peroneal tendons, appearing as distension of the tendon sheath with fluid of varied echogenicity based on the composition and the presence of synovial hypertrophy that results in a more echogenic appearance than simple fluid (Bianchi et al. 2010a). The presence of peritendinous hyperemia indicates the presence of synovial tissue rather than fluid (Breidahl et al. 1998).

Dynamic imaging of the peroneal tendons is important, particularly in the setting of a prior superior peroneal retinaculum injury that can occur following lateral ankle sprain. Injury to the retinaculum may result in subluxation or frank dislocation of the peroneal tendons anterolaterally that may only be demonstrated during dynamic evaluation in dorsiflexion and ankle eversion (Diaz et al. 1998; Neustadter et al. 2004). Another variant of subluxation is termed intrasheath subluxation where the tendons demonstrate abnormal motion with respect to each other but remain located along the posterior margin of the fibula (Fig. 5.104). This is frequently associated with tendinosis and tendon tearing (Thomas et al. 2009).

5.9.4 Anterior Extensor Tendons

The anterior extensor tendons of the ankle are the less frequently injured than both the medial flexor and peroneal tendons. Nevertheless, when abnormal, the imaging characteristics are similar to the other ankle tendons described previously. This pathology includes tendinosis, tenosynovitis, partial tearing, and full-thickness tearing.

Of the extensor tendons, the anterior tibialis (AT) tendon is more frequently injured than the extensor hallucis longus and extensor digitorum tendons. Although chronic pathology of the AT tendon has more frequently been reported in overweight, middle-aged women between the ages of 50 and 70 years, it has also been seen in young athletes involved in uphill or downhill running due to overuse (Mengiardi et al. 2005; Ng et al. 2013). Acute, spontaneous rupture has been seen in other athletes including fencing and cross-country skiing (Ng et al. 2013). Clinically, patients present with a palpable mass related to the retracted tendon and a palpable defect in the tendon (Ng et al. 2013). Penetrating trauma may result in injury of the tendon, possibly due to laceration from a ski boot or hockey skate blade (Ebrahimi et al. 2010). Rupture of the AT tendon most commonly occurs between 5 and 30 mm from the insertion (Fig. 5.105) (Dooley et al. 1980; Geppert et al. 1993; Ouzounian and Anderson 1995). At ultrasound, the torn tendon presents with a gap between the torn edges with thickening of and decreased echogenicity within the tendon stumps. The retracted end may display a refractive shadow.

Because of their superficial location, extensor digitorum longus (EDL) and extensor hallucis longus (EHL) are more frequently injured in the setting of penetrating trauma (Al-Qattan 2007). Sports-related injuries have been reported during ultramarathon running and tae kwon do (Kobayashi et al. 2007; Lee et al. 2009).

Other pathology involving the anterior compartment of the ankle includes muscle hernias, most commonly involving the anterior tibialis muscle. Sonographically, muscle hernias appear as hypoechoic muscle tissue that bows the overlying hyperechoic fascia or extends through a defect in the fascia. A perforating vessel may accompany the hernia. This is frequently due to the sequela of prior trauma. Patients frequently present with a palpable mass that is accentuated with muscle contraction. Dynamic imaging may be necessary to elicit the pathology (Fig. 5.106) (Beggs 2003).

5.9.5 Ligaments of the Ankle

The lateral ligaments of the ankle, specifically the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), are more frequently injured than the medial ligaments, specifically the deltoid ligament. At imaging, the normally hyperechoic band-like ligaments may appear enlarged and hypoechoic in the setting of acute sprain. Partial tearing manifests as a focal hypoechoic or anechoic cleft within the ligament, with some fibers remaining intact. Full-thickness tears are characterized by complete disruption of the ligament fibers with intervening fluid or hemorrhage (Fig. 5.107) (Peetrons et al. 2004). In the setting of an osseous avulsion, a hyperechoic, linear bone fragment remains attached to the torn ligament fibers. Remote ligament injuries may appear as thickening or attenuation of the affected ligament, with possible heterotopic ossification (Hsu et al. 2006; Peetrons et al. 2004).

The ATFL and CFL are readily evaluated sonographically; however, the posterior talofibular ligament (PTFL) is not well assessed, as it is partially obscured by the lateral malleolus (Peetrons et al. 2004).

The major medial ankle ligament, the deltoid ligament, is more difficult to image sonographically because it is composed of multiple ligaments that form the superficial and deep components. Everting and dorsiflexing the ankle allow for an improved acoustic window to evaluate the ligament. Injuries to the ligament appear similar sonographically to lateral ligament injuries (Fig. 5.108) (Adler et al. 2004; Peetrons et al. 2004).

Injuries to the syndesmotic ligaments may also be imaged sonographically, in particular the anterior tibiofibular ligament. The appearance of the injured anterior tibiofibular ligament is similar to that of the ATFL, CFL, and deltoid ligaments with fiber disruption in the setting of a tear and hypoechoic thickening in the setting of an acute sprain (Peetrons et al. 2004). Dynamic imaging with the ankle in dorsiflexion and eversion may produce widening of the interspace between the distal tibia and fibula (Peetrons et al. 2004). This injury has been termed a “high ankle sprain,” and if undiagnosed, it may result in persistent anterolateral ankle pain (Peetrons et al. 2004).

5.9.6 Plantar Fascia

The normal plantar fascia appears as a hyperechoic, fibrillar structure similar to normal tendons. The fascia attaches to the plantar surface of the calcaneus and normally measures 3–4 mm (Rawool and Nazarian 2000). In the setting of plantar fasciitis, the fascia is thickened greater than 4 mm and is hypoechoic. Tears may be present manifesting as hypoechoic or anechoic clefts involving some or all of the fascia fibers (Fig. 5.109) (Cardinal et al. 1996; Rawool and Nazarian 2000).

5.9.7 Plantar Plate and Turf Toe

The plantar plates of the great toe and lesser toes may be assessed sonographically. The normal sonographic appearance of the plantar plate is a hyperechoic band of tissue extending from the head of the metatarsal to the base of the proximal phalanx in the lesser toes (Fig. 5.110) (Klein et al. 2012). In the great toe, the anatomy is more complex and includes the intersesamoidal ligaments, the metatarsosesamoid ligaments, the plantar plate, and the sesamoid–phalangeal ligaments (Stoller 2007b). Like ligaments elsewhere in the body, these ligaments appear as echogenic, band-like structures (Jacobson 2002). When abnormal, the plantar plate may appear inhomogeneous and hypoechoic with hypoechoic or anechoic focal clefts or defects reflecting tears. The tears in the lesser toes most frequently occur at the distal insertion at the base of the proximal phalanx (Fig. 5.111) (Klein et al. 2012). Tears may be accentuated with dynamic imaging of the toe in dorsiflexion (Klein et al. 2012). Tears of the plantar plate complex in the great toe more frequently occur at the metatarsal neck (Stoller 2007b).

5.9.8 Stress Fractures

As stated above, MRI is the modality of choice for the diagnosis of stress injuries due to its greater sensitivity and specificity in all stages of stress injury, particularly when plain radiographs are normal (Khy et al. 2012). Nevertheless, ultrasound has been shown to be beneficial in the diagnosis of stress fractures in the metatarsal bones. Sonographically, stress fractures demonstrate hypoechoic periosteal thickening with a small adjacent hypoechoic fluid collection and soft tissue edema (Fig. 5.112). Hyperemia with color or power Doppler interrogation is also present. Occasionally, a focal disruption of the hyperechoic cortex is present (Fig. 5.113). As the healing process progresses, hyperechoic callous formation develops at the fracture site (Fig. 5.112) (Bodner et al. 2005; Khy et al. 2012). Patients will report point tenderness with transducer pressure.

5.9.9 Ganglia of the Foot and Ankle

The most frequently encountered mass in the foot and ankle is a ganglion cyst. Like in the hand and wrist, these cysts are usually anechoic with posterior acoustic enhancement (Fig. 5.114). Sometimes, particularly after trauma, the cyst may appear more complex, multiloculated, and hypoechoic. Cysts may communicate with joints or tendon sheaths in the foot and ankle. No internal flow should be present with power or color Doppler interrogation (Ortega et al. 2002). As in the hand and wrist, ganglia may be safely aspirated percutaneously with ultrasound guidance.

5.10 Percutaneous Ultrasound-Guided Interventions in Sports Medicine

A full discussion of musculoskeletal ultrasound-guided interventional procedures and techniques is beyond the scope of this chapter. Nevertheless, a number of interventional procedures that are useful in the treatment of athletes deserve mention.

The real-time nature of ultrasound makes it ideally suited to provide guidance for a variety of musculoskeletal interventions (Adler and Sofka 2003; Brophy et al. 1995; Cardinal et al. 1998; Christensen et al. 1988; Cunnane et al. 1996; Davidson and Jayaraman 2011; Grassi et al. 2001; Koski 2000; Sofka et al. 2001). Continuous observation of the needle ensures accurate needle placement and appropriate distribution of the injected and/or aspirated material (Fig. 5.115). Needles can be positioned close to neurovascular bundles without damaging nerves or vessels (Fig. 5.116).

The current generation of high-frequency small parts transducers allows excellent depiction of soft tissue details and articular surfaces, particularly in the hand, wrist, foot, and ankle (Ahmed and Nazarian 2010), facilitating exact needle insertion into nondistended structures, such as joints, tendon sheaths, or bursae. Injected fluid produces a contrast effect, which improves delineation of adjacent structures (e.g., labral morphology) and shows the distribution of the injected material (Koski et al. 2005; Luchs et al. 2007). The advent of newer technology that permits image registration to other modalities, such as computed tomography or MRI, is expected to enhance further the role of ultrasound in performing a broad variety of interventions (Krücker et al. 2011). Ultrasound guidance to target sites of maximal tendon and/or muscle pathology has been used to administer growth factors using platelet-rich plasma (PRP) or autologous blood (Connell et al. 2006; de Vos et al. 2010; James et al. 2007; Mishra and Pavelko 2006; Peerbooms et al. 2010). Ultrasound guidance does not involve ionizing radiation, and this is an advantage in the pediatric and adolescent population.

5.10.1 Ultrasound-Guided Therapeutic Injections/Aspirations into Joints and Tendon Sheaths

The most common clinical indication for ultrasound-guided injections generally relates to pain that has failed to respond to conservative measures, regardless of the anatomic site. The pain may be the result of a chronic repetitive or an acute sports-related injury. These injections may be performed within or around joints (Fig. 5.115) or surrounding tendons (Fig. 5.117). Bursae and ganglia may also be aspirated and injected. Ultrasound guidance is effective in ensuring that the needle tip is correctly placed prior to injection of the therapeutic mixture.

Most injections use long-acting corticosteroid in combination with local anesthetic in relatively small volumes. A detailed review of these agents is beyond the scope of this chapter. Examples of the corticosteroids utilized are triamcinolone, methylprednisolone, betamethasone, and dexamethasone.

The most commonly used anesthetics are lidocaine and bupivacaine (i.e., Marcaine) (Cox et al. 2003; Kamath et al. 2008; MacMahon et al. 2009). They are both local injectable anesthetics but differ in the onset and duration of action. Lidocaine has rapid onset (seconds) and short duration (1–2 h). Bupivacaine becomes effective in 5–10 min and generally lasts 4–6 h.

A test injection with 1 % lidocaine (Fig. 5.118) shows bright echoes filling the joint or tendon sheath demonstrating appropriate location of the needle tip. This will prevent injection of the therapeutic mixture directly into a tendon during peritendinous injections (Fig. 5.117). Intratendinous injections have been associated with tendon rupture as has been reported with blind injections of the plantar fascia. Blind injections into the heel have been associated with rupture of the plantar fascia and failure of the longitudinal arch (Kim et al. 2010). Occasionally, abnormalities such as tendon tears, following intrasheath injections, or intra-articular pathology, such as labral tears, after joint injections may become more visible following distension with the injected material, similar to MR arthrography (Fig. 5.119).

5.10.2 Bursal and Ganglion Cyst Injections

Distended bursae provide anatomic targets for therapeutic injections. Injections are often requested for localized bursitis with or without tendon abnormality. Alternatively, bursitis or a distended synovial cyst or ganglion cyst may cause mechanical impingement of adjacent tendons and/or neurovascular structures as seen in the setting of paralabral cysts in the shoulder. Cyst decompression and administration of a therapeutic agent may alleviate symptoms. Ultrasound guidance avoids intratendinous injections and adjacent neurovascular structures (Figs. 5.120 and 5.121), and the needle may be redirected as necessary in a multiloculated cyst (Aina et al. 2001; Farin et al. 1996).

5.10.3 Calcific Tendonitis

Symptomatic intra- or peritendinous deposition of calcium hydroxyapatite often appears as a nodular echogenic mass within or adjacent to the tendon and may or may not display posterior acoustic shadowing. Calcific tendonitis most often occurs in the shoulder but may occur elsewhere in the musculoskeletal system as described above. Ultrasound-guided fragmentation and lavage have been described (Jensen et al. 2008; Lin et al. 2007; Rabago et al. 2009) with excellent results reported.

Injection of small aliquots (1–2 cc) of saline into the calcification results in distension, followed by the release of pressure and subsequent decompression back into the syringe, releasing calcium from the deposit. The returning fluid often has the appearance of a “puff of smoke,” as it contains progressive amounts of calcific debris (Fig. 5.122).

The needle is then used to fenestrate the pseudocapsule and to inject anesthetic and steroid mixture into the subdeltoid bursa. If the calcification is too small or too fragmented to allow lavage and decompression, an effective technique is to fenestrate the calcium deposit and perform a peritendinous therapeutic injection (Rabago et al. 2009).

5.10.4 Intratendinous Injections/Percutaneous Dry Needling Techniques

Intratendinous injection therapies are thought to promote a direct healing response. These techniques date back to as early as the 1930s in the case of prolotherapy and to the 1970s in the case of autologous blood/PRP injections (Mehdizade and Adler 2007). Ultrasound imaging is believed to ensure optimal deposition of injected material and can be used to assess the distribution of injected material and the response to therapy (Fig. 5.123).

Dry needling (i.e., multiple needle perforations of the tendon without injection of therapeutic material) can promote a healing response, which has been postulated to relate to the presence of microhemorrhage with the release of platelets (de Mos et al. 2008).

Autologous blood or platelet concentrates derived from autologous blood take advantage of a variety of growth factors contained within platelets that promote vascular and cellular proliferation. Platelet-rich plasma, in particular, allows for the delivery of high concentrations of these growth factors to the area of injury (Foster et al. 2009; Klauser et al. 2010). Theoretically, PRP has the potential to improve tendon healing. It contains a more concentrated amount of platelets than whole blood and includes many reparative growth factors such as platelet-derived growth factor, transforming growth factor-beta, epidermal growth factor, and vascular endothelial growth factor. Clinical studies have suggested that autologous blood or PRP significantly improves healing in refractory tendinosis, although definitive studies showing the efficacy of either technique are still lacking (Connell et al. 2006; James et al. 2007; Klauser et al. 2010; Mishra and Pavelko 2006; Peerbooms et al. 2010). Dry needling techniques have been employed successfully in patients with lateral epicondylitis refractory to other conservative measures (de Mos et al. 2008). Autologous blood and PRP injections have been successfully used in the elbow and knee (Connell et al. 2006; James et al. 2007). The advantage of performing these procedures under ultrasound guidance becomes evident when injecting tendons close to neurovascular structures, such as the hamstring tendon origin.

5.10.5 Perineural Injections

Ultrasound has shown promise in evaluating and treating patients with painful lesions of peripheral nerves due to compressive neuropathies (Speed 2007; Tagliafico et al. 2010a, 2012). Injections include nerve blocks with long-acting anesthetic, therapeutic injections (Fig. 5.124) using an injectable steroid, or neurolytic therapy with an agent that promotes cellular death such as absolute ethanol (Chua et al. 2011; Ramamurthy et al. 1989; Sabharwal et al. 2009; Tagliafico et al. 2010b). A thorough knowledge of the normal sonographic appearances of nerves and their anatomic course is a prerequisite (Martinoli 2010). In the case of small sensory nerves, which can be difficult to visualize, knowledge of the anatomic relationships of the nerves to adjacent anatomic compartments is of value. As previously described, nerves are best visualized in short axis as clusters of hypoechoic fascicles with echogenic septations (endoneurium), which have a surrounding echogenic epineurial sleeve. An enlarged hypoechoic nerve may indicate neuritis.

5.10.6 Percutaneous Tenotomy

A promising new technique is percutaneous tenotomy with ultrasound guidance termed “fasciotomy and surgical tenotomy” (FAST) (Koh et al. 2013). This technique has been described in the treatment of chronic elbow tendinopathy (lateral epicondylitis). A detailed discussion of the technique is beyond the scope of this chapter; however, the procedure involves placement of a small device through a skin incision under ultrasound guidance into an area of tendinopathy to debride and remove the diseased tissue (Fig. 5.125) (Barnes 2011; Koh et al. 2013). The use of ultrasound allows for targeting and removal of the pathologic tissue without damage to the surrounding normal tissue (Koh et al. 2013). Recent studies have shown similar efficacy and results to arthroscopic tenotomy with few complications (Koh et al. 2013). Candidates for the FAST procedure are those who have failed conservative therapy (Koh et al. 2013). FAST is now being used to treat recalcitrant tendinopathy elsewhere in the body (Koh et al. 2013).

5.10.7 Summary

Ultrasound provides several distinct advantages as a guidance method for therapeutic injections. Observing and adjusting the needle position in real time ensures that therapeutic injections are delivered accurately and other structures such as neurovascular bundles are avoided. As clinical examples have shown, the current generation of ultrasound scanners provides excellent depiction of the relevant anatomy. The needle has a unique sonographic appearance and can be monitored in real time, as can the steroid–anesthetic injection. The same principles apply to ultrasound-guided aspirations and biopsies. Given these advantages, ultrasound guidance should be the method of choice to perform a large variety of guided musculoskeletal interventions.

5.11 Conclusion

In summary, ultrasound is an extremely useful tool in the evaluation of sports-related injuries due to its wide availability as well as the ability to perform dynamic imaging while interacting with the patient and correlating symptoms with findings at imaging. A wide spectrum of structures in the musculoskeletal system is amenable to detailed evaluation, including tendons, ligaments, muscles, nerves, joints, cartilage, and bursae. In addition, the lack of radiation makes ultrasound a desirable modality to use in the young, athletic population for both diagnosis and guidance of therapeutic interventions. The real-time nature of ultrasound and the ability to identify soft tissue structures sonographically allow for a greater flexibility in treating a wide range of musculoskeletal disorders percutaneously. With continued advances in technology, image quality and the diagnostic capabilities of ultrasound will continue to expand.

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Department of Radiology, NYU Langone Medical Center, New York, NY, USA
Gina A. Ciavarra MD & Ronald S. Adler MD

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Gina A. Ciavarra MD
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Ronald S. Adler MD
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Correspondence to Gina A. Ciavarra MD .

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Department of Radiology, Boston University School of Medicine , Boston, Massachusetts, USA
Ali Guermazi
Department of Radiology, Boston University School of Medicine , Boston, Massachusetts, USA
Frank W. Roemer
Department of Radiology, Boston University School of Medicine , Boston, Massachusetts, USA
Michel D. Crema

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Ciavarra, G.A., Adler, R.S. (2016). The Role of Ultrasound in Sports Medicine. In: Guermazi, A., Roemer, F., Crema, M. (eds) Imaging in Sports-Specific Musculoskeletal Injuries. Springer, Cham. https://doi.org/10.1007/978-3-319-14307-1_5

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