Musculoskeletal

Ultrasound in Orthopedic
and Rheumatic disease in
Adults

Fabio Martino
Enzo Silvestri
Davide Orlandi
Editors

123
Musculoskeletal Ultrasound in
Orthopedic and Rheumatic
disease in Adults
Fabio Martino • Enzo Silvestri
Davide Orlandi
Editors

Musculoskeletal
Ultrasound in
Orthopedic and
Rheumatic disease
in Adults
Editors
Fabio Martino Enzo Silvestri
Radiology Radiology
Sant’Agata Diagnostic Center Alliance Medical
Bari, Italy Genova, Genova, Italy

Davide Orlandi
Department of Radiology
Ospedale Evangelico Internazionale
Genova, Genova, Italy

ISBN 978-3-030-91201-7    ISBN 978-3-030-91202-4 (eBook)

https://doi.org/10.1007/978-3-030-91202-4

© Springer Nature Switzerland AG 2022

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Foreword

It is my great honor to write a preface for the book of my dear friends Martino,
Silvestri, and Orlandi.
Some may think that in 2021, a text on ultrasonography might be no lon-
ger necessary. Having read the book, I must say that I am, on the contrary,
deeply convinced that it is extremely relevant and useful.
The combination of images and diagrams, both anatomical and pathologi-
cal, allows for a clear understanding of even the most complicated anatomy
and the most sophisticated semiotics and eases the comprehension of the ele-
ments, which lead to a clear differential diagnosis among different
pathologies.
This text addresses with great didactic ability the various diagnostic chal-
lenges and most importantly has a very contemporary conception and effi-
cient chapter organization; moreover, the presence of illustrative didactic
diagrams is highly effective.
The goal, in my opinion, has been fully achieved.
On top of everything already said, I must add that the three editors possess
great experience and unquestionable knowledge and come from an Italian
school, which across the years has engaged with the orthopedic, rheumato-
logic, and surgical worlds in extremely high-level international settings.
The confrontation and exchange with other specialists emerge clearly in
the way the diagnostic challenges are approached from a clinical point of
view, keeping a watchful eye on the subsequent therapeutical options.
In this text, ultrasonography is not only dignified but also raised to an
exceptionally high level, comparable in its specificity to that of other diagnos-
tic methods.
In conclusion, I would like to thank my friends for the effort they have
made, whose outcome is a book of absolute value that will remain among the
“important” ones.

Carlo Masciocchi
Direttore della U.O.C. di Radiologia universitaria
del P.O. San Salvatore della suddetta ASL e della
U.O. di Radioterapia dell’Ospedale San Salvatore dell’Aquila,
L’Aquila, Italy

v
Contents

Part I Sonographic Semiology in Musculoskeletal Pathologic

Involvement

1 Osseous and Cartilaginous Surface������������������������������������������������   3

Enzo Silvestri, Davide Orlandi, and Elena Massone
2 Synovial Spaces�������������������������������������������������������������������������������� 11
Davide Orlandi, Enzo Silvestri, and Alessandro Muda
3 Tendons and Ligaments������������������������������������������������������������������ 27
Davide Orlandi, Umberto Viglino, and Elena Massone
4 Muscles���������������������������������������������������������������������������������������������� 49
Davide Orlandi, Enzo Silvestri, and Matteo De Cesari
5 Peripheral Nerves���������������������������������������������������������������������������� 61
Enzo Silvestri, Davide Orlandi, and Elena Massone
6 Dermis and Hypodermis������������������������������������������������������������������ 67
Davide Orlandi, Enzo Silvestri, and Alessandro Muda

Part II Ultrasound Pathologic Findings in Rheumatic Diseases

7 Osteoarthritis������������������������������������������������������������������������������������ 73
Marco Di Carlo, Edoardo Cipolletta, Emilio Filippucci,
and Fabio Martino
8 Rheumatoid Arthritis���������������������������������������������������������������������� 81
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino
9 Seronegative Spondyloarthritis������������������������������������������������������ 91
Edoardo Cipolletta, Marco Di Carlo, Emilio Filippucci,
and Fabio Martino
10 Crystal-Related Arthropathies������������������������������������������������������� 101
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino
11 Connective Tissue Disorders ���������������������������������������������������������� 113
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino

vii
viii Contents

12 Metabolic Diseases �������������������������������������������������������������������������� 119

Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino
13 Synovial Osteochondromatosis ������������������������������������������������������ 121
Alessandro Muda and Fabio Martino
14 Pigmented Villonodular Synovitis�������������������������������������������������� 125
Alessandro Muda and Fabio Martino
15 Shoulder Calcific Tendinopathy����������������������������������������������������� 129
Gianluigi Martino, Enzo Silvestri, Davide Orlandi,
Alessandro Muda, and Fabio Martino
16 Frozen Shoulder ������������������������������������������������������������������������������ 137
Enzo Silvestri, Davide Orlandi, Alessandro Muda,
and Fabio Martino
17 Septic Arthritis �������������������������������������������������������������������������������� 143
Alessandro Muda and Fabio Martino
18 Hemophiliac Arthropathy �������������������������������������������������������������� 149
Alessandro Muda and Fabio Martino

Part III Ultrasound Pathologic Findings in Orthopedic Diseases

19 Bone Trauma������������������������������������������������������������������������������������ 157

Luca Cavagnaro, Davide Orlandi, Enzo Silvestri,
Armanda De Marchi, and Elena Massone
20 Muscle Injury ���������������������������������������������������������������������������������� 163
Giulio Pasta, Davide Orlandi, Enzo Silvestri, Biagio Moretti,
Lorenzo Moretti, Davide Bizzoca, Piero Volpi,
and Gian Nicola Bisciotti
21 Tendon Trauma�������������������������������������������������������������������������������� 177
Umberto Viglino, Davide Orlandi, Alberto Aliprandi,
and Elena Massone
22 Superficial Interosseous Ligament Injury ������������������������������������ 185
Enzo Silvestri, Davide Orlandi, Elena Massone,
and Ernesto La Paglia
23 Peripheral Entrapment Neuropathies�������������������������������������������� 193
Salvatore Guarino, Davide Orlandi, Enzo Silvestri,
and Marcello Zappia

Part IV Ultrasound in Healing Evaluation and in Therapy Monitoring

24 Bone Fracture Healing�������������������������������������������������������������������� 215

Armanda De Marchi, Davide Orlandi, Enzo Silvestri,
Luca Cavagnaro, and Alessandro Muda
Contents ix

25 Tendon and Muscle Rupture Repair���������������������������������������������� 219

Giovanni Rusconi, Giulio Pasta, Davide Orlandi,
Enzo Silvestri, and Francesco Di Pietto
26 Therapy Efficacy Evaluation in Synovitis ������������������������������������ 233
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino

Part V Generalities in Ultrasound-guided Procedures

27 Introduction�������������������������������������������������������������������������������������� 251
Carlo Faletti, Davide Orlandi, and Enzo Silvestri
28 Joint and Bursal Infiltration ���������������������������������������������������������� 253
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
Fabio Martino, Enzo Silvestri, and Davide Orlandi
29 Tendon Infiltrative and Regenerative Treatments������������������������ 267
Davide Orlandi, Elena Massone, and Enzo Silvestri
30 Shoulder Calcific Tendinitis Treatment ���������������������������������������� 273
Massimo De Filippo, Fabio Martino, and Francesco Pagnini
31 Peripheral Nerve Block ������������������������������������������������������������������ 279
Giuseppe Sepolvere, Mario Tedesco, and Davide Orlandi
32 Fluid Collection Evacuation������������������������������������������������������������ 293
Ernesto La Paglia, Enzo Silvestri, and Davide Orlandi

Index�������������������������������������������������������������������������������������������������������� 297
Contributors

Alberto Aliprandi Responsabile Servizio di Radiologia, Istituti Clinici

Zucchi, Monza (MB), Italy
Gian Nicola Bisciotti Kinemove Rehabilitation Centers, Pontremoli (SP),
Italy
Davide Bizzoca Orthopedic & Trauma Unit, Department of Basic Medical
Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”,
AOU Consorziale “Policlinico”, Bari, Italy
Marco Di Carlo Clinica Reumatologica, Dipartimento di Scienze Cliniche
e Molecolari, Università Politecnica delle Marche, Jesi (Ancona), Italy
Marina Carotti Clinica di Radiologia, Dipartimento di Scienze
Radiologiche – Azienda Ospedali Riuniti di Ancona Universita’ Politecnica
delle Marche, Ancona, Italy
Luca Cavagnaro Ortopedia e Traumatologia 2- Joint Replacement, Unit/
Bone Infection Unit, Ospedale Santa Corona, Pietra Ligure (SV), Italy
Matteo De Cesari Department of Radiology, Ospedali del Tigullio, Lavagna,
Italy
Edoardo Cipolletta Clinica Reumatologica, Dipartimento di Scienze Cliniche
e Molecolari, Università Politecnica delle Marche, Jesi (Ancona), Italy
Carlo Faletti Direttore tecnico Radiodiagnostica Centro Diagnostico
Cernaia, Asti Direttore scientifico Master MSK di II livello, Università degli
studi di Torino, Turin, Italy
Massimo De Filippo Director of Diagnostic an Interventional Unit, Azienda
Ospedaliero-Universitaria di Parma, Parma, Italy
Professor of Radiology, Department of Medicine and Surgery, University of
Parma, Parma, Italy
Emilio Filippucci Clinica Reumatologica, Dipartimento di Scienze Cliniche
e Molecolari, Università Politecnica delle Marche, Jesi (Ancona), Italy
Salvatore Guarino Department of Radiology, Monaldi Hospital, AORN
Ospedali dei Colli, Naples, Italy
Armanda De Marchi Radiologia CIDIMU: Centro Italiano di Diagnostica
Medica Ultrasonica, Torino, Italy

xi
xii Contributors

Department of Imaging, Azienda Ospedaliera Città della Salute e della

Scienza, CTO Hospital, Torino, Italy
Fabio Martino Radiology, Sant’Agata Diagnostic Center, Bari, Italy
Radiologist Diagnostic an Interventional Unit, Azienda Ospedaliero-
Universitaria di Parma, Parma, Italy
Gianluigi Martino Institute of Radiology, University of Bari, Bari, Italy
Elena Massone Postgraduate School of Radiology, Genoa University,
Genova, Italy
Department of Radiology, Ospedale Santa Corona, Pietra Ligure (SV), Italy
Biagio Moretti Orthopedic & Trauma Unit, Department of Basic Medical
Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”,
AOU Consorziale “Policlinico”, Bari, Italy
Lorenzo Moretti Orthopedic & Trauma Unit, Department of Basic Medical
Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”,
AOU Consorziale “Policlinico”, Bari, Italy
Alessandro Muda Department of Radiology, IRCCS Policlinico San
Martino-IST, Genova, Italy

Davide Orlandi Radiology, Alliance Medical, Genova, Italy

Department of Radiology, Ospedale Evangelico Internazionale, Genova, Italy
Radiology Unit, Ospedale Evangelico Internazionale, Genova, Italy
Department of Diagnostic Imaging, Ospedale Evangelico Internazionale,
Genova, Italy
Ernesto La Paglia Department of Radiology, Humanitas Cellini, Torino,
Italy
Francesco Pagnini Radiologist, Diagnostic an Interventional Unit, Azienda
Ospedaliero-Universitaria di Parma, Parma, Italy
Giulio Pasta Specialista in Radiologia e Diagnostica per Immagini, Studio
Associato di Radiologia Dr. Pasta, Emilia-Romagna, Italy
Francesco Di Pietto Dipartimento di Diagnostica per Immagini “Pineta
Grande Hospital”, Castel Volturno, Italy
Giovanni Rusconi Dipartimento di Diagnostica per Immagini “Pineta
Grande Hospital”, Castel Volturno (CE), Italy
Fausto Salaffi Clinica Reumatologica, Dipartimento di Scienze Cliniche e
Molecolari, Università Politecnica delle Marche, Jesi (Ancona), Italy
Giuseppe Sepolvere Department of Anesthesia and Cardiac Surgery
Intensive Care Unit, San Michele Hospital, Maddaloni, Italy
Enzo Silvestri Radiology, Alliance Medical, Genova, Italy
Mario Tedesco Department of Anesthesia and Intensive Care Unit and Pain
Therapy, Mater Dei Hospital, Bari, Italy
Contributors xiii

Umberto Viglino Postgraduate School of Radiology, Genoa University,

Genova, Italy
Piero Volpi IRCCS Humanitas Research Hospital, Milano, Italy
Marcello Zappia Musculoskeletal Radiology Unit, Istituto Diagnostico
Varelli, Napoli, Italy
Dipartimento di Medicina e Scienze della Salute, Università degli Studi del
Molise (CB), Campobasso, Italy
 Part I
Sonographic Semiology in Musculoskeletal
Pathologic Involvement
 Osseous and Cartilaginous Surface
1
Enzo Silvestri, Davide Orlandi ,
and Elena Massone

Contents
1.1   Sonographic and Doppler Normal Anatomy  3
1.1.1 Cartilage  3
1.1.2 Osseous Tissue  7
1.2   Osteochondral Degenerative Changes  8
1.3   Osteochondral Erosive Lesion  9
1.4   Bone Fracture  9
Further Readings  9

1.1 Sonographic and Doppler In the musculoskeletal system there are two
Normal Anatomy types of cartilage: hyaline and fibrocartilage.
Fibrocartilage (also called white cartilage) is
1.1.1 Cartilage a specialized type of cartilage that contains more
collagen and is more resistant at tensile strength.
Cartilage is a greatly specialized type of flexible, It is found in areas requiring tough support or
semitransparent, and elastic, connective tissue, great tensile strength, such as between interverte-
mainly composed of water (70–80% by wet bral disk, at the pubic and other symphyses, and
weight). It is avascular and aneural. at sites connecting tendons or ligaments to bones.
This tissue is formed by cartilage cells scat- Hyaline cartilage is the most common variety
tered through a glycoprotein material that is of cartilage. It is found in costal cartilage, epiph-
strengthened by collagen fibers. yseal plates, and covering bones in joints (articu-
lar cartilage). The free surfaces of most hyaline
cartilage (but not articular cartilage) are covered
E. Silvestri by a layer of fibrous connective tissue (perichon-
Radiology, Alliance Medical, Genova, Italy
drium). It is stratified and divided into four zones
D. Orlandi (*) (Fig. 1.1): superficial (called also tangential
Department of Radiology, Ospedale Evangelico
Internazionale, Genova, Italy zone), middle, deep, and calcified.
The orientation of collagen fibers varies
E. Massone
Department of Radiology, Ospedale Santa Corona, through the four zones of articular cartilage in
Pietra Ligure (SV), Italy order to give better tensile strength.
© Springer Nature Switzerland AG 2022 3
F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_1
4 E. Silvestri et al.

Tangential Zone

Transitional Zone
Radiate Zone

Tide-Mark

Calcified Cartilage

Subchondral Bone

Fig. 1.1 Anatomical diagram of hyaline cartilage structure

homogeneity of the echotexture are hallmarks of

normal cartilage (Fig. 1.3).
The synovial space-cartilage interface is
slightly thinner than the bone-cartilage interface.
Both margins are best visualized when the direc-
tion of the ultrasound (US) beam is perpendicular
to the cartilage surface.
The pronounced difference in chemical struc-
Fig. 1.2 Healthy subject. Longitudinal dorsal US scan of ture between articular cartilage and subchondral
the second metacarpophalangeal joint obtained with a bone allows easy detection of the deep margin,
5–13 MHz broadband linear transducer. The articular car- while the superficial margin requires careful
tilage of the metacarpal head appears as a homogeneous
anechoic layer with clearly defined hyperechoic contours. examination techniques for clear identification.
m metacarpal head; p proximal phalanx Optimization of the visualization of the carti-
lage margins is essential for measuring the carti-
lage thickness.
Hyaline cartilage is detectable by ultrasonog- Cartilage thickness ranges from 0.1 mm on
raphy as a homogeneously hypo-anechoic layer the articular surface of the head of the proximal
(high water content) delimited by thin, sharp, and phalanx to 2.6 mm on the lateral femoral condyle
hyperechoic margins (superficial margin: syno- of the knee joint. The inter-observer reproducibil-
vial space-cartilage interface; deep margin: bone-­ ity of measurements of cartilage thickness seems
cartilage interface) (Fig. 1.2). Sharp margins and to be relatively good.
1 Osseous and Cartilaginous Surface 5

a b

Fig. 1.3 (a and b) Healthy subject. Knee. Suprapatellar tilage (*) obtained with the ultrasound beam directly per-
longitudinal scan of the articular cartilage of the lateral pendicular to the cartilage surface. (b) Apparent loss of
femoral condyle obtained with a 5–10 MHz broadband sharpness of the cartilage margins due to imperfect
linear transducer. (a) Normal features of the articular car- insonation angle

a b

Fig. 1.4 (a and b) Healthy subject. Knee. Suprapatellar homogeneous echotexture of the cartilage layer. (a)
longitudinal scan of the articular cartilage of the lateral Anechoic, obtained with low levels of gain. (b)
femoral condyle obtained with an 8–16 MHz broadband Hypoechoic, obtained with relatively higher levels of gain
linear transducer. Both images show the characteristic

These sonographic features are remarkably • Size of the acoustic window

similar at different anatomic sites and largely • Operator experience
dependent upon the equipment settings. • Transducer frequency
The typical anechoic pattern is obtained at • Patient position
lower levels of gain (Fig.1.4a and b).
The relative lack of echoes and the sharpness US examination may show a wide range of
of the synovial space-cartilage interface and of possible changes such as loss of sharpness, loss
the cartilage-bone interface are the main features of clarity of the cartilaginous layer, joint space
of a healthy tissue. narrowing, or increased intensity of posterior
Many different factors contribute to the final bone-cartilage interface.
sonographic visualization of the hyaline cartilage:
6 E. Silvestri et al.

In order to reduce misinterpretation, multipla- angle of incidence, leading to apparent inhomo-

nar examination and comparison with the contra- geneity in the cartilaginous echotexture and pro-
lateral side must be carried out. file of the margins.
Hyaline cartilage can be examined at different In addition, the transverse scan demonstrates
anatomical sites, including hip, knee, shoulder, the femoral cartilage most clearly at the level of
elbow, and metacarpophalangeal joints. peripheral portions of femoral condyles.
The complex anatomical structure of the knee Conversely, longitudinal scans carried out on
joint poses particular acoustic barriers to accurate contiguous planes allow for accurate evaluation
evaluation of the cartilage, meaning that only of the profile of the condylar cartilage, from its
femoral condylar cartilage can be assessed. most proximal portions that articulate with the
The weight-bearing surfaces of the femoral patella to the more distal portions that relate to
condyles can be assessed by transverse suprapa- the tibial plateau (Fig. 1.3).
tellar scanning with the knee in maximal flexion Recent data showed that US scanning
or with an infrapatellar transverse scan with the approach allows similar diagnostic performance
leg fully extended. compared to routine MRI for knee cartilage
Suprapatellar scanning of weight-bearing area defects at the femoral trochlea. Diagnostic per-
can be difficult in patients with limited degrees of formance of US has been tested even using
flexion due to pain. arthroscopic findings as a gold standard with a
Further assessment of the weight-bearing car- notably high correlation. Moreover, US is more
tilage of the medial femoral condyle can also be accessible, easier to perform, and less expensive
obtained by the medial parapatellar view with the than MRI, with potential advantages of easier ini-
knee in maximal flexion. The transverse suprapa- tial screening and assessment of cartilage defects.
tellar scan of the knee demonstrates that, in However, because weight-bearing sites at the
healthy subjects, the femoral cartilage typically femoral condyles and tibial plateau cannot be
appears as a clear-cut, wavy hypo-anechoic layer, assessed with US, this represents a significant
with upper concavity, which is thicker at the level limitation of such method.
of the intercondyloid fossa (Fig. 1.5). This par- Articular cartilage of the metacarpal head can
ticular scan should be carried out with the knee be evaluated by longitudinal and transverse dor-
flexed to an angle of at least 90°. A panoramic sal scans with the metacarpophalangeal joint held
view of the entire cartilaginous profile can best in maximal flexion. Standard longitudinal dorsal
be obtained with wide footprint and medium-­ and volar scans may also be useful.
frequency probes (not higher than 10 MHz). Higher frequency probes (>10 MHz) must be
Linear probes do not allow the ultrasound beam used in order to study the articular cartilage of the
to reach the cartilaginous layer with the same metacarpal head. Particular attention must be
paid to the identification of the superficial margin
that, in healthy subjects, appears as a thin hyper-
echoic line (of about a tenth of a millimeter
thick), visible in tracts perpendicular to the direc-
tion of the ultrasound beam. This must be identi-
fied in order to obtain a correct measurement of
the cartilaginous thickness. In a healthy subject,
the thickness of the cartilage of the metacarpal
head can vary between 0.2 and 0.5 mm.
Ultrasound can also provide a good insight
even in some fibrocartilaginous structures such as
Fig. 1.5 Transverse view of the knee. Articular cartilage
(*) appears as a curved anechoic band. The image was
knee menisci and triangular fibrocartilage com-
obtained with a 7–14 MHz broadband linear transducer. f plex (TFCC), which will be extensively treated in
femur Chap. 2.
1 Osseous and Cartilaginous Surface 7

1.1.2 Osseous Tissue and lymphatic vessels that nourish compact

bone. Tendons and ligaments also attach to
Bone tissue is a biological tissue characterized by bones at the periosteum. The periosteum cov-
a remarkable hardness and resistance. It has a ers the entire outer surface except where the
honeycomb-like structure internally, which helps epiphyses meet other bones to form joints. In
to give the bone rigidity. Bone tissue is made up this region, the epiphyses are covered with
of different types of bone cells; osteoblasts and articular cartilage, a thin layer of cartilage
osteocytes are involved in the formation and min- that reduces friction and acts as a shock
eralization of bone; osteoclasts are involved in absorber.
the resorption of bone tissue. All these cells are • Flat bones (scapula, skull, and sternum): two
entrenched in a matrix of collagen fibers that pro- dimensions more developed than the third (in
vide a surface for inorganic salt crystals to adhere. fact they are bones with a very small thick-
Bones protect the various organs of the body, ness, if compared to the total area of the bone).
produce red and white blood cells, store miner- • Short bones (vertebrae and the carpal bones):
als, provide structure and support for the body, small, stocky bones, with all three dimensions
and enable mobility. of the same order of magnitude. It consists of
Bones come in a variety of shapes and sizes a central part called the diaphysis and two
and have a complex internal and external vaguely rounded ends, called the epiphysis.
structure. During the development of the skeleton,
Based on shape, bones can be classified into between the diaphysis and the epiphysis there
three types: is a layer of cartilage, called conjugation carti-
lage or epiphyseal disk. As long as this carti-
• Long bones (e.g., femur, humerus, phalanges): lage is not mineralized and ossified, bone
characterized by a more developed dimension lengthening is possible. The bone is totally
than the other two (precisely, the length com- covered by a dense elastic connective mem-
pared to the thickness). A long bone has two brane, called the periosteum; the exceptions
parts: the diaphysis and the epiphysis. The are the epiphyseal articular surfaces which are
diaphysis is the tubular shaft that runs between instead covered by a hyaline cartilage incrus-
the proximal and distal ends of the bone. The tation. The interior of the diaphyseal cavity as
hollow region in the diaphysis is called the well as that of the epiphyses is instead covered
medullary cavity (endosteum), which is by a layer of paving cells called the
filled with yellow marrow. The walls of the endosteum.
diaphysis are composed of dense and hard
compact bone. The epiphysis is the rounded The high-impedance difference between bone
end of a long bone which is filled with spongy and soft tissue such as muscle, fat, or water
bone. Red marrow fills the spaces in the causes an almost complete reflection of the
spongy bone. Each epiphysis meets the diaph- acoustic waves at the bone’s surface. As a result,
ysis at the metaphysis, the narrow area that the bone surface is seen, and the underlying
contains the epiphyseal plate (growth plate), structures are not seen (“shadow region”).
a layer of hyaline (transparent) cartilage in a So the interior bone surfaces cannot be imaged
growing bone. When the bone stops growing with US imaging. The high-intensity feature
in early adulthood (approximately depicting bone boundary response looks like a
18–21 years), the cartilage is replaced by line with a shape closely resembling the surface
osseous tissue and the epiphyseal plate (Fig. 1.6). The bone surface appearance in US
becomes an epiphyseal line. A fibrous mem- has a thickness which can reach a value of 4 mm
brane called the periosteum (peri- = “around” in certain cases. The response thickness is
or “surrounding”) covers the outer surface of affected by the inclination of the image surface
the bone. It contains blood vessels, nerves, with respect to the US transducer.
8 E. Silvestri et al.

The greater the inclination of the imaged sur- 1.2 Osteochondral Degenerative
face, the greater the response thickness. Changes

These include:
• Loss of sharpness of the synovial
space-cartilage
• Loss of transparency of the cartilaginous layer
(it reflects pathological changes such as fibril-
lation of cartilage and cleft formation)
• Cartilage thinning and subchondral bone pro-
file irregularities (most common US findings
in advanced osteoarthritis) (Fig. 1.7a and b)

Fig. 1.6 Bone surface appearance; anterior transversal

view of humeral head: (H) bone surface (arrowheads),
bicipital groove (arrows), long head of biceps tendon (T)

a b

c d

Fig.1.7 (a and b) Osteoarthritis. Transverse (a and b) of sharpness of the superficial margin and circumscribed
and longitudinal (c and d) suprapatellar US scans of the thinning (arrows) of the cartilage layer of the medial fem-
knee. (a and c) Normal cartilage features. (b and d) Loss oral condyle (F)
1 Osseous and Cartilaginous Surface 9

Fig. 1.8 Rheumatoid arthritis. Longitudinal dorsal scan

of a metacarpophalangeal joint shows proliferative syno-
vitis with early erosive changes. Complete loss of the car-
tilage layer of the metacarpal head with initial subchondral
involvement (arrowhead). m metacarpal head; p proximal; Fig. 1.9 Second metacarpophalangeal joint, US color
t tendon power Doppler longitudinal scan: metacarpal head (MC)
and cartilage (c), first phalanx (P1), bone erosion (arrow),
hypertrophic and hyperemic synovia (asterisk)
1.3 Osteochondral Erosive
Lesion

US can visualize pre-erosive changes (such as in

rheumatoid arthritis), particularly at the level of
the metacarpophalangeal joint, together with loss
of the cartilage layer and irregularities of the sub-
chondral bone (Fig. 1.8).
Several studies in rheumatoid arthritis have
confirmed that ultrasonography permits accurate Fig. 1.10 Third metatarsal bone, US longitudinal scan:
and detailed analysis of the anatomical changes bone (M), fracture (arrow), reactive tissue thickening
(asterisk)
induced by the inflammatory process and is more
sensitive than conventional X-rays for the detec-
tion of bone erosions. • To diagnose common pediatric fractures
Bone erosions’ US appearance looks like oval • To detect occult injuries and stress fractures in
well-defined cortical breaks with an irregular adults
floor visible in transverse and longitudinal planes, • To judge reduction of distal radius fractures in
in most cases filled by hyperperfused synovial real in the emergency department
pannus (Fig. 1.9). • To detect long bone fractures in the resuscita-
tion setting
• To monitor callus progression and fracture
1.4 Bone Fracture union
• With the advent of 3D image processing, to
Fractures can be visualized as a break in the hyper- study a fracture site from multiple angles and
echoic cortical surface and the developing hema- compile them into a 3D reconstruction
toma, and subsequent callus formation can be
visualized from an early stage starting as an
anechoic (dark) shadow, with a similar appearance Further Readings
to articular cartilage, becoming increasingly hyper-
echoic with calcification such that the normal Aisen AM, McCune WJ, MacGuire A, et al. Sonographic
evaluation of the cartilage of the knee. Radiology.
appearance of cortical bone is restored (Fig. 1.10). 1984;153:781–4.
Ultrasound can be used:
10 E. Silvestri et al.

Backhaus M, Burmester GR, Gerber T, et al. Guidelines Grassi W, Lamanna G, Farina A, Cervini C. Sonographic
for musculoskeletal ultrasound in rheumatology. Ann imaging of normal and osteoarthritic cartilage. Semin
Rheum Dis. 2001;60:641–9. Arthritis Rheum. 1999;28:398–403.
Cao J, Zheng B, Meng X, Lv Y, Lu H, Wang K, Huang McCune WJ, Dedrick DK, Aisen AM, MacGuire
D, Ren J. A novel ultrasound scanning approach for A. Sonographic evaluation of osteoarthritic femoral
evaluating femoral cartilage defects of the knee: com- condylar cartilage. Correlation with operative find-
parison with routine magnetic resonance imaging. J ings. Clin Orthop. 1990;254:230–5.
Orthop Surg Res. 2018;13(1):178. Razek A, Fouda N, Elmetwaley N, et al. Sonography of
Castriota-Scanderbeg A, De Micheli V, Scarale MG, et al. the knee joint. J Ultrasound. 2009;12(2):53e60.
Precision of sonographic measurement of articular Saarakkala S, Waris P, Wasris V, Tarkiainen I, Karvanen E,
cartilage: inter- and intraobserver analysis. Skeletal Aarnio J, Koski JM. Diagnostic performance of knee
Radiol. 1996;25:545–9. ultrasonography for detecting degenerative changes
Disler DG, Raymond E, May DA, et al. Articular car- of articular cartilage. Osteoarthritis Cartilage. 2012
tilage defects: in vitro evaluation of accuracy and May;20(5):376–81.
interobserver reliability for detection and grading with Schmitz RJ, Wang HM, Polprasert DR, Kraft RA,
US. Radiology. 2000;215:846–51. Pietrosimone BG. Evaluation of knee cartilage
Grassi W, Tittarelli E, Pirani O, et al. Ultrasound exami- thickness: A comparison between ultrasound and
nation of metacarpophalangeal joints in rheumatoid magnetic resonance imaging methods. Knee.
arthritis. Scand J Rheumatol. 1993;22:243–7. 2017;24(2):217–23.
Grassi W, Cervini C. Ultrasonography in rheumatology: Sheperd DET, Seedhom BB. Thickness of human articu-
an evolving technique. Ann Rheum Dis. 1998;57: lar cartilage in joints of the lower limb. Ann Rheum
268–71. Dis. 1999;58:27–34.
 Synovial Spaces
2
Davide Orlandi , Enzo Silvestri,
and Alessandro Muda

Contents
2.1   Sonographic and Doppler Normal Anatomy  11
2.2   Joint Effusion  15
2.3   Synovial Inflammation and Proliferation  16
2.4   Bursitis  18
2.4.1 Non-communicating Bursitis  18
2.4.2 Communicating Bursitis  19
2.5   Synovial Ganglia  21
2.6   Synovial Calcifications  21
2.7   Meniscal Lesions  22
2.8   Endoarticular Loose Bodies  24
Further Readings  25

2.1 Sonographic and Doppler film of synovial fluid. The synovial cavity con-
Normal Anatomy sists, depending on where it is found, of the joint
cavity, the bursae, and the tendon sheaths.
The synovial cavity (Fig. 2.1) is the space found The synovial fluid has a variable volume
between bone segments and articular capsule; it according to the dimension of the articular cavity
is delimited by a fibrous wrap internally covered and it represents, physiologically, a thin veil to
by a synovial membrane and contains a slight protect the cartilage surface; it acts as a lubricant
and it has nourishing functions for the cartilage
itself. The synovial fluid is filtered from the blood
D. Orlandi (*) plasma and it contains a maximum of 200 cell/cc.
Department of Radiology, Ospedale Evangelico
Internazionale, Genova, Italy
It also contains electrolytes, glucose, enzymes,
immunoglobulins, and proteins mainly originat-
E. Silvestri
Radiology, Alliance Medical, Genova, Italy
ing from blood, with the addition of mucin,
mostly hyaluronic acid, which is well repre-
A. Muda
Department of Radiology, IRCCS Policlinico San
sented. The mucin makes the synovial fluid vis-
Martino-IST, Genova, Italy cous, elastic, and plastic.
© Springer Nature Switzerland AG 2022 11
F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_2
12 D. Orlandi et al.

of the synovial cavity, supporting the lubrication

of the joint surfaces.
The synovial membrane is made of a cellular
intima lying on a fibrovascular subintimal lamina
consisting of abundant loose areolar tissue, col-
lagen, and elastic fibers. When the synovial
membrane covers the intracapsular tendons or
ligaments, the subintima is hardly identifiable as
a separate layer, being fused together with the
capsule, the ligament, or the adjacent tendon.
The synovial intima is made of cells, called
synoviocytes A and B, whose function is to
remove the debris found in the joint cavity and to
synthesize some molecules for the synovial fluid.
The synoviocytes do not actively proliferate
under basal conditions, while the speed of cellu-
lar division is considerably increased after trauma
and acute hemarthrosis.
The bursae are virtual spaces localized in spe-
Fig. 2.1 Anatomical diagram of a synovial joint.
Insertion and development of the articular capsule with
cific regions of the joint where high friction
the synovial membrane (in blue), articular cartilage (in between closely opposing structures occurs. The
turquoise), bursae (in blue), fat pads (honeycomb), and bursae can be visualized almost solely in patho-
menisci (in red) are clearly shown logic conditions, because they physiologically
contain a slight film of synovial fluid. As above,
The articular capsule consists of intertwisted the bursae are covered by the synovial membrane
bundles of connective fibrous tissue, whose inser- that continues from the synovial membrane of the
tion onto bone occurs as a continuous line. At articular cavity, so that it constitutes communi-
some points the capsule is strengthened by the cating bursae where the synovial fluid is freely
intrinsic capsular ligaments, represented by local circulating.
thickenings (made of fibrous or fibroelastic tis- The communicating bursae have a further bio-
sue) of the capsule itself, where the fiber bundles mechanical function: they decrease the endoar-
become parallel. The articular capsule is inter- ticular pressure when there is a fluid collection in
nally covered by the synovial membrane. The the joint cavity.
synovial membrane is a connective tissue of mes- Normally, the synovial cavities are barely vis-
enchymal origin, covering any exposed osseous ible or invisible with US, whereas they can be
surface, the synovial bursae in communication easily evaluated when a thickening of the syno-
with the joint cavity, and the intracapsular liga- vial membrane or a joint fluid collection occurs.
ment and tendons; it is not present on meniscal The size of the synovial cavity of the hip can be
and discal surfaces and it stops right before the depicted and measured by US using a sagittal
edge of joint cartilage, the peripheral area of view passing through the femoral head—the
which, only a few millimeters thick, constitutes a lower limb externally rotated 10–15°; in healthy
zone of transition from synovial membrane to subjects the interposed distance between the fem-
cartilage. oral neck outline and the articular capsule has a
In the synovial cavities of some joints, adipose mean value of 5.1 mm (range 3–7 mm). There is
tissue is stored in specific regions, forming no evident relationship between the sonographic
mobile and elastic pads that fill in the spaces of size of the synovial cavity and age, gender,
the articular cavity. Such fat pads, when the joint height, or body weight; the maximum difference
moves, adapt to the changes of shape and volume between one side and the contralateral side is
2 Synovial Spaces 13

about 1 mm. In the knee, the only synovial cavity

accessible to US is the suprapatellar recess. The
examination can be performed through suprapa-
tellar longitudinal and axial views, with the
patient lying supine with the knee in the extended
position. The suprapatellar recess appears as a
hypoechoic flat structure, with a regular and clear
contour, whose anteroposterior diameter does not Fig. 2.2 Longitudinal extended field-of-view (EFOV)
US scan of anterior compartment of the knee. Small
measure more than 3–4 mm. Dynamic assess- amount of fluid in the joint (*) and distension of suprapa-
ment, performed during the contraction of the tellar capsular recess. T quadriceps tendon; P patella
quadriceps femoris muscle, shows a slight
increase both in the anteroposterior diameter and
in the recess length. In order to identify the capsule, it is necessary
The increase in fluid collection during this to have precise anatomical reference points, joint
phase, related to the mean sagittal diameter by joint.
increase of the bursa (1 mm), can be related to the The articular capsule appears as a thin hyper-
simultaneous contraction of the suprapatellar echoic layer, hard to differentiate from the adja-
recess tensor muscle. This small muscle drags the cent tendons and ligaments that have very similar
bursa, causing a vacuum effect that causes the echogenicity.
bursa to be filled with fluid coming from the joint In the shoulder, the superior edge of the cap-
cavity. In people who are fit, compared to those sule corresponds to the inferior echoic edge of
who lead a sedentary life, the suprapatellar recess the tendons of the rotator cuff muscles (supraspi-
diameter does not change, but it is well visualized natus, infraspinatus, and teres minor); it is only
in 25% and 66% of patients, respectively, accord- when pathology occurs, such as an adhesive cap-
ing to the relaxation and the contraction of the sulitis—causing thickening and retraction—that
quadriceps femoris. The synovial membrane con- the capsule can be identified as a marked irregu-
tour can be indirectly assessed when the suprapa- larity of the inferior profile of the rotator cuff ten-
tellar recess is distended by synovial fluid. It dons. The axillary recess of the inferior edge of
appears as a thin echoic band of 1.7 mm (mean the capsule is more easily explored. The articular
value). The anterior synovial layer of the supra- capsule of the knee can be easily assessed in the
patellar recess is usually more easily identified internal and external compartments, where the
than the deep layer. The first can be easily collateral ligaments delineate the capsule bor-
assessed thanks to the different echogenicity of ders. The same procedure can be applied to assess
the overlying quadriceps tendon, which appears any other joint of the hand and foot.
moderately echoic, while the latter is strictly con- Ultrasound is a highly sensitive technique for the
tiguous with the pre-femoral fat pad, which is detection of even minimal fluid collections and it
echoic and has a maximum thickness of about still represents a particularly useful diagnostic tool
1 cm. Normally the synovial fluid in the sub-­ to quantify fluid and to monitor its evolution.
quadricipital recess is homogeneously The considerable sensitivity of the identifica-
hypoanechoic and any change is related to pathol- tion of synovial fluid collection, the highly
ogy (Fig. 2.2). detailed anatomical depiction, and the real-time
The articular capsule is extremely thin and can visualization of tissues make US the ideal imag-
be barely identified by ultrasound in physiologi- ing technique for interventional guided proce-
cal situations, whereas acute, inflammatory, or dures, such as arthrocentesis.
post-traumatic pathology makes it easily visible Thanks to US, the aspiration of synovial fluid
because of the natural acoustic window provided is possible even when the joint collection is
by the joint fluid collection. minimal.
14 D. Orlandi et al.

Pathologic conditions that can be assessed a point-of-­injury diagnostic modality for menis-
within the synovial cavity with US include cal injuries. According to others, it is considered
hydrarthrosis, pneumohydrarthrosis, pyarthrosis, as a useful tool to image the meniscus, but there
hemarthrosis, lipohemarthrosis, bursitis, tenosy- are no reliable data on its accuracy. Therefore, it
novitis, and synovial thickening. appears to be useful for the screening of menis-
The menisci are fibrocartilaginous structures cal tears but detection of the morphology of
that partially divide an articular cavity. They are meniscal tears seems insufficient compared to
present in the knee, wrist, acromioclavicular, MRI. Both in coronal (for the body) and sagittal
sternoclavicular, and temporomandibular joints. (for the anterior or posterior horn) section
The menisci are derived from a condensation of planes, the normal meniscus appears with the
the intermediate layer of the mesenchymal tis- characteristic triangular shape, homogeneously
sue to form attachments to the surrounding joint hyperechoic (Fig. 2.3 a and b). The prevalent
capsule. Their shape is characteristic for each limit of the method is represented by the poor
joint and is vital for normal biomechanics and evidence of meniscus internal margin. Usually,
joint stability. Particularly at knee and wrist lev- there is a better evidence of the medial meniscus
els, ultrasound can visualize and evaluate the with respect to the lateral one, and of the poste-
meniscal structure, as a possible alternative to rior horn with respect to the body and the ante-
MRI, rapidly and less costly performed. Menisci rior one.
appear as a wedge-shaped echogenic formation. The TFCC consists of the triangular fibrocar-
The usefulness of ultrasound in the diagnosis of tilage proper (TFC), the dorsal and volar radioul-
lesions of the menisci of the knee remains con- nar ligaments, the ulnar collateral ligament, the
troversial. According to some authors, ultraso- meniscal homologue, the sheath of the extensor
nography has high accuracy in detecting the carpi ulnaris, and the ulnolunate and ulnotrique-
presence of tears in menisci, and can be used as tral ligament.

a b

Fig. 2.3 Ultrasound (a) and MRI (b) appearance of normal meniscus (*)
2 Synovial Spaces 15

According to Taljanovic et al. the TFC disk and inhomogeneous clusters, with a scirrhous
was considered normal if it was seen as homoge- conformation.
neously echogenic triangular tissue in the proper Pyarthrosis occurs in bacterial arthritis, which
anatomic location at the articular aspect of the is usually rare in patients with normal immune
ulnar head. It was considered torn if hypoechoic systems, while it is common in children, in
clefts or defects were seen in the substance of the immunosuppressed patients, in diabetics, and in
TFC disk. If some irregularity of the TFC disk patients on dialysis. In acute infections with joint
was observed without a frank cleft on sonogra- fluid collection, it is necessary to sample the fluid
phy it was considered partially torn. in order to prescribe the most appropriate antibi-
Usually, a linear transducer of 7–11 MHz is otic therapy.
used for TFCC examination. The patient is exam- In chronic infections the fluid collection is
ined while sitting upright, with the hand placed usually poor and it is often associated with
on a cushion and fully pronated and then ­considerable synovial thickening. In infections
supinated. the fluid is usually hypoechoic, but it may appear
hyperechoic in more superficial joints. In such
cases, the synovial hyperemia can be well
2.2 Joint Effusion depicted with the use of Doppler techniques as a
complement to grayscale US. However, it should
A collection of fluid within the synovial cavity be kept in mind that synovial hyperemia in bacte-
causes the swelling of the involved joint. In rial arthritis is not a mandatory finding, because it
hydrarthrosis, US shows fluid collection within depends on the patient’s age, duration of the
the cavity, which has an anechoic appearance with infection, and immune status. Therefore, since
dorsal acoustic enhancement (Fig. 2.4a and b). there is no certainty in differentiating septic from
The amount of fluid within the joint is directly aseptic inflammation, it is more suitable to per-
proportional to the severity of the synovial form a biopsy when clinical suspicion is high.
inflammation and to the capability of the capsular Hemarthrosis exhibits a peculiar US pattern
wall to expand. In some cases the anechoic that changes with time similar to hematoma.
appearance of the fluid collection can be inhomo- Hemorrhagic fluid collections are in fact homo-
geneous because of the presence of dot-like geneously echogenic within the first 2–3 days
echoes scattered within the collection itself. This from onset, due to the presence of a corpuscular
more complicated appearance of the collection content. After the third day, the hemarthrosis
may depend on the presence of a fibrinous com- shows a progressive reduction in echogenicity
ponent within the inflammatory exudate, which due to lytic enzyme release. Eventually, US
can be particularly abundant in relapsing collec- shows echogenic branches, corresponding to
tions and can be visualized as arranged echogenic fibrinous clots, crossing the anechoic appearing

a b

Fig. 2.4 (a) Posterior transverse US scan at the level of tudinal US scan; first phalanx (P I), second phalanx (P II),
glenohumeral joint: glenoid (G), humeral head (H), joint. joint effusion (asterisk), synovial thickening (s)
(b) Proximal interphalangeal joint (second finger), longi-
16 D. Orlandi et al.

zone. Occasionally, the post-arthrocentesis fol-

low-­up examination demonstrates the presence
of pneumohydrarthrosis. The presence of gas in
the joint cavity produces a highly reflective mist
within the anechoic fluid collection, forming an
air-fluid level that changes together with the
patient’s position. When assessing hydrarthrosis
and pneumohydrarthrosis, color and power
Doppler techniques do not demonstrate signifi- Fig. 2.5 Longitudinal sonogram of wrist, dorsal side in a
cant vascular changes. patient affected by rheumatoid arthritis. Synovial prolif-
eration appears hypoechoic (*). T extensor tendons
Lipohemarthrosis is easily identified by means
of US and it appears as a dual-phase collection,
showing a fluid-fluid level. The overlying echo-
genic fraction corresponds to the lipid content,
while the underlying fraction is hemorrhagic.
When lipohemarthrosis is found in a post-­
traumatic limb, the presence of a joint fracture
can be suspected.

2.3 Synovial Inflammation

and Proliferation Fig. 2.6 Longitudinal sonogram of wrist, dorsal side.
Patient affected by rheumatoid arthritis. In this case, syno-
Hypertrophic or hyperplasic synovial thickening vial proliferation (arrowheads) has a hyperechoic
is a condition found in several long-standing appearance
inflammatory arthropathies and it can be the
cause of bone and cartilage erosion in the joint.
US nowadays can identify inflammatory synovial
thickening more accurately than clinical exami-
nation, especially when small joints such as the
metacarpophalangeal and interphalangeal joints
are affected, commonly observed in chronic
polyarthropathies. Synovial thickening is charac-
terized by heterogeneous echotexture varying
from hypoechoic to hyperechoic, depending on
the amount of water contained in the synovial tis-
sue (Figs. 2.5 and 2.6).
In larger joints, such as the knee, synovial
thickening appears as a succession of irregularly
proliferating branches, mildly echoic, jutting out
Fig. 2.7 Longitudinal US scan of suprapatellar recess
from the synovia into the articular cavity; the showing a large amount of anechoic fluid collection with
assessment of synovial pannus is considerably hyperechoic synovial proliferation (*). TQ quadricipital
easier when associated with a fluid collection tendon; F femur
because it works as a contrast agent (Fig. 2.7).
In pigmented villonodular synovitis, the syno- collection. A similar appearance can be observed
vial hypertrophy is usually overabundant, made in joints affected by relapsing hemarthrosis in
of thick fusiform villi and gross nodules, with a hemophilic arthropathies. The continual presence
winding outline surrounded by abundant fluid of hemorrhagic effusion irritates the synovial
2 Synovial Spaces 17

membrane and determines the formation of pan- vial wall and the differentiation of the two articu-
nus that starts as a simple thickening and then lar contents.
turns into villous hypertrophy. The sonographer When doubt persists with grayscale US, power
should always keep in mind that synovial hyper- and color Doppler techniques can be applied to
trophy is a nonspecific finding and that the dif- differentiate the fluid from the proliferating tis-
ferentiation between a nonspecific synovitis and sue, with the presence or absence of vascular sig-
a synovial tumor can be very tricky (hemangi- nals (Fig. 2.8).
oma, synovial sarcoma). A fibrinous exudate can The role of Doppler techniques for the assess-
make it difficult to detect the thickened synovial ment of synovial vascularization in rheumatoid
membrane contour, especially when it is abun- arthritis is very important. In rheumatoid arthri-
dant, because it may simulate the US pattern of tis, the formation of pannus is a crucial event in
synovial hyperplasia. In these cases, when fluid the pathogenesis of articular degeneration.
and hypertrophic synovial cannot be differenti- Neoangiogenesis is an important pathological
ated it is possible to use dynamic and compres- element in rheumatoid synovitis. Since hypervas-
sive maneuvers. Such a technique allows the fluid cularization is proportional to the degree of
to be “squeezed out” from the hypertrophic syno- inflammation of the synovial pannus, it is
­fundamental to study and quantify the vascular
signals in order to evaluate the aggressiveness of
the pannus itself. Power Doppler is able to assess
the increased vascularization involving synovial
hyperplasic tissue and consequently to give infor-
mation regarding the activity of the synovial pan-
nus (Fig. 2.9a and b).
Despite attempts at semiquantitative or quan-
titative evaluation of the vascularization by
means of dedicated software, the technique is
limited by poor reproducibility. Nevertheless, the
Fig. 2.8 Second metacarpophalangeal joint, US color recent availability of power Doppler techniques
power Doppler longitudinal scan: metacarpal head (MC) in association with the use of contrast agents
and cartilage (c), first phalanx (P1), bone erosion (arrow), (contrast-enhanced power Doppler—CePD) has
synovial hyperemic proliferation (asterisk) allowed a more detailed analysis of the synovial

a b

Fig. 2.9 Patient with rheumatoid arthritis. (a) The power therapy. A significant reduction in flow signal is shown
Doppler scan shows a high degree of hyperperfusion, an within the pannus (arrows)
expression of hyperactive pannus. (b) Follow-up during
18 D. Orlandi et al.

a b c

Fig. 2.10 Patient with rheumatoid arthritis. (a) Shoulder, cant hyperemia of synovial proliferation. The hyperechoic
posterior scan. Expansion of posterior capsular recess appearance is due to the contrasting microbubbles. G pos-
with inhomogeneous hypoechoic synovial proliferation terior margin of humeral glenoid process; H posterior
(*). (b and c) Images taken before (b), and after (c), injec- aspect of humeral head
tion of contrast agent (CeUS). These scans show a signifi-

vascularization. It should be considered that the

information derived from power Doppler and
CePD refers exclusively to the macrovasculariza-
tion of synovial pannus. Such limits have now
been overcome by the introduction of new-­
generation contrast agents that allow quantitative
analysis of the synovial microvascularization to
be performed by means of grayscale US (contrast-­
enhanced US—CeUS) (Fig. 2.10a–c).

2.4 Bursitis

Bursae are anatomical entities located near joints

(non-communicating bursae) or in direct commu-
nication with the joint cavity (communicating bur- Fig. 2.11 US power color Doppler scan; acute thicken-
sae). The main function of non-­ communicating ing of the bursal wall (arrowheads) with some color spot
bursae, located at the insertional areas of the anchor of hyperemia; fluid effusion (f)
tendons of several joints, is to reduce the friction
between tendon and bone. Communicating bursae, trauma. The most commonly involved bursae
on the other hand, when an abundant intra-articular are the subacromial-deltoid bursa, the prepa-
fluid collection occurs, function by reducing the tellar and deep infrapatellar bursa, the retro-
joint cavity pressure, by expanding and being filled calcaneal and superficialis bursa of the
with the fluid coming from the cavity. Bursitis rep- Achilles tendon, and the trochanteric bursa. In
resents the most common bursal pathology and US acute forms, an increase in anechoic fluid
is the first-choice diagnostic technique. within the bursa is observed (a comparison
with the contralateral limb may be useful),
while the synovial wall keeps its original
2.4.1 Non-communicating Bursitis thickness (Fig. 2.11a).
2. In chronic forms, the fluid often appears
1. Acute traumatic bursitis: affecting several hypoechoic and contains hyperechoic spots
synovial bursae, the bursal expansion follows consistent with microcalcification, and the
direct impact or chronic frictional micro- bursal walls are thickened (Fig. 2.12a and b).
2 Synovial Spaces 19

Fig. 2.13 Patient with gout, olecranon bursitis. The bursa

is expanded by a small amount of synovial fluid (circles)
with some hyperechoic synovial proliferation
(arrowheads)
b

membrane (Fig. 2.13). The presence of gas

within the bursa may be consistent with septic
bursitis, but the final diagnosis can be obtained
by performing a color or power Doppler
examination that allows the detection of vas-
cular signals within the soft tissues, indicating
an inflammatory hyperemia, or, even better,
by sampling the bursal fluid.
Fig. 2.12 Posterior aspect of elbow, transverse scan:
olecranic chronic bursitis (white arrows), fluid distension
(f), and synovial thickening and septa (asterisks) (a); US 2.4.2 Communicating Bursitis
color power Doppler longitudinal scan: synovial hyper-
emia (b)
Communicating synovial bursae develop during
adolescence and are characterized by the pres-
3. Hemorrhagic bursitis: usually following a ence of a tract that connects them to the nearby
violent sporting trauma on artificial surfaces joint. Their function is to reduce intra-articular
and mainly affects the hands and knees. The pressure in order to avoid the onset of joint com-
hemorrhagic effusion may organize and form plications. The most common communicating
adhesions or calcifications. Clots and fibrin, bursitis is the medial gastrocnemius and semi-
appearing as irregular hyperechoic masses, membranosus tendon bursitis, with a particularly
are easily distinguished from synovial hyper- high incidence in rheumatoid arthritis compared
trophy because of their mobility and the with other rheumatic disorders such as Reiter’s
absence of vascular signal on power or color syndrome, villonodular arthrosynovitis, Sjogren’s
Doppler analysis. syndrome, ankylosing spondylitis, psoriatic
4. Chemical bursitis: often associated with meta- arthritis, gonococcal arthritis, and gout (Fig. 2.14a
bolic disease, and inflammatory and degener- and b).
ative processes. The most common cause is In long-standing fluid collections, the progres-
the monosodium urate crystal deposition in sive filling of the bursa leads to the formation of
gout. a cyst (Baker’s cyst), which can be easily pal-
5. Septic bursitis: difficult to differentiate from pated on clinical examination when it reaches
chronic inflammatory bursitis, but it is charac- considerable dimensions (gigantic cysts) and can
terized by intrabursal hyperechoic diffuse be completely visible thanks to panoramic imag-
areas, corresponding to thickened synovial ing (extended field of view (EFOV)) (Fig. 2.15).
20 D. Orlandi et al.

a b

Fig. 2.14 Transverse US scan of popliteal fossa in a patient affected by knee OA. Baker’s cyst is shown. (a) MR scan
of the same patient (axial view, fat suppression technique); cyst (asterisk) (b)

Fig. 2.16 Small popliteal cyst with fluid content and

hyperechoic spots, caused by small clots and debris
Fig. 2.15 Rheumatoid arthritis; EFOV scan shows the
whole extent of a popliteal cyst (arrows) that courses
toward the proximal third of the leg; connecting peduncleWhen swelling is appreciated in the popliteal
with the joint (arrowhead) fossa, it is necessary to perform an US to
­differentiate a Baker’s cyst from vascular (popli-
The US appearance of a Baker’s cyst is that of teal artery aneurysms, venous thrombosis) or
a hypoanechoic pear-shaped cavity, with a well-­ muscular (different degrees of injuries involving
defined outline, presenting with posterior acous- the popliteal fossa muscles) pathologies. In
tic enhancement. Communication with the chronic inflammatory arthropathies, hypertro-
superior aspect of the posteromedial edge of the phic synovial tissue is observed, with a particu-
articular cavity can often be detected at the larly abundant and irregular appearance in
medial femoral condyle. Echoes within the cyst rheumatoid arthritis. In this case the bursa may
confirm the presence of debris and clots that, grow considerably, surrounding the tendon of the
especially when abundant, make the US detec- medial gastrocnemius muscle (Fig. 2.18).
tion of small popliteal cysts difficult (Fig. 2.16). Sometimes a gigantic cyst may end up ruptur-
The dimension of a Baker’s cyst at follow-up ing leading to inflammation of the surrounding
can correlate with the clinical progression of adipose tissue and of the myofascial components,
arthritis and the efficacy of medical therapy and, so that it clinically simulates a thrombophlebitis
in selected cases, US may be used as a guide for (pseudo-thrombophlebitic syndrome). A fresh
the aspiration and injection of the cyst (Fig. 2.17a rupture of a gigantic cyst can be detected by US
and b). by hazy appearance of the cyst’s fundus, with an
2 Synovial Spaces 21

a b

Fig. 2.17 Popliteal cyst before (a) and after (b) US-guided aspiration. N needle, asterisk=cyst. The reverberation arti-
fact is clearly shown (arrows)

Fig. 2.18 Patient

affected with rheumatoid
arthritis. The EFoV scan
shows the whole extent
of a giant popliteal cyst
(calipers) that courses
toward the proximal
third of the leg and has
hemorrhagic content

associated free fluid collection located irregular margins, presenting internal thin hyper-
superficially and distally from the cyst itself.
­ echoic septa and a slender peduncle that connects
When doubt persists, grayscale US and color or it to the scapho-lunate joint (Fig. 2.20). The
power Doppler techniques play a fundamental application of dynamic maneuvers to the stan-
role in the differential diagnosis. In normal cir- dard ultrasound examination can be particularly
cumstances the subacromial-deltoid bursa of the useful for the detection of the connecting pedun-
shoulder does not communicate with the joint cle and for better assessment of the cyst’s rela-
cavity, while in cases of complete rupture of the tionships with the surrounding tissues.
rotator cuff, direct connection between the two
cavities is observed (Fig. 2.19a and b).
2.6 Synovial Calcifications

2.5 Synovial Ganglia Synovial calcification appears on US as a hyper-

echoic “platelike” area with posterior acoustic
Synovial ganglia are mostly found in the upper shadowing. The calcified plates, following the
limb, particularly at the wrist and hand. The most synovial membrane outline, have a linear or
common location is the carpal dorsum. In this coarsely wavy appearance and do not move, even
case the cyst usually arises from the scapho-­ when compression is applied with the transducer.
lunate joint because of mucoid degeneration phe- This sonographic pattern is typical of synovial
nomena of the tissues due to repeated osteochondromatosis, but can also be found, less
microtrauma. US allows the ganglion to be visu- frequently, in chondrocalcinosis and in sclero-
alized as a typical hypoanechoic nodule, with derma; the calcification process may involve both
22 D. Orlandi et al.

a b

Fig. 2.19 Complete rupture of rotator cuff. (a) US coro- sion (f), acromion acoustic shadow (A). (b) In this case,
nal scan shows a complete tear of supraspinatus tendon; MR shows the expansion of the articular capsule and
deltoid muscle (D), humerus (H), great tuberosity (GT), subacromial-­deltoid bursa (SE T1)
glenohumeral joint and subacromial-deltoid bursa effu-

lage, which conversely can be easily assessed by

ultrasound (Fig. 2.21a and b). CPPD crystal
deposits in the peripheral portion of the fibrocar-
tilaginous menisci of the knee appear as centrally
embedded hyperechoic deposits.
Meniscal pathologic findings are common
among persons with knee osteoarthritis. In the
knee joint, the menisci play a vital role in joint
stability. Thus, mechanical impairment of the
Fig. 2.20 Ganglion cyst of radiocarpal joint (G); pedun-
cle (asterisk), bone surfaces (white arrows)
meniscus alters the weight-bearing capacities of
the tibiofemoral compartments, contributing to
the further progression of knee osteoarthritis.
the synovial membrane of joints and that of Degenerative changes and extrusion of meniscus
mucosal bursae and of tenosynovial sheaths. are being frequently reported in patients with
clinically symptomatic osteoarthritis of the knee.
Degenerative changes of meniscus appear as loss
2.7 Meniscal Lesions of homogeneous echostructure, and linear or
nodular hypoechoic or echogenic areas, which do
Currently, meniscal pathology is most often diag- not involve an articular surface.
nosed based on history, clinical examination, Meniscal extrusion is referred to as meniscal
magnetic resonance imaging, and/or arthroscopic bulging or external displacement with regard to
visualization. As possible alternative to MRI, the external aspect of the tibiofemoral compart-
high-frequency ultrasound imaging has been ment. It is thought to be a predictor of meniscal
reported to be a sensitive method for the evalua- degeneration and tibiofemoral osteoarthritis.
tion of meniscal injuries and degenerative Ultrasound exhibits excellent diagnostic perfor-
changes. mance for the detection of meniscal extrusion
Usually MRI fails to identify the crystal compared with MRI. The medial meniscal extru-
deposits in or on the femoral hyaline cartilage, as sion assessment is performed using sonographic
can crystal depositions in the meniscus fibrocarti- coronal section at the medial aspect of the knee,
2 Synovial Spaces 23

a b

Fig. 2.21 (a) Knee ultrasound. Hyperechoic, oval shaped structure of CPPD deposition (arrow) is seen between lateral
bony outlines of femur and tibia. (b) Knee MRI in same patient. CPPD deposition cannot be visualized by this MRI

Fig. 2.22 Ultrasound evaluation of meniscal extrusion. A distance less than 2 mm is normal (grade 0), while the extru-
sion is moderate (grade 1) when the distance is between 2 and 4 mm, and is severe (grade 2) if it exceeds 4 mm

along the medial collateral ligament, with patient has proven to be a sensitive modality for detect-
in supine position, and fully extended knee. A ing parameniscal cysts and also a useful tool for
reference line is drawn tangent to the bone profile guiding the needle in its transcutaneous evacua-
of medial aspect of femur and tibia at joint level tion. It typically appears as an anechoic thin-­
(excluding osteophytes). The extent of meniscal walled cyst located in the parameniscal soft
extrusion can be assessed by semiquantitative tissue. A meniscal horizontal tear, which proba-
grading system, based on the measurement of bly communicates with the cyst, coexists not
distance between the reference line and the most infrequently (Fig. 2.23). It is more common in
prominent point on external profile of meniscus. the lateral compartment of the knee than in the
A distance less than 2 mm is normal (grade 0), medial one.
while the extrusion is moderate (grade 1) when A meniscal tear is a disruption of the structure
the distance is between 2 and 4 mm, and is severe of the meniscus affecting its integrity and stabil-
(grade 2) if it exceeds 4 mm (Fig. 2.22a and b). ity, and thus its ability to absorb shock. Clinical
The meniscal cyst can represent a degenera- examination still plays an important role in diag-
tive process of the meniscus, as a consequence of nosing meniscal tears, but accurate diagnosis
local mucoid degeneration. A fluid collection is depends upon imaging, which is largely repre-
formed in the meniscus which, through a hori- sented by MR imaging as “gold standard” for
zontal cleavage, flows into the parameniscal soft confirming and assessing meniscal tears.
tissues, forming a parameniscal cyst. Ultrasound Ultrasound is another, less used, useful d­ iagnostic
24 D. Orlandi et al.

test for assessing meniscal tears (Fig. 2.24). The detect in arthroscopy. Instead, ultrasonography can
highest sensitivity and accuracy of ultrasound in be not only diagnostically useful, but also useful in
the detection of meniscal tears are obtained in the assisting arthroscopic surgery. In summary, the
assessment of the horizontal tear and complex ultrasound does not represent the first-level imag-
one; instead, the radial tear is almost never ing for detecting meniscal diseases, surely sur-
detected. passed by the MRI in this role, but it can certainly
Meniscocapsular separation results from dis- participate usefully in their diagnosis, particularly
ruption of the meniscotibial ligaments of the poste- in meniscocapsular separation.
rior horn of the medial meniscus, frequently
associated with anterior cruciate ligament damage.
This meniscal injury, also called ramp lesion, when 2.8 Endoarticular Loose Bodies
mild, can be responsible for persistent gonalgia; it
may escape the MRI assessment and be difficult to These can be found in all joints but mostly the
knee, where they can be easily detected when
located in the suprapatellar recess. Loose bodies
occur in several pathologies such as osteochon-
dritis dissecans, osteochondral fractures, osteo-
necrosis, osteoarthritis, and synovial
osteochondromatosis. Since they have a highly
calcified content, they appear on US as hyper-
echoic curvilinear bodies, with posterior acoustic
shadowing, and are mobile, depending on the
patient’s position. The mobility of a loose body
can be demonstrated, in dubious cases, by
dynamic passive maneuvers that also help differ-
entiate it from gross osteophytes. When a loose
Fig. 2.23 Ultrasound appearance of a horizontal menis- body contains osteochondral tissue, the cartilagi-
cal tear (arrows) seen between the bony outlines of femur nous covering (hypoechoic) can be differentiated
(f) and tibia (t) from the bony component (Fig. 2.25a–c).

a b

Fig. 2.24 Ultrasound (a) and MRI (b) appearance of an oblique meniscal tear (arrow). Note that ultrasound is able to
clearly visualize the superficial aspect of the tear but offers a really poor detection of its deeper aspect. f femur; t tibia
2 Synovial Spaces 25

a b c

Fig. 2.25 Loose endoarticular osteochondral body in the pression technique) (b) confirms the presence of the loose
suprapatellar recess. (a) The US scan shows a double-­ body in the suprapatellar recess (white arrow) and (c)
layered loose body (empty white arrow) due to its dual shows the osteochondral detachment location (black
composition (cartilage and bone). The MR scan (fat sup- arrow) on the femoral condyle (TSE T2)

Mahdy NS, Sakr HM, Allam AE. The role of ultrasound

Further Readings in evaluation of meniscal injury. Egypt J Hosp Med.
2018;72(10):5490–4.
Bianchi S, Martinoli C. Detection of loose bodies in Martino F, Angelelli G, Ettorre GC, et al. Aspetto normale
joints. Radiol Clin North Am. 1999;37:679–90. della borsa sovrarotulea nell’ecografia del ginocchio.
Bianchi S, Martinoli C, Bianchi-Zamorani M, Radiol Med. 1992;83:43–8.
Valle M. Ultrasound of the joints. Eur Radiol. Newman JS, Adler R, Bude RO, Rubin J. Detection of
2002;12:56–61. soft-tissue hyperemia: value of power Doppler sonog-
Cardinal E, Buckwalter KA, Braunstein EM, Mih raphy. AJR Am J Roentgenol. 1994;163:385–9.
AD. Occult dorsal carpal ganglion: comparison of US Nogueira-Barbosa MH, Gregio-Junior E, Lorenzato MM,
and MR imaging. Radiology. 1994;193:259–62. Guermazi A, Roemer FW, Chagas-Neto FA, Crema
Carotti M, Salaffi F, Manganelli P, et al. Power Doppler MD. Ultrasound assessment of medial meniscal extru-
sonography in the assessment of synovial tissue of the sion: a validation study using MRI as reference stan-
knee joint in rheumatoid arthritis: a preliminary expe- dard. AJR Am J Roentgenol. 2015;204(3):584–8.
rience. Ann Rheum Dis. 2002;61:877–88. Roberts D, Miller TT, Erlanger SM. Sonographic appear-
De Flaviis L, Musso MG. Hand and wrist. Clin Diagn ance of primary synovial chondromatosis of the knee.
Ultrasound. 1995;30:151–78. J Ultrasound Med. 2004;23:707–9.
Fitzgerald O, Bresnihan B. Synovial vascularity is Schmidt WA, Volker L, Zacher J, et al. Colour Doppler
increased in rheumatoid arthritis: comment on the ultrasonography to detect pannus in knee joint synovi-
article by Stivens et al. (letter). Arthritis Rheum. tis. Clin Exp Rheumatol. 2000;18:439–44.
1992;35:1540–1. Shetty AA, Tindall AJ, James KD, Relwani J, Fernando
Gibbon WW. Applications of ultrasound in arthritis. KW. Accuracy of hand-held ultrasound scanning in
Semin Musculoskelet Radiol. 2004;8:313–28. detecting meniscal tears. J Bone Joint Surg Br. 2008
Gibbon WW, Wakefield RJ. Ultrasound in inflammatory Aug;90(8):1045–8.
disease. Radiol Clin North Am. 1999;37:633–51. Silvestri E, Martinoli C, Onetto F, et al. Valutazione
Grobbelaar N, Bouffard JA. Sonography of the Knee, dell’artrite reumatoide del ginocchio con color
a pictorial review. Semin Ultrasound CT MR. Doppler. Radiol Med. 1994;88:364–7.
2000;21:231–74. Steiner E, Steinbach LS, Schnarkowski P, et al. Ganglia
Hlavacek M. The role of synovial fluid filtration by car- and cysts around joints. Radiol Clin North Am.
tilage in lubrification synovial joints. Squeeze film 1996;34:395–425.
lubrification: homogeneous filtration. J Biomech. Szkudlarek M, Court-Payen M, Strandberg C, et al. Power
1993;26:1151–60. Doppler ultrasonography for assessment of synovitis in the
Klauser A, Frauscher F, Schirmer M, et al. The value metacarpophalangeal joints of patients with Rheumatoid
of contrast enhanced color Doppler ultrasound in Arthritis: a comparison with dynamic magnetic resonance
the detection of vascularization of finger joint in imaging. Arthritis Rheum. 2001;44(9):2018–23.
patients with rheumatoid arthritis. Arthritis Rheum. Taljanovic MS, Sheppard JE, Jones MD, Switlick DN,
2002;46:647–53. Hunter TB, Rogers LF. Sonography and sonoarthrog-
Klauser A, Demharten J, De Marchi A, et al. Contrast raphy of the scapholunate and lunotriquetral ligaments
enhanced gray-scale sonography in assessment of joint and TFC: initial experience and correlation with
vascularity in rheumatoid arthritis: result from the arthrography and magnetic resonance arthrography. J
IACUS study group. Eur Radiol. 2005;15:2404–10. Ultrasound Med. 2008;27(2):179–91.
26 D. Orlandi et al.

Teefey SA, Middleton WD, Patel V, et al. The accu- Van Holsbeeck MT, Introcaso JH. Musculoskeletal ultra-
racy of high-resolution ultrasound for evaluating sound. 2nd ed. Maryland Heights: Mosby; 2001.
focal lesions of the hand and wrist. J Hand Surg. Van Holsbeeck M, Strouse PJ. Sonography of the shoul-
2004;29:393–9. der: evaluation of the subacromial-subdeltoid bursa.
Hesham El Sheikh, Mohamed H. Faheem, Ahmed K. AJR. 1993;160:561–4.
Abdelmoeim. Role of ultrasonographic examination Walsh DA. Angiogenesis and arthritis. Rheumatology.
of the knee in evaluation of meniscal injury in cor- 1999;38:103–12.
relation with magnetic resonance imaging. BMFJ. Wang SC, Chen RK, Cardinal E, Cho KH. Joint sonogra-
2021;38:90–7. phy. Radiol Clin North Am. 1999;37:653–68.
 Tendons and Ligaments
3
Davide Orlandi , Umberto Viglino,
and Elena Massone

Contents
3.1 Sonographic and Doppler Normal Anatomy  27
3.2 Paratenonitis  35
3.2.1 Tenosynovitis  36
3.2.2 Peritendinitis  37
3.3 Tendinosis  39
3.4 Degenerative and Inflammatory Enthesopathy  40
3.5 Entheseal Tear and Tendon Rupture  42
3.6 Tendon Dislocation  42
3.7 Tendon Cysts  45
3.8 Ligament Tears  45
Further Readings  47

3.1 Sonographic and Doppler tal segments. They are extremely resistant to trac-
Normal Anatomy tion, almost like bone. A tendon with a 10 mm2
transverse section can bear a maximum of 600–
Tendons are critical biomechanical units in the 1000 kg. On the other hand, tendons are not very
musculoskeletal system, the function of which is elastic, and can only tolerate a maximum elonga-
to transmit the muscular tension to mobile skele- tion of 6% before being damaged.
Tendons have very slow metabolism, even
D. Orlandi (*) during action. This can be significantly increased
Department of Radiology, Ospedale Evangelico only by inflammatory conditions and traumas.
Internazionale, Genova, Italy
When a reparative process occurs, a proliferation
U. Viglino of fibrocytes is observed with deposition of col-
Postgraduate School of Radiology, Genoa University,
lagen cells.
Genova, Italy
Tendons macroscopically appear as ribbon-
E. Massone
like structures, with extremely variable shape and
Department of Radiology, Ospedale Santa Corona,
Pietra Ligure (SV), Italy

© Springer Nature Switzerland AG 2022 27

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_3
28 D. Orlandi et al.

dimensions, characterized by the presence of tenosynovial sheath and the epitenon together
dense fibrous tissue arranged in parallel bundles. constitute the paratenon of the sliding tendon.
More specifically, they consist of about 70% The vascularization varies according to the
of type I collagen fibers that form primary bun- type of tendon. In sliding tendons, the vessels run
dles. Among the primary bundles are fibrocytes within the mesotenon, the mentioned synovial
endowed with large laminar protrusions, named “fold,” which connects the parietal and visceral
tenocytes or alar cells. Among the collagen fibers layers.
of tendons, elastic fibers (about 4%) can also be The vessels pass therefore along the tendon’s
found; their role is not different from that of a surface, where some arterioles arising from the
“shock absorber” when muscular contraction vessels penetrate into the tendon following the
begins. The collagen and elastic fibers both have course of connective laminae (Fig. 3.3b).
the same direction as the main lines of force and On the other hand, the vessels of the anchor
lie in a gel consisting of proteoglycans and water. tendons constitute a thick and irregular anasto-
The primary bundles are assembled to form sec- motic net within the paratenon. Arteriolar vessels
ondary bundles (representing the tendon’s func- arise from this net and penetrate inside the tendon
tional unit), which are clustered in tertiary to different levels, following the course of the
bundles. connective laminae. The arterioles, within these
The endotenon is a thin connective strip sur- connective structures, form vascular arcades with
rounding the primary, secondary, and tertiary the nearby arterioles. Tendons may present with
bundles, and separating them. Vessels and nerves less vascularized zones, named critical areas,
run within the endotenon thickness. The epitenon which are extremely important in the pathogene-
is a stronger connective covering, surrounding sis of several tendon diseases. Examples include
the whole tendon (Fig. 3.1). the pre-insertional area of the supraspinatus ten-
From a functional and anatomical point of don of the shoulder, or the central part of the
view, tendons can be divided into two types: sup- Achilles tendon, which typically constitutes
porting tendons (or anchor tendons) and sliding highly susceptible sites of degenerative disease
tendons. Anchor tendons (such as the Achilles and tendon rupture.
and the patellar tendon) are typically bigger and The points of union between the tendons and
stronger than sliding tendons; they are not pro- the muscle or the bone are named myotendinous
vided with a synovial sheath, but they are sur- junction and osteotendinous junction (enthesis),
rounded by a connective lamina external to the respectively. The myotendinous junction is usu-
epitenon, called peritenon; the two connective ally well defined: at this level the tendon fibers
sheaths (epitenon and peritenon) form the are intertwined with the endomysium fibers. The
paratenon together with highly vascularized adi- osteotendinous junction has a more complicated
pose and areolar tissue (Fig. 3.2). structure: its nature may be either fibrous or
Sliding tendons are wrapped in a covering fibrocartilaginous according to the tendon mobil-
sheath (tenosynovial sheath) whose function is to ity, the angle formed between the tendon fibers
guarantee better sliding and protection to the ten- and the bone, and the presence of an underlying
dons when they run adjacent to irregular osseous retinaculum. The tendons moving in a single spa-
surfaces, sites of potential friction. The tenosyno- tial plane and whose insertion on the bone occurs
vial sheath consists of two layers: a visceral layer, with an acute angle (e.g., flexor tendons of the
and a strictly connected synovial “fold” named toes) have a fibrous enthesis. The same situation
mesotenon. A closed cavity, nearly virtual, con- occurs for tendons whose course is modified and
taining a very small amount of synovial fluid, is kept in position by a retinaculum—for example
found between the two layers (Fig. 3.3a). the peroneal tendons—and whose insertion on
The tenosynovial sheath of sliding tendons the bone once again forms an acute angle.
corresponds anatomically and functionally to the The tendons controlling multiplanar move-
peritenon of anchor tendons and, similarly, the ment (e.g., Achilles tendon) and whose insertion
3 Tendons and Ligaments 29

Fig. 3.1 Anatomical

drawing of a tendon

EPITENON

ENDOTENON

TERTIARY BUNDLE

SECONDARY BUNDLE

PRIMARY BUNDLE

on the bone surface is orthogonal have a thick vial sheath, which always covers these types of
fibrocartilaginous enthesis that minimizes the tendons, makes the sliding of a tendon easy, and
risk of tendon tear. This more complicated type reduces friction. Retinacula are typically found in
of osteotendinous junction consists of four layers the wrist and ankle. Some examples are the trans-
in quick succession, represented—from the most verse carpal ligament, which defines the superior
superficial to the deepest one—by tendinous tis- aspect of the carpal tunnel, where the flexor digi-
sue, fibrocartilage, calcified fibrocartilage, and torum tendons and the median nerve run, and the
bone. The osteotendinous junction is well vascu- ankle retinacula, which stabilize the flexor and
larized and the paratenon vascular net is anasto- extensor tendons in their deflection points. Some
mosed with that of the periosteum. specific types of retinacula are found in the fin-
A retinaculum is a transversal thickening of gers, where the flexor digitorum tendons,
the deep fascia attached to a bone’s eminence. wrapped in the synovial sheath, run along osteo-
The biomechanical function of a retinaculum is fibrous canals extending from the palm of the
to keep the tendons in position as they pass hand to the distal phalanx. The superior aspect of
underneath it, in order to avoid their dislocation these osteofibrous canals (the “vault”) consists of
during muscular action. Retinacula therefore archlike fibers running over the tendons, in points
guarantee that tendons are correctly deviated and where more stabilization is needed. For their
kept in position in their respective osteofibrous peculiar biomechanical function, these structures
canals, allowing their efficient action; the syno- are named flexor annular pulleys. On the ­contrary,
30 D. Orlandi et al.

TERTIARY
BUNDLE
EPIT
ENON
MESOTENON

ENDOTENON

ANCHORING
TENDON SLIDING
PERI TENDON TENOS
TENO YNOVIA
N L
SHEATH

EPIT EPIT
ENON ENON

Fig. 3.2 Schematic drawing of the tendon sheaths. The under which the vascular network runs, embedded in
tendons are differentiated into anchoring tendons and slid- loose connective tissue (colored pink in the figure). The
ing tendons, depending on the structure of the sheath synovial sheath is made up of two serous sheaths that
enclosing it. The sheath of the anchor tendon is named delimit the synovial space, containing the synovial fluid
epitenon, while that of the sliding tendon is called tenosy- that guarantees slipping. The blood vessels are distributed
novial sheath. The epitenon is constituted by a strong around the tendon below the synovial sheath, with vascu-
superficial covering, of dense fibrous connective tissue, lar peduncles afferent through the mesotenon

a b

Fig. 3.3 Anatomy (a) and vascularization (b) of a sliding tendon. Vessels arise from mesotenon
3 Tendons and Ligaments 31

in regions where the canal needs to be more flex- In transverse views the Achilles tendon thick-
ible, in order to allow the flexion of joints, a ness (anteroposterior diameter) can be best
device consisting of loose plaited fibers is ­present, assessed. In transverse section the Achilles ten-
providing support to the tendon sheath without don is elliptical, with its major axis following an
fixing it. oblique anteromedial direction. The sonographer
Ligaments have an analogous structure to that must be aware of the risk of overestimating ten-
of tendons; however, they are thinner and they don thickness when assessed on longitudinal
contain a higher amount of elastin, which is a scans. When evaluating a tendon by US, it is
necessary element to supply these structures with extremely important to apply a correct orthogo-
some degree of elasticity for their very important nal direction to the US beam, both for longitudi-
biomechanical role in the stabilization of joints. nal and axial views. When the US beam is not
There are two types of ligaments: the intrinsic orthogonal to the tendon course, both a decrease
capsular ligaments, which appear as localized of the reflected echoes and an increase of the dif-
thickenings within the capsule with a strengthen- fracted ones occur, resulting in a significant or
ing function, and the extrinsic ligaments, which partial reduction of the tendon echotexture (ten-
are independent from the fibrous capsule and can don anisotropy). This artifact is more frequently
be further classified as extracapsular and intra- found when assessing the rotator cuff tendons of
capsular ligaments. the shoulder, the quadriceps femoris, the patellar
Nowadays US represents the gold standard and Achilles tendons, the osteotendinous junc-
technique for the assessment of tendons. With the tions, and the flexor and extensor tendons of the
advent, for clinical purposes, of high-resolution ankle, hand, and wrist. In these regions a less
transducers and specific image processing soft- experienced sonographer can risk making an
ware, it became possible to make detailed analysis incorrect diagnosis (Fig. 3.5).
of the shape and structure of tendons. In addition, The sliding and anchor tendons present some
US is the only technique that allows the radiolo- differences regarding their US appearance.
gist to perform a dynamic study of tendons, which Sliding tendons, as already described, are
is extremely important for the diagnosis of tendon wrapped in a synovial sheath which contains,
pathology. In longitudinal ultrasound views (long even in physiological situations, a minimum
axis), the tendons appear as echoic ribbon-like amount of synovial fluid acting as a lubricant.
bands, defined by a marginal hyperechoic line This slight film of fluid can be easily recognized,
corresponding to the paratenon and characterized both in axial views and in longitudinal views, as
by a fibrillar internal structure. a thin anechoic halo surrounding the tendon. The
The fibrillar echotexture is represented by a pathological increase in synovial fluid inside the
succession of thin hyperechoic parallel bands, tendon sheath often allows the mesotenon to be
slightly wavy, which tend to grow apart from one identified. On the other hand, anchor tendons are
another when the tendon is released and to move surrounded by the peritenon, a layer of dense
closer when the tendon is tense. This fibrillar connective tissue leaning on the epitenon, which
echostructure is caused by the specular reflec- contributes to constitute the paratenon. The
tions within the tendon determined by the exist- paratenon appears as an echoic line surrounding
ing acoustic interface between the endotenon the tendon, without the possibility of distinguish-
septa (Fig. 3.4a). ing, in normal conditions, between peritenon and
The number and thickness of such structures epitenon. High-resolution ultrasound is per-
change depending on the frequency of the trans- formed to study the inflammatory pathology of
ducer. In transversal views (short axis) tendons tendons in order to depict the morphological and
appear as round or oval shaped structures, char- structural variety of tendons and the synovial
acterized by several homogeneously scattered sheath expansion. The grayscale ultrasound tech-
spotty echoes (Fig. 3.4b). nique is still not able to recognize indirect signs
32 D. Orlandi et al.

a b

Fig. 3.4 Ultrasound anatomy of normal tendon: (a) long axis; (b) short axis

Annular pulleys are biomechanical devices

made of fibrous connective tissue, which keep the
flexor digitorum tendons in position during
flexion-­extension movements. For this reason,
the sonographic assessment of the pulleys has to
be performed with a dynamic method; the US
dynamic analysis should be obtained during
flexion-­extension movements of the fingers and,
if a tendon tear is suspected, it should be supple-
mented with contrasted flexion. The transducer
should always have a perpendicular and trans-
Fig. 3.5 Longitudinal US scan of relaxed quadriceps ten- verse position over the flexor tendons, with a
don in a healthy man. The hypoechoic spot (*) (tendon
anisotropy) corresponds to the pre-insertional area
high amount of gel used as a spacer in order to
avoid any pressure on the tissue. In longitudinal
views of flexor tendons, the pulley appears as a
thin oval structure lying superficially compared
with the tendon sheath (Fig. 3.7).
The structure of ligaments is very similar to
that of tendons; the main differences are reduced
thickness and a less regular arrangement of struc-
tural elements; for this reason, it is harder to
study ligaments with US than tendons. The US
examination of ligaments, unlike tendons, is
mainly performed using long-axis views, the
transducer being aligned on the ligament’s major
Fig. 3.6 Transverse anterior US scan (22 MHz) of the axis. Transverse views (short axis) have poor
ankle. The retinaculum (white arrows) is the thin hyper- diagnostic value.
echoic line that lies around the tendon. TA tibialis anterior
tendon With US, ligaments appear as homogeneous,
hyperechoic bands, 2–3 mm thick, lying close to
of inflammation and needs to be implemented by the bone (Fig. 3.8a, b).
power Doppler evaluation. The easiest ligaments to assess with US are
Retinacula at ultrasound appear as thin hyper- those of the medial and lateral compartments of
echoic structures located more superficially than the ankle (deltoid, anterior talofibular, and fibulo-
the sliding tendons, in very critical areas from a calcaneal), the collateral ligaments of the knee,
biomechanical point of view (Fig. 3.6). the collateral and annular ligaments of the elbow,
3 Tendons and Ligaments 33

the coracoacromial and coracohumeral ligaments superficial component from the deep one
of the shoulder, and the ulnar collateral ligament (Fig. 3.9).
of the thumb. The medial collateral ligament of By implementing the information obtained
the knee (MCL) has a very complicated structure from a grayscale ultrasound examination with
that deserves detailed description. The MCL is a that obtained from a power Doppler study, the
flattened, large structure extending from the dis- sonographer is able to identify functional param-
tal extremity of the medial femoral condyle to the eters regarding the vascularization of the tendons
proximal tibial extremity; it is about 9 cm long for a better clinical evaluation. In standard condi-
and it is divided into two components, deep and tions, tendons have low metabolic activity and
superficial, which are separated by a thin layer of the blood supply is given by high-resistance
loose connective tissue. The deep component is arteries and small veins, too thin to be studied
then divided into two small ligaments that fix the with the Doppler technique. In such cases, weak
medial meniscus, respectively, to the femur flow signals can be observed near small arterial
(menisco-femoral ligament) and to the tibia structures afferent to the cortical bone. These
(menisco-tibial ligament). Sonographically the vascular structures are usually arteries with a
MCL appears as a trilaminar structure consisting high resistance index, corresponding to the peri-
of two hyperechoic layers, separated by a central osteal vessels. Several conditions such as inflam-
interleaved hypoechoic area. The hyperechoic matory, post-traumatic, and infectious are
bands correspond to deep and superficial fiber responsible for the activation of vascular hyper-
bundles, whereas the loose areolar tissue consti- emia with an increase in blood flow and a drop in
tutes the hypoechoic central area that divides the vascular resistance. In this way the tendon ves-
sels become easy to assess with color or power
Doppler technique and it is also possible to per-
form a semiquantitative flow analysis of pulsed-­
wave Doppler ultrasound spectrum (Fig. 3.10).
A recently developed imaging technique,
sonoelastography (SEL), allows for qualitative
visual or quantitative measurements of the
mechanical properties of tissues. It is based on
the principle for which, applying an extrinsic
Fig. 3.7 Longitudinal US scan of flexor digitorum ten- (mechanical or physical) stress, it is possible to
dons at the metacarpophalangeal joint. The first (A1) out induce changes in a determined tissue, depend-
of five pulleys is clearly shown over the tendons. FP
flexor digitorum profundus; FS flexor digitorum superfi-
ing on the elastic properties of the tissue itself;
cialis; PH proximal phalanx; H metacarpal head; P pal- hence, qualitative and/or quantitative measure-
mar plate; C cartilage ments of the elastic changes induced through

a b

Fig. 3.8 (a, b) Transverse fusion US-MR scan of the lateral ankle compartment showing the course of the anterior
talo-fibular ligament (*) F fibula; T talus
34 D. Orlandi et al.

tissue deformation (strain) relative to the sur-

rounding normal tissue is measured, usually
with a tracking algorithm working on the
radiofrequency data. The resulting data can
then be used to form an image that is coded in
color or grayscale to show the pattern of strain,
which is inversely related to tissue stiffness
and can be assessed subjectively. These are
Fig. 3.9 Longitudinal US scan of the medial side of the
knee: medial collateral ligament; asterisks = superficial qualitative data; however, regions of interest
component; C femoral condyle; T tibial plateau; m (ROIs) can be positioned over target areas in
meniscus the screen in order to obtain semiquantitative
analysis (Fig. 3.11).
• Shear-wave elastography: It is a very poten-
tial technique for the noninvasive quantifica-
tion of tissue stiffness. Shear waves in the
body can be induced by various methods,
including physiological motion, external
mechanical excitation, or acoustic radiation
force (by a focused ultrasound beam). Shear
waves are transverse; they are rapidly attenu-
ated by tissue, they travel much more slowly
(between 1 and 10 m/s), and they are not sup-
ported by liquids of low viscosity. Using a
real-time imaging modality such as ultrasound
(but also magnetic resonance), the underlying
tissue stiffness can be estimated measuring the
Fig. 3.10 Color Doppler scan in jumper’s knee. Peri- and produced shear-wave speeds. Their speed is
intratendinous hypervascularization of the proximal third
commonly expressed in meters per second
of the tendon is clearly shown. The spectral analysis
shows arteries with low resistance and high diastolic flow (m/s); it is closely related to the modulus of
elasticity of the tissue, and there is a simplified
the tissue could be obtained, usually by means formula for converting between the shear-­
of an ­ultrasound transducer in clinical practice. wave speed and the elastic modulus of the tis-
EUS could detect or differentiate an early-stage sue to locally quantify its stiffness in
alteration which could progress to higher stages kilopascals (kPa). In contrast to strain elastog-
of tendinopathy, providing supplementary infor- raphy, this technique allows for the perfor-
mation useful for diagnostic, therapeutic mance of quantitative analysis of the tissue
(ultrasound-­guided procedures), and follow-up stiffness (Fig. 3.12).
purposes.
Two main types of SEL have become estab- In strain elastography, data acquisition and
lished in clinical practice, in particular for mus- interpretation of elasticity images are largely
culoskeletal evaluation: dependent on the “operators’” experience and
skills. In contrast, the quantitative nature of
• Strain elastography: It is also described as shear-wave elastography is an advantage and
“quasi-static elastography,” “compression seems to let this technique be more reproducible;
elastography,” and “real-time elastography.” the fact that the system displaces the tissue could
The stress is applied by repeated manual com- improve consistency since the examiner does not
pression of the transducer, and the amount of need to move the transducer.
3 Tendons and Ligaments 35

a b

Fig. 3.11 Strain elastography. Qualitative analysis: the ues are depicted in green and the higher ones in red; in this
modulus of elasticity of the soft tissue scanned in the case the elastogram helps in a more precise quantification
B-mode image (a) is represented by a superimposed of a supraspinatus tendon tear (double-headed arrow)
color-coded map (b) in which (in this case) the lower val-

3.2 Paratenonitis

Nowadays, US is the imaging tool of first choice

for the study of tendons. Compared to other
imaging techniques, such as MR, US allows
static evaluation, with a highly detailed represen-
tation of the intrinsic anatomic structure of ten-
dons and a dynamic evaluation, which is an
extremely important element for an accurate
diagnosis. Tendons are divided, from an anatomic
and functional point of view, into two types: (1)
supporting tendons and (2) sliding tendons.
This distinction is extremely important in
order to understand the most common pathologi-
cal conditions, both rheumatological and trau-
matic. In inflammatory tendinopathies all the
layers of the tendons are involved (paratenonitis),
while the tendon’s parenchyma (collagen fibers,
Fig. 3.12 Shear-wave elastography of rectus femoris proteoglycans) is usually only affected in degen-
muscle: after the generation of the “pushing” beam by the erative conditions (tendinosis), where the two
transducer, the values of the shear modulus in the targeted pathologic conditions often coexist.
area are represented by means of a color-coded map set. It Moreover, paratenonitis can be distinguished
is possible to get also a quantitative analysis of the inves-
tigated tissue by placing some ROIs (with modifiable in tenosynovitis and peritendinitis, according to
dimensions) over the map and get the corresponding value the specific involvement of sliding tendons or
at the left bottom angle of the screen supporting tendons. Inflammatory and degenera-
36 D. Orlandi et al.

tive involvement of the osteotendinous junction views, and lying along the tendon course in lon-
is called enthesopathy and is very common in gitudinal views, frequently with a fusiform
seronegative spondyloarthritis, but it can also be appearance (Fig. 3.13a, b).
the expression of a microcrystalline arthropathy, Sometimes increased echogenicity of the
or the result of chronic functional overuse of the tenosynovial fluid collection may be observed,
osteotendinous junction. Tendon tears and dislo- due to the presence of clusters of leukocytes,
cations usually follow mechanical overload fibrin, cholesterol, uric acid, calcium pyro-
which exceeds the resistance threshold of the sys- phosphate, or hydroxyapatite crystals. This
tem, the latter being the final expression of a hyperechoic appearance may create doubts
potential instability of sliding tendons lying in about the diagnosis of exudative tenosynovitis
critical areas. and, in such cases, compression made with the
Tendon cysts represent quite a common condi- transducer may help to confirm the liquid
tion, frequently found in the hand and causing nature of the finding. Power Doppler analysis
painful swelling. gives no evidence of vascular signal; therefore
it can be used to complement the information
obtained with grayscale US. It should be
3.2.1 Tenosynovitis pointed out that in some anatomical locations,
the tenosynovial sheath may be in communica-
Tenosynovitis is an inflammatory process affect- tion with the joint cavity. For example, the
ing the tenosynovial sheath. Tenosynovitis can be tenosynovial sheaths of the flexor hallucis lon-
classified as acute, subacute, or chronic, while gus tendon at the ankle and the long head of
from a pathologic point of view they are distin- biceps tendon at the shoulder are in communi-
guished in exudative, proliferative, and mixed cation with the tibiotalar and glenohumeral
forms. Even though the clinical diagnosis of joint. In these cases, when the sheath is
tenosynovitis may seem easy, the distinction expanded with fluid the presence of a joint
between the different pathologic forms can fluid collection must be considered. In prolif-
instead be difficult without US examination, erative tenosynovitis hypertrophic prolifera-
which allows an easy and quick diagnosis to be tion of the synovial tissue is observed, showing
made. various degrees of echogenicity (Fig. 3.14).
A peculiar form of tenosynovitis is the chronic Dynamic ultrasound examination and com-
stenosing tenosynovitis, affecting biomechani- pression of the transducer performed by the oper-
cally critical anatomic regions. An exudative ator are helpful to assess the solid nature of the
tenosynovitis can be easily diagnosed by means finding. In these cases the power Doppler analy-
of US. In this case, an increase of fluid is seen sis is very useful to confirm the diagnosis by
within the tenosynovial sheath appearing as an detecting vascular signals within a thickened
anechoic halo surrounding the tendon in axial tenosynovial sheath (Fig. 3.15a, b).

a b

Fig. 3.13 (a) Transverse scan, dorsum of wrist: synovial effusion (asterisk) into IV compartment extensor tendons (T);
(b) longitudinal view
3 Tendons and Ligaments 37

The degree of vascularization is strictly related In all cases where inflammatory involvement
to the severity of the inflammation and to the of the tenosynovial sheath is observed, US evalu-
“activity” of the synovial proliferation. These ation of the tendon’s morphology and intrinsic
forms of tenosynovitis are often an extra-articular structure should be performed. Tendons present-
expression of some rheumatic diseases such as ing with an alteration of their echotexture express
rheumatoid arthritis. Mixed tenosynovitis is the concomitant pathologic involvement of its paren-
most common form of tenosynovitis. It is charac- chyma (Fig. 3.17).
terized by the simultaneous presence of both Chronic stenosing tenosynovitis occurs in
synovial fluid and proliferative thickening of the peculiar anatomical regions, where the tendons
synovial membrane within the sheath. The US run through fibro-osseous canals. The most com-
pattern shows several echoic spots of synovial mon US pattern is that of a mixed tenosynovitis,
tissue jutting from the sheath expanded by accompanied by thickening of the corresponding
anechoic fluid (Fig. 3.16). retinaculum and consequent stenosis of the canal
In order to differentiate fluid from the prolifer- (Fig. 3.18).
ating tissue it is very useful to apply compression From a functional point of view, the dynamic
with the transducer. In dubious cases the two US examination may demonstrate a defective
components can also be distinguished with power sliding of the tendon within the sheath which
Doppler, because vascular signals exclusively could be easily seen on long-axis scans
occur within the solid tissue. (Fig. 3.19).
Notta-Nelaton’s disease, also known as “trig-
ger finger,” and De Quervain’s disease are the
most common forms of chronic stenosing
tenosynovitis.

3.2.2 Peritendinitis

The term peritendinitis refers to inflammation of

the paratenon of anchor tendons, especially
involving the highly vascular loose areolar con-
nective tissue that is found between epitenon and
Fig. 3.14 Transverse scan, finger flexor tendons.
peritenon.
Expansion of the tendon sheath with hyperechoic synovial In practice, peritendinitis of anchor tendons
proliferation (*) is shown. T tendon corresponds to tenosynovitis of sliding tendons,

a b

Fig. 3.15 (a) Finger flexor tendon, transverse power Doppler scan; proliferative tenosynovitis with diffuse hypervas-
cularization is shown; P flexor profundus tendon; (b) longitudinal view
38 D. Orlandi et al.

Fig. 3.16 Long head of biceps tendon of the shoulder,

transverse scan. Fluid expansion (*) of the synovial sheath
with synovial proliferation (arrowheads) is shown (mixed
tenosynovitis); m mesotenon; G intertubercular groove; T
tendon Fig. 3.18 Chronic stenosing tenosynovitis of first exten-
sor compartment tendons (T). 18 MHz US shows synovial
tendon sheath enlargement (*)

Fig. 3.19 Longitudinal scan of first extensor compart-

ment. Tendon (T) sliding could be seen during dynamic
maneuvers under synovial sheath enlargement (*)
Fig. 3.17 Wrist US dorsal longitudinal scan; extensor
tendons of fingers (T): tenosynovitis with inflammatory
expansion of the sheath (asterisks); inhomogeneous
fibrillar tendon echotexture does not appear
echotexture of tendons (arrowheads), subcutaneous fat altered; it is altered instead in mixed forms where
(SF), bone surface (white arrows) peritendinitis and tendinosis coexist.
The information obtained with grayscale US
for they both represent a paratenonitis. can be usefully integrated with an accurate color
Peritendinitis often affects tendons of the lower and power Doppler analysis that can add further
limbs, particularly the patellar and Achilles ten- information regarding the presence of peritendi-
dons. Like tenosynovitis, peritendinitis can be nous inflammation and hyperemia. It should also
classified as acute, subacute, or chronic. The be mentioned that in standard conditions the vas-
most common cause of peritendinitis is repeated cularization of tendons is very poor with low-­
microtrauma. US highlights the inflammatory speed flow, invisible on Doppler analysis. When
edema, a hypoechoic thickening of the peritendi- hyperemia is detected, a typical hypervascular
nous wrapping layers (Fig. 3.20) with a pattern is observed; this is characterized by sev-
hypoechoic ring-like appearance in short-axis eral signal spots and typically located in the peri-
views. In the classic pattern of peritendinitis, the tendinous area.
3 Tendons and Ligaments 39

Fig. 3.21 Low-grade tendinosis. The characteristic frag-

mentation of the fibrillar echotexture is shown (asterisk)

Fig. 3.20 Peritendinitis of the Achilles tendon (T); the

power Doppler scan shows some peritendineal vascular
signals (arrows), expression of hyperemia, and inflamma-
tion. C: calcaneus

3.3 Tendinosis

Tendinosis is a degenerative pathology affecting Fig. 3.22 Longitudinal scan of Achilles tendon (T)
both anchor and sliding tendons, presenting with enthesopathy; diffuse fibrillar echotexture disarray (f),
mild pain or with no symptoms at all. calcifications (arrowheads), and peri-calcaneal soft-tissue
Consequently, US plays a fundamental role in thickening (asterisk). C: calcaneus
diagnosis, because the patient’s history and clini-
cal examination alone cannot accurately ­implicate The largest hyperechoic spots show posterior
the involved tendon. From a histopathologic acoustic shadowing, representing areas of calcific
point of view, fibroblasts are activated with the metaplasia within the tendon (Fig. 3.23).
production of high-molecular-weight collagen Further assessment of intratendinous
and proteoglycans, causing diffuse edema. hypoechoic focal areas using color or power
Necrosis and fibrinous exudation occur with a Doppler techniques can be useful to detect vascu-
probable consequent fibrocartilaginous metapla- lar signals within the degenerative spots, a find-
sia and calcium deposition. US is able to detect ing suggestive of the presence of angiogenesis,
tendon alteration in early phases. The earliest US with a potential consequent substitution of the
sign of tendinosis, in long-axis views, is a disar- degenerate area. The absence of vascular signals
ray of tendon echotexture and its fusiform thick- within the degenerate areas of the tendon sug-
ening corresponding, in short-axis views, to the gests necrotic evolution of the degenerative
rounded appearance with loss of the typical ven- focus. It should be mentioned that in clinical
tral concavity. In early US patterns of tendinosis, practice it is common to find cases in which an
fragmentation of the fibrillar echotexture is overlap between degenerative (tendinosis) and
observed (Fig. 3.21). inflammatory (paratenonitis) tendon conditions
In later phases, focal hypoechoic areas related occurs, and in these cases the complex color and
to mucoid degeneration can be observed power Doppler images can be integrated with
(Fig. 3.22). Collagen fibers show a lack of orga- grayscale US to give a more precise assessment
nization; several hyperechoic spots can be (Fig. 3.24a–c).
detected, suggesting the presence of micro- and It should also be considered that some ana-
macro-calcification. tomical regions present peculiar biomechanical
40 D. Orlandi et al.

characteristics that promote the onset of tendino- neous and is often associated with a precalcaneal
sis. For instance, the presence of a prominent and retrocalcaneal bursitis (Fig. 3.25a, b).
posterosuperior calcaneal tubercle (Haglund’s Sonoelastography shows increased stiffness in
disease) may cause friction with the pre-­ symptomatic enlarged Achilles tendons in com-
insertional portion of the Achilles tendon. In parison to normal ones.
these cases, ultrasound shows the presence of
inflammatory and degenerative tendon involve-
ment, especially located at the pre-insertional 3.4 Degenerative
portion, which appears thickened and inhomoge- and Inflammatory
Enthesopathy

Enthesopathy, also known as insertional tendi-

nopathy, is an inflammatory-degenerative pathol-
ogy involving the osteotendinous junction,
usually caused by functional overload. It typi-
cally affects anchor tendons submitted to contin-
ual and intense mechanical stress. The affected
anatomical region, therefore, varies according to
the athletic task, resulting in the onset of typical
pathologies associated with specific sports, such
as tennis elbow and jumper’s knee.
In standard conditions the enthesis consists of
Fig. 3.23 Transverse scan of Achilles tendinosis (A).
The tendon is thickened and inhomogeneous with a small
intertwined tendon fibers and fibrocartilage, with
focus of calcification (*) slow-flowing vessels that cannot be visualized on

a c

Fig.3.24 (a) Longitudinal scan of Achilles tendinosis power Doppler scan shows some intratendinous vascular
(A). The tendon is thickened and inhomogeneous and signals. (c) An MR STIR longitudinal scan of Achilles
devoid of its characteristic fibrillar echotexture. (b) The tendinosis (A) and peritendinitis (circles)
3 Tendons and Ligaments 41

a b

Fig. 3.25 Haglund’s disease. (a) Longitudinal scan. The scan of the same patient (gradient echo (GE) T2W
pre-insertional segment of Achilles tendon (A) appears sequence) demonstrating a prominent posterosuperior cal-
inhomogeneous and thickened, with a longitudinal tear caneal tubercle. T = tubercle
and inflammation of the retrocalcaneal bursa (*). (b) MR

Fig. 3.27 Longitudinal scan of terminal extensor slip of

digitorum tendon; diffuse disarray of the fibrillar echotex-
ture, calcifications, and thickening; tendon slip (white
arrows), distal phalanx (DP), calcifications (C), joint (J)
Fig. 3.26 Longitudinal US scan of epicondylitis. The
power Doppler scan shows some intratendinous vascular
signal; enthesis (E), extensor tendons (T), bone surface are often associated. On US, erosions appear as
(white arrows), joint space (J), radial head (H). R: radius. interruptions of the hyperechoic cortical bone
outline. In advanced cases, an MR examination
Doppler analysis. In enthesopathies, the earliest should be performed, because it represents the
pathologic finding is local hyperemia and angio- only technique capable of determining the inser-
genesis; with Doppler techniques the increase of tional bone involvement appearing as medullary
vascular signals can be identified early (Fig. 3.26). edema within the bone in high-contrast sequences
US is a highly sensitive technique for identify- (Fig. 3.28).
ing and quantifying the tendon insertional thick- A peculiar form of enthesopathy is that affect-
ening, the hypoechoic pattern, and the ing patients in adolescence. During growth, the
inhomogeneous echotexture. Insertional calcifi- tendon insertion does not occur on the bone, but
cation and hypoechoic focal areas, corresponding on the growth plate cartilage, which represents a
to myxoid degeneration within the tendon, may weaker structure of the enthesis compared to
be observed (Fig. 3.27). bone and tendon, and is less resistant to mechani-
An inflammatory reaction of the adjacent cal stress. Impact is therefore mostly absorbed by
serous bursa and the presence of erosions and of the growth plate cartilage, and the corresponding
an irregular cortical bone outline at the insertion bone and tendon are relatively spared. Typical
42 D. Orlandi et al.

continuity and consequently its integrity.

Histological samples show degenerative involu-
tion of the collagen fibers, with necrotic foci. On
US scans, a tear appears as a hypo- to anechoic
spot that interrupts the fibrillar structure of the
tendon (Fig. 3.30a, b).
In complete tears, US allows the discontinuity
of the fibers, the two tendon stumps, and the
hemorrhagic collection within the retraction gap
to be visualized (Fig. 3.31).
In these cases it is important to perform a
dynamic US examination for a more accurate
evaluation of the tear location. In some regions,
the US signs of tendon tears can be very compli-
cated. A clear example is represented by the rota-
tor cuff tendons and particularly by the
supraspinatus tendon in which tears are classi-
fied, according to the site and extension of the
lesion, into the following:

Fig. 3.28 MR of the ankle, sagittal scan (fat suppression

1. Partial lesions: These can be further divided
technique). Reactive hyperemia (asterisk) of calcaneus
(C) at the Achilles tendon (T) insertion into bursal, when the involved aspect of the
tendon is in contact with the subacromial-­
clinical conditions that follow this situation are deltoid bursa (Fig. 3.32); articular, when the
some juvenile osteochondrosis, such as Osgood-­ involved aspect is in contact with the humeral
Schlatter’s disease (affecting the patellar tendon head; and intratendinous. A partial intraten-
at its distal insertion), Sinding-Larsen-Johansson dinous tear appears as an anechoic line within
disease (affecting the patellar tendon at its proxi- the tendon substance (Fig. 3.33).
mal insertion), and Haglund-Sever’s disease 2. Complete lesions, which correspond to full-­
(affecting the Achilles). All these patients present thickness tears of the tendon (small, interme-
with pain at the enthesis level and functional loss. diate, wide, total) (Fig. 3.34), with possible
The typical US pattern shows thickened growth retraction of the two stumps.
plate cartilage and fragmented nucleus of ossifi-
cation, suggestive of irregular endochondral ossi- In complete lesions of the rotator cuff, the
fication (Fig. 3.29a, b). humeral head appears uncovered with a tendency
to articulate with the acromion (subacromial
impingement). Hypoanechoic fluid collection is
3.5 Entheseal Tear and Tendon observed between the two tendon stumps with a
Rupture consequent expansion of the subacromial-deltoid
bursa (Fig. 3.35a, b).
A tendon tear may be observed after an acute
injury or as a poor outcome of tendinosis, with a
spontaneous rupture. Mechanical overload, espe- 3.6 Tendon Dislocation
cially when excessive and repetitive, may eventu-
ally cause partial or total tears within a Along their course, sliding tendons may undergo
degenerative tendon structure. Such tears are flexion and consequent spatial misalignment
often incomplete, but they still alter the tendon from the corresponding muscle’s functional axis.
3 Tendons and Ligaments 43

a b

Fig. 3.29 Sinding-Larsen-Johansson syndrome in a patellar (P) pole. (b) The US scan shows an irregular bone
young patient. (a) The plain film shows fragmented outline (arrow) and swelling at the patellar tendon
appearance of the ossification center (arrow) of the lower insertion

a b

Fig. 3.30 (a) This longitudinal scan at the proximal third scan of the same patient (sagittal scan, fat suppression
of patellar tendon shows a partial tear (*) with inflamma- technique) confirms the US findings and highlights the
tory involvement of peritenon (arrowheads). P lower inflammation of peritendinous tissues. T patellar tendon;
patellar extremity; B deep pretibial bursa. (b) The MR arrowheads partial tear

Fig. 3.31 Longitudinal scan of complete Achilles tendon Fig. 3.32 Transverse scan of the shoulder: partial tear
tear; soleus muscle (S), posterior aspect of tibiotalar joint (j), (asterisk) of bursal side of supraspinatus tendon (SS);
tibia (Ti), talus (T), Achilles tendon (thin white arrows), tear humerus (H), deltoid muscle (D)
area (thick arrows), hemorrhagic (#) and fluid (*) collection
44 D. Orlandi et al.

In order for correct biomechanical function, the

angular points and lever fulcra of the tendon must
be kept in their physiological osteofibrous
grooves. The anatomic structures that carry out
this task are the retnacula: focal transverse thick-
enings of the deep fascia that are securely
anchored to bone eminences. The correct func-
tioning of their stabilizing role is therefore of
great importance because whenever it is lacking,
the tendon tends to dislocate, with consequent
Fig. 3.33 Transverse scan of the shoulder: partial tear instability. There are several degrees of severity
(asterisk) of supraspinatus tendon (SS); humerus (H), del- in tendon instability: in moderate lesions the ten-
toid muscle (D) don tends to dislocate only when a specific move-
ment is performed, while in more severe lesions
subluxation and luxation can be observed. The
possibility of performing dynamic examination
makes US the gold standard technique when ten-
don instability is suspected. Even though tendon
instability is not very common, it should always
be considered when deriving a differential diag-
nosis, because an early diagnosis is fundamental
to avoid the onset of tendinosis or of a tendon
tear. The most commonly affected tendons are
the long head of the brachial biceps at the shoul-
Fig. 3.34 Complete tear of supraspinatus tendon (arrow- der and the fibular tendons at the ankle.
heads) is clearly shown as a full-thickness rupture in this
US scan. SS supraspinatus tendon; D deltoid; G greater Dislocation of the long head of biceps may fol-
humeral tubercle low a transverse ligament tear or a coracohumeral

a b

Fig. 3.35 (a) Complete tear of a degenerative supraspinatus tendon with retraction of the two tendon stumps. (b) MPR
reconstruction on a coronal plane (view from the top). T tendon stumps
3 Tendons and Ligaments 45

ligament tear, with or without an associated tear lesion of the superior fibular retinaculum with
of the subscapularis tendon. It should be men- subsequent tendency of the fibular tendons to dis-
tioned that there are several congenital conditions locate anteriorly over the lateral malleolus. In
that promote instability, such as the presence of a short-axis views, with the transducer on the
flat intertubercular groove. When dislocation angular flexion point and performing a dynamic
occurs, US shows an empty groove and a medi- maneuver of dorsal flexion of the foot, disloca-
ally dislocated tendon (Fig. 3.36). tion of the fibular tendons over the lateral malleo-
The application of dynamic maneuvers with lus can be observed (Fig. 3.37a, b).
external rotation of the arm, with 90° flexion of
the elbow, can be useful because they reproduce
the stressing action. At the ankle, the fibular ten- 3.7 Tendon Cysts
dons are kept in site by the fibular retinacula,
superior and inferior, that are, respectively, Tendon cysts occur more frequently in the palmar
located over and under the angular flexion point, aspect of fingers, along the flexor tendons’
at the lateral malleolus. Instability is caused by a course, strictly in contact with the tenosynovial
sheath from which they arise. The US diagnosis
is simple because they usually appear as round,
anechoic, formations with well-defined walls.
They should always be evaluated in long- and
short-axis views (Fig. 3.38a, b); short-axis views
allow the relation between cyst and tenosynovial
sheath to be demonstrated. A dynamic examina-
tion can be performed during flexion of the
fingers.

3.8 Ligament Tears

Fig. 3.36 Transverse scan of the anterior aspect of the
shoulder: complete medial dislocation of long head of
Compared to tendons, ligaments are thinner and
biceps tendon; humerus (H), bicipital groove (arrows), contain a higher amount of elastin, to give a bet-
long head of biceps tendon ter stabilization of the joints with the necessary

a b

Fig. 3.37 (a) Lateral compartment of ankle, transverse patient (axial scan, SE T1W sequence) confirms the fibu-
scan. Dislocation of fibular tendons (arrows) over the fibu- lar tendon luxation (arrowhead)
lar malleolus (*) is shown. (b) MR scan in the same
46 D. Orlandi et al.

elasticity. There are two different types of liga- trauma, in a subacute phase. Only then does the
ments: intrinsic capsular ligaments, consisting of enzymatic lysis of figurative elements cause a
focal thickenings of the articular capsule with a progressive reduction of the echoes and of the
strengthening function, and extrinsic ligaments, corpuscular appearance of the hemorrhagic
which do not depend on the capsule and can be effusion. Finally, the collection appears anechoic
further divided into extracapsular and intracapsu- and it is used as acoustic window to visualize
lar. US can easily assess the ligaments of the the ligament lesion. In first-­degree injuries, US
medial and lateral compartments of the ankle shows a thickened ligament with a relatively
(deltoid, anterior talofibular, and calcaneofibu- hypoechoic appearance, depending on the inter-
lar), the collateral ligaments of the knee, the col- stitial edema; the ligament is continuous with a
lateral and annular ligaments of the elbow, the regular outline (Fig. 3.39).
coracoacromial and coracohumeral ligaments of In second-degree injuries the normal echotex-
the shoulder, and the ulnar collateral ligament of ture appears altered. The ligament is thickened
the first metacarpophalangeal joint. and inhomogeneous and shows an irregular out-
When assessing a ligament tear, it should line; a minimal discontinuity of the ligament can
always be remembered that US, unlike MR, is be observed. In third-degree injuries, US allows a
limited by its small field of view that does not full-thickness lesion to be detected, with possible
allow an overview of the joint compartments. retraction of the fibers and the hemorrhagic col-
US, therefore, is not able to detect a possible lection filling the gap (Fig. 3.40).
concomitant lesion of the joint, which is a fun- A dynamic examination is always useful in
damental diagnosis in order to plan correct ther- doubtful cases.
apy. Ligaments are mainly affected by traumatic To assess subacute and acute ligament inju-
injuries that can be classified as first degree ries, power Doppler analysis allows the presence
(stretching lesions), second degree (partial of diffuse perilesional hyperemia to be detected.
lesions), and third degree (complete lesions). In the presence of fibrous and scar tissue
They can be divided into acute, subacute, and resulting from a post-traumatic ligament lesion,
chronic. It should be kept in mind that the US US shows typically focal hypoechoic tissue. In
assessment of a ligament injury can be more some cases, minute calcification can also be
accurate when performed a few days after the found.

a b

Fig. 3.38 (a) Longitudinal and (b) transverse scans of first foot finger. Anechoic cyst (C) of flexor tendon (T) synovial
sheath
3 Tendons and Ligaments 47

Further Readings
Bruce RK, Hale TL, Gilbert SK. Ultrasonographic evalu-
ation for ruptured Achilles tendon. J Am Pediatr Med
Assoc. 1982;72:15–7.
Davis WH, Sobel M, Deland J, et al. The superior pero-
neal retinaculum: an anatomic study. Foot Ankle Int.
1994;15:271–5.
Dillehay GL, et al. The ultrasonographic characterization
of tendons. Invest Radiol. 1984;19:338–41.
Grechenig W, Clement H, Bratschitsch G, et al. Ultrasound
Fig. 3.39 US scan of the lateral compartment of the diagnosis of the Achilles tendon. Orthopade.
ankle. The anterior talofibular ligament is continuous but 2002;31:319–25.
thickened and inhomogeneous for a first-degree lesion. F Jozsa L, Kannus P, Balint JB, Reffy A. Three-­
fibula; T talus dimensional ultrastructure of human tendons. J Anat.
1995;142:306–12.
Ling SC, Chen CF, Wang SC. A study on the vascular
supply of the supraspinatus tendon. Surg RadiolAnat.
1990;12:161–5.
Martinoli C, Derchi LE, Pastorino C, et al. Analysis
of echotexture of tendons with US. Radiology.
1993;186:839–43.
O’Brien M. Functional anatomy and physiology of ten-
dons. Clin Sports Med. 1992;11:505–20.
Silvestri E, Biggi E, Molfetta L, et al. Power Doppler
Analysis of tendon vascularization. Int J Tissue React.
2003;25:149–58.
Stolinski C. Disposition of collagen fibrils in human ten-
dons. J Anat. 1995;186:577–83.
Fig. 3.40 US scan of the lateral side of the ankle. The
anterior talofibular ligament is completely torn with mini-
mal effusion; talofibular joint (j), fibula (F), talus (T),
anterior talofibular ligament (arrows), tear area (arrow-
heads), soft-tissue thickening (#)
 Muscles
4
Davide Orlandi , Enzo Silvestri,
and Matteo De Cesari

Contents
4.1 Sonographic and Doppler Normal Anatomy  49
4.2 Inflammatory and Degenerative Diseases  55
4.3 Traumatic Injury  57
Further Readings  60

4.1 Sonographic and Doppler cle fibers can be observed and, even within the
Normal Anatomy same muscle, the fibers’ diameter can vary
according to work, nutritional conditions, and
Muscle is made of bundles of contractile elemen- other causes.
tary units—the striated muscle fibers—with their Muscular fibers are arranged parallel to one
major axis lying along the contraction direction. another and they are supported by a structure of
The muscular fibers are multinuclear cellular connective tissue. Muscle is externally sur-
units derived, during embryonal development, rounded by a thick connective sheath called the
from mesodermal cells of the primitive segments. epimysium; from the internal aspect of this
The fibers have a cylindrical or polyhedral shape sheath several septa depart to constitute the peri-
with smoothed angles; they have a considerable mysium, which surrounds diverse bundles of
length, varying from a few millimeters to several muscular fibers, named fascicles. Blood vessels
centimeters, and a width between 10 and 100 mm. and nerves run within the perimysium, which
Considerable differences between different mus- also contains neuromuscular spindles. Very light
and thin septa arising from the perimysium
spread into the fascicles to surround every single
D. Orlandi (*) muscular fiber and thus form the endomysium.
Department of Radiology, Ospedale Evangelico The endomysium, a network made of reticular
Internazionale, Genova, Italy
fibers, blood capillaries, a few connective cells
E. Silvestri together with some small nervous bundles, con-
Radiology, Alliance Medical, Genova, Italy
stitutes the framework found right around the
M. De Cesari striated muscle fibers, and it represents the site of
Department of Radiology, Ospedali del Tigullio,
Lavagna, Italy

© Springer Nature Switzerland AG 2022 49

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_4
50 D. Orlandi et al.

metabolic exchange between striated muscle cle architecture, which determines a muscle’s
fibers and blood (Figs. 4.1 and 4.2). mechanical function, particularly affecting the
The epimysial, perimysial, and endomysial force–velocity relationship. The main types of
coverings come together converging where mus- muscle architecture include the parallel type and
cles merge with adjacent structures: the extremity the pennate one. The parallel type corresponds to
of the muscle may continue as a tendon or insert muscle in which fibers with length close to that of
onto the periosteum, aponeurosis, or dermis; this the whole muscle run almost parallel to each
structure is extremely resistant, since the tensile other and to the muscle line of action. It includes
forces turn into tangential forces that are more the flat muscles and the fusiform one (Fig. 4.3),
easily born. At a submicroscopic level, the mus- e.g., the sartorius and biceps brachii muscles,
cular fibers end in a conical shape and adapt to respectively.
the connective tissue just like fingers adapt to a In pennate-type muscles, e.g., the gastrocne-
glove; at the two endpoints of the muscular fiber, mius and deltoid muscles, short fibers are ori-
the myofibrils are attached to the sarcolemma. ented at an angle relative to the muscle’s line of
The muscular myofibers, and mostly the connec- action. In fact, in pennate muscles, from each
tive framework, are strongly connected to the ter- side the tendon penetrates far into the muscle, as
minal insertion and the force developed by thick superficial fascia (in unipennate muscles)
contraction does not lose any efficiency at the or deeply as central tendon (in bipennate and
passage from muscle to tendon and there is no multi-pennate muscles). Relatively short muscle
risk of detachment. From a clinical point of view, fibers attach diagonally onto the central tendon at
such detachments occur only in rare situations, an oblique angle. The arrangement of fibers and
for it is much easier for a tendon to detach from a tendons in these muscles resembles the shape of
bone fragment at its insertion, in the case of an a bird feather, leading to the designation of such
exceptionally strong contraction. muscles as pennate (from Latin “penna” or
Each muscle presents at least one muscular feather). If all the fascicles of a pennate muscle
belly and two tendons, one at the origin and the are on the same side of the tendon, the pennate
other at the distal insertion. The physical arrange- muscle is called unipennate. If the fascicles lie to
ment of fibers inside the muscle defines the mus- either side of the tendon, the muscle is called

EPIMYSIUM

PERIMYSIUM

ENDOMYSIUM

MUSCLE FIBER
(length from a few mm up to 30 cm) SKELETAL MUSCLE BELLY
(composed of about 60-100 fascicles)
MUSCLE FASCICLE
(composed of about 150 fibers)

Fig. 4.1 Schematic drawing of the gross organization of skeletal muscle

4 Muscles 51

PERIMYSIAL BLOOD VESSELS

EPIMYSIUM

ENDOMYSIAL
FREMEWORK
THICK
PERIMYSIAL
SEPTUM

FASCICLE THIN
PERIMYSIAL
THICK SEPTA
PERIMYSIAL
SEPTUM
F
F F
F

Fig. 4.2 Architectural arrangement of muscle fascicles. sium, loose connective septa (perimysium) divide the
Muscle fibers (F) are grouped into fascicles, and bundles muscle in fascicles, surrounding each one, and also
of fascicles comprise the entire muscle. The skeletal mus- between the individual muscle fibers (endomysium).
cle is enclosed externally in a thick connective tissue Blood vessels run within the connective framework
envelope (epimysium). From the inner side of the epimy-

FLAT FUSIFORM UNI-PENNATE BI-PENNATE MULTI-PENNATE

PARALLEL-TYPE PENNATE-TYPE

Fig. 4.3 Skeletal muscle architecture

bipennate. If the central tendon branches within a fibers’ length and the energy of contraction
pennate muscle, the muscle is called multi-­ depends on the number of fibers constituting the
pennate (Fig. 4.3). muscle. The parallel-type muscles, such as the
Skeletal muscle architecture, defined by the biceps brachii, are composed of relatively long
length and the arrangement of fascicles relative fibers lying nearly parallel to each other. Since
to the axis of force generation, influences strongly muscle fibers can contract about one-third of
the muscle functional properties. This is because their resting length, this arrangement is suitable
the degree of muscular shortening depends on the to an extensive and quick movement. Then, these
52 D. Orlandi et al.

muscles have a long excursion (% of shortening), structure varies according to its specific func-
but they are only moderately strong in terms of tion, not only the volume should be taken into
the whole muscle force that they can generate, account, but also the type of insertion, whose
due to the low number of fibers constituting the width influences the number, length, and slope
muscle. Conversely, the pennate muscles, e.g., of the fibers. The speed and extent of muscle
the rectus femoris muscle, have a greater thick- shortening during contraction depend a lot on
ness and many more muscle fibers than similarly the fibers’ direction with respect to the longitu-
sized parallel-type muscle, due to angled disposi- dinal axis of the muscle itself. These are the
tion of fibers, thus allowing the muscle to pro- greater the smaller the inclination of the fibers,
duce more force. In fact, the fiber quantity that as in the case of parallel muscles; conversely,
makes up a muscle is expressed by the physio- they progressively decrease as the angle of incli-
logical cross-sectional area (PCSA), which is nation of the fibers increases. The obliquity of
measured perpendicular to the axis of the fibers at the muscle fibers is defined by the pennation
muscle largest point, not to the axis of the whole angle, which refers to the angle that the muscle
muscle (Fig. 4.4). fibers run across the load axis of the muscle; it
The muscle bundles are directed obliquely varies from 0° to 30°. In pennate muscles the
from tendon to tendon, and the shorter and more load axis (line of action) corresponds to that of
numerous they are, the wider the tendon inser- the central tendon (Fig. 4.5).
tion is. This setting influences biomechanics, The muscle morphology, internal structure,
because the degree of muscle shortening and architecture can be easily assessed by ultra-
depends on the fibers’ length and the energy of sound imaging. The external connective sheath of
contraction depends on the number of fibers that the muscle (epimysium) appears as a hyperechoic
make up the muscle; two muscles with the same external band measuring a maximum of 2–3 mm
length, width, and thickness, and therefore the of thickness and, on longitudinal US sections,
same volume, but with different number, length, continues without interruption along the corre-
and slope of the fibers, will also have different sponding tendon profile.
shortening capability and contraction energy. The fibro-adipose septa (perimysium) are seen
Therefore, when assessing the biomechanical as hyperechoic lines separating the contiguous
characteristics of a muscle, whose internal

FUSIFORM PENNATE

Large PCSA
large force

Small PCSA
small force

Long fiber length Short fiber length

rapid and large slow and small
length change length change

Fig. 4.4 Physiological cross-sectional area (PCSA) measured perpendicular to the axis of the fibers at muscle largest
point
4 Muscles 53

Ftendon= Ffibre COSα

Fig. 4.5 Pennation angle evaluation

Fig. 4.7 The transverse echographic scan of a muscle

shows the polygonal arrangement of the hyperechoic peri-
mysial framework, which separates the hypoechoic
fascicles

Fig. 4.6 Longitudinal US scan of a pennate muscle. The

characteristic pennate appearance is given by the conver-
gence of perimysial septa

hypoechoic muscular bundles (fascicles) from

one to another (Fig. 4.6).
In transverse views, the muscle is sectioned
according to a plane that is orthogonal to the Fig. 4.8 Muscle architecture US evaluation. The fascicle
muscular longitudinal axis, with a typical US length is measured as the distance between the two inter-
section points, while the pennation angle refers to the
structure appearance; the first- and second-order angle between the fascicle line and line passing along the
fascicles show an irregular polygonal shape, deep aponeurosis (usually corresponding to central
defined by thin, hyperechoic septa corresponding tendon)
to the perimysial fibro-adipose framework
(Fig. 4.7). Using color or power Doppler, vascu- also proposed in the literature, using digitizing
lar flow in normal resting muscles is usually not software.
observed. The muscle thickness in the longitudinal plane
There is proven relationship between perfor- is defined as the orthogonal distance between the
mance and muscle architecture, which main com- superficial and deep aponeuroses.
ponents are muscle thickness, fascicle length, After drawing of two guidelines on the muscle
and pennation angle. contours with the aim to highlight the superficial
The most common method of assessing mus- and deep aponeuroses, a line is drawn as an
cle architecture is by ultrasound, acquiring longi- extension of the fascicle using a linear path until
tudinal images of the muscle. By orienting the it intersects both aponeuroses. The fascicle length
ultrasound probe in the plane of the fascicles, the is measured as the distance between the two
thickness of the muscle, fascicle lengths, and intersection points, while the pennation angle
pennation angle can be accurately measured refers to the angle between the fascicle line and
(Fig. 4.8). Manual measurement of muscle archi- line passing along the deep aponeurosis (usually
tecture parameters takes time and subjective; corresponding to central tendon). The value of
various semiautomatic or automatic methods are the angle is 12°–20° in mean and can vary
54 D. Orlandi et al.

between the nearly 0° of parallel-type muscles, particularly the resistance training, causes certain
e.g., biceps brachii, and at most the 30° of large changes in muscle architecture parameters. In
pennate-type muscles. It has been demonstrated ­literature it has been referred that the quadriceps
that the muscle size, determined as anatomical or muscle of subjects experienced to intensive train-
physiological cross-sectional area (PCSA), is ing (already after a month) first shows changes in
closely and directly related to the maximal mus- muscle architecture and, subsequently, hypertro-
cle strength: the larger the PCSA, the greater the phy. On average, the following can be observed:
strength. In addition, the muscle pennation angle increase in fascicle length (+10% approximately),
also influences maximal isometric strength, with increase in pennation angle (+8% approxi-
negative correlation: the higher the degree, the mately), and increase in muscle thickness
lower the strength (Fig. 4.9). The relationship (approximately +7%), due to the overall increase
between the force of the muscle effectively trans- in the diameter of the fascicles. Some authors
mitted to the tendon and the pennation angle is reported that in the elite sprinters’ leg muscles
regulated by the equation: (LV, MG, and LG), a greater fascicle length and a
lower pennation angle have been detected, com-
Ftendon = cos a pennation angle ´ Fmuscle
pared to what is found in the elite distance run-
Ultrasound evaluation of muscle architecture ners’ muscles. If the training is performed at
parameters should always be performed as a speed and without load, the elongation of the fas-
comparative technique with the contralateral cicles is prevalent with respect to the increase in
muscle and in an active and passive dynamic the pennation angle. The sedentary lifestyle and
way, both at rest and during muscle contraction. aging induce a shortening of the fascicles and a
The muscle thickness and the pennation angle are lower pennation angle. Therefore, the architec-
not static values, but adapt to the different func- ture parameters allow a functional evaluation of
tional conditions of the muscle. Their values the muscle. Hypertrophy of the muscular bun-
increase linearly as the intensity of contraction dles, typically observed in athletes, can be associ-
increases. It has been shown that muscle training, ated with increased muscular hypoechogenicity.

Fig. 4.9 Graphical 90°

representation of the Zero strength
relationship between the
pennation angle and
de
muscle strength gre
ev
ar
ia
tio
n
of
pe
nn
at
ion
an
gle

)
ction
le dire
scic
io n (fa
erat
gen
orce
of F
Line
α Pennation angle 0°
Maximum strength
Line of Action (deep aponeurosis or central tendon)
4 Muscles 55

a b

Fig. 4.10 (a, b) Color Doppler ultrasound of the quadriceps (vastus lateralis) before (a) and after exercise (b). A dif-
fuse intramuscular hypervascularization is shown after intense activity. This is related to the physiological hyperemia

Finally, physical exercise is also associated with 1. Inflammatory and degenerative

an increase in muscle vascularization (blood flow 2. Malignant
is 20 times higher than in standard conditions) 3. Traumatic (major and minor lesions)
and a consequent increase of the muscular mass
volume, up to 10–15%. The muscular volume Rheumatology mostly deals with inflamma-
gets back to standard conditions after about tory and degenerative pathology, but a deep
10–15 min of rest. Doppler techniques and, more knowledge of the other lesions is necessary for a
specifically, power Doppler can demonstrate the correct differential diagnosis. Degenerative
physiological muscular hyperemia after contrac- muscular pathology does not show any specific
tion (Fig. 4.10a, b). Typically, blood vessels run features within the echotextures, but it is possi-
in the septa of the perimysium. ble to detect some characteristic ultrasound
When studying both muscles and tendons, it signs of degeneration in several inflammatory
is fundamental that the ultrasound beam is cor- pathologies.
rectly tilted so that it is always perpendicular to
the examined muscular plane, in order to avoid
the appearance of hypoechoic artifactual zones 4.2 Inflammatory
that can be misinterpreted by inexperienced and Degenerative Diseases
operators. In some body regions the sonogra-
pher can observe accessory muscles, not to be Muscular inflammatory pathology can be divided
misinterpreted as pathologic masses. The most into:
commonly described “pseudomasses” are the
palmaris longus muscle at the wrist, and the 1. Nonspecific myositis (serous, purulent, and
accessory soleus and the peroneus quartus at the chronic)
ankle. 2. Specific myositis (syphilitic, tubercular, and
Ultrasound has a very important role in the viral)
diagnosis of muscle pathology and should be 3. Focal myositis ossificans (post-traumatic,
considered the first-choice imaging technique for post-inflammatory, and chronic)
traumatic pathology. When an inflammatory, 4. Interstitial granulomatous myositis of
degenerative, or a malignant pathology is in unknown origin
progress, US must be complemented with mag- 5. Polymyositis
netic resonance (MR) and sometimes with com-
puted tomography (CT). Serous myositis has a traumatic, toxi-­infective,
According to etiology, muscular pathology or viral origin. It is characterized by interstitial
can be divided into: inflammatory, hyperemia, and serous infiltration
56 D. Orlandi et al.

and extensive fistulous tracts. Hematogenous

tubercular dissemination in patients affected by
miliary tuberculosis is extremely rare. The most
common viral myositis is caused by Coxsackie B
virus (Bornholm’s disease) and is characterized
by necrotic and degenerative lesions of the mus-
cle fibers.
Myositis ossificans may have different forms:
focal myositis ossificans can represent the fibro-
calcific involution following violent trauma,
chronic inflammatory processes, or suppurative
Fig. 4.11 Serous myositis. The muscle appears thick- lesions, or it can be the direct consequence of
ened and hypoechoic in relation to an extensive perimy- central or peripheral nervous system diseases.
sial edema Sometimes, it can represent natural evolution of
an intramuscular hematoma that calcifies and
of the perimysium. The thickening of the muscle leads to an ossification process (Fig. 4.12); the
fascicles is a typical degenerative aftereffect. In development of these lesions occurs over a 5–6-­
the earlier stages, the muscular structure can be month period. In earlier phases, the lesion has an
easily assessed with US and it appears thickened inhomogeneous architecture and may mimic neo-
and diffusely hypoechoic, due to the perimysial plasia; afterwards, the first calcification appears,
edema, with hazy muscular fascicles that appear mostly on the margins, which is then followed by
interrupted and spaced (Fig. 4.11). true ossification.
In the later stages, fibro-adipose involution Progressive myositis ossificans (PMO) or pro-
has an inhomogeneous appearance. Purulent gressive ossificans fibrodysplasia of Munchmeyer
myositis, usually caused by deep and infected is a rare and incurable genetic disease with auto-
wounds or by blood flow-derived bacteria, is somal dominant transmission, characterized by a
characterized by several scattered abscessed foci. progressive ossification of skeletal muscles until
With US, the abscess appears as a hypo-anechoic a complete substitution with a mineralized osse-
rounded mass, with hazy margins and inhomoge- ous matrix has occurred. The early histopatho-
neous echoes. This kind of examination allows logic alterations of connective tissue (particularly
the size and the site of the abscess to be precisely aponeurosis, fascias, tendons, and ligaments)
described and a percutaneous drainage of the represent the basics of the disease, while skeletal
purulent material to be performed. In the later muscle is involved last. At first, US shows typical
stages, the echogenicity of the abscess either fur- muscular inflammation, with reduced echoes
ther reduces or, if they become chronic, increases within the involved areas; then the consequent
according to the inner organization of the collec- fibrous involution causes a hypoechoic appear-
tion (filaments, fibrous branches, or sediments) ance (Fig. 4.13) until several ossified foci can be
with a consensual hyperechoic appearance of the observed in later stages. In these cases, other
wall (pseudocapsular appearance). Chronic myo- imaging techniques are necessary to understand
sitis follows an acute nonspecific myositis and is the exact origin of the bony growths.
characterized by fibrosclerotic substitution of the Polymyositis consists of a group of muscular
normal echotexture with an increase of the inter- disorders of unknown origin characterized by an
stitial connective tissue that can also involve inflammatory process of the skeletal muscula-
large parts of the muscle belly. Tubercular myosi- ture. Polymyositis is classified among the sys-
tis is usually the result of direct propagation of temic rheumatic diseases, more precisely among
bone, articular or lymphoglandular granulomas; the connective tissue diseases, and can be idio-
the caseous exudate spreads through the intersti- pathic, juvenile, or tumor related. The main
tium to the muscular tissue, producing complex symptom is muscular weakness that mainly
4 Muscles 57

Fig. 4.12 Ultrasound

longitudinal view of the
thigh showing myositis
ossificans, with blurred
calcified spots within the
muscle

which is necessary to definitively confirm the

diagnosis.

4.3 Traumatic Injury

US is extremely helpful in the field of muscular

trauma. Within minor traumatic lesions, muscu-
lar contractures and contusions are difficult to
detect with US, unless complemented with an
accurate comparative examination. They are
Fig. 4.13 Extensive muscular fibrosis with multiple
characterized by slight widening of perimysial
fibrocalcific areas (arrows) within the muscle; muscle (M)
partitions with hypoechoic post-traumatic edema.
Major traumatic lesions are represented by intra-
muscular hematoma and muscle rupture.
Muscular hematoma is the typical sign of a mus-
cular tear and its dimensions usually indicate the
extension of the tear (excluding some hemato-
logical conditions). The formation of a hema-
toma creates dissection of the fascial planes, and
if the collection exceeds 100 ml of fluid—as in
case of a complete rupture—it must be drained
quickly to avoid any compression on the
­surrounding muscular and neurovascular struc-
tures (Fig. 4.14).
Fig. 4.14 Longitudinal scan of the posterior side of the The evolution of an intramuscular hematoma
thigh: hamstrings tear with bell-clapper aspect (M) and is not dissimilar to that which occurs in other
extensive effusion (E) sites of the human body. A recent hemorrhage has
a hyperechoic appearance (Fig. 4.15) but becomes
affects the proximal muscles of the limb girdle hypoechoic after a couple of hours until a separa-
musculature. Several cutaneous symptoms are tion between the liquid and the corpuscular phase
typically associated with this disease. US is help- occurs.
ful both as a diagnostic tool, detecting the muscu- When the hematoma is resolving, it appears as
lar degeneration areas and the intramuscular a homogeneous anechoic collection (Fig. 4.16)
calcific foci, and as a guide to muscular biopsy, that can be more or less organized.
58 D. Orlandi et al.

Fig. 4.15 Diffusely

hyperechoic hematoma
(arrows) following
recent muscle trauma

b
Fig. 4.16 Extended field of view: (*) muscular hema-
toma, (F) femur, (M) vastus intermedius muscle; white
arrows = fascia

Muscular ruptures can be caused by compres-

sion (direct trauma) or by a distraction of the
muscular extremities. If direct trauma occurs, the
muscle is directly compressed against the under-
Fig. 4.17 Normal appearance of medial gastrocne-
lying bone. US demonstrates an irregular cavity mius (M) myotendinous junction (a). Partial tear
with rough borders followed, a few hours after (arrows) of medial gastrocnemius (M) at the myotendi-
the trauma, by a hematoma. As the lesion heals, nous junction (b)
US can detect extensive scar tissue that appears
hyperechoic and calcific (post-traumatic myositis from 2 to 10 mm of diameter. On US, these col-
ossificans). Indirect trauma is caused by a sudden lections have a stretched and irregular hypoechoic
and violent contraction of the muscle and is more appearance. Healing occurs in about 2 weeks.
frequent in the lower limbs, especially in those Partial rupture (grade II) is a lesion that occurs
muscles that connect two bone segments. when the muscle is stretched over its maximal
Distraction traumas can be basically divided into elastic potential. It involves more than 5% of the
three groups, according to their ultrasound fea- muscular tissue but not the whole transverse sec-
tures: strain (grade I), partial rupture (grade II), tion. In acute cases, the patient reports a “snap”
and complete rupture (grade III). More detailed with localized sharp pain and a complete loss of
muscle tear classifications are also available (see muscle function that is usually recovered in a
Chap. 24). couple of days. US clearly shows the discontinu-
Muscle strain occurs when it is stretched ity of the muscle with interruption of the fibro-­
beyond its elastic limit. The patient reports acute adipose septa, in particular at the myotendinous
pain that cannot be distinguished from cramp. junction, as in the gastrocnemius (Fig. 4.17a, b).
The lesions are mostly microscopic but the mac- A partial rupture shows three different US
roscopic exam can detect several small sero-­ findings: a hypoechoic cavity within the muscu-
hemorrhagic collections up to 6–7 cm long and lar tissue, a thick hyperechoic cavity border, and
4 Muscles 59

the “bell-clapper” sign, due to small shreds of

muscular tissue floating in the hematoma
(Fig. 4.18).
Complete ruptures (grade III) are far less com-
mon than the other lesions. The initial clinical
presentation is very similar to the partial rupture
but the functional loss persists longer and, if the
muscle is superficial, the lesion can be appreci-
ated on palpation. US shows complete disloca-
tion of the muscular ends with a hematoma filling
Fig. 4.18 Bell-clapper (asterisk) appearance of muscular the gap (Fig. 4.19).
stump. P pubis

a b

Fig. 4.19 Transverse (a) and longitudinal (b) US scans of a severe rupture of rectus femoris with retraction of muscular
stumps (*) and wide sero-hemorrhagic collection filling the resulting gap (circles)
60 D. Orlandi et al.

Further Readings Narici MV, Maganaris CN, Reeves ND, Capodoglio

P. Effect of aging on human muscle and architecture. J
Appl Phisiol. 2003;95:2229–34.
Abe T, et al. Fascicle length of leg muscles is greater in
Park A, Lehnerdt G, Lautermann J. Myositis of the ster-
sprinters than distance runners. Med Sci Sport Exerc.
nocleidomastoid muscle as a result of arthritis of
2000;32(6):1125–9.
the sternoclavicular joint. Laryngorhinootologie.
Bianchi S, Martinoli C, Sureda D, Rizzatto G. Ultrasound
2006;86(2):124–7.
of the hand. Eur J Ultrasound. 2001;14:234.
Peetrons P. Ultrasound of muscles. Eur Radiol.
Blazevich OJ. Effects of physical training and detraining,
2002;12:35–43.
immobilisation, growth and aging on human fascicle
Reimens K, Reimens CS, Wagner S, et al. Skeletal muscle
geometry. Sports Med. 2006;36(12):1003–17.
sonography: a correlative study of echogenicity and
Bureau NJ, Chhem RK, Cardinal E. Musculoskeletal
morphology. J Ultrasound Med. 1993;2:73–7.
infections: US manifestations. Radiographics.
Scott JE. High resolution imaging of the musculoskeletal
1999;19:1585–92.
system. Radiology. 1997;205:593–618.
Chau CL, Griffith JF. Musculoskeletal infections: ultra-
Seynnes OR, et al. Early skeletal muscle hypertro-
sound appearances. Clin Radiol. 2005;60:149–59.
phy and architectural changes in response to
de Oliveira FTM, de Oliveira CG, Farinatti P. Pennation
high-intensity resistance training. J Appl Physiol.
angle of vastus lateralis during isometric contrac-
2007;102(1):368–73.
tions performed at two knee angles. Fisioter Mov.
Van Holsbeeck M, Introcaso JH. Musculoskeletal
2017;30(Suppl 1):S75–83.
Ultrasonography. Radiol Clin North Am.
Erickson S. High resolution imaging of the musculoskel-
1992;5:907–25.
etal system. Radiology. 1997;205:593–618.
 Peripheral Nerves
5
Enzo Silvestri, Davide Orlandi ,
and Elena Massone

Contents
5.1 Sonographic and Doppler Normal Anatomy  61
5.2 Compressive Chronic Involvement  63
5.3 Acute Traumatic Injuries  64
Further Readings  65

5.1 Sonographic and Doppler epineurium which houses the nerve vascular
Normal Anatomy structure. The nerve is then wrapped in the main
outer epineurium—an external sheath. Clinical
Peripheral nerves are usually made of nervous experience with ultrasound and improvements in
fibres (containing axons, myelin sheaths and technology have been helpful in the evaluation of
Schwann cells) grouped in fascicles and loose peripheral nerve, and the improvements in
connective tissue (containing elastic fibres and Doppler sensitivity and power Doppler have
vessels). Each fascicle is encased by a proper made it possible to assess vascular changes
connective sheath called perineurium. Inside the within major nerve segments. Peripheral nerve
fascicle are a group of axons bathed in endoneu- ultrasound, when compared to electrodiagnostic
rial fluid. Each axon has an insulating lining of testing, adds the possibility to provide anatomic
myelin: a fatty material inside the Schwann cells. detail of the affected site without any discomfort.
Between the fascicles and the outer nerve sheath, In fact, ultrasound is a low-cost, quick and non-­
there is a fatty material called the interfascicular invasive imaging method, providing an excellent
view of peripheral nerve anatomy as well as of
surrounding structures. US provides high spatial
E. Silvestri resolution and the ability to explore long seg-
Radiology, Alliance Medical, Genova, Italy ments of nerve trunks in a single study, also
D. Orlandi (*) allowing nerve examination in both static and
Department of Radiology, Ospedale Evangelico dynamic conditions, during passive or active
Internazionale, Genova, Italy
movements of the extremities. US enables the
E. Massone identification of post-traumatic changes of
Department of Radiology, Ospedale Santa Corona,
nerves, neuropathies secondary to compression
Pietra Ligure (SV), Italy

© Springer Nature Switzerland AG 2022 61

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_5
62 E. Silvestri et al.

Endoneurium
Fig. 5.2 Peripheral nerves. Longitudinal 3–16 MHz US
Perineurium
image obtained over the median nerve (white arrows) at
Epineurium the middle third of the forearm. The nerve is made of par-
allel linear hypoechoic areas, the fascicles, separated by
Fig. 5.1 Scheme of peripheral nerve illustrating its inner hyperechoic bands, the interfascicular epineurium; mus-
structure cles (M), subcutaneous fat (sf)

syndromes and inflammatory or neoplastic nerve

lesions as well as the evaluation of post-operative
complications, and it is increasingly used in
anaesthesiology for regional anaesthesia. Nerves
present cable-like structures and have a distinct
architecture consisting of fascicles and surround-
ing epineurium (Fig. 5.1).
In the transverse plane, the echo pattern is
described as a ‘honeycomb’ aspect because tiny
round and hypoechogenic areas representing the
nerve bundles with hyperechogenic rims of the
epineurium are visible. In the longitudinal plane,
nerves present as long, slim structures with a
mixture of parallel hyperechogenic lines, repre-
senting the perineurium, between two more Fig. 5.3 Nerve echotexture. Transverse US image of the
prominent and also hyperechogenic layers of the median nerve at the middle third of forearm. The nerve
epineurium. This image resembles that of an (white arrowhead) is characterized by a honeycombing
appearance made of round hypoechoic areas in a homoge-
electric cable (Figs. 5.2 and 5.3). neous hyperechoic background; subcutaneous fat (sf),
The transverse image is much more frequently muscles (M)
used in clinical practice, as it allows for the nerve
to be examined by the so-called elevator tech-
nique which consists of finding the set nerve at a changes from hypo- to hyperechogenic as they
characteristic anatomic point and ‘tracking it’ are followed more peripherally for an increasing
either proximally or distally. In this way, it is pos- amount of connective tissue between the nerve
sible to assess the nerve’s shape, echogenicity bundles. It has been assumed that nerves are not
and thickness and its relation to the surrounding anisotropic even if the property of anisotropy is
tissues, the surface area of the nerve and its vas- seen in cases of nerves with large cross sections.
culature. If an abnormality is seen in the trans- The shape of a nerve may also be different and
verse view, the nerve should be examined in the vary between individuals, round, oval, triangular
longitudinal view. The US aspect of nerves or irregularly shaped, which may change under
5 Peripheral Nerves 63

compression by the probe or with the movement tary assessment in evaluating nerve entrapment
of a neighbouring muscle. Nerve may change its syndromes; in particular, US can be very helpful
shape along its course, for example, from a for the detection of the site of compression and
­triangular to a round cross section, or may pres- for the identification of abnormal findings in the
ent anatomic variants (e.g. bifid or trifid variants nerve surroundings. Ultrasound can directly
of the median nerve). demonstrate morphologic changes in the nerve
Motor and motor-sensory nerves may be eval- appearance, and, sometimes, it can identify sec-
uated indirectly analysing the skeletal muscles ondary causes (i.e. accessory muscle, thickened
which they innervate: we can evaluate muscular fibrous band, cyst, bony prominence, vascular or
atrophy in case of chronic denervation as a neoplastic mass, foreign body, orthopaedic
decrease of the muscle’s volume and fatty infil- implants); this is especially true for larger and
tration, which increases its echogenicity. more superficial nerves. In case of nerve com-
Ultrasound measurement of nerve size is very pression, a focal flattening with reduction of
important because nerve enlargement is the most nerve cross-sectional area (CSA) at the compres-
important diagnostic marker of an abnormal sion point can be appreciated. Proximal to the
nerve: cross-sectional area and swelling ratio (the level of compression, a fusiform enlargement of
ratio between the cross-sectional area of the the nerve could be observed: it usually extends
nerve at the site of maximal enlargement and that 2–4 cm in length and presents maximum diame-
at an unaffected site) can be measured on trans- ter immediately before the compression point,
verse images, and diameter can be measured on where the nerve suddenly flattens. In combina-
longitudinal images. For correct measurement, tion to such morphologic changes, also the nor-
the transducer should be perpendicular to the mal US echotexture is altered: the nerve appears
nerve, with minimal pressure, and the site of homogeneously hypoechoic with loss of the typi-
maximal enlargement should be selected for the cal fascicular pattern, reflecting the substanding
measurement of nerve size. Variability within a venous congestion and consecutive epi/endoneu-
measurement can be reduced doing multiple rial oedema; consequently the outer lining of the
measures. Measuring just inside the echogenic nerve becomes well delineated from the hyper-
rim of the nerve is the preferred technique. echoic perineural fat. Furthermore, intraneural
Placing the power Doppler box over the nerve microcirculation can be assessed with colour or
and slowly increasing the gain can be useful to power Doppler US examination: in cases of acute
evaluate the vascularity of the peripheral nerves. compression, a local interruption in the microcir-
No colour Doppler signal will be observed in culation can occur with possible venous conges-
the normal nerve. tion; on the other hand, an increase in intraneural
Nerve mobility can be routinely assessed to blood flow signals can be appreciated in chronic
exclude nerve entrapments. compressive neuropathies. Long-standing nerve
compression leads to fibrosis and eventually to
damage to the myelin sheath and to axonal degen-
5.2 Compressive Chronic eration. At this stage, a diffuse hyperechogenicity
Involvement and reduction of volume of the innervated mus-
cles can be assessed because of muscular
Nerve compressive syndromes are relatively atrophy.
common pathologies. They can occur acutely or Carpal tunnel syndrome is the most common
chronically anywhere in the body; however, they entrapment neuropathy. It results from the com-
develop more frequently at certain anatomic sites pression of the median nerve in the fibro-osseous
where the nerve passes through fibro-osseous tunnel between the carpal bones and flexor reti-
tunnels or at the level of anomalous bony, muscu- naculum (or carpal transverse ligament). US may
lar or connective structures. Nerve conduction demonstrate the homogeneously hypoechoic
study and US examination provide complemen- enlargement of the median nerve proximal to the
64 E. Silvestri et al.

a b

Fig. 5.4 Carpal tunnel syndrome. (a) axial view, median nerve (dots) with hypoechoic appearance and loss of the typi-
cal fascicular pattern; (b) Longitudinal view, flattened (arrows) median nerve (N)

carpal tunnel, with sudden flattening through the

fibro-osseous tunnel (Fig. 5.4a and b); palmar
bowing of the flexor retinaculum and
hypomobility of the nerve during dynamic
­
manoeuvres (opening and closing of fingers) may
be associated. However, in few cases, the median
nerve may appear normal even in the presence of
positive clinical and electrophysiological
findings.

5.3 Acute Traumatic Injuries

Fig. 5.5 Brachial plexus stretching. Supraclavicular
Three different types of traumatic or iatrogenic region, oblique view: subclavian artery (SA), enlarged
cords (N), rib (R)
nerve damage have been described based on the
mechanism of injury: traction, contusion and
penetrating trauma (multiple mechanisms may nerve roots of the brachial plexus during motor
coexist), which could result in neurapraxia, axo- vehicle accidents. Another typical injury is the
notmesis or neurotmesis. Ultrasound examina- peroneal nerve traction at the popliteal fossa dur-
tion, being able to evaluate and differentiate ing high-grade sprain traumas. Neurapraxic
fascicles, perineurium, epineurium and surround- injury can be appreciated as a swollen nerve with
ing tissues, can be used to assess the site of injury, hypoechoic appearance. The outer nerve sheath
discriminate nerve injury in continuity from may be intact. In cases of partial nerve tear, a so-­
nerve transection and identify foreign bodies, called traction neuroma can be seen along the
neuroma and scarring. It is very useful in the case course of the stretched nerve without discontinu-
of traumatic nerve injury and could help clinical ity: it appears as an irregular focal thickening of
examination and nerve conduction studies to pro- hypoechoic tissue (Fig. 5.5).
vide information about the condition of the In mild traumas, the neuroma may involve
injured nerve and, consequently, possible surgi- only one or few fascicles without resulting in
cal indications. nerve cross-sectional enlargement. In complete
Nerve-stretching syndromes can occur from nerve lesions, US demonstrates the retraction of
sprain or strain injuries and, less frequently, from the fascicles with a wavy appearance of the nerve
overuse. A typical injury is the avulsion of the ends.
5 Peripheral Nerves 65

Fig. 5.7 Terminal post-traumatic neuroma. Longitudinal

view of a digital nerve (N) and traumatic neuroma (Ne)

hypoechoic neuroma may develop from the

resected fascicles preserving the healthy fascicles,
Fig. 5.6 Radial nerve injury; US longitudinal scan:
radius (R), bone surface (arrowheads), fracture (arrow), and its size would be smaller than the CSA of the
subcutaneous fat (sf), thickened radial nerve (N) with nerve, or it may encase both the resected and the
irregular shape and loss of fascicular aspect unaffected fascicles determining a fusiform swell-
ing of the nerve. In complete tears, the so-called
Contusion traumas typically occur where stump neuromas or terminal neuromas appear as
nerves run in proximity of bony surfaces. In most hypoechoic mass-like lesions at the resected nerve
cases, they do not cause morphologic changes edges with a CSA slightly larger than the nerve
detectable with US, and the pathologic process is itself. The detection of terminal neuromas is of
self-resolving. Nevertheless, in some cases additional help when the resected nerve ends are
repeated minor traumas could lead to a focal fusi- retracted from the site of injury (Fig. 5.7).
form thickening of the nerve at the site of repeti-
tive contusions (e.g. peroneal nerve neuritis in
soccer players and ulnar nerve friction neuritis in Further Readings
cubital tunnel instability). In penetrating wounds
or in bone fracture such as radial bone fracture, Beekman R, Visser LH. High-resolution sonography of
the peripheral nervous system: a review of the litera-
where the radial nerve runs in proximity of bony ture. Eur J Neurol. 2004;11:305–14.
surfaces, US can detect shape alteration, loss of Martinoli C, Bianchi S, Derchi LE. Tendon and nerve
normal echostructure and thickening (Fig. 5.6), a sonography. Radiol Clin N Am. 1999;37(691–711):41.
partial tear or a complete transection of the nerve Martinoli C, Bianchi S, Gandolfo N, et al. US of nerve
entrapments in osteofibrous tunnels of the upper and
fascicles. lower limbs. Radiographics. 2000;20:199–217.
In the last two cases, the regenerative process Silvestri E, Martinoli C, Derchi LE, et al. Echo-texture
leads to the formation of a hypoechoic fibrous of peripheral nerves: correlation between US and his-
mass in the attempt to restore the continuity of the tologic findings and criteria to differentiate tendons.
Radiology. 1995;197:291–6.
nerve, but in different ways. In partial tears, the
 Dermis and Hypodermis
6
Davide Orlandi , Enzo Silvestri,
and Alessandro Muda

Contents
6.1 Sonographic and Doppler normal anatomy  67
6.2 Main Pathological Findings  67
Further Readings  70

6.1 Sonographic and Doppler 6.2 Main Pathological Findings

normal anatomy
Currently US has no role in the diagnosis of skin
Assessment of skin and subcutaneous tissue is lesions but can be very helpful in assessing and
possible using high-frequency transducers (up to following up several systemic pathologies with
30 MHz) that are able to differentiate skin from cutaneous involvement. In dermatopolymyositis,
subcutaneous tissue (Fig. 6.1). cutaneous lesions can be easily found: for exam-
Specific skin diseases are usually diagnosed ple, the characteristic Gottron’s papule, erythem-
by clinical examination, sometimes followed by atous or violaceous plaques, slightly thickened
skin biopsy. over bony eminences, often detected on the
extensor aspect of finger joints. With US they
appear as small nodular iso-hyperechoic areas
with characteristic calcification if the disease
occurs in childhood. Involvement of adipose tis-
sue is observed as moderate thickening that
appears as a homogeneous hyperechoic line
affecting the fibrous connective tissue bands that
lose their linear architecture.
D. Orlandi (*) On US, liposclerosis is characterized by
Department of Radiology, Ospedale Evangelico hypoechoic micro- and macronodules of fibrous
Internazionale, Genova, Italy
tissue that progressively replace the subcutane-
E. Silvestri ous tissue. Rheumatic nodules have a hypoechoic
Radiology, Alliance Medical, Genova, Italy
appearance with smooth margins and can be
A. Muda sometimes mistaken for gout tophi; the incidental
Department of Radiology, IRCCS Policlinico San
Martino-IST, Genova, Italy finding of calcific intralesional foci (hyperechoic

© Springer Nature Switzerland AG 2022 67

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_6
68 D. Orlandi et al.

with posterior acoustic shadow) makes the diag-

nosis easier. In systemic sclerosis, sclero-­atrophic
hypo-isoechoic alteration of the subcutaneous
tissue can be seen, especially in the fingertips.
Subcutaneous edema is characterized by a large
mesh hypoechoic net with a characteristic “cob-
blestone” appearance.
Panniculitis is an inflammatory phenomenon
of the subcutaneous tissue with a probable vascu-
litic origin. It can be divided into lobular and sep-
Fig. 6.1 Normal dermis and hypodermis (22 MHz trans-
ducer): skin (arrow), superficial dermis (asterisk), hypo-
tal panniculitis and appear as hypo-hyperechoic
dermis (D), subcutaneous fat (S) inhomogeneous areas, rich in calcific nodules of
various dimensions (1 cm up to 15 cm in ery-
thema nodosum). Moreover, in the acute phases,
marked surrounding edema and thickening of the
septa can be seen.
Lipomas and angiomas are common findings
and are characterized by specific US vascular
pattern (Figs. 6.2 and 6.3a, b).
There are several pathologies—less important
but not less common—involving the overloaded
fat pads in specific anatomical sites, such as the
fibro-adipose subcalcanear sole, that may be
Fig. 6.2 Superficial lipoma (white arrows), subcutaneous affected in overload syndromes that involve the
fat (SF), muscle (M), muscle fascia (f) nearby plantar fascia (Fig. 6.4).

a b

Fig. 6.3 (a) Hypoechoic, ovoid, well-defined mass typical of an angioma (A). (b) The corresponding power Doppler
scan shows the typical vascular pattern with a single pedicle (*)
6 Dermis and Hypodermis 69

Plantar fibromatosis (Ledderhose disease) is a

pathological condition characterized by nodular-
ity along the aponeurosis course which appears
homogeneously hypoechoic (Fig. 6.5a, b) and
shows no vascular signals at color and power
Doppler analysis.
A similar condition, sometimes connected
with plantar fibromatosis, is Dupuytren’s con-
tracture, in which the hypoechoic nodules are
found in longitudinal bundles of the palmar fas-
cia along the course of the flexor tendons.
Fig. 6.4 Plantar fasciitis: inhomogeneous appearance of
subcutaneous planes (*); plantar fascia thickening (white
arrows); calcaneus (C)

a b

Fig. 6.5 Ledderhose disease; (a) plantar fascia longitudinal scan, fibrous nodule (white arrows), plantar fascia (F); (b)
power Doppler showing mild nodule vascularity
70 D. Orlandi et al.

Further Readings Wortsman X, Jemec GBE. Dermatologic ultrasound

with clinical and histological correlations. New York:
Springer ed; 2018.
Grassi W, Cervini C. Ultrasonography in rheumatology: an
Wortsman X. Atlas of Dermatologic ultrasound with clini-
evolving technique. Ann Rheum Dis. 1998;57:268–71.
cal and histological correlations. New York: Springer
Grassi W, Lamanna G, Farina A, Cervini C. Sonographic
ed; 2013.
imaging of normal and osteoarthritic cartilage. Semin
Xu H, Guo L, Wang Q. Diagnostic ultrasound in derma-
Arthritis Rheum. 1999;28:398–403.
tology. Shangai: Springer ed; 2022.
Sheperd DET, Seedhom BB. Thickness of human articu-
lar cartilage in joints of the lower limb. Ann Rheum
Dis. 1999;58:27–34.
 Part II
Ultrasound Pathologic Findings
in Rheumatic Diseases
 Osteoarthritis
7
Marco Di Carlo , Edoardo Cipolletta ,
Emilio Filippucci , and Fabio Martino

Contents
7.1 Introduction  73
7.2 Synovitis  74
7.3 Synovial Fluid  75
7.4 Cartilage Damage  76
7.5 Osteophytes  78
Further Readings  79

7.1 Introduction imaging techniques have been indicated as

important tools to help in the diagnosis and fol-
Osteoarthritis (OA) is the most common joint low-­up of OA. Conventional radiography remains
disease in the world and its prevalence is rising the most widely used imaging technique for the
with the growing ageing population of Western diagnosis of OA. It allows the detection and
countries. Knee or hip OA has a prevalence of assessment of two main pathological findings,
40% in people over 65 years of age. Pain with joint space narrowing and osteophytes, which are
movement, limited mobility, and consequent dis- fundamental to determine the extent of the OA
ability are the main features of this disease. process. In fact, the Kellgren-Lawrence score, the
The early detection of the clinical expressions most widespread composite index allowing the
of the disease is fundamental to start adequate assessment of OA severity, is based on these two
therapeutic interventions before the development pathological findings. In particular, joint space
of irreversible joint damage. In this perspective, narrowing represents in daily clinical practice the
“gold standard” to estimate the OA severity.
However, conventional radiography is able to
M. Di Carlo · E. Cipolletta · E. Filippucci detect joint space narrowing only in advanced
Clinica Reumatologica, Dipartimento di Scienze stages of joint damage and it is therefore not sen-
Cliniche e Molecolari, Università Politecnica delle
Marche, Jesi (Ancona), Italy sitive to early degenerative cartilaginous changes,
which start largely earlier than the radiographic
F. Martino (*)
Radiology, Sant’Agata Diagnostic Center, evidence of joint space narrowing and/or osteo-
Bari, Italy phytes which appear only in established OA. Joint

© Springer Nature Switzerland AG 2022 73

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_7
74 M. Di Carlo et al.

space narrowing, in particular, continues to be cations to perform an US examination. In light of

widely applied as an indirect indicator of tibio- these aspects, there is increasing evidence to sup-
femoral cartilage thinning, even in the more port the use of US as the first imaging technique
recent Kellgren-Lawrence scoring methods. in OA together with conventional radiography.
However, the reduction of articular space in con- This chapter focuses on the basic US patho-
ventional radiography does not necessarily iden- logical findings that are commonly detected in
tify cartilage damage, being detectable also in patients with OA.
case of meniscal extrusion.
Over the years, the imaging technique that has
probably gained the most importance in OA is 7.2 Synovitis
magnetic resonance imaging (MRI). This tech-
nique is currently considered the “gold standard” OA is classically considered as a degenerative
for the evaluation of OA, allowing a detailed disease; however, it is frequently associated with
visualization of articular cartilage and other intra-­ a low degree of joint inflammation. In order to
articular structures. However, MRI is not appli- avoid diagnostic mistakes, it is essential to distin-
cable on a large scale as a first-line imaging guish joint inflammation resulting from OA from
technique due to the high costs, scarce availabil- the one that may be a consequence of joint
ity, and high prevalence of OA in the general inflammatory disease.
population. Conventional radiography is of limited help in
Over the last few years, musculoskeletal ultra- assessing soft tissue inflammatory involvement.
sound (US) has been increasingly investigated, Conversely, US and MRI are the imaging methods
mainly in research areas, but also with interesting of choice for assessing the joint inflammation.
applications in daily clinical practice. A great According to the recent redefinition of the ter-
advantage is US ability to reveal subclinical minology proposed by the Outcome Measures in
inflammatory features such as intra-articular Rheumatology (OMERACT) US Working
effusion or synovitis. Moreover, US allows the Group, US synovitis is defined by the “presence
detection and assessment of morpho-structural of a hypoechoic synovial hypertrophy regardless
changes involving the joint cartilage reachable by of the presence of effusion or any grade of
the US beam, the outer profile of the bony cortex, Doppler signal” (Fig. 7.1).
and the external portions of the menisci. Power Doppler (PD) US provides an estima-
Compared to MRI it is a cheaper and more avail- tion of synovial tissue hyperemia and measures
able method and overall there are no contraindi- the degree of synovial inflammation. In patients

a b

Fig. 7.1 Osteoarthritis. Knee synovitis. Suprapatellar views obtained using longitudinal (a) and transverse (b) scans
show areas of synovial hypertrophy (arrowheads) and fluid collections (*). f femur; p upper pole of the patella
7 Osteoarthritis 75

with chronic inflammatory arthritis, intra-­ ence of joint effusion is in most cases docu-
articular PD signal represents the US finding mented in the suprapatellar recess. To increase
indicative of “active” synovitis. the sensitivity of US examination in the detection
In the course of OA, synovitis, when present, of even small amount of synovial fluid, the
is usually of low grade. However, its detection is ­suprapatellar recess can be assessed during active
important because, at the knee level, it is a pre- contraction of quadriceps muscle. Nevertheless a
dictor of future joint replacement. Of note, in OA comprehensive US examination should also
patients the presence of US synovitis (i.e., intra-­
articular PD signal) has shown to have a greater
correlation with histopathological findings than a
MRI signs of joint inflammation.
In patients with painful OA of the thumb car-
pometacarpal joint, intra-articular PD signal is a
relatively common finding (Fig. 7.2).

7.3 Synovial Fluid

In the preliminary definition of the OMERACT b

Special Interest Group on US dating back to
2005, synovial fluid was defined as an “intra-­
articular anechogenic or hypoechogenic material
that is displaceable and compressible (Fig. 7.3)
but does not exhibit power Doppler signal.” The
degree of echogenicity of synovial fluid depends
on several factors, and it is increased by the pres-
ence of high-protein material and/or calcified
material in the liquid itself. Fig. 7.2 Osteoarthritis. Trapeziometacarpal joint.
As a general rule, the more abundant the joint Longitudinal scan through the thenar eminence shows
osteophytes (arrowheads) at the base of the first metacar-
effusion, the greater the degree of inflammatory
pal bone (a) and “active” synovitis (b). mc base of the first
activity in the joint itself. At knee level, the pres- metacarpal bone; tr trapezius

a b

Fig. 7.3 Osteoarthritis. Knee effusion. Suprapatellar lon- reveals synovial effusion. *synovial fluid; f femur; p upper
gitudinal scan with quadriceps muscle relaxed (a) and pole of the patella; t quadriceps tendon
during active contraction (b). Quadriceps contraction
76 M. Di Carlo et al.

Fig. 7.5 Healthy subject. Knee. Longitudinal scan of the

medial femoral condyle (f) with knee in 90° flexion. Note
Fig. 7.4 Osteoarthritis. Popliteal cyst. Transverse poste- the ultrasound features of the normal hyaline cartilage
rior view showing mainly anechoic enlargement of the when perpendicularly insonated: sharply defined continu-
semimembranosus gastrocnemius bursa. f femur ous hyperechoic margins with the chondro-synovial inter-
face (arrowhead) thinner than the osteochondral interface;
homogeneously anechoic echotexture of the cartilage
include other potential sites of synovial fluid col- layer
lection, such as popliteal cysts (Fig. 7.4). US
examination of the popliteal cavity can document para-patellar view, and a large portion of the tib-
the presence of a cyst more frequently than clini- ial and patellar cartilage is not accessible by US.
cal examination, even in the absence of symp- From a technical point of view, the correct US
toms at this level. visualization of the hyaline cartilage requires an
When joint effusion is small in size or deeply insonation angle of 90° which is obtained when
located, US facilitates synovial fluid aspiration the US beam direction is perpendicular to the car-
guiding the needle placement at the target area. tilage surface.
The thickness of the cartilage is an important
parameter to detect and possibly monitor the pro-
7.4 Cartilage Damage gression of OA. At least in the early stages of
OA, the typical injury is a reduction in hyaline
US appearance of the normal hyaline cartilage is cartilage thickness. With respect to healthy con-
characterized by a homogeneously anechoic trols, a reduction in tibiofemoral cartilage thick-
layer delimited by two hyperechoic, regular, and ness has been documented during knee OA and
continuous margins: the superficial margin (the measurement of cartilage thickness in the middle
chondro-synovial interface) and the deep margin of the medial femoral condyle could be a useful
(osteochondral interface). The superficial margin parameter to assess early morphological changes.
is typically thinner than the deep one (Fig. 7.5). Comparing US and MRI in the measurement of
The US features of cartilage damage include cartilage thickness in the medial femoral con-
the loss of normal anechogenicity, the loss of dyle, the correlation between the two methods is
sharpness of the superficial margin, the thinning significantly positive. US can therefore be used
of the cartilage layer which can be partial or com- as a reliable examination to assess cartilage thick-
plete, and the subchondral bone erosions ness in the medial femoral condyle.
(Fig. 7.6). Moreover, US allows the visualization of the
The main limit of US in the assessment of car- meniscal fibrocartilage (Fig. 7.7). At knee level
tilage is in the limited acoustic window. Taking the normal menisci appear as homogenous echo-
the knee joint as an example, the hyaline cartilage genic triangular structures located between femo-
of the femoral condyles requires the flexion of ral and tibial epiphysis (Fig. 7.7a). Only outer
the knee to be visualized using a supra or medial portions of the menisci can be clearly visualized,
7 Osteoarthritis 77

a c

b d

Fig. 7.6 Osteoarthritis. Knee. Suprapatellar views arthritic changes of the hyaline cartilage. Note the focal
obtained with knee in 90° flexion using transverse (a and thinning (arrow) and the loss of the homogeneous
c) and longitudinal (b and d) of the lateral (a and b) and echotexture of the cartilage layer (arrowhead). lc lateral
medial (c and d) facets of femoral trochlea showing osteo- condyle; mc medial condyle

a c

b d

Fig. 7.7 Healthy subject (a) and osteoarthritis (b–d). medial meniscus (a), osteophytes of different size (b–d),
Knee. Medial longitudinal scan showing the normal and medial meniscal protrusion (c). arrow medial menis-
appearance of the femoral and tibial bone profiles and cal protrusion; arrowheads osteophytes; f femur; t tibia
78 M. Di Carlo et al.

with the acoustic window for the US assessment a

of the medial meniscus being wider than the one
for the lateral meniscus.
There is evidence supporting the use of US to
detect medial meniscal extrusion (Fig. 7.7c), a
typical OA lesion positively correlated with
medial joint space narrowing documented by
conventional radiography.

b
7.5 Osteophytes

Osteophytes are pathological bony prominences

at the margins of the articular surface of the bone.
From a prognostic point of view, the size of
osteophytes correlates with the duration and
severity of OA.
Using US, osteophytes appear as abnormal
Fig. 7.8 Healthy subject (a) and osteoarthritis (b).
step-up prominences of the bone which may Trapeziometacarpal joint. Longitudinal scan through the
exhibit acoustic shadowing (Fig. 7.7b–d). thenar eminence shows normal appearance of the bony
Compared to conventional radiography, US cortex (a) and osteophytes (b). mc base of the first meta-
has proven to be a sensitive imaging technique to carpal bone; tr trapezius
detect osteophytes, especially at small joints of
the hand (Figs. 7.8 and 7.9).
a
Moreover, there is evidence documenting the
US ability to reveal the presence of osteophytes
at the medial femoral condyle of the knee joint in
a relevant proportion of patients with no radio-
graphic findings indicative of osteophytes.
The main advantage of the US over conven- b
tional radiography is the possibility to perform a
multiplanar study which allows the visualization of
areas of the joint margin where osteophytes may
result hidden to the radiographic examination.
Some US grading systems have been devel-
oped to score osteophytes and some studies have Fig. 7.9 Osteoarthritis. Hand. Longitudinal dorsal scan
found a significant correlation between the radio- of distal interphalangeal joint (a) and metacarpophalan-
graphic and US assessments of femoral osteo- geal joint (b) showing osteophytes (arrowheads). dp distal
phyte size at knee level, both on the medial and phalanx; mp middle phalanx; pp proximal phalanx; mc
metacarpal bone; t finger extensor tendon
lateral joint aspects.
7 Osteoarthritis 79

Further Readings Koski JM, Kamel A, Waris P, et al. Atlas-based knee

osteophyte assessment with ultrasonography and
radiography: relationship to arthroscopic degen-
Altman RD, Gold GE. Atlas of individual radiographic
eration of articular cartilage. Scand J Rheumatol.
features in osteoarthritis, revised. Osteoarthr Cartil.
2016;45:158–64.
2007;15 Suppl A:A1–56.
Iagnocco A, Naredo E. Ultrasound of the osteoarthritic
Amin S, LaValley MP, Guermazi A, Grigoryan M, Hunter
joint. Clin Exp Rheumatol. 2017;35:527–34.
DJ, Clancy M, Niu J, Gale DR, Felson DT. The rela-
Martino F, Ettorre GC, Patella V, et al. Articular carti-
tionship between cartilage loss on magnetic reso-
lage echography as a criterion of the evolution of
nance imaging and radiographic progression in men
osteoarthritis of the knee. Int J Clin Pharmacol Res.
and women with knee osteoarthritis. Arthritis Rheum.
1993;13:35–42.
2005;52:3152–9.
Mathiessen A, Haugen IK, Slatkowsky-Christensen B,
Bruyn GA, Naredo E, Damjanov N, et al. An OMERACT
reliability exercise of inflammatory and structural Bøyesen P, Kvien TK, Hammer HB. Ultrasonographic
abnormalities in patients with knee osteoarthri- assessment of osteophytes in 127 patients with hand
tis using ultrasound assessment. Ann Rheum Dis. osteoarthritis: Exploring reliability and associations
2016;75:842–6. with MRI, radiographs and clinical joint findings. Ann
Bruyn GA, Iagnocco A, Naredo E, et al. OMERACT Rheum Dis. 2013;72:51–6.
definitions for ultrasonographic pathologies and ele- Mathiessen A, Slatkowsky-Christensen B, Kvien TK,
mentary lesions of rheumatic disorders 15 years on. J Haugen IK, Berner HH. Ultrasound-detected osteo-
Rheumatol. 2019;46:1388–93. phytes predict the development of radiographic and
Buck RJ, Wyman BT, Le Graverand MP, Hudelmaier M, clinical features of hand osteoarthritis in the same fin-
Wirth W, Eckstein F, investigators A. Osteoarthritis ger joints 5 years later. RMD Open. 2017;3:e000505.
may not be a one-way-road of cartilage loss - com- Möller I, Bong D, Naredo E, Filippucci E, Carrasco I,
parison of spatial patterns of cartilage change between Moragues C, et al. Ultrasound in the study and moni-
osteoarthritic and healthy knees. Osteoarthr Cartil. toring of osteoarthritis. Osteoarthr Cartil. 2008;16:S4.
2010;18:329–35. Naredo E, Cabero F, Palop MJ, Collado P, Cruz A, Crespo
Conaghan PG, D’Agostino MA, Le Bars M, et al. Clinical M. Ultrasonographic findings in knee osteoarthritis:
and ultrasonographic predictors of joint replace- a comparative study with clinical and radiographic
ment for knee osteoarthritis: results from a large, assessment. Osteoarthr Cartil. 2005;13:568–74.
3-year, prospective EULAR study. Ann Rheum Dis. Okano T, Filippucci E, Di Carlo M, Draghessi A, Carotti
2010;69:644–7. M, Salaffi F, Wright G, Grassi W. Ultrasonographic
D’Agostino MA, Iagnocco A, Aegerter P, et al. Does evaluation of joint damage in knee osteoarthritis:
subclinical inflammation contribute to impairment feature-­specific comparisons with conventional radi-
of function of knee joints in aged individuals? High ography. Rheumatology (Oxford). 2016;55:2040–9.
prevalence of ultrasound inflammatory findings. Østergaard M, Pedersen SJ, Døhn UM. Imaging in rheu-
Rheumatology (Oxford). 2015;54:1622–9. matoid arthritis - status and recent advances for mag-
Dawson J, Linsell L, Zondervan K, Rose P, Randall T, netic resonance imaging, ultrasonography, computed
Carr A, Fitzpatrick R. Epidemiology of hip and knee tomography and conventional radiography. Best Pract
pain and its impact on overall health status in older Res Clin Rheumatol. 2008;22:1019–44.
adults. Rheumatology (Oxford). 2004;43:497–504. Podlipská J, Guermazi A, Lehenkari P, Niinimäki J,
Guermazi A, Hayashi D, Eckstein F, Hunter DJ, Duryea Roemer FW, Arokoski JP, et al. Comparison of diag-
J, Roemer FW. Imaging of osteoarthritis. Rheum Dis nostic performance of semi-quantitative knee ultra-
Clin N Am. 2013;39:67–105. sound and knee radiography with MRI: Oulu Knee
Hunter DJ, Zhang YQ, Tu X, Lavalley M, Niu JB, osteoarthritis study. Sci Rep. 2016;6:22365.
Amin S, Guermazi A, Genant H, Gale D, Felson Pradsgaard D, Fiirgaard B, Spannow AH, Heuck C,
DT. Change in joint space width: hyaline articular car- Herlin T. Cartilage thickness of the knee joint in juve-
tilage loss or alteration in meniscus? Arthritis Rheum. nile idiopathic arthritis: comparative assessment by
2006;54:2488–95. ultrasonography and magnetic resonance imaging. J
Kawaguchi K, Enokida M, Otsuki R, Teshima Rheumatol. 2015;42:534–40.
R. Ultrasonographic evaluation of medial radial dis- Reichmann WM, Maillefert JF, Hunter DJ, Katz JN,
placement of the medial meniscus in knee osteoarthri- Conaghan PG, Losina E. Responsiveness to change
tis. Arthritis Rheum. 2012;64:173–80. and reliability of measurement of radiographic joint
Kellgren JH, Lawrence JS. Radiological assessment of space width in osteoarthritis of the knee: a systematic
osteo-arthrosis. Ann Rheum Dis. 1957;16:494–502. review. Osteoarthr Cartil. 2011;19:550–6.
80 M. Di Carlo et al.

Riecke BF, Christensen R, Torp-Pedersen S, Boesen M, MR imaging: computational method and reproducibil-
Gudbergsen H, Bliddal H. An ultrasound score for ity in the living. Magn Reson Med. 1999;41:529–36.
knee osteoarthritis: a cross-sectional validation study. Takase K, Ohno S, Takeno M, et al. Simultaneous evalu-
Osteoarthr Cartil. 2014;22:1675–91. ation of long-lasting knee synovitis in patients under-
Roemer FW, Eckstein F, Hayashi D, Guermazi A. The going arthroplasty by power Doppler ultrasonography
role of imaging in osteoarthritis. Best Pract Res Clin and contrast-enhanced MRI in comparison with histo-
Rheumatol. 2014;28:31–60. pathology. Clin Exp Rheumatol. 2012;30:85–92.
Saarakkala S, Waris P, Waris V, Tarkiainen I, Karvanen Wakefield RJ, Balint PV, Szkudlarek M, et al.
E, Aarnio J, et al. Diagnostic performance of Musculoskeletal ultrasound including defini-
knee ultrasonography for detecting degenerative tions for ultrasonographic pathology. J Rheumatol.
changes of articular cartilage. Osteoarthr Cartil. 2005;32:2485–24.
2012;20:376–81. Wang Y, Wluka AE, Jones G, Ding C, Cicuttini FM. Use
Stammberger T, Eckstein F, Englmeier KH, Reiser magnetic resonance imaging to assess articular carti-
M. Determination of 3D cartilage thickness data from lage. Ther Adv Musculoskelet Dis. 2012;4:77–97.
 Rheumatoid Arthritis
8
Marina Carotti, Emilio Filippucci , Fausto Salaffi,
and Fabio Martino

Contents
8.1 Introduction  81
8.2 Synovitis  83
8.3 Bone Erosions  84
8.4 Cartilage Damage  85
8.5 Tenosynovitis  87
8.6 Tendon Damage  88
Further Readings  89

8.1 Introduction appropriate treatment, RA leads to irreversible ana-

tomical damage, disability and premature death.
Rheumatoid arthritis (RA) is the archetypal inflam- In North America and Europe, the prevalence
matory arthritis. It primarily targets the synovium of RA is estimated to be 0.5–1.0% and annual
of peripheral joints. RA can be defined as an incidence is approximately 0.02–0.05%, with the
inflammatory autoimmune disease, characterized age of onset highest in the fifth decade of life.
by chronic synovitis mainly involving the small Epidemiologic studies suggest genetic and envi-
joints of the hands and feet. In the absence of ronmental contributions in the aetiology of
RA. This multifactorial hypothesis is confirmed
M. Carotti by the presence of multiple risk factors for
Clinica di Radiologia, Dipartimento di Scienze RA. Females have a higher risk of disease by 2–3
Radiologiche – Azienda Ospedali Riuniti di Ancona times and smoking is also associated with an
Universita’ Politecnica delle Marche, Ancona, Italy
increased risk of seropositive RA by 1.5 times.
E. Filippucci · F. Salaffi RA patients have an increased risk of cardio-
Clinica Reumatologica, Dipartimento di Scienze
vascular disease morbidity and mortality. Overall,
Cliniche e Molecolari, Università Politecnica delle
Marche, Jesi (Ancona), Italy patients with RA have a 3–10 years reduction of
life expectancy, depending on both their age at
F. Martino (*)
Radiology, Sant’Agata Diagnostic Center, Bari, Italy disease onset and RA severity.

© Springer Nature Switzerland AG 2022 81

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_8
82 M. Carotti et al.

Joint pain and swelling are two of the hall- mark of the structural damage in RA. Erosive
mark manifestations of RA, usually character- process usually appears in the “bare areas” of the
ized by a symmetric distribution usually involving joint, where the intra-articular bone surface is not
wrist, metacarpophalangeal (MCP), proximal covered by the hyaline cartilage and is exposed to
interphalangeal (PIP) and metatarsophalangeal the hyperplastic synovial tissue. In later stages,
(MTP) joints. Larger joints (e.g. elbow and knee) concentric joint space narrowing (JSN) could
may be involved during the disease course. occur. Subchondral radiolucent areas are com-
Synovial inflammation is typically related to mon in RA and usually are the consequence of
morning stiffness lasting more than half an hour the extension of synovial proliferation into the
and may be associated with a relevant impair- trabecular bone. In end stages of the disease, irre-
ment of daily living activities. versible joint deformities can be observed.
RA should be suspected in a patient who pres- However, the main limitations of CR are the lack
ents with inflammatory polyarthritis. The initial of sensitivity in detecting RA joint structural
evaluation of such patients requires a careful his- changes especially in early disease phases and
tory and physical examination, along with selected the inability to assess directly soft tissues (such
laboratory testing to identify features that are as synovium, tendons) and cartilage.
characteristic of RA or that suggest an alternative The use of magnetic resonance imaging (MRI)
diagnosis. Symptoms of arthritis should be pres- and ultrasound (US) has undoubtedly enhanced
ent for more than 6 weeks to increase the specific- the understanding of the pathological processes at
ity of the diagnosis. In fact, symptoms that have both articular and periarticular levels. MRI allows
been present for a shorter time may be due to an the detection of all relevant changes of RA (i.e.
acute viral polyarthritis rather than to RA. synovitis, tenosynovitis, bone marrow oedema,
Laboratory tests may support the diagnosis. bone erosions and cartilage damage). MRI allows
Rheumatoid factor (RF) and anti-­cyclic citrulli- the identification of bone marrow oedema, which
nated peptide (ACPA) antibody positivity represents a strong predictor of subsequent radio-
increases overall diagnostic accuracy. Despite graphic progression in early RA.
this, both tests are negative on presentation in up US permits an accurate and real-time analysis
to 50% of patients and remain negative during of articular and periarticular structures. Moreover,
follow-up in 20% of patients with RA. According US is increasingly used to guide interventional
to serological status, RA patients can be classified procedures in rheumatological daily practice.
as seropositive or seronegative. This distinction However, US cannot assess osteitis and its accu-
has a prognostic value in terms of disease severity, racy depends on the equipment used and the cor-
and clinical responsiveness to some medications. rectness of the procedure.
In 2010, the ACR and the European League US provides additional benefits over the phys-
Against Rheumatism (EULAR) developed the ical examination in the early identification of
latest classification criteria for RA. These criteria inflammation and may increase the performance
required the presence of synovitis in at least one of the 2010 ACR/EULAR criteria in the early
joint and the absence of an alternative diagnosis diagnosis of RA especially in subjects negative
that offered a more suitable explanation for the for ACPA and RF.
synovitis. Colour Doppler and power Doppler modali-
Traditionally, conventional radiography (CR) ties are able to detect even small changes of the
has been the imaging technique most used in the synovial vascularization, estimating the inflam-
assessment of RA and it remains widely used matory activity at joint level. Power Doppler
both in daily practice and in clinical trials. CR mode is theoretically more sensitive than colour
allows to assess multiple joints simultaneously in Doppler one in the assessment of small-vessel
a reasonable amount of time and without impor- flow, because of its higher sensitivity for low-­
tant radiation exposure. Juxta-articular osteopo- volume, low-velocity blood flow at the microvas-
rosis is a feature usually detected in the early cular level. It has been shown that both synovial
stages of the disease. Bone erosions are the hall- vascularization and power Doppler signal
8 Rheumatoid Arthritis 83

increase in active joint inflammation and decrease

after an appropriate treatment. In addition to a
dichotomous scoring method (presence or
absence of pathological synovial vasculariza-
tion), several semiquantitative scoring systems
have been proposed to evaluate the synovial
blood flow. In 2017, the OMERACT/EULAR
ultrasound taskforce described a four-grade scor-
ing system of power Doppler (grade 0: no Fig. 8.1 Rheumatoid arthritis. Metacarpophalangeal
joint on longitudinal dorsal scan showing a representative
Doppler signal, grade 1: up to three single
example of exudative synovitis. Note the anechoic joint
Doppler spots or up to one confluent spots and cavity widening. mc metacarpal bone; pp proximal pha-
two single spots or up to two confluent spots, lanx; *synovial fluid
grade 2: more than grade 1 but less than 50% of
Doppler signals in the total greyscale back-
ground, grade 3: more than 50% of Doppler sig- a
nals in the total greyscale background) to be
applied in MCP, PIP, MTP joints, wrist and knee.
Moreover, US evaluation of synovitis has been
shown to have internal and external validity
allowing the US assessment of treatment
response. Finally, US has been used to guide
therapy decisions such as biologics discontinua-
tion, showing that power Doppler was a predictor b
of biologics tapering failure.
US in patients with RA allows the detection of
a wide range of morphostructural abnormalities.
The main pathological findings detectable by US
at joint and tendon level can be divided into two
major categories, those revealing inflammation
and those indicative of anatomic damage.
Fig. 8.2 Rheumatoid arthritis. Metacarpophalangeal
Inflammatory changes in RA include joint joint on longitudinal dorsal scan showing a representative
space/tendon sheath widening, synovial effusion example of proliferative synovitis using B-mode (a) and
and synovial hypertrophy. The most relevant power mode (b). Note the marked joint widening due to
structural changes are bone erosions, cartilage an abnormal amount of synovial fluid and areas of syno-
vial hypertrophy showing intense power Doppler signal.
damage and tendon tears. mc metacarpal bone; pp proximal phalanx; §synovial
hypertrophy; *synovial fluid

8.2 Synovitis
inflammatory process detectable by US. Even a
Joint cavity widening is the key finding indicative minimal intra-articular effusion can be detected
of synovitis and may depend on a variable amount by US. However, due to the lack of specificity of
of synovial fluid and synovial proliferation. this finding, very recently, the Outcome Measures
Synovial effusion appears as an anechoic or a in Rheumatology (OMERACT) US Task Force
hypoechoic (relative to subdermal fat, but some- stated that synovial effusion alone is not enough
times isoechoic or hyperechoic) material which to be indicative of synovitis in RA.
is easily displaceable and compressible by pres- On the other hand, synovial proliferation is a
sure exerted using the examining probe and does hypoechoic (relative to subdermal fat, but some-
not exhibit power Doppler signal (Fig. 8.1). times isoechoic or hyperechoic) not displaceable
Synovial effusion is virtually the first step of the
84 M. Carotti et al.

a a

b
b

Fig. 8.4 Rheumatoid arthritis. Wrist on longitudinal (a)

Fig. 8.3 Rheumatoid arthritis. Fifth toe. and transverse (b) dorsal scans showing “active” synovi-
Metatarsophalangeal joint on longitudinal lateral scan tis. Radio-carpal, intercarpal and carpo-metacarpal joints
showing pre-erosive changes at the bare area of the meta- present evident joint cavity widening with intense intra-­
tarsal head (arrowheads) and bone erosion at the base of articular power Doppler signal (score 3 of OMERACT/
the proximal phalanx (arrow) using B-mode (a) and power EULAR ultrasound taskforce). mc base of the third meta-
Doppler mode (b). Note the distribution of the power carpal bone; ca capitate bone; lu lunate bone; ra radius; sc
Doppler signal at the areas of bony damage. mt metatarsal scaphoid bone; t common extensor tendons of the fingers
bone; pp proximal phalanx
8.3 Bone Erosions
and poorly compressible intra-articular tissue
which may exhibit power Doppler signal (Fig. 8.2). Bone erosion is one of the hallmarks of RA. The
Synovial effusion can be easily distinguished presence of a bone erosion is a predictor of poor
from the “dark-grey” hypoechogenicity of syno- outcome. According to its presence RA is classi-
vial proliferation, which can appear as a homoge- fied into two different prognostic categories: ero-
nous or irregular (villous, polypoid or bushy sive and non-erosive disease.
appearance) thickening of the synovial membrane. Over the last two decades, several studies con-
Currently, synovial hypertrophy is the mandatory firmed that US allows an accurate and detailed
US abnormality for the definition of synovitis even analysis of the bony changes induced by the
in the absence of power Doppler signal. inflammatory process. US has been shown to be
The presence of a highly vascularized syno- more sensitive than CR for the detection of bone
vial proliferation has been identified as a strong erosions because of a higher spatial resolution
predictor of the subsequent development of struc- and the multiplanar assessment of the bone sur-
tural damage both at joint and tendon level face. A disadvantage of US is its relative inacces-
(Fig. 8.3) and it has been linked with the amount sibility to certain sites due to the lack of an
of inflammatory changes in histological speci- acoustic window (e.g. lateral sides of III and IV
mens. Despite synovial hypertrophy, power metacarpal heads). When US was compared with
Doppler signal may be considered the best US micro-CT scan a large proportion of bone lesions
biomarker of inflammation in RA because its detected by US were identified by micro-CT. In
identification is independent of disease duration general, the sensitivity for detecting erosions is
(Fig. 8.4). higher than 85% when the US examination is
confined to well-accessible joint regions such as
II and V MCP joints and V MTP joint.
8 Rheumatoid Arthritis 85

a a′

b b′

Fig. 8.5 Rheumatoid arthritis. Second finger dominant B-mode (a–a′) and power Doppler mode (b–b′). Note the
hand. Metacarpophalangeal joint on longitudinal (a, b) presence of power Doppler signal inside the erosive crater
and transverse (a′, b′) lateral scans showing bone erosion indicative of “hot” erosion. mc metacarpal bone; pp proxi-
at the bare area of the metacarpal head (arrows) using mal phalanx

Bone erosions are defined as an intra-articular and V metacarpal heads, of the V metatarsal head
discontinuity of the bone surface that is visible in and of the ulnar styloid should be included in a
at least two perpendicular planes (Fig. 8.5). dedicated scanning protocol aiming at revealing
While assessing bone defects, particular atten- bone erosions. Humeral head and first metatarsal
tion should be paid especially when these abnor- head should not be assessed, being relatively high
malities are smaller than 1 mm in size. In fact, it the prevalence of US abnormalities totally fulfill-
is essential to distinguish true bone erosions from ing the definition of bone erosions in healthy
other causes of cortical bone irregularities includ- subjects.
ing physiologic small vascular bone channels, Greyscale assessment should always be com-
and wider smooth depression at the metaphysis, pleted with power Doppler evaluation to distin-
bone microfracture, multiple osteophytes in guish between “hot” and “cold” bone erosions
osteoarthritis and bone proliferation in psoriatic (Figs. 8.5 and 8.6).
arthritis. US depicts the walls and the floor of the
erosive crater that is generally filled by rheuma-
toid pannus. Erosion borders usually appear as 8.4 Cartilage Damage
irregular and jagged. At the level of the MCP
joints, US can identify bone erosions more fre- Cartilage thinning is one of the most relevant fac-
quently than CR in early RA (Fig. 8.6). tors in the development of irreversible loss of the
Several studies showed the US bone erosions joint function and long-term disability in RA
are “true erosions” using computed tomography patients. In fact, as showed by CR studies, carti-
as the gold standard. The lateral aspect of the II lage damage appears to be more clearly ­associated
86 M. Carotti et al.

a a’ c d

b b’

Fig. 8.6 Rheumatoid arthritis. Second finger dominant (arrows) using B-mode (a–a′) and power Doppler mode
hand. Metacarpophalangeal joint on longitudinal (a, b) (b–b′). (c and d) Conventional radiography using frontal
and transverse (a′–b′) lateral scans showing a large “hot” (c) and oblique (d) views. mc metacarpal bone; pp proxi-
bone erosion at the bare area of the metacarpal head mal phalanx

a b

Fig. 8.7 Healthy subject. Metacarpophalangeal joint on anechoic layer with sharp continuous hyperechoic mar-
longitudinal (a) and transverse (b) dorsal scans with joint gins. mc metacarpal bone; pp proximal phalanx; t finger
in flexed position to enhance the visualization of the meta- extensor tendon
carpal head hyaline cartilage appearing as a subtle

with irreversible physical disability than bony should be explored with the subject seated with
damage. hands placed on the examination table and MCP
US is not routinely performed to assess the joints in maximal flexion (more than 60°). This
hyaline cartilage of both small and large joints in position increases the extent of the metacarpal
RA. In fact, there is only limited US evidence head hyaline cartilage detectable by US on the
about the burden of cartilage damage in RA and dorsal aspect. Normal appearance of hyaline car-
its natural history. Moreover, in most of the US tilage is characterized by homogenous anechoic
studies aiming at assessing hyaline cartilage band delimited by two hyperechoic sharp, regular
involvement in RA, the MCP joints were investi- and continuous interfaces, when it is perpendicu-
gated. The hyaline cartilage of metacarpal heads larly insonated by the US beam (Fig. 8.7). The
8 Rheumatoid Arthritis 87

a b c

Fig. 8.8 Rheumatoid arthritis. Metacarpophalangeal the sharpness of the chondrosynovial margin. (b) More
joint on longitudinal dorsal scan with joint in flexed posi- advanced stages of the cartilage damage which show par-
tion to enhance the visualization of the metacarpal head tial and complete thinning of the cartilage layer. (c)
hyaline cartilage, showing initial (a), established (b) and Cartilage is completely reabsorbed and a subchondral
long-standing cartilage damage. (a) The early stages of bone erosion is refilled by an inflamed pannus (arrow). mc
the cartilage involvement are characterized by the loss of metacarpal bone; pp proximal phalanx

loss of the sharpness of the chondrosynovial mar- Tendon sheath widening is the hallmark of
gin is the initial US abnormality of cartilage tenosynovitis in RA. Tenosynovitis can be
involvement. In advanced stages, partial or com- defined on greyscale US imaging as an abnormal
plete thinning of the cartilage layer and subchon- anechoic and/or hypoechoic (relative to tendon
dral bone erosion can occur (Fig. 8.8). fibres) tendon sheath widening, which can be
related to both the presence of tenosynovial
abnormal fluid and hypertrophy.
8.5 Tenosynovitis Tendon sheath effusion can be defined as an
abnormal anechoic or hypoechoic (relative to
In RA, tenosynovitis is a well-known, but under- tendon fibres) material within the synovial
estimated, component of the disease. In addition, sheath, either localized or surrounding the tendon
tenosynovitis is often misinterpreted as joint that is displaceable and seen in two perpendicular
inflammation by physical examination. planes. Tenosynovial hypertrophy appears as the
Although US is particularly useful in the eval- presence of abnormal hypoechoic (relative to ten-
uation of tendon involvement in RA, to date, only don fibres) tissue within the synovial sheath that
few studies have been performed to investigate its is not displaceable and poorly compressible and
role in the assessment of tendon inflammatory seen in two perpendicular planes.
changes in RA patients. The tendons most fre- In greyscale US, transverse view allows for a
quently involved in RA are the flexor tendons of more sensitive detection of abnormal synovial
the II, III and IV fingers; posterior tibialis tendon fluid at tendon sheath level, revealing small col-
and extensor carpi ulnaris tendon. The US assess- lections on the sides of the tendon.
ment of tendon pathology has been shown to While using power Doppler mode, particular
have a prognostic factor. In fact, the presence of attention must be paid to avoid misinterpretation
an extensor carpi ulnaris tendon tenosynovitis of power Doppler signal due to normal feeding
has been linked to the development of ulnar sty- vessels. Tenosynovitis is characterized by the
loid bone erosions in early RA, and tibial poste- detection of peritendinous power Doppler signal
rior tenosynovitis to flatfoot deformity in RA. within a widened synovial sheath; such a finding
88 M. Carotti et al.

a a’

b b’

Fig. 8.9 Rheumatoid arthritis. Extensor carpi ulnaris ten- (arrowheads) using B-mode (a–a’) and power Doppler
don on transverse (a, b) and longitudinal (a′, b′) scans mode (b–b′). t=extensor ulnaris carpi tendon;
showing “active” tenosynovitis and partial tendon tear tr=triquetrum; u = ulna

should be documented on at least two perpendic-

ular planes (Fig. 8.9). 8.6 Tendon Damage
Several US patterns of tendon sheath widen-
ing can be identified. Tenosynovitis can be fur- The range of tendon tears in RA is wide and
therly characterized by the extent of the widening includes loss of “fibrillar” echotexture and partial
and the presence of synovial proliferation. The and complete tendon rupture. Physical examina-
amount of synovial fluid within a tendon sheath tion provides only limited information on the
may be considerably different, ranging from presence and extent of a partial tendon tear.
minimal diffuse widening to important focal Analysis of tendon echotexture is one of the
enlargement. No direct relationship between the fundamental roles of US assessment. In the early
extent of tenosynovitis and clinical symptoms phases of persistent tenosynovitis the initial
has been reported. The profile of a widened ten- abnormality is the loss of the fibrillar
don sheath can be regular or extremely non- echotexture.
homogeneous with saccular or aneurysmal This finding can precede a partial rupture of
appearance, especially in chronic tenosynovitis. tendon (Fig. 8.10) and the subsequent evolution
into a complete tendon tear. Tendon damage
should always be assessed by dynamic examina-
tion (to exclude anisotropy artefacts). To avoid
8 Rheumatoid Arthritis 89

a a’

b b’

Fig. 8.10 Rheumatoid arthritis. Tibialis posterior tendon using B-mode (a–a′) and power Doppler mode (b–b′).
on transverse (a, b) and longitudinal (a′–b′) scans show- Note the loss of the fibrillar echotexture and the presence
ing “active” tenosynovitis and partial tendon tear (arrows) of intra-tendinous power Doppler signal. ti tibia; ta talus

Cipolletta E, Filippucci E, Di Matteo A, et al. The reli-

anisotropy artefacts, the suspicion of a tendon ability of ultrasound in the assessment of hyaline
tear on a single scanning plane must be verified cartilage in rheumatoid arthritis and healthy meta-
carpal heads [published online ahead of print,
changing the US beam direction. Complete ten- 2020 Oct 30]. Ultraschall Med. 2020. https://doi.
don tear is characterized by the depiction of both org/10.1055/a-1285-4602.
the complete loss of fibrillar structure and the gap D’Agostino MA, Terslev L, Wakefield R, Østergaard M,
between the retracted tendon edges, frequently Balint P, Naredo E, et al. Novel algorithms for the
pragmatic use of ultrasound in the management of
refilled by fluid or synovial proliferation. patients with rheumatoid arthritis: From diagnosis to
remission. Ann Rheum Dis. 2016;75:1902–8.
Døhn UM, Ejbjerg BJ, Court-Payen M, Hasselquist M,
Further Readings Narvestad E, Szkudlarek M, et al. Are bone erosions
detected by magnetic resonance imaging and ultraso-
nography true erosions? A comparison with computed
Bruyn GAW, Hanova P, Iagnocco A, D’Agostino MA, tomography in rheumatoid arthritis metacarpophalan-
Möller I, Terslev L, et al. Ultrasound definition of geal joints. Arthritis Res Ther. 2006;8:R110. https://
tendon damage in patients with rheumatoid arthritis. doi.org/10.1186/ar1995.
Results of a OMERACT consensus-based ultrasound Filippou G, Sakellariou G, Scirè CA, Carrara G, Rumi
score focussing on the diagnostic reliability. Ann F, Bellis E, et al. The predictive role of ultrasound-­
Rheum Dis. 2014;73:1929–34. detected tenosynovitis and joint synovitis for flare in
Cipolletta E, Hurnakova J, Di Matteo A, et al. Prevalence patients with rheumatoid arthritis in stable remission.
and distribution of cartilage and bone damage at meta- Results of an Italian multicentre study of the Italian
carpal head in healthy subjects. Clin Exp Rheumatol. Society for Rheumatology Group for Ultrasound: The
2021;39(6):1394–401. STARTER study. Ann Rheum Dis. 2018;77:1283–9.
Cipolletta E, Mandl P, Di Matteo A, et al. Sonographic Filippucci E, Iagnocco A, Meenagh G, Riente L, Delle
assessment of cartilage damage at the metacarpal head Sedie A, Bombardieri S, et al. Ultrasound imaging for
in rheumatoid arthritis: qualitative versus quantitative the rheumatologist VII. Ultrasound imaging in rheu-
methods. Rheumatology (Oxford). 2022;61(3):1018– matoid arthritis. Clin Exp Rheumatol. 2007;25:5–10.
25. https://doi.org/10.1093/rheumatology/keab472.
90 M. Carotti et al.

Filippucci E, Cipolletta E, Mashadi Mirza R, Carotti M, Szkudlarek M, Klarlund M, Narvestad E, Court-Payen

Giovagnoni A, Salaffi F, et al. Ultrasound imaging in M, Strandberg C, Jensen KE, et al. Ultrasonography
rheumatoid arthritis. Radiol Med. 2019;124:1087–100. of the metacarpophalangeal and proximal interpha-
Finzel S, Ohrndorf S, Englbrecht M, Stach C, langeal joints in rheumatoid arthritis: a comparison
Messerschmidt J, Schett G, et al. A detailed compara- with magnetic resonance imaging, conventional radi-
tive study of high-resolution ultrasound and micro-­ ography and clinical examination. Arthritis Res Ther.
computed tomography for detection of arthritic bone 2006;8:R52. https://doi.org/10.1186/ar1904.
erosions. Arthritis Rheum. 2011;63:1231–6. Szkudlarek M, Terslev L, Wakefield RJ, Backhaus M,
Han J, Geng Y, Deng X, Zhang Z. Subclinical synovitis Balint PV, Bruyn GAW, et al. Summary findings of a
assessed by ultrasound predicts flare and progressive systematic literature review of the ultrasound assess-
bone erosion in rheumatoid arthritis patients with clin- ment of bone erosions in rheumatoid arthritis. J
ical remission: A systematic review and meta-analysis. Rheumatol. 2016;43:12–21.
J Rheumatol. 2016;43:2010–8. Tămaş M-M, Filippucci E, Becciolini A, Gutierrez M, Di
Koski JM, Saarakkala S, Helle M, Hakulinen U, Geso L, Bonfiglioli K, et al. Bone erosions in rheuma-
Heikkinen JO, Hermunen H. Power Doppler ultraso- toid arthritis: ultrasound findings in the early stage of
nography and synovitis: Correlating ultrasound imag- the disease. Rheumatology (Oxford). 2014;53:1100–7.
ing with histopathological findings and evaluating the Terslev L, Østergaard M, Sexton J, Hammer HB. Is syno-
performance of ultrasound equipments. Ann Rheum vial hypertrophy without Doppler activity sensitive to
Dis. 2006;65:1590–5. change? Post-hoc analysis from a rheumatoid arthri-
Jindal S, Kaushik R, Raghuvanshi S, Kaushik RM, Kakkar tis ultrasound study 11 Medical and Health Sciences
R. Gray scale and power doppler ultrasonographic 1103 Clinical Sciences. Arthritis Res Ther. 2018;20
findings in the assessment of disease activity and their https://doi.org/10.1186/s13075-­018-­1709-­6.
correlation with disease activity parameters in rheuma- Vreju FA, Filippucci E, Gutierrez M, Di Geso L, Ciapetti
toid arthritis. Curr Rheumatol Rev. 2017;14:153–62. A, Ciurea ME, et al. Subclinical ultrasound synovitis
Mandl P, Studenic P, Filippucci E, Bachta A, Backhaus in a particular joint is associated with ultrasound evi-
M, Bong D, et al. Development of semiquantitative dence of bone erosions in that same joint in rheumatoid
ultrasound scoring system to assess cartilage in rheu- patients in clinical remission. Clin Exp Rheumatol.
matoid arthritis. Rheumatology (United Kingdom). 2016;34:673–8.
2019;58:1802–11. Zayat AS, Ellegaard K, Conaghan PG, Terslev L, Hensor
Naredo E, D’Agostino MA, Wakefield RJ, Möller I, Balint EMA, Freeston JE, et al. The specificity of ultrasound-­
PV, Filippucci E, et al. Reliability of a ­consensus-­based detected bone erosions for rheumatoid arthritis. Ann
ultrasound score for tenosynovitis in rheumatoid Rheum Dis. 2015;74:897–903.
arthritis. Ann Rheum Dis. 2013;72:1328–34.
 Seronegative Spondyloarthritis
9
Edoardo Cipolletta , Marco Di Carlo ,
Emilio Filippucci , and Fabio Martino

Contents
9.1 Introduction  91
9.2 General Concepts  93
9.3 Joint Involvement  93
9.4 Dactylitis  95
9.5 Enthesitis  95
9.6 Tendon Involvement  96
Further Readings  98

9.1 Introduction tory bowel diseases are characteristic extra-­

articular features of spondyloarthritides.
Seronegative spondyloarthritides represent a Spondyloarthritides can be classified as
group of heterogeneous inflammatory joint dis- follows:
eases characterized by shared epidemiology,
pathogenesis, and clinical manifestations. The • Ankylosing spondylitis
typical musculoskeletal manifestations are • Psoriatic arthritis
peripheral and axial joint involvement, enthesitis, • Reactive arthritis
and dactylitis. Uveitis, psoriasis, and inflamma- • Enteropathic arthritis (spondyloarthritis
related to inflammatory bowel diseases)
• Undifferentiated spondyloarthritis

E. Cipolletta · M. Di Carlo · E. Filippucci The prevalence of spondyloarthritides ranges

Clinica Reumatologica, between 0.2% and 2%. Males in the second and
Dipartimento di Scienze Cliniche e Molecolari, third decades are the most affected by
Università Politecnica delle Marche, spondyloarthritides.
Jesi (Ancona),
Italy HLA-B27 antigen is closely related to the
development of spondyloarthritides; however, its
F. Martino (*)
Radiology, Sant’Agata Diagnostic Center, prevalence varies considerably in the different
Bari, Italy subsets of spondyloarthritides (up to 95% of

© Springer Nature Switzerland AG 2022 91

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_9
92 E. Cipolletta et al.

ankylosing spondylitis patients are HLA-B27 shown that dactylitis corresponds to a multi-­
positive in comparison with the 40% of psoriatic tissue inflammation of tendons, subcutaneous tis-
arthritis patients). sues, and joints.
Moreover, bacterial infections have been rec- Enthesitis is an inflammation at tendon and
ognized as trigger factors of spondyloarthritides. ligament insertion into a bony structure. The
Chlamydia, Mycoplasma, and several most commonly involved entheses are the distal
Enterobacteriaceae species are able to trigger a insertion of Achilles tendon, the calcaneus inser-
reactive arthritis in susceptible individuals, tion of plantar fascia, both the proximal and dis-
through a molecular mimicry mechanism. tal insertions of patellar tendon, the distal
The two main spondyloarthritides are the insertion of the quadriceps tendon, the triceps
ankylosing spondylitis as the archetypal inflam- insertion into the olecranon process, and the
matory disease that primarily targets axial skele- common extensor tendon insertion into the lat-
ton (sacroiliac joints and spine), and psoriatic eral epicondyle of the elbow.
arthritis as the one that primarily targets periph- According to the European League Against
eral joints. Rheumatism (EULAR), conventional radiogra-
Psoriatic arthritis may be defined as an inflam- phy and MRI are the only recommended imag-
matory joint disease associated with psoriasis ing techniques in the diagnosis of the axial
and is usually negative for rheumatoid factor; it involvement in spondyloarthritides. Thus, the
affects up to 30% of patients with psoriasis. role of US in the assessment of sacroiliac and
Wright and Moll described five clinical patterns spine involvement in ankylosing spondylitis and
of joint involvement in psoriatic arthritis: other types of axial spondyloarthritis is cur-
rently limited to research purposes. In patients
• Asymmetric oligoarthritis with peripheral involvement, US may be used to
• Symmetric polyarthritis detect the presence of enthesitis, since US has
• Predominant distal interphalangeal (DIP) joint shown to be more sensitive than clinical exami-
involvement nation in the identification of the entheseal
• Predominant spondyloarthritis abnormalities. Furthermore, as in rheumatoid
• Destructive (mutilans) arthritis arthritis, US might be used to detect peripheral
arthritis, tenosynovitis, and bursitis, in doubtful
More recently, an international study [The cases.
Classification of Psoriatic Arthritis (CASPAR)] The EULAR recommendations support the
reported that polyarticular joint involvement was use of US to monitor disease activity, since US
the most common (63%) followed by the oligoar- may provide additional information on top of
ticular pattern. clinical and laboratory data. However, the deci-
Characteristic features of psoriatic arthritis sion on when to repeat US depends on the clini-
include dactylitis and enthesitis. Dactylitis clini- cal circumstances and, until now, a standardized
cally presents as a sausage-shaped swelling of protocol has not been proposed. The evaluation
the digit. It may be found in one-third of patients of structural damage in peripheral spondyloar-
with psoriatic arthritis at first presentation, and in thritis is predominantly the prerogative of con-
up to 50% during the disease course. Dactylitis ventional radiography.
affects the right more than left side, involves feet The radiographic picture of psoriatic arthri-
more than hands, and often affects multiple digits tis is quite variable, but it is often distinctive.
at the same time. Acute dactylitis usually pres- Peripheral joint involvement is common, and
ents as a tender, warm, and often erythematous the hand and wrist are most often involved.
digit while chronic dactylitis as a swollen and Joint involvement is usually asymmetric; in
often asymptomatic digit. Ultrasound (US) and contrast to rheumatoid arthritis, the distal inter-
magnetic resonance imaging (MRI) studies have phalangeal joints may be more frequently
9 Seronegative Spondyloarthritis 93

involved; juxta-­ articular osteoporosis is fre- 9.3 Joint Involvement

quently absent whereas there is a propensity for
bone proliferation. This may be in the form of Every single US finding in seronegative spondy-
periostitis of the shafts of the phalanges or in loarthritides is nonspecific as it may occur also in
the form of irregular bony spurs at joints or patients with other inflammatory conditions such
entheses. Bone damage can present the simulta- as rheumatoid arthritis. Synovial effusion and
neous coexistence of bone erosions and of new synovial hypertrophy are common features of
bone formation resulting in a particularly char- articular involvement in seronegative spondylo-
acteristic “whiskering” appearance. In advanced arthritides (Figs. 9.1, 9.2, 9.3, and 9.4). US can be
disease, “pencil-in-cup” deformity may be used to assess all the elementary findings of joint
observed as severe marginal erosion of the involvement: synovitis, bone erosions, and carti-
metacarpal or phalanx head producing the lage damage. The dynamic examination may be
appearance of a pencil, and deep central ero- helpful in the differentiation between synovial
sion of phalangeal base, of a cup. effusion (compressible by the probe pressure)
and synovial proliferation (only poorly com-
pressible by probe pressure). Although not fully
9.2 General Concepts validated, in recent years, several US findings
have been proposed to differentiate hand involve-
Psoriatic arthritis and in general seronegative ment in rheumatoid arthritis and psoriatic arthri-
spondyloarthritides are characterized by multiple tis. Peritendinitis, entheseal involvement (i.e.,
targets. Therefore, US assessment can be focused extensor tendon enthesitis at proximal interpha-
on joints, tendons with and without synovial langeal joint and collateral ligament enthesitis)
sheaths, entheses, skin, and nails. Basic sono- (Fig. 9.4), periarticular soft tissue edema, and
graphic changes of joint and tendons with syno- palmar plate inflammation are more indicative of
vial sheaths can be similar to those of RA (e.g., psoriatic arthritis than rheumatoid arthritis.
synovial effusion and synovial proliferation).
However, in psoriatic arthritis synovial hypertro-
a
phy is usually more vascularized than in rheuma-
toid arthritis.
US is more sensitive than clinical examination
for the detection of synovitis, tenosynovitis, and
enthesitis in patients with seronegative spondylo-
arthritides. Although several US findings have
been proposed as highly specific features of
spondyloarthritides (i.e., peritendinous extensor
tendon inflammation and enthesitis), to date, no
studies have evaluated the role of US in distin- b
guishing spondyloarthritides (i.e., psoriatic
arthritis) from other arthritides in early undiffer-
entiated arthritis. Only a few studies aimed at
evaluating the role of US in the prediction of pso-
riatic arthritis development in patients with pso-
riasis. There is some evidence supporting that
subclinical enthesitis and nail bed vascular
Fig. 9.1 Psoriatic arthritis. Wrist. Right (a)–left (b) com-
changes may be predictors of psoriatic arthritis parison. Longitudinal dorsal scan showing “active” syno-
development. vitis of radio-carpal and intercarpal joints. ca capitate
bone; lu lunate bone; ra radius
94 E. Cipolletta et al.

a c

b d

Fig. 9.2 Psoriatic arthritis. Distal interphalangeal joint the hyperemia of the surrounding periarticular soft tissues
on longitudinal (a, b) and transverse (c, d) dorsal scans (i.e., distal insertion of the finger extensor tendon into the
showing a representative example of proliferative synovi- basis of the distal phalanx and nail bed). dp distal phalanx;
tis with intense intra-articular power Doppler signal. Note mp middle phalanx; §synovial hypertrophy

a a

b b

Fig. 9.4 Psoriatic arthritis. Longitudinal dorsal scan

Fig. 9.3 Psoriatic arthritis. Proximal interphalangeal
showing exudative synovitis of the second metacarpopha-
joint. Longitudinal dorsal scan showing proliferative
langeal joint and “active” enthesitis of the insertion of the
synovitis with evident intra-articular power Doppler sig-
finger extensor tendon into the base of the proximal pha-
nal. (a) gray scale mode, (b) power Doppler mode.
lanx. (a) gray scale mode, (b) power Doppler mode. pp
mp=middle phalanx; pp=proximal phalanx; § = synovial
proximal phalanx; mc metacarpal bone; t finger extensor
hypertrophy
tendon; *synovial fluid
9 Seronegative Spondyloarthritis 95

9.4 Dactylitis ening as inflammatory changes. Recently, the

Outcome Measures in Rheumatology US
The “sausage” digit, which is a common finding Working Group defined each elementary findings
in psoriatic arthritis, is characterized by a vari- as reported in Table 9.1.
able combination of the following US features: The same group of experts performed a reli-
tenosynovitis of flexor digitorum tendons ability exercise on those definitions. The accepted
(Fig. 9.5), synovitis of metacarpophalangeal and US elementary findings of entheseal involvement
interphalangeal joints, and diffuse edema of the are reported in Table 9.2.
soft tissues. Due to the poor reliability of calcification and
enthesophyte definitions, the OMERACT US
Working Group decided to merge the two defini-
9.5 Enthesitis tions with an improvement in the reliability.
The final OMERACT definition of US enthesi-
US can identify a wide range of abnormalities at tis is “a hypoechoic and/or thickened insertion of
the entheseal level. Bone erosions (Fig. 9.6), cal- the tendon close to the bone (within 2 mm from
cification, and enthesophytes (Figs. 9.7 and 9.8) the bony cortex) which exhibits Doppler signal if
are regarded as elements indicative of “structural active and which may show erosions and enthe-
changes,” whereas power Doppler signal sophytes/calcifications as a sign of structural
(Fig. 9.9), hypoechogenicity, and entheseal thick- damage.”
However, several issues should be still clari-
fied. Defining enthesitis as being within 2 mm of
the bony cortex remains an area of active debate.
In fact, the Group for Research and Assessment
of Psoriasis and Psoriatic Arthritis US Working
Group supports the concept that the enthesis
could also extend beyond the cutoff of 2 mm.
Thus, the OMERACT US Working Group defini-
tion may not fully capture the entire spectrum of
entheseal abnormalities.
Fig. 9.5 Psoriatic arthritis. Dactylitis. Longitudinal volar US has shown to be more sensitive than clini-
scan showing finger flexor tendon tenosynovitis. Note the cal examination in the detection of entheseal
hypoechoic widening of the synovial tendon sheath with involvement in seronegative spondyloarthritides.
evident abnormal power Doppler signal at synovial tissue
level. mp middle phalanx; pp proximal phalanx; t finger
Although most studies explored the entheses of
flexor tendons the lower limbs, there is an increasing evidence

a b

Fig. 9.6 Psoriatic arthritis. Longitudinal (a) and transverse (b) scans showing Achilles tendon (At) and a bone erosion
(arrows) of the calcaneal bone (ca)
96 E. Cipolletta et al.

a a

b
b

Fig. 9.9 Psoriatic arthritis. Distal patellar tendon inser-

tion into the anterior tibial tuberosity. Longitudinal scan
showing “active” enthesitis. (a) gray scale mode, (b)
Fig. 9.7 Psoriatic arthritis. Achilles tendon insertion into
power Doppler mode. pt patellar tendon; ti anterior tibial
the calcaneal bone. Longitudinal scan showing “active”
tuberosity
enthesitis with evident enthesophytes (arrow). (a) gray
scale mode, (b) power Doppler mode. At Achilles tendon;
ca calcaneal bone
the presence of enthesophytes, calcifications,
and/or bone erosions.

9.6 Tendon Involvement

Tenosynovitis is relatively common in psoriatic

arthritis. US appearance of tenosynovitis is similar
to that described in rheumatoid arthritis. Hands,
wrists, and ankles are the most frequently involved
Fig. 9.8 Psoriatic arthritis. First metacarpophalangeal
anatomical areas. At ankle level, posterior tibialis
joint. Longitudinal dorsal scan showing “active” enthesi-
tis of the insertion of the finger extensor tendon into the and peroneal tendons are frequently involved in
base of the proximal phalanx. pp proximal phalanx; mc PsA patients (Fig. 9.10). At hand level, particular
metacarpal bone attention should be paid in distinguishing flexor
digitorum tendon tenosynovitis and finger tendon
of US ability to evaluate enthesitis of the upper pulley inflammation. Dynamic maneuvers could
limbs and, in particular, of small joints of the help in distinguishing fluid and pulleys.
hands. Among tendons without synovial sheath,
In the early stages, the enthesis may reveal Achilles tendon, plantar fascia, and patellar ten-
mainly inflammatory changes such as entheseal don are the most frequently involved. US find-
thickening, hypoechogenicity due to intra-­ ings indicative of tendinitis include tendon
tendinous edema, with or without associated bur- thickening, usually leading to a fusiform appear-
sitis, and different amounts of Doppler signal. In ance, hypoechogenicity due to edema, and focal
later stages, structural changes may be related to derangement of tendon echotexture with a vari-
9 Seronegative Spondyloarthritis 97

Table 9.1 OMERACT definitions of US elementary pathologic findings at entheseal level

Findings indicative of structural changes
Bone irregularity Bone profile changes not including definite enthesophytes nor bone erosions.
Calcification Hyperechoic foci, with or without acoustic shadow, detected at the enthesis (<2 mm from the
cortical bone).
Enthesophyte Enthesophyte was defined as a step-up of bony prominence, seen in two perpendicular planes
at the end of the bone contour of the enthesis.
Bone erosion Cortical break with a step-down contour defect, seen in two perpendicular planes, at the
insertion of the enthesis.
Inflammatory findings
Hypoechogenicity Lack of the homogeneous fibrillar pattern in the enthesis (<2 mm from the cortical bone) with
at the enthesis loss of the tightly packed echogenic lines after correcting for anisotropy.
Entheseal Increased thickness of the tendon insertion into the bone (<2 mm from the cortical bone) as
thickening compared with the body of tendon, with or without blurring of the tendon margins.
Doppler signal at Doppler signal seen at bone insertion (<2 mm from the cortical bone), different from reflecting
enthesis surface artifact or nutrition vessel signal, with or without cortical irregularities, erosions, or
enthesophytes.
Doppler signal Doppler signal far from the enthesis (i.e., >2 mm from the cortical bone, within the body of
outside the enthesis tendon) and clearly different from nutrition vessel signals.
Bursitis An enlargement (i.e., increase in diameter of the bursa), with well-defined, anechoic or
hypoechoic area inside, with or without Doppler signal.

Table 9.2 Accepted US elementary findings for OMERACT US definition of enthesitis

Inflammatory findings Findings indicative of structural changes
Doppler signal at the enthesis Calcification/enthesophyte at the enthesis
Hypoechogenicity at the enthesis Bone erosion at the enthesis
Thickened enthesis

a a’

b b’

Fig. 9.10 Psoriatic arthritis. Ankle. Tibialis posterior tendon. Transverse (a–a′) and longitudinal (b–b′) scans showing
“active” tenosynovitis (§) . ti tibia; ta talus; tp tibialis posterior tendon
98 E. Cipolletta et al.

TNF-alpha antagonist therapy: an ultrasound study.

a Rheumatology (Oxford). 2010;49(3):578–82. https://
doi.org/10.1093/rheumatology/kep410. Epub 2009
Dec 29
Balint PV, Kane D, Wilson H, McInnes IB, Sturrock
RD. Ultrasonography of entheseal insertions in the
lower limb in spondyloarthropathy. Ann Rheum
Dis. 2002;61:905–10. https://doi.org/10.1136/
ard.61.10.905.
Balint PV, Terslev L, Aegerter P, Bruyn GAW, Chary-­
Valckenaere I, Gandjbakhch F, et al. Reliability of
a consensus-based ultrasound definition and scor-
b ing for enthesitis in spondyloarthritis and psoriatic
arthritis: An OMERACT US initiative. Ann Rheum
Dis. 2018;77:1730–5. https://doi.org/10.1136/
annrheumdis-­2018-­213609.
Delle Sedie A, Riente L, Filippucci E, Scirè CA, Iagnocco
A, Gutierrez M, et al. Ultrasound imaging for the
rheumatologist XXVI. Sonographic assessment of
the knee in patients with psoriatic arthritis. Clin Exp
Rheumatol. n.d.;28:147–52.
Delle Sedie A, Riente L, Filippucci E, Scirè CA, Iagnocco
A, Meenagh G, et al. Ultrasound imaging for the
rheumatologist. XXXII. Sonographic assessment of
Fig. 9.11 Psoriatic arthritis. Peritendinous inflammation the foot in patients with psoriatic arthritis. Clin Exp
at second finger metacarpophalangeal joint level. Rheumatol. n.d.;29:217–22.
Longitudinal (a) and transverse (b) dorsal scans showing Filippucci E, Aydin SZ, Karadag O, Salaffi F, Gutierrez M,
power Doppler signal surrounding the finger extensor ten- Direskeneli H, Grassi W. Reliability of high-­resolution
don. pp proximal phalanx; mc metacarpal bone; t=finger ultrasonography in the assessment of Achilles tendon
extensor tendon enthesopathy in seronegative spondyloarthropathies.
Ann Rheum Dis. 2009;68(12):1850–5. https://doi.
org/10.1136/ard.2008.096511. Epub 2009 Apr 8
able amount of intra-tendinous Doppler signal. Filippucci E, Smerilli G Di Matteo A, Cipolletta E, Destro
Castaniti GM, et al. Reliability assessment of the
Moreover, a peritendinous inflammation may
definition of ultrasound enthesitis in SpA: results of
appear as a hypoechoic swelling of the soft tissue a large, multicentre, international web-based study
surrounding the tendon with or without the pres- [published online ahead of print, 2022 Mar 16].
ence of power Doppler signal (i.e., peritendinous Rheumatology (Oxford). 2022;keac162. https://doi.
org/10.1093/rheumatology/keac162.
involvement of finger extensor tendon at meta-
Filippucci E, Smerilli G, Di Matteo A, Grassi W.
carpophalangeal joint) (Fig. 9.11). Ultrasound definition of enthesitis in spondyloarthri-
tis and psoriatic arthritis: arrival or starting point?.
Ann Rheum Dis. 2021;80(11):1373–5. https://doi.
org/10.1136/annrheumdis-2021-220478.
Further Readings Girolimetto N, Macchioni P, Tinazzi I, Costa L, Peluso R,
Tasso M, et al. Predominant ultrasonographic extra-
Aydin SZ, Bas E, Basci O, Filippucci E, Wakefield RJ, capsular changes in symptomatic psoriatic dactylitis:
Çelikel Ç, et al. Validation of ultrasound imaging results from a multicenter cross-sectional study com-
for Achilles entheseal fibrocartilage in bovines and paring symptomatic and asymptomatic hand dactyli-
description of changes in humans with spondyloar- tis. Clin Rheumatol. 2019; https://doi.org/10.1007/
thritis. Ann Rheum Dis. 2010;69:2165–8. https://doi. s10067-­019-­04683-­2.
org/10.1136/ard.2009.127175. Gutierrez M, Filippucci E, De Angelis R, Filosa G, Kane D,
Aydin SZ, Castillo-Gallego C, Ash ZR, Marzo-Ortega Grassi W. A sonographic spectrum of psoriatic arthri-
H, Wakefield R, McGonagle D. Vascularity of nail tis: “the five targets.”. Clin Rheumatol. 2010;29:133–
bed by ultrasound to discriminate psoriasis, psoriatic 42. https://doi.org/10.1007/s10067-­009-­1292-­y.
arthritis and healthy controls. Clin Exp Rheumatol. Gutierrez M, Filippucci E, De Angelis R, Salaffi F,
n.d.;35:872. Filosa G, Ruta S, et al. Subclinical entheseal involve-
Aydin SZ, Karadag O, Filippucci E, Atagunduz P, Akdogan ment in patients with psoriasis: an ultrasound study.
A, Kalyoncu U, Grassi W, Direskeneli H. Monitoring Semin Arthritis Rheum. 2011;40:407–12. https://doi.
Achilles enthesitis in ankylosing spondylitis during org/10.1016/j.semarthrit.2010.05.009.
9 Seronegative Spondyloarthritis 99

Gutierrez M, Filippucci E, Salaffi F, Di Geso L, Grassi Tinazzi I, McGonagle D, Macchioni P, Aydin SZ. Power
W. Differential diagnosis between rheumatoid arthri- Doppler enhancement of accessory pulleys con-
tis and psoriatic arthritis: the value of ultrasound firming disease localization in psoriatic dactyli-
findings at metacarpophalangeal joints level. Ann tis. Rheumatology. 2020; https://doi.org/10.1093/
Rheum Dis. 2011;70:1111–4. https://doi.org/10.1136/ rheumatology/kez549.
ard.2010.147272. Tinazzi I, McGonagle D, Zabotti A, Chessa D, Marchetta
Mandl P, Navarro-Compán V, Terslev L, Aegerter A, Macchioni P. Comprehensive evaluation of finger
P, Van Der Heijde D, D’Agostino MA, et al. flexor tendon entheseal soft tissue and bone changes
EULAR recommendations for the use of imag- by ultrasound can differentiate psoriatic arthri-
ing in the diagnosis and management of spon- tis and rheumatoid arthritis. Clin Exp Rheumatol.
dyloarthritis in clinical ­ practice. Ann Rheum n.d.;36:785–90.
Dis. 2015;74:1327–39. https://doi.org/10.1136/ Tom S, Zhong Y, Cook R, Aydin SZ, Kaeley G, Eder
annrheumdis-­2014-­206971. L. Development of a preliminary ultrasonographic
Martínez-Vidal MP, Fernández-Carballido C. Is the enthesitis score in psoriatic arthritis – GRAPPA ultra-
SCORE chart underestimating the real cardiovas- sound working group. J Rheumatol. 2019;46:384–90.
cular (CV) risk of patients with psoriatic arthritis? https://doi.org/10.3899/jrheum.171465.
Prevalence of subclinical CV disease detected by Zabotti A, Piga M, Canzoni M, Sakellariou G, Iagnocco A,
carotid ultrasound. Joint Bone Spine. 2018;85:327– Scirè CA, et al. Ultrasonography in psoriatic arthritis:
32. https://doi.org/10.1016/j.jbspin.2017.07.002. Which sites should we scan? Ann Rheum Dis. 2018;77
Tinazzi I, McGonagle D, Aydin SZ, Chessa D, Marchetta https://doi.org/10.1136/annrheumdis-­2018-­213025.
A, Macchioni P. “Deep Koebner” phenomenon of Zabotti A, Salvin S, Quartuccio L, De Vita
the flexor tendon-associated accessory pulleys as a S. Differentiation between early rheumatoid and early
novel factor in tenosynovitis and dactylitis in psoriatic psoriatic arthritis by the ultrasonographic study of the
arthritis. Ann Rheum Dis. 2018;77:922–5. https://doi. synovio-entheseal complex of the small joints of the
org/10.1136/annrheumdis-­2017-­212681. hands. Clin Exp Rheumatol. 2016;34:459–65.
 Crystal-Related Arthropathies
10
Marina Carotti, Emilio Filippucci , Fausto Salaffi,
and Fabio Martino

Contents
10.1 Introduction  101
10.2  out 
G 102
10.2.1 U ltrasound Findings at Joint Level  102
10.2.2 Ultrasound Findings at Tendon, Bursa, and Subcutaneous Level  104
10.2.3 Scanning Protocol  105
10.2.4 Disease Monitoring  105
10.3  yrophosphate Arthropathy 
P 105
10.3.1 U ltrasound Findings at Joint Level  106
10.3.2 Ultrasound Findings at Tendon and Periarticular Level  107
10.4 Basic Calcium Phosphate Crystal Deposition Disease  108
Further Readings  109

10.1 Introduction (CPP) crystals, responsible for calcium pyro-

phosphate deposition disease (CPPD); and basic
Crystal-related arthropathies are diseases charac- calcium phosphate crystals.
terized by crystal deposition at articular and peri- In recent years, several articles have shown
articular level. There are three main types of that ultrasound (US) is an accurate imaging tech-
crystals: monosodium urate (MSU) crystals, nique to detect crystal deposits, and in experi-
responsible for the gout; calcium pyrophosphate enced hands, US may change the standard
diagnostic approach in patients with suspicion of
M. Carotti crystal-related arthropathies.
Clinica di Radiologia, Dipartimento di Scienze Either the MSU or the CCP crystal deposits are
Radiologiche – Azienda Ospedali Riuniti di Ancona characterized by a high reflectivity of the US beam,
Universita’ Politecnica delle Marche, Ancona, Italy
independently of the angle of insonation. The US
E. Filippucci · F. Salaffi appearance of crystal deposits is heterogeneous in
Clinica Reumatologica, Dipartimento di Scienze
Cliniche e Molecolari, Università Politecnica delle size (from millimetric spots to large aggregates),
Marche, Jesi (Ancona), Italy shape (rounded or poorly defined), and echostruc-
F. Martino (*) ture (homogeneous or heterogeneous). Although
Radiology, Sant’Agata Diagnostic Center, CPP crystals can sometimes be undistinguishable
Bari, Italy from those of MSU, the identification of US pat-
© Springer Nature Switzerland AG 2022 101
F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_10
102 M. Carotti et al.

terns defined by the topographic distribution of normal especially in the early disease. Early radio-
crystal deposits at different tissues has been shown logical findings are limited at soft tissue level and
to be accurate in distinguishing MSU from CPP mainly restricted to asymmetric swelling in the
crystal deposits. In fact, the value of each US find- joints with tophaceous deposits. In later phases of
ing depends mainly on its characteristics and its the disease, gout may determine intra-­articular and
topographic distribution in the different tissues extra-articular bone erosions. Typically, bone ero-
(e.g., hyperechoic spots within the hyaline cartilage sions in gout are well-defined, “punched-out,”
are indicative of CPPD, whereas an enhancement of periarticular erosions with overhanging edges,
the chondrosynovial interface is indicative of gout). often located next to a tophus. Joint involvement is
These differences account for a large spectrum usually asymmetric and joint space is relatively
of US features and this wide heterogeneity gener- preserved until late stage. Thus, the CR findings
ates many different scenarios not only in different suggestive of gout are absence of juxta-articular
patients but also in the same subject. Such a high osteoporosis and of joint space narrowing, sharply
variety has prompted the development of a stan- marginated erosions with sclerotic borders and
dardization for the definition of each single US overhanging edges, and asymmetric distribution of
finding as reported later in this chapter. the joint. Despite highly characteristic of gout
The diagnostic potential of US in the diagno- these CR findings are indicative of structural dam-
sis of crystal-related arthropathies depends on the age and CR may underestimate the extent of MSU
high- resolution power (<0.1 mm) at superficial crystal deposition.
tissues (targets not deeper than 1 cm), the possi-
bility to carry out a multisite and multitissue
examination, and the capability of real-time 10.2.1 U
 ltrasound Findings at Joint
imaging providing a safe guidance for the aspira- Level
tion of even minimal synovial fluid collections in
order to obtain a definite diagnosis. US findings in gout include joint effusion, syno-
Unlike polarized light microscopy, US assess- vitis, bone erosions, and MSU deposits at joint
ment does not need the presence of synovial fluid and periarticular soft tissue level.
or tophi to identify crystal deposits. Thus, US can Acute gouty arthritis is typically characterized
be performed during intercritical phases to obtain by a joint space widening due to the presence of
information useful to reach a definite diagnosis. variable amount of synovial fluid. In some
patients a “snowstorm” appearance can be seen,
when hyperechoic spots can be identified floating
10.2 Gout in the synovial fluid (Fig. 10.1).
Synovitis in gout appears as a heterogeneous,
Gout occurs when body tissues become super- but predominantly hyperechoic intra-articular tis-
saturated with urate, leading to the formation of sues because of MSU deposits. The presence of
MSU crystals in and around joints. The tradi- hyper-reflective spots of MSU deposits may be
tional clinical features of gout include acute pain- helpful to further differentiate gout from other
ful synovitis, tophaceous deposits, chronic joint inflammatory arthritis such as rheumatoid arthritis.
damage, renal stones, and chronic kidney dis- Bone erosions are seen in long-standing gouty
ease. Gout leads to impaired quality of life and it arthropathy. Bone erosions are defined as an
is associated with a variety of cardiovascular and intra- and/or extra-articular discontinuity of the
metabolic comorbidities. bone surface, visible in at least two perpendicular
Gout is mainly diagnosed by identification of planes. Bone erosions are usually located next to
the pathognomonic MSU crystals by synovial tophi, due to the osteoclastogenic activity of
fluid analysis or by clinical evidence of tophi. MSU deposits. The overhanging edges of bone
The assessment of joint damage in gout tradi- erosions and the presence of hyperechoic depos-
tionally relied on conventional radiography (CR). its filling the bone cavity are characteristic
However, CR has been shown to be frequently ­features of gout. Moreover, bone erosions in gout
10 Crystal-Related Arthropathies 103

cific sign for the diagnosis of gout (i.e., more

than 90%), it is not very sensitive (i.e., between
60% and 80%). The reported sensitivity of the
double-contour sign is highly variable mainly
according to the number of scanned anatomic
sites, the width of the cartilage surface explor-
able by US, and the disease duration. Special
care should be paid avoiding to misinterpret
the normal cartilage interface as double-­
contour sign. Normal cartilage surface is
hyperechoic only when it is insonated perpen-
dicularly or in the presence of overlying fluid.
Double-contour sign does not disappear
Fig. 10.1 Gout. Popliteal cyst. Snowstorm appearance of where the cartilage curves away from the hori-
the synovial fluid, characterized by multiple hyperechoic zontal plane, and where the US beam is not
spots with different shape and size. The probe compres- perpendicular to the cartilage. For example,
sion during real-time examination shows their floating in
the synovial fluid the presence of synovial effusion in the first
metatarsophalangeal joint can enhance the
visualization of the outer margin of the hya-
line cartilage. In such cases, the dislocation of
the synovial fluid applying a gentle probe
compression can help in the correct interpreta-
tion of this finding. Finally, the double-­contour
sign should be differentiated from intracarti-
laginous hyperechoic spots, seen in CPPD.
• Tophi: [independent of location (e.g., extra-­
articular/intra-articular/intra-tendinous)]: “A
circumscribed, inhomogeneous, hyperechoic,
Fig. 10.2 Gout. Tibiotalar joint on longitudinal anterior and/or hypoechoic aggregation (which may or
scan showing double-contour sign due to urate deposits may not generate posterior acoustic shadow)
on the surface of the talar hyaline cartilage. Note the
enhancement of the chondrosynovial interface (arrow- which may be surrounded by a subtle ‘anechoic
heads). ti tibia; ta talus halo’” (Fig. 10.3). Tophaceous deposits may
show a different degree of reflectivity according

can be either intra- or extra-articular and tend to

be deep and destructive.
According to OMERACT definitions MSU
deposits can be defined as:

• Double-contour sign: “Abnormal hyper-

echoic band over the superficial profile of the
joint hyaline cartilage, independent of the
angle of insonation and which may be either
irregular or regular, continuous or intermittent
and can be distinguished from the cartilage
interface sign” (Fig. 10.2). The deposits are Fig. 10.3 Tophaceous gout. Achilles tendon insertion
into the calcaneal bone on longitudinal scan showing a
found on the outer layer of the hyaline carti-
peri-tendinous tophus appearing as an oval shaped area.
lage and appear as an irregular enhancement The arrow indicates a retrocalcaneal spur. Ac Achilles ten-
of the cartilage surface. Although this is a spe- don; ca calcaneal bone
104 M. Carotti et al.

Fig. 10.5 Olecranon bursitis in patient with tophaceous

gout. The longitudinal view shows bursal enlargement due
to anechoic synovial fluid (*) in-between echogenic
branches of synovial hypertrophy. Tophus is made of
inhomogeneous echogenic aggregate deposits with
rounded edges (arrowheads). u ulna, olecranon process; t
Fig. 10.4 Gout. (a) Tibialis posterior tendon on trans- triceps tendon
verse scan at tibial malleolus level. The arrow indicates an
intra-tendinous urate deposit. (b) Note the reduction of
the tendon echogenicity induced by the change of the
probe inclination; conversely the crystal deposit did not 10.2.2 Ultrasound Findings
decrease its echogenicity. tp tibialis posterior tendon; ti at Tendon, Bursa,
tibia and Subcutaneous Level

to the density of the deposits. These vary from US is able to clearly depict tophaceous deposits in
soft tophi, with an inhomogeneous echogenicity bursae, tendons, and subcutaneous tissues. The
and polymorphic appearance, to hard tophi olecranon bursa is the commonly involved site in
characterized by dense and compact aggregates gout. US features of an acute gouty bursitis are sub-
of MSU crystals that generate a hyperechoic stantially similar to those of acute arthritis. The high
band and a posterior acoustic shadow. sensitivity of US in the detection of even a minimal
• Aggregates [independent of location (intra-­ amount of synovial fluid allows easy identification
articular/intra-tendinous)]: “Heterogeneous of inflammation even in case of small bursae (i.e.,
hyperechoic foci that maintain their high degree retrocalcaneal bursa and olecranon bursa) (Fig. 10.5)
of reflectivity even when the gain setting is or deep ones (i.e., iliopsoas bursa).
minimized or the insonation angle is changed Deposition of MSU crystals may also involve
and which occasionally may generate posterior both sliding and supporting tendons. MSU depos-
acoustic shadow” (Fig. 10.4). Aggregates are its can be found both at intra- and peri-tendinous
the least defined form of MSU deposits. The level. Knowledge of the most frequently involved
appearance of aggregates can vary consider- tendons can also be helpful in the diagnosis of
ably ranging from the smallest form of aggre- gout. The Achilles and peroneal tendons are com-
gates, the “isolated shining dots,” described as mon sites of involvement at ankle level, whereas
submillimeter homogenous hyperechoic punc- the popliteus and the patellar tendons are com-
tiform spots, to dense microdotted deposits mon locations at knee level. Moreover, the tri-
inside the joint cavity with or without small or ceps tendon has been indicated as frequently
large hyperechoic spots. involved tendon in the upper limb.
10 Crystal-Related Arthropathies 105

The identification of MSU crystals within ten- A correct position of the joint to be examined
dons is easy because in the background of the is essential to ensure the best exposure of the car-
typical fibrillar echotexture of the tendon, they tilaginous structure. For instance, the maximal
appear as inhomogeneous spots or bands derang- flexion of the knee joint allows the perpendicular
ing the tendon echostructure. Extensive and/or insonation of the femoral trochlea hyaline carti-
multiple crystal clouds have a variable and inho- lage using suprapatellar axial views.
mogeneous echotexture with aggregates of dif-
ferent reflectivity, mainly related to crystal
density. Tendon deposits maintain their high 10.2.4 Disease Monitoring
degree of reflectivity, even when the gain value is
reduced and the tendon is not perpendicularly With appropriate and effective treatment, primar-
insonated. Finally, the main findings indicating ily involving urate-lowering drugs, MSU depos-
acute gouty tendinopathy include hypoechoic its may reduce in size and completely resolve.
thickening and intra-tendinous Doppler signal Thus, the efficacy of urate-lowering therapy can
which may be found in between and outside the be monitored by US by the disappearance of
MSU deposits. MSU crystal deposits. However, to date, despite
the great potential of US, there are only few stud-
ies supporting the ability of US to monitor
10.2.3 Scanning Protocol changes induced by urate-lowering therapy. Still
unresolved issues are the lack of standardization
Even if US allows for rapid, safe, and easy multi- of monitoring parameters (i.e., tophus largest
site and multitissue evaluation, in daily practice diameter or volume), the identification of the best
the sonographic examination should be guided MSU deposit to be followed up (double-contour
by patient history and physical examination. sign or tophus), and the different speed of disso-
Nevertheless, US can reveal the presence of lution process at different anatomical areas.
crystal deposits in asymptomatic sites without
previous involvement. Thus, in gouty patients,
the first MTP joint, the elbow, the patellar, and 10.3 Pyrophosphate Arthropathy
the Achilles tendons could be considered sites to
scan even if not clinically involved. Recently a Calcium pyrophosphate deposition disease
dedicated US protocol was developed. The (CPPD) is characterized by the deposition of cal-
assessment of radio-carpal joint, patellar tendon, cium pyrophosphate (CPP) crystals in and around
and triceps tendon for the presence of hyper- the joints. Although the main target of CPPD is
echoic aggregates, and of the articular cartilage the cartilaginous structure, both fibrocartilage and
of the first metatarsophalangeal, tibiotalar, and hyaline cartilage, CPP crystal deposits may occur
knee joints for double-contour sign, showed the also at tendon, joint capsule, and ligament level.
best balance between sensitivity and specificity CPPD occurs mainly in the elderly, although a
(84.6% and 83.3%) in patients with gout. mono-oligo articular form of young-­onset CPPD
MSU crystal deposits were documented also (<55 years old) may happen at sites of prior joint
in subjects with asymptomatic hyperuricemia. In injury and osteoarthritis (OA), whereas a polyar-
asymptomatic hyperuricemia, scanning of the ticular form may be due to genetic or metabolic
first metatarsophalangeal joint and knee femoral disorders. CPPD is frequently asymptomatic and
condyles for double contour and the first metatar- it is usually an incidental finding of chondrocalci-
sophalangeal joint for tophus has the highest dis- nosis on imaging studies. In a minority of patients,
criminative power in comparison with CPPD can cause an acute CPP-crystal arthritis or
normouricemic subjects. a chronic CPP-crystal inflammatory arthritis or
106 M. Carotti et al.

may be associated with a form of OA with chon-

drocalcinosis. CPPD can occur in any synovial or
fibrocartilaginous joint; however, knee, wrist,
symphysis pubis, hip, and shoulder are the most
frequent targets.
The “definite” diagnosis of CPPD is based on
the identification of CPP crystals in the synovial
fluid. However, during intercritical phases, a
“probable” diagnosis of CPPD is generally estab-
lished on the typical CR findings displaying car-
tilage calcification and structural changes typical
of OA.
Although CR is traditionally considered as the
reference imaging modality in daily practice,
other imaging techniques such as US and com-
puted tomography (CT) can be used to identify
CPP crystal deposits. Of these, US is more com- Fig. 10.6 Calcium pyrophosphate deposition disease. (a)
monly used because it is inexpensive, safe, and Knee. Medial longitudinal scan showing meniscal calcifi-
well accepted by patients, but it requires experi- cation (arrowhead). (b) Wrist. longitudinal scan on the
enced operators. On the other hand, CT may be ulnar side showing calcification of the triangular fibrocar-
tilage complex (arrowheads). fe medial femoral condyle;
particularly useful in demonstrating axial CPPD, ti medial tibia; tr triquetral bone; u ulna
such as in the crowned dens syndrome.
In recent years, a growing body of evidence
has shown that US is more sensitive than CR in create posterior shadowing, localized within
the detection of CPP crystal deposits at knee and the hyaline cartilage and that remain fixed and
wrist level. move together with the hyaline cartilage dur-
ing the joint movement (Fig. 10.7).
• Synovial fluid calcifications: deposits of vari-
10.3.1 U
 ltrasound Findings at Joint able size (from punctuate to large), hyper-
Level echoic (similar to the bone cortex
echogenicity), that generally do not create
CPP crystals appear as hyperechoic dots which posterior shadowing, localized within the
may be isolated or aggregated, typically without synovial fluid and mobile according to joint
acoustic shadowing and usually located within movement and probe pressure.
the cartilaginous structures. According to
OMERACT definitions CPP crystal deposits can In healthy subjects, the hyaline cartilage
be defined as follows: appears as an anechoic layer having two sharp,
continuous, and regular hyperechoic margins (of
• Fibrocartilaginous calcifications: deposits note the outer chondrosynovial interface is
of variable shape, hyperechoic (similar to the detectable only where the US beam is perpen-
bone cortex echogenicity), localized within dicular to the cartilage surface), whereas the
the fibrocartilage structure, that remain fixed fibrocartilage shows a mild and homogeneous
and move together with the fibrocartilage dur- punctate echogenicity. Fibrocartilaginous calcifi-
ing dynamic assessment (i.e., joint movement cations detectable on US in CPPD can show
and probe compression) (Fig. 10.6). widely variable appearance, depending on the
• Hyaline cartilage calcifications: deposits of size, distribution, and density of crystal aggre-
variable size and shape, hyperechoic (similar gates, ranging from isolated hyperechoic dots to
to the bone cortex echogenicity) that do not large and heterogeneous aggregates.
10 Crystal-Related Arthropathies 107

a a

b
b

Fig. 10.8 Calcium pyrophosphate deposition disease. (a)

Medial aspect of the knee on longitudinal scan showing
meniscal calcifications (arrowheads). (b) Same view after
reducing the gain value; note the disappearance of the
meniscus while calcifications are still detectable. fe
Fig. 10.7 Calcium pyrophosphate deposition disease. (a) medial femoral condyle; ti tibia
Medial femoral condyle of the knee on longitudinal
parapatellar scan (a) and longitudinal anterior radial scan
of the elbow (b) showing hyperechoic deposits (arrow-
synovial fluid, and intra-articular air bubbles.
heads) not generating acoustic shadowing within the hya-
line cartilage layer. fe medial femoral condyle; ra radius; Characteristically the CPP crystal deposits main-
hu humerus tain their hyperechogenicity despite changing the
insonation angle and reducing the gain level
In the hyaline cartilage, the intracartilaginous (Fig. 10.8).
distribution of the crystal deposits differs from The dynamic assessment can help in discrimi-
that of the MSU deposits, which are on the carti- nating the exact position of the deposits. It is par-
lage surface. ticularly useful in the assessment of the knee
Fibrocartilage is the most frequent anatomical menisci to distinguish whether the crystals are on
target of CPPD disease. Meniscal calcification the condylar hyaline cartilage or within the
was reported as highly prevalent in patients with meniscal fibrocartilage and in the evaluation of
CPPD disease, being identified in more than 75% hyaline cartilage to differentiate between carti-
of cases. laginous calcification and capsular calcification.
Although a multisite scanning protocol in
CPPD patients was not already described, the
hyaline cartilage of femoral condyles, humeral 10.3.2 Ultrasound Findings
head, humeral trochlea and capitellum, the talus at Tendon and Periarticular
and the metacarpal heads and the fibrocartilage Level
of menisci, triangular fibrocartilage complex and
acromioclavicular joint could be considered sites Calcifications in tendons are also typical imaging
to scan even if not clinically involved. features of CPPD. CPP crystal deposits appear as
CPP crystal deposits are usually easy to detect, hyperechoic bands and spots, generally, without
by their characteristic appearance. However, they posterior acoustic shadow and often distributed
must be distinguished from other “shining dots” along the major axis of the tendon. According to
such as the MSU aggregates, osteoarthritic debris OMERACT definition, tendon calcifications are
and proteinaceous material floating within the multiple hyperechoic (in relation to the tendon
108 M. Carotti et al.

echogenicity) and linear deposits (parallel to the 10.4  asic Calcium Phosphate
B
tendon fibrillar structure and not in continuity Crystal Deposition Disease
with the bone profile) that generally will not cre-
ate posterior shadowing, localized within the ten- Basic calcium phosphate (BCP) crystal-related
don, and that remain fixed and move together musculoskeletal pathology can be divided into
with the tendon during movement and probe two main conditions, osteoarthritis secondary to
compression (Fig. 10.9). Achilles tendon and intra-articular BCP crystals and calcific periar-
plantar fascia are frequently involved in patients thritis due to BCP crystal deposition in tendons,
with CPPD. The identification of crystals is easy bursae, and other soft tissues around joints.
when they are located within tissues showing The term “hydroxyapatite” is often used as a
anisotropy, such as the tendons. In these cases, synonymous of “basic calcium phosphate,” with
changing the probe inclination allows the carbonated hydroxyapatite being the most preva-
enhancement of the crystals, which maintain lent mineral type in BCP crystal-related
their brightness while the surrounding tendon arthropathy.
fibers reduce their echogenicity. Calcific periarthritis is the main BCP-related
condition. Calcium deposits are easily detected by
US because of their high reflectivity. Differently
to calcium pyrophosphate (CPP) crystals, BCP
crystals usually generate a posterior acoustic
shadow (Fig. 10.10a). However, as in other crys-
tal-related arthropathies, BCP crystal deposits
may have different degrees of compaction of the
crystalline aggregates. Moreover, their size,
shape, and location can vary significantly.
Shoulder results the most frequently affected ana-
Fig. 10.9 Calcium pyrophosphate deposition disease. tomic site and ultrasound (US) examination
Achilles tendon insertion into the calcaneal bone on longi- allows for an accurate assessment of inflamma-
tudinal scan showing an intra-tendinous linear deposit tory and structural changes at shoulder level.
appearing as a hyperechoic band (arrowheads) not
attached to the bone and without posterior acoustic shad- Among inflammatory findings, tenosynovitis
owing. Ac Achilles tendon; ca calcaneal bone of the long head of the biceps tendon, subacromial-­

Fig. 10.10 (a) Calcific tendinopathy of the supraspinatus novitis of the long head of the biceps tendon. h humerus;
tendon and subdeltoid bursitis (*). (b) Transverse view at a acromion
the bicipital groove shows subdeltoid bursitis and tenosy-
10 Crystal-Related Arthropathies 109

subdeltoid bursitis, and rotator cuff tendonitis are Cipolletta E, Filippou G, Scirè CA, et al. The diagnostic
value of conventional radiography and musculoskeletal
the most frequent (Fig. 10.10b). In tenosynovitis ultrasonography in calcium pyrophosphate deposition
of the long head of the biceps tendon, the most disease: a systematic literature review and meta-anal-
characteristic US finding is distension of the ten- ysis. Osteoarthritis Cartilage. 2021;29(5):619–32.
don sheath. Subacromial-deltoid bursitis appears https://doi.org/10.1016/j.joca.2021.01.007.
Cipolletta E, Smerilli G, Mashadi Mirza R, et al.
as an anechoic or hyperechoic, generally con- Sonographic assessment of calcium pyrophosphate
spicuous, fluid collection that separates the bursal deposition disease at wrist. A focus on the dorsal scapho-
walls. lunate ligament. Joint Bone Spine. 2020;87(6):611–7.
In lesions of the rotator cuff, US allows the https://doi.org/10.1016/j.jbspin.2020.04.012.
Delle Sedie A, Riente L, Iagnocco A, Filippucci E,
identification of a wide range of structural Meenagh G, Grassi W, et al. Imaging Ultrasound
changes: partial or complete tendon tear, supra- imaging for the rheumatologist X. Ultrasound imaging
and/or infraspinatus tendon thinning, and BCP in crystal-related arthropathies. Clin Exp Rheumatol.
crystal deposits. Single or multiple calcifications 2007;25:513–7.
Di Matteo A, Filippucci E, Salaffi F, Carotti M, Carboni
can often be observed also in clinically asymp- D, Di Donato E, et al. Diagnostic accuracy of mus-
tomatic patients. culoskeletal ultrasound and conventional radiography
All patients with acute “painful shoulder” in the assessment of the wrist triangular fibrocartilage
must be examined using a comprehensive and complex in patients with definite diagnosis of calcium
pyrophosphate dihydrate deposition disease. Clin Exp
standardized scanning protocol, given the possi- Rheumatol. 2017;35:647–52.
bility that there may be more than one pathologic Di Matteo A, Filippucci E, Cipolletta E, Ausili M, Martire
condition within the same patient. V, Di Carlo M, et al. The popliteal groove region: a
Finally, apart from reliably assessing calcific new target for the detection of monosodium urate crys-
tal deposits in patients with gout. An ultrasound study.
tendonitis, US allows for a real-time guidance of Joint Bone Spine. 2018; https://doi.org/10.1016/j.
needle percutaneous treatment. jbspin.2018.06.008.
Di Matteo A, Filippucci E, Cipolletta E, Musca A,
Carotti M, Mashadi Mirza R, et al. Hip involvement
in patients with calcium pyrophosphate deposition
Further Readings disease: potential and limits of musculoskeletal ultra-
sound. Arthritis Care Res (Hoboken). 2018; https://
Barskova VG, Kudaeva FM, Bozhieva LA, Smirnov AV, doi.org/10.1002/acr.23814.
Volkov AV, Nasonov EL. Comparison of three imag- Ellabban AS, Kamel SR, Omar HAA, El-Sherif AM,
ing techniques in diagnosis of chondrocalcinosis of Abdel-Magied RA. Ultrasonographic findings of
the knees in calcium pyrophosphate deposition dis- Achilles tendon and plantar fascia in patients with
ease. Rheumatology. 2013;52:1090–4. calcium pyrophosphate deposition disease. Clin
Chianca V, Albano D, Messina C, Midiri F, Mauri G, Rheumatol. 2012;31:697–704.
Aliprandi A, Catapano M, Pescatori LC, Monaco Filippou G, Scanu A, Adinolfi A, et al. Criterion valid-
CG, Gitto S, Pisani Mainini A, Corazza A, Rapisarda ity of ultrasound in the identification of calcium pyro-
S, Pozzi G, Barile A, Masciocchi C, Sconfienza phosphate crystal deposits at the knee: an OMERACT
LM. Rotator cuff calcific tendinopathy: from diagno- ultrasound study. Ann Rheum Dis. 2021;80(2):261–7.
sis to treatment. Acta Biomed. 2018;89(1-S):186–96. https://doi.org/10.1136/annrheumdis-2020-217998.
Chowalloor PV, Keen HI. A systematic review of ultraso- Filippou G, Filippucci E, Tardella M, Bertoldi I, Di Carlo
nography in gout and asymptomatic hyperuricaemia. M, Adinolfi A, et al. Extent and distribution of CPP
Ann Rheum Dis. 2013;72:638–45. deposits in patients affected by calcium pyrophosphate
Cipolletta E, Di Matteo A, Smerilli G, et al. Ultrasound dihydrate deposition disease: an ultrasonographic
findings of calcium pyrophosphate deposition dis- study. Ann Rheum Dis. 2013;72:1836–9.
ease at metacarpophalangeal joints [published online Filippou G, Adinolfi A, Cimmino MA, Scirè CA, Carta S,
ahead of print, 2022 Feb 1]. Rheumatology (Oxford). Lorenzini S, et al. Diagnostic accuracy of ultrasound,
2022;keac063. https://doi.org/10.1093/rheumatology/ conventional radiography and synovial fluid analy-
keac063. sis in the diagnosis of calcium pyrophosphate dihy-
Cipolletta E, Di Battista J, Di Carlo M, et al. Sonographic drate crystal deposition disease. Clin Exp Rheumatol.
estimation of monosodium urate burden predicts the 2016;34:254–60.
fulfillment of the 2016 remission criteria for gout: a Filippou G, Scirè CA, Damjanov N, Adinolfi A, Carrara
12-month study. Arthritis Res Ther. 2021;23(1):185. G, Picerno V, et al. Definition and reliability assess-
Published 2021 Jul 9. https://doi.org/10.1186/ ment of elementary ultrasonographic findings in
s13075-021-02568-x. calcium pyrophosphate deposition disease: a study
110 M. Carotti et al.

by the OMERACT calcium pyrophosphate deposi- Louwerens JKG, Sierevelt IN, Kramer ET, Boonstra R, van
tion disease ultrasound subtask force. J Rheumatol. den Bekerom MPJ, van Royen BJ, Eygendaal D, van
2017;44:1744–9. Noort A. Comparing ultrasound-guided needling com-
Filippou G, Scirè CA, Adinolfi A, Damjanov NS, Carrara bined with a subacromial corticosteroid injection versus
G, Bruyn GAW, et al. Identification of calcium high-energy extracorporeal shockwave therapy for cal-
pyrophosphate deposition disease (CPPD) by ultra- cific tendinitis of the rotator cuff. A randomized con-
sound: reliability of the OMERACT definitions in an trolled trial. Arthroscopy. 2020;36(7):1823–1833.e1.
extended set of joints—an international multiobserver Naredo E, Uson J, Jiménez-Palop M, Martínez A, Vicente
study by the OMERACT Calcium Pyrophosphate E, Brito E, et al. Ultrasound-detected musculoskeletal
Deposition Disease Ultrasound Su. Ann Rheum Dis. urate crystal deposition: which joints and what find-
2018;77:1194–9. ings should be assessed for diagnosing gout? Ann
Filippucci E, Gutierrez M, Georgescu D, Salaffi F, Rheum Dis. 2014;73:1522–8.
Grassi W. Hyaline cartilage involvement in patients Ogdie A, Taylor WJ, Neogi T, Fransen J, Jansen TL,
with gout and calcium pyrophosphate deposition Schumacher HR, et al. Performance of ultrasound
disease. An ultrasound study. Osteoarthr Cartil. in the diagnosis of gout in a multicenter study: com-
2009;17:178–81. parison with monosodium urate monohydrate crystal
Filippucci E, Scirè CA, Delle Sedie A, Iagnocco A, Riente analysis as the gold standard. Arthritis Rheumatol.
L, Meenagh G, et al. Ultrasound imaging for the rheu- 2017;69:429–38.
matologist. XXV Sonographic assessment of the knee Ottaviani S, Juge P-A, Aubrun A, Palazzo E, Dieude
in patients with gout and calcium pyrophosphate P. Sensitivity and reproducibility of ultrasonogra-
deposition disease. Clin Exp Rheumatol. 2010;28:2–5. phy in calcium pyrophosphate crystal deposition in
Filippucci E, Di Geso L, Grassi W. Tips and tricks to knee cartilage: a cross-sectional study. J Rheumatol.
recognize microcrystalline arthritis. Rheumatology. 2015;42:1511–3.
2012;51:vii18–21. Pascual E, Sivera F. Time required for disappearance of
Filippucci E, Delle Sedie A, Riente L, Di Geso L, Carli urate crystals from synovial fluid after successful hyp-
L, Ceccarelli F, Sakellariou G, Iagnocco A, Grassi ouricaemic treatment relates to the duration of gout.
W. Ultrasound imaging for the rheumatologist. Ann Rheum Dis. 2007;66:1056–8.
XLVII. Ultrasound of the shoulder in patients with Peiteado D, De Miguel E, Villalba A, Ordóñez MC,
gout and calcium pyrophosphate deposition disease. Castillo C, Martín-Mola E, et al. Value of a short four-­
Clin Exp Rheumatol. 2013;31(5):659–64. joint ultrasound test for gout diagnosis: a pilot study.
Filippucci E, Di Geso L, Girolimetti R, Grassi Clin Exp Rheumatol. 2012;30:830–7.
W. Ultrasound in crystal-related arthritis. Clin Exp Perez-Ruiz F, Calabozo M, Pijoan JI, Herrero-Beites
Rheumatol. 2014;32:S42–7. AM, Ruibal A. Effect of urate-lowering therapy on
Forien M, Combier A, Gardette A, Palazzo E, Dieudé P, the velocity of size reduction of tophi in chronic gout.
Ottaviani S. Comparison of ultrasonography and radi- Arthritis Rheum. 2002;47:356–60.
ography of the wrist for diagnosis of calcium pyrophos- Perez-Ruiz F, Martin I, Canteli B. Ultrasonographic mea-
phate deposition. Joint Bone Spine. 2018;85:615–8. surement of tophi as an outcome measure for chronic
Frediani B, Filippou G, Falsetti P, Lorenzini S, Baldi F, gout. J Rheumatol. 2007;34:1888–93.
Acciai C, et al. Diagnosis of calcium pyrophosphate Pineda C, Amezcua-Guerra LM, Solano C, Rodriguez-­
dihydrate crystal deposition disease: ultrasonographic Henriquez P, Hernandez-Diaz C, Vargas A, et al.
criteria proposed. Ann Rheum Dis. 2005;64:638–40. Joint and tendon subclinical involvement suggestive
Grassi W, Meenagh G, Pascual E, Filippucci E. “Crystal of gouty arthritis in asymptomatic hyperuricemia:
Clear”—sonographic assessment of gout and calcium an ultrasound controlled study. Arthritis Res Ther.
pyrophosphate deposition disease. Semin Arthritis 2011;13:R4.
Rheum. 2006;36:197–202. Roddy E, Menon A, Hall A, Datta P, Packham
Grassi W, Okano T, Di Geso L, Filippucci E. Imaging in J. Polyarticular sonographic assessment of gout:
rheumatoid arthritis: options, uses and optimization. a hospital-­ based cross-sectional study. Joint Bone
Expert Rev. Clin Immunol. 2015;11:1131–46. Spine. 2013;80:295–300.
Gutierrez M, Di Geso L, Salaffi F, Carotti M, Girolimetti Rosenthal AK. Basic calcium phosphate crystal-­
R, De Angelis R, et al. Ultrasound detection of car- associated musculoskeletal syndromes: an update.
tilage calcification at knee level in calcium pyro- Curr Opin Rheumatol. 2018;30(2):168–72.
phosphate deposition disease. Arthritis Care Res Ruta S, Catay E, Marin J, Rosa J, García-Monaco R,
(Hoboken). 2014;66:69–73. Soriano ER. Knee effusion: ultrasound as a useful tool
Lee KA, Lee SH, Kim HR. Diagnostic value of ultrasound for the detection of calcium pyrophosphate crystals.
in calcium pyrophosphate deposition disease of the Clin Rheumatol. 2016;35:1087–91.
knee joint. Osteoarthr Cartil. 2019;27:781–7. Stewart S, Dalbeth N, Vandal AC, Allen B, Miranda R,
Löffler C, Sattler H, Löffler U, et al. Size matters: obser- Rome K. Ultrasound features of the first metatarso-
vations regarding the sonographic double contour phalangeal joint in gout and asymptomatic hyperuri-
sign in different joint sizes in acute gouty arthritis. Z cemia: comparison with normouricemic individuals.
Rheumatol. 2018;77(9):815–23. Arthritis Care Res. 2017;69:875–83.
10 Crystal-Related Arthropathies 111

Terslev L, Gutierrez M, Christensen R, Balint PV, Bruyn Wright SA, Filippucci E, McVeigh C, Grey A, McCarron
GA, Delle Sedie A, et al. Assessing elementary lesions M, Grassi W, et al. High-resolution ultrasonography
in gout by ultrasound: Results of an OMERACT of the first metatarsal phalangeal joint in gout: a con-
patient-based agreement and reliability exercise. J trolled study. Ann Rheum Dis. 2007;66:859–64.
Rheumatol. 2015;42:2149–54. Zhang T, Duan Y, Chen J, Chen X. Efficacy of ultrasound-­
Thiele RG, Schlesinger N. Ultrasonography shows dis- guided percutaneous lavage for rotator cuff calcific
appearance of monosodium urate crystal deposition tendinopathy: a systematic review and meta-analysis.
on hyaline cartilage after sustained normouricemia is Medicine (Baltimore). 2019;98(21):e15552.
achieved. Rheumatol Int. 2010;30:495–503. Zufferey P, Pascal Z, Valcov R, Fabreguet I, Dumusc A,
Ventura-Ríos L, Sánchez-Bringas G, Pineda C, Omoumi P, et al. A prospective evaluation of ultra-
Hernández-Díaz C, Reginato A, Alva M, et al. Tendon sound as a diagnostic tool in acute microcrystalline
involvement in patients with gout: an ultrasound study arthritis. Arthritis Res Ther. 2015;17:188.
of prevalence. Clin Rheumatol. 2016;35:2039–44.
 Connective Tissue Disorders
11
Marina Carotti, Emilio Filippucci , Fausto Salaffi,
and Fabio Martino

Contents
11.1 Systemic Lupus Erythematosus  113
11.2 Systemic Sclerosis  114
11.3 Salivary Gland Ultrasonography in Sjögren’s Syndrome  114
11.4 Lung Ultrasound in Patients with Connective Tissue Disease  116
Further Readings  117

11.1 Systemic Lupus Erythematosus

Joint involvement was long regarded as a minor

clinical feature in systemic lupus erythematosus
(SLE), although almost all patients refer musculo-
skeletal symptoms (i.e., arthralgias, which are
usually transient and migratory) during the dis-
Fig. 11.1 Systemic lupus erythematosus. Dorsal longitu-
ease course. In a minority of patients, the pres-
dinal scan of a metacarpophalangeal joint showing
ence of an arthritis may be documented (Fig. 11.1). “active” synovitis. mc metacarpal bone; pp proximal
Together with the joint disorders, the spec- phalanx
trum of musculoskeletal disease in SLE also
includes tenosynovitis, tendon rupture, tendon- itis, osteonecrosis, myositis, and fibromyalgia.
Three main forms of SLE arthropathy based on
the evidence and degree of deformities and the
M. Carotti presence/absence of erosive damage were tradi-
Clinica di Radiologia, Dipartimento di Scienze tionally described: nondeforming and nonerosive
Radiologiche – Azienda Ospedali Riuniti di Ancona
Universita’ Politecnica delle Marche, Ancona, Italy arthritis, Jaccoud’s arthropathy, and Rhupus
syndrome.
E. Filippucci · F. Salaffi
Clinica Reumatologica, Dipartimento di Scienze Despite being promising, the use of ultrasound
Cliniche e Molecolari, Università Politecnica delle (US) in the assessment of musculoskeletal mani-
Marche, Jesi (Ancona), Italy festations in patients with SLE is still limited. A
F. Martino (*) wide heterogeneity of US pathologic findings in
Radiology, Sant’Agata Diagnostic Center, Bari, Italy the joints and tendons of patients with SLE was
© Springer Nature Switzerland AG 2022 113
F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_11
114 M. Carotti et al.

reported. Synovial effusion, synovial hypertrophy, 11.3 Salivary Gland

“mixed” synovitis (coexistence of synovial ­effusion Ultrasonography in Sjögren’s
and synovial hypertrophy), joint dislocation, abnor- Syndrome
mal power Doppler signal, bone erosion, and carti-
lage damage were all reported in SLE. Sjögren’s syndrome is a systemic autoimmune
Cartilage damage and bone erosions are more disease primarily characterized by a focal chronic
frequently detected in Rhupus syndrome, while inflammation of glandular parenchyma, with
joint dislocation is more common in Jaccoud’s chronic and persistent involvement of major sali-
arthropathy. Besides the synovial targets, US also vary gland remaining a key element of the dis-
revealed inflammatory changes in non-synovial ease. In the last decade, advances in ultrasound
areas, such as tendons with no synovial sheath technology and practice have resulted in a nonin-
(peritendinous extensor tendon inflammation) vasive method to investigate the major salivary
and their entheses (patellar tendon insertion into gland in different diseases, including Sjögren’s
the anterior tibial tuberosity). syndrome. Several studies published over the
past 20 years reported a sensitivity of 80% and a
specificity of more than 90% for the diagnosis of
11.2 Systemic Sclerosis Sjögren’s syndrome. Salivary gland ultrasonog-
raphy is also of high value for the identification
Very-high-frequency ultrasound (>20 MHz) of patients prone to systemic disease complica-
offers a potential for quantitative assessment of tions, high disease activity, and lymphoma devel-
skin thickness and skin echogenicity in patients opment. The useful combination of US gray scale
with systemic sclerosis. The degree of skin and color/power Doppler technique provides
involvement is a very important outcome mea- more valuable details regarding the presence and
sure in patients with systemic sclerosis. Although the degree of soft tissue blood perfusion and may
US is a promising technique there have been rela- be valuable in narrowing the differential
tively few studies examining the use of dermal diagnosis.
ultrasound in patients with systemic sclerosis. A The main echostructural abnormalities
significant correlation between US findings and detectable on ultrasound are represented by the
Rodnan Skin Score was reported. parenchymal inhomogeneity, hypoanechoic or
US findings in systemic sclerosis include soft hyperechoic areas (due to multiple cysts or cal-
tissue calcification and narrowing of the distance cifications, respectively), increased or reduced
between phalangeal apex and skin surface at the size, irregularity of the margins, and presence
distal phalanx. of peri-intraglandular lymph nodes (Fig. 11.2).
In the musculoskeletal system, US was found As underlined by several authors, the most rel-
more sensitive than clinical examination in the evant sonographic sign in primary Sjögren’s
detection of synovitis and tenosynovitis at hand syndrome is the bilateral parenchymal inhomo-
and foot level, and US synovitis of the hand was geneity which is considered to be the most rel-
found to be associated with higher hand evant anatomical structural change in these
disability. patients, with good agreement between salivary
Finally, color and power Doppler techniques gland scintigraphy, sialography, and minor
may play a valuable role in the assessment of labial salivary gland biopsy. Ultrasound abnor-
blood perfusion, especially of the hand and foot malities are strongly correlated to the histologi-
extremities, and elastography has been described cal changes and the proposed ultrasound
as effective in the assessment of affected tissue scoring system correlates well with sialographic
stiffness. gradings.
11 Connective Tissue Disorders 115

a b

Fig. 11.2 (a) US longitudinal scan of parotid gland in a hypoechogenic areas (with a maximal diameter >6 mm as
pSS patient. The parenchyma is completely heteroge- indicated by calipers), and multiple cysts with echogenic
neous with hypoechogenic areas and echogenic bands due bands, resulting in severe damage to the glandular archi-
to replacement of connective fibrous tissue. The borders tecture, decreased glandular volume, and posterior glan-
of the glands are not well defined. (b) The parenchyma dular border not well visible
shows irregular contour, multiple large confluent

At present, there are several different scoring Table 11.1 Ultrasound grading score proposed by
systems suggested in the literature for the ultra- Salaffi F et al.
sound assessment of major salivary glands in Grade 0 Normal glands
patients with Sjögren’s syndrome. An e­ chographic Grade 1 Regular contour, small hypoechoic spots/
score, ranging from 0 to 16, was obtained from areas, without echogenic bands, regular or
increased glandular volume (mean values
the sum of the scores (0–4) for each parotid and 20 + 3 mm for the parotids and 13 + 2 mm
submandibular gland. The following ultrasound for the submandibular glands), and ill-defined
parameters were recorded: parenchymal homo- posterior glandular border (definite echogenic
geneity, echogenicity, size of the glands, and pos- border with respect to the neighboring
structures)
terior glandular border. Each of these parameters Grade 2 Regular contour, evident multiple scattered
was scored according to the previously described hypoechogenic areas usually of variable size
scoring system (Table 11.1). A sonographic pat- (<2 mm) and not uniformly distributed,
tern was considered abnormal if both parotids or without echogenic bands, regular or increased
glandular volume, and ill-defined posterior
both submandibular glands exhibited a minimum glandular border
score of 1. According to this ultrasound scoring Grade 3 Irregular contour, multiple large
system grade 2 corresponds to a clear parenchy- circumscribed or confluent hypoechogenic
mal inhomogeneity, characterized by multiple areas (2–6 mm) and/or multiple cysts, with
echogenic bands, regular or decreased
scattered hypoechogenic areas of variable size
glandular volume, and no visible posterior
(<2 mm) and not uniformly distributed. Setting glandular border
the cutoff ultrasound score >6 resulted in the best Grade 4 Irregular contour, multiple large
ratio of sensitivity (75.3%) to specificity (83.5%), circumscribed or confluent hypoechogenic
with a likelihood ratio of 4.58. areas (>6 mm), and/or multiple cysts or
multiple calcifications, with echogenic bands,
Vitali C et al. suggested to include ultrasound resulting in severe damage to the glandular
as a complementary diagnostic tool in the architecture, decreased glandular volume,
American–European Consensus Group classifi- and posterior glandular border not visible.
116 M. Carotti et al.

cation criteria for primary Sjögren’s syndrome. increased in patients with rheumatoid arthritis
Ultrasound contributes significantly to the per- (RA) and systemic lupus erythematosus, and in
formance of the criteria, because it is more widely diffuse and limited systemic sclerosis lung
available and cheaper than both sialography, involvement is the leading cause of death.
which is an invasive and obsolete imaging proce- Therefore, patients with CTD-ILD require
dure for major salivary gland investigation, and aggressive and personalized treatment.
salivary scintigraphy, which has low specificity The role of pulmonary ultrasound in the evalu-
and limited availability and involves radiation ation of a variety of lung conditions has been
exposure. However, for early detection of widely reported in the literature. Recently, lung
Sjögren’s syndrome, however, and probably for ultrasound validity in the evaluation of CTD-ILD
follow-up monitoring within clinical trials and of has been investigated using high-resolution com-
lymphoma development, more advanced and puted tomography (HRCT) as the contemporary
elaborate scoring systems, including color/power “gold standard.” In fact, HRCT provides a
Doppler assessments of vascularity, will be detailed morphological representation of even
necessary. minimal lung involvement, even in patients with-
out any alteration of lung volumes and the diffu-
sion capacity of carbon monoxide. However,
11.4  ung Ultrasound in Patients
L HRCT carries the risk of radiation exposure.
with Connective Tissue Sonographic signs (Fig. 11.3) such as B-lines and
Disease pleural irregularities are suitable screening tools
for the presence of ILD. B-lines consist of arti-
Interstitial lung disease (ILD) is a frequent mani- facts appearing as hyperechoic comet tails gener-
festation of lung involvement in patients with ated by the reflection of the US beam from
systemic autoimmune disease. ILD mortality is thickened subpleural interlobar septa. B-lines are

a b

Fig. 11.3 Ultrasound (US) evaluation of a patient with scanning performed with a 2–7 MHz broadband convex
interstitial lung disease and systemic sclerosis, showing transducer; (b) US scanning performed with a 4–13 MHz
pleural irregularities and B-lines at the level of the eighth broadband linear transducer
intercostal space on the right subscapular line. (a) US
11 Connective Tissue Disorders 117

a reliable instrument for assessing diffuse paren- Ferro F, Delle Sedie A. The use of ultrasound for assess-
ing interstitial lung involvement in connective tis-
chymal lung disease, because their presence and sue diseases. Clin Exp Rheumatol. 2018;36 Suppl
number correlate with the HRCT extension of 114(5):165–70.
ILD, although the mechanisms for generating Gabba A, Piga M, Vacca A, Porru G, Garau P, Cauli A,
B-lines are not yet clear. A recent meta-analysis Mathieu A. Joint and tendon involvement in systemic
lupus erythematosus: an ultrasound study of hands
of published studies and a review of the literature and wrists in 108 patients. Rheumatology (Oxford).
revealed that lung ultrasound has high diagnostic 2012;51(12):2278–85.
accuracy, correlates well with HRCT results, and Gargani L, Doveri M, D'Errico L, Frassi F, Bazzichi
could be considered as the first lung imaging ML, Delle Sedie A, Scali MC, Monti S, Mondillo S,
Bombardieri S, Caramella D, Picano E. Ultrasound
technique in subjects with suspected CTD-­ lung comets in systemic sclerosis: a chest sonog-
ILD. Therefore, in order to validate the use of raphy hallmark of pulmonary interstitial fibrosis.
lung ultrasound as a management tool for ILD in Rheumatology. 2009;48:1382–7.
patients with rheumatic diseases, an OMERACT-­ Gutierrez M, Gomez-Quiroz LE, Clavijo-Cornejo
D, Lozada CA, Lozada-Navarro AC, Labra RU,
LUS Sub-Task Force provided an overview of the Fernandez-Torres J, Sanchez-Bringas G, Salaffi F,
potential role of lung ultrasound in the evaluation Bertolazzi C, Pineda C. Ultrasound in the interstitial
of ILD in patients with systemic sclerosis based pulmonary fibrosis. Can it facilitate a best routine
on a review of the systemic literature. Current assessment in rheumatic disorders? Clin Rheumatol.
2016;35(10):2387–95.
evidence and validation status are discussed, sup- Gutierrez M, Soto-Fajardo C, Pineda C, Alfaro-Rodriguez
porting their clinical relevance and usefulness in A, Terslev L, Bruyn GA, Iagnocco A, Bertolazzi C,
daily clinical practice. Lung ultrasound passed D'Agostino MA, Delle Sedie A. Ultrasound in the
the filter of face, content validity, and feasibility. assessment of interstitial lung disease in systemic
sclerosis. A systematic literature review by the
However, there is no evidence to support the cri- OMERACT Ultrasound Group. J Rheumatol. 2019;
terion validity, reliability, and sensitivity to https://doi.org/10.3899/jrheum.180940.
change. Han N, Tian X. Detection of subclinical synovial hyper-
trophy by musculoskeletal gray-scale/power Doppler
ultrasonography in systemic lupus erythematosus
patients: a cross-sectional study. Int J Rheum Dis.
Further Readings 2019;22(6):1058–69.
Hubac J, Gilson M, Gaudin P, Clay M, Imbert B,
Cannaò PM, Vinci V, Caviggioli F, Klinger M, Orlandi Carpentier P. Ultrasound prevalence of wrist, hand,
D, Sardanelli F, Serafini G, Sconfienza LM. Technical ankle and foot synovitis and tenosynovitis in systemic
feasibility of real-time elastography to assess the peri-­ sclerosis, and relationship with disease features and
oral region in patients affected by systemic sclerosis. J hand disability. Joint Bone Spine. 2020; https://doi.
Ultrasound. 2014;17(4):265–9. org/10.1016/j.jbspin.2020.01.011.
Carotti M, Ciapetti A, Jousse-Joulin S, Salaffi Jousse-Joulin S, Gatineau F, Baldini C, et al. Weight of
F. Ultrasonography of the salivary glands: the role salivary gland ultrasonography compared to other
of grey-scale and colour/power Doppler. Clin Exp items of the 2016 ACR/EULAR classification cri-
Rheumatol. 2014;32(1 Suppl 80):S61–7. teria for Primary Sjögren’s syndrome. J Intern Med.
Carotti M, Salaffi F, Di Carlo M, Barile A, Giovagnoni 2020;287(2):180–8.
A. Diagnostic value of major salivary gland ultraso- Kaloudi O, Bandinelli F, Filippucci E, Conforti ML,
nography in primary Sjögren’s syndrome: the role Miniati I, Guiducci S, Porta F, Candelieri A, Conforti
of grey-scale and colour/power Doppler sonography. D, Grassiri G, Grassi W, Matucci-Cerinic M. High
Gland Surg. 2019;8(Suppl 3):S159–67. frequency ultrasound measurement of digital der-
Di Geso L, Filippucci E, Girolimetti R, Tardella mal thickness in systemic sclerosis. Ann Rheum Dis.
M, Gutierrez M, De Angelis R, Salaffi F, Grassi 2010;69(6):1140–3.
W. Reliability of ultrasound measurements of dermal Salaffi F, Argalia G, Carotti M, Giannini FB, Palombi
thickness at digits in systemic sclerosis: role of elasto- C. Salivary gland ultrasonography in the evaluation of
sonography. Clin Exp Rheumatol. 2011;29(6):926–32. primary Sjogren’s syndrome. Comparison with minor
Di Matteo A, Isidori M, Corradini D, Cipolletta E, salivary gland biopsy. J Rheumatol. 2000;27:1229–36.
McShane A, De Angelis R, Filippucci E, Grassi Salaffi F, Carotti M, Di Carlo M, Tardella M, Giovagnoni
W. Ultrasound in the assessment of musculoskeletal A. High-resolution computed tomography of the
involvement in systemic lupus erythematosus: state of lung in patients with rheumatoid arthritis: Prevalence
the art and perspectives. Lupus. 2019;28(5):583–90. of interstitial lung disease involvement and deter-
118 M. Carotti et al.

minants of abnormalities. Medicine (Baltimore). arteries to differentiate primary from secondary

2019;98(38):e17088. forms of Raynaud’s phenomenon. J Rheumatol.
Salaffi F, Carotti M, Iagnocco A, Luccioli F, Ramonda R, 2008;35(8):1591–8. Epub 2008 Jul 15
Sabatini E, De Nicola M, Maggi M, Priori R, Valesini Tani C, Carli L, Stagnaro C, Elefante E, Signorini V,
G, Gerli R, Punzi L, Giuseppetti GM, Salvolini U, Balestri F, Delle Sedie A, Mosca M. Imaging of joints
Grassi W. Ultrasonography of salivary glands in pri- in systemic lupus erythematosus. Clin Exp Rheumatol.
mary Sjögren’s syndrome: a comparison with con- 2018;36 Suppl 114(5):68–73.
trast sialography and scintigraphy. Rheumatology Tardella M, Di Carlo M, Carotti M, Filippucci E, Grassi
(Oxford). 2008;47(8):1244–9. W, Salaffi F. Ultrasound B-lines in the evaluation of
Salliot C, Denis A, Dernis E, et al. Ultrasonography and interstitial lung disease in patients with systemic
detection of subclinical joints and tendons involve- sclerosis: cut-off point definition for the presence of
ments in Systemic Lupus erythematosus (SLE) significant pulmonary fibrosis. Medicine (Baltimore).
patients: a cross-sectional multicenter study. Joint 2018;97(18):e0566.
Bone Spine. 2018;85(6):741–5. Vitali C, Carotti M, Salaffi F. Is it the time to adopt sali-
Santiago T, Santiago M, Ruaro B, Salvador MJ, Cutolo vary gland ultrasonography as an alternative diagnos-
M, da Silva JAP. Ultrasonography for the assessment tic tool for the classification of patients with Sjögren’s
of skin in systemic sclerosis: a systematic review. syndrome? Comment on the article by Cornec et al.
Arthritis Care Res (Hoboken). 2019;71(4):563–74. Arthritis Rheum. 2013;65:1950.
Schmidt WA, Krause A, Schicke B, Wernicke D. Color
Doppler ultrasonography of hand and finger
 Metabolic Diseases
12
Marina Carotti, Emilio Filippucci, Fausto Salaffi,
and Fabio Martino

Contents
12.1 Metabolic Diseases  119
Further Readings  120

12.1 Metabolic Diseases Detection of loss of the normal fibrillar struc-

ture and/or hypo-anechoic areas may be an
Tendon involvement is a prominent feature in important finding indicative of low mechanical
patients with metabolic syndrome. US has shown tendon resistance. Lack of homogeneity of ten-
to be a useful imaging technique in establishing don structure may range from focal aspects of
the diagnosis of heterozygous familial hypercho- fibrillar interruption to diffuse blurring of the ten-
lesterolemia in subjects with high levels of cho- don texture.
lesterol and with no clinically evident xanthomata. Enthesophytes and/or calcification are fre-
The typical sonographic appearance of chronic quent US pathological findings at the tendon
tendinopathy is characterized by heterogeneous insertions of patients with metabolic diseases
echotexture, loss of the normal fibrillar pattern, (Fig. 12.1). Conversely, bone erosions and abnor-
blurring of the tendon margins, and increased mal vascularization (i.e., intra-tendinous power
tendon size. In Achilles tendon, these abnormali- Doppler signal) are more frequently detected at
ties are usually located in the central third of entheseal level in patients with seronegative
tendon. spondyloarthropathy.

M. Carotti
Clinica di Radiologia, Dipartimento di Scienze
Radiologiche – Azienda Ospedali Riuniti di Ancona
Universita’ Politecnica delle Marche, Ancona, Italy
E. Filippucci · F. Salaffi
Clinica Reumatologica, Dipartimento di Scienze
Cliniche e Molecolari, Università Politecnica delle
Marche, Jesi (Ancona), Italy
F. Martino (*)
Radiology, Sant’Agata Diagnostic Center, Bari, Italy

© Springer Nature Switzerland AG 2022 119

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_12
120 M. Carotti et al.

a Further Readings
Bude RO, Nesbitt SD, Adler RS, Rubenfire M. Sonographic
detection of xanthomas in normal-sized Achilles’ ten-
dons of individuals with heterozygous familial hyper-
cholesterolemia. AJR. 1998;170:621–5.
Dagistan E, Canan A, Kizildag B, Barut AY. Multiple ten-
don xanthomas in patient with heterozygous familial
hypercholesterolaemia: sonographic and MRI find-
ings. BMJ Case Rep. 2013;2013:bcr2013200755.
Okur SC, Dogan YP, Mert M, Aksu O, Burnaz O, Caglar
b
NS. Ultrasonographic evaluation of lower extrem-
ity entheseal sites in diabetic patients using Glasgow
ultrasound enthesitis scoring system score. J Med
Ultrasound. 2017;25(3):150–6.
Sakellariou G, Iagnocco A, Delle Sedie A, Riente L,
Filippucci E, Montecucco C. Ultrasonographic evalu-
ation of entheses in patients with spondyloarthritis:
a systematic literature review. Clin Exp Rheumatol.
2014;32(6):969–78.
Terslev L, Naredo E, Iagnocco A, Balint PV, Wakefield RJ,
Fig. 12.1 Chronic enthesopathy of the Achilles tendon Aegerter P, Aydin SZ, Bachta A, Hammer HB, Bruyn
(t) insertion into the posterior calcaneal tuberosity. GA, Filippucci E, Gandjbakhch F, Mandl P, Pineda C,
Longitudinal (a) and transverse (b) scans showing enthe- Schmidt WA, D’Agostino MA. Outcome measures in
sophytes (arrows) generating an acoustic shadow. ca cal- rheumatology ultrasound task force. defining enthesi-
caneal bone tis in spondyloarthritis by ultrasound: results of a
Delphi process and of a reliability reading exercise.
Arthritis Care Res (Hoboken). 2014;66(5):741–8.
Ursini F, Arturi F, D’Angelo S, Amara L, Nicolosi K,
Russo E, Naty S, Bruno C, De Sarro G, Olivieri I,
Grembiale RD. High prevalence of Achilles tendon
enthesopathic changes in patients with type 2 diabe-
tes without peripheral neuropathy. J Am Podiatr Med
Assoc. 2017;107(2):99–105.
 Synovial Osteochondromatosis
13
Alessandro Muda and Fabio Martino

Contents
13.1 Introduction  121
13.2 Diagnostic Imaging  122
Further Readings  123

13.1 Introduction fifth decades of life, with men affected two to

four times more frequently than women. The sec-
Synovial osteochondromatosis is a benign condi- ondary form is more common than primary and is
tion characterized by proliferation of synovial believed to be due to or associated with joint
membrane, in which there is metaplasia of the abnormalities, such as mechanical or arthritic
synovial lining of a joint into cartilaginous or conditions that cause intra-articular chondral
osteocartilaginous nodules. In more rare cases, bodies.
an extra-articular form of the condition can be Based on histopathology, synovial chondrom-
identified, in which lesions are found in bursal atosis is classified into three stages: Stage 1 shows
tissue and/or in tendon sheath. active chondroid metaplasia of synovium without
There are two forms: primary (also referred to intra-articular chondroid nodules. Stage 2 repre-
as Reichel syndrome) and secondary synovial sents both intrasynovial chondroid metaplasia and
chondromatosis. The primary form is uncom- intra-articular chondral nodules. Stage 3 docu-
mon, has unknown etiology, and is usually mono- ments the presence of intra-articular chondroid
articular, although rare cases of multiple joint nodules, but no active synovial based disease.
involvements occur. Any joint may be affected, Later on, chondroid nodules spread and finally
and the knee is the most commonly involved site become calcified. Detachment of some calcified
(65%), followed by the hip (20%) and elbow. It bodies embedded in the synovium gives rise to
preferentially occurs in between the third and intra-articular loose bodies that are quite uniform
in size and shape, which may eventually occupy
A. Muda the whole joint space. These nodules, nourished
Department of Radiology, IRCCS Policlinico San by synovial fluid, grow and most of them pro-
Martino-IST, Genova, Italy gressing to ossification. It should be pointed out
F. Martino (*) that there is no correlation between these stages
Radiology, Sant’Agata Diagnostic Center, and duration of clinical symptoms or patient age.
Bari, Italy

© Springer Nature Switzerland AG 2022 121

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_13
122 A. Muda and F. Martino

At the beginning, the affected joints do not appear ease, signs of degenerative joint disease may be
inflamed; however, joint effusion may be occa- present. In case of suspected joint effusion sonog-
sionally present. Symptoms are insidious and raphy is usually the first-line examination tech-
slowly progressive; they often include chronic nique and in such cases can detect also the
joint pain, swelling, tenderness, and limitation of presence of a mass-like process corresponding to
joint motility. The condition progresses slowly chondroid nodule aggregate (Fig. 13.1).
and can lead to secondary erosive and arthritic The ultrasound appearance of synovial osteo-
degenerative changes of joint bones. The disease chondromatosis is characterized by numerous
may recur and malignant transformation has echogenic foci, representing the fronds of the
rarely been reported. Nevertheless, only few cases growing process, and the synovium may be thick-
of true malignant transformation in chondrosarco- ened; most of these are associated with distal
mas have been described in literature. acoustic shadowing, corresponding to the con-
glomeration of calcified chondroid islands. On
ultrasound, the uncalcified component of the
13.2 Diagnostic Imaging mass is hypoechoic and avascular. Calcifications
are very commonly seen and when extensive will
Conventional radiology usually represents the be the prominent feature visible on ultrasound.
first-line imaging exam in the diagnostic suspi- Therefore, ultrasound can suggest the pres-
cion of synovial osteochondrosis. In general, ence of synovial osteochondromatosis, but is not
radiographic results are pathognomonic of syno- definitively diagnostic, and conventional radiog-
vial osteochondromatosis and vary in relation to raphy is usually required to confirm the suspected
the form (primary or secondary) and the evolutive diagnosis. If loose bodies are present, they are
stage of the diseases. Generally, the calcifications visible as small echogenic lobules of cartilage,
are ring-shaped; sometimes they have a calcified with possible posterior acoustic shadowing, free-­
central focus and ring-shaped peripheral calcifica- floating in the effusion within the articular space.
tion, or a target sign with a radiolucent center and Extensive mineralization may hide lobular con-
calcified periphery. In the case of secondary dis- tours of chondral bodies.

a b

Fig. 13.1 Synovial osteochondromatosis of the elbow. posterior acoustic shadowing (*) lining synovial profile
(a) Longitudinal US scan of the volar aspect of the elbow are evident. (b) Frontal radiograph in same patient show-
showing bulge and thickening of the capsular profile ing several rounded opacities (empty black arrowheads),
(empty white arrowheads). Multiple echogenic foci with corresponding to calcified chondroid islands
13 Synovial Osteochondromatosis 123

a b

Fig. 13.2 MRI of the knee in patient with osteochondral nodule (arrows): (a) sagittal T1-weighted image; (b) axial
T2-weighted image

Gille J, Krueger S, Aberle J, Boehm S, Ince A, Loehr

Changing position during the examination can JF. Synovial chondromatosis of the hip: a case report
be helpful to reveal loose bodies and determine if and clinicopathologic study. Acta Orthop Belg.
they are indeed loose by assessing their possibil- 2004;70:182–8.
ity of free movement. Kumar DS, Ethiraj D, Indiran V, Maduraimuthu P. Bilateral
shoulder synovial chondromatosis: Multimodality
Color and power Doppler technique reveals no imaging. Indian J Rheumatol. 2019;14:161–2.
vascularity within the loose bodies and this fea- Maghear L, Serban O, Papp I, Otel O, Manole S, Botan E,
ture may be useful to guide the examiner in the Fodor D. Multimodal ultrasonographic evaluation in a
differential diagnosis. case with unossified primary synovial osteochondro-
matosis. Med Ultrasonogr. 2018;20(4):527–30.
MRI is sometimes required, particularly when Martino F, Silvestri E, Grassi W, Garlaschi
the lesion is arising from a joint. MRI can be use- G. Musculoskeletal sonography. New York: Springer;
ful in identifying osteochondromatosis nodules, 2006.
which if calcified have low signal in the T1 and McKenzie G, Raby N, Ritchie D. A pictorial review of
primary synovial osteochondromatosis. EurRadiol.
T2 sequences weighted (Fig. 13.2). 2008;18:2662–9.
Murphey MD, Vidal JA, Fanburg-Smith JC, Gajewski
DA. Imaging of synovial chondromatosis with
Further Readings radiologic-pathologic correlation. Radiographics.
2007;27(5):1465–88.
Roberts D, Miller TT, Erlanger SM. Sonographic appear-
Campeau NG, Lewis BD. Ultrasound appearance of syno- ance of primary synovial chondromatosis of the knee.
vial osteochondromatosis of the shoulder. Mayo Clin J Ultrasound Med. 2004;23:707–9.
Proc. 1998;73:1079–81. Terazaki CRT, Trippia CR, Trippia CH, Caboclo MFSF,
Fuerst M, Zustin J, Lohmann C, Rüther W. Synoviale Medaglia CRM. Synovial chondromatosis of the shoul-
chondromatose. Der Orthopäde. 2009;38(6):511–9. der: imaging findings. Radiol Bras. 2014;47(1):38–42.
 Pigmented Villonodular Synovitis
14
Alessandro Muda and Fabio Martino

Contents
14.1 Introduction  125
14.2 Diagnostic Imaging  126
Further Readings  127

14.1 Introduction grows inside the joint cavity as a nodular mass, or

it can be extra-articular when it involves a bursa
Pigmented villonodular synovitis (PVNS) is a or a tendon sheath (termed “giant cell tumor of
slow-growing synovial proliferative disorder, the tendon sheath”—GCTTS), which appears as
which is locally invasive similar to a tumor and nodular tenosynovitis nearly always related to the
usually involves a single joint, tendon sheath, or fingers or thumb. The localized (or nodular)
bursa. It is a rare benign condition that primarily intra-articular form is usually monoarticular and
affects young adults. Patients are usually between most commonly affects knee (up to 80% of
the second and fourth decades of life, and both cases), hip, and ankle. The localized PVNS
sexes are equally affected. Although the recur- (intra- or extra-articular form) usually responds
rence is high, malignant transformation is consid- well to treatment.
ered rare. The etiology is unknown but it is thought Diffuse PVNS is so called when the condition
to be related to trauma, intra-articular hemorrhage, is more widespread and involves an entire joint. It
and recurrent inflammation; some cytogenetic is characterized by a diffused thickening of the
abnormalities also seem to be implicated. synovium with coarse villi, finer fronds, and dif-
There are two forms of PVNS: (1) localized, fuse nodularity. It also tends to be more destruc-
that is, predominantly nodular, and (2) diffuse, tive and more difficult to treat.
that is, mostly villous. The initial clinical presentation of intra-­articular
Localized PVNS can be intra-articular, when form is typically a monoarticular joint effusion with
it occurs in a restricted area of the joint, and no history of trauma or inciting event. Aspiration of
synovial fluid will lead to hemarthrosis in more than
A. Muda 60% of patients. They usually have mild discomfort
Department of Radiology, IRCCS Policlinico San and stiffness in the affected joint. Thereafter, pain-
Martino-IST, Genova, Italy
less or painful local swelling of chronic duration
F. Martino (*) becomes the typical clinical pattern.
Radiology, Sant’Agata Diagnostic Center, Bari, Italy

© Springer Nature Switzerland AG 2022 125

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_14
126 A. Muda and F. Martino

Once the PVNS is confirmed by biopsy, the Later on, the hypertrophic synovium and
main and most effective treatment is complete inflammation may damage the bone cortex pro-
surgical synovectomy. Since diffuse PVNS has a ducing erosions and cystic degeneration that can
relatively high recurrence rate, radiation therapy be evaluated by MRI, as well as by X-ray
or chemotherapy can be considered a treatment (Fig. 14.2) or sonography.
option.

14.2 Diagnostic Imaging

The histological composition of the PVNS is also

relevant for diagnostic imaging. Indeed, histol-
ogy reveals a state of chronic inflammation char-
acterized by the presence of large amounts of
mononuclear cells with hemosiderin deposits and
multinucleated giant cells. Chronic inflammation
increases the possibility of intra-articular bleed-
ing, thereby providing more iron available for the
PVNS tissue, which in turn probably constitutes
an additional stimulus for mononuclear cells and
fibroblasts, creating a vicious circle. So, the
heavy deposition of hemosiderin inside the vil-
lous tissue and nodules enhances the diagnostic
value of MRI, especially T2-weighted images,
due to the “blooming” effect of hemosiderin
deposits that return low signal intensity on all
sequences. Therefore, MRI is considered the
Fig. 14.2 Diffuse intra-articular PVNS of the hip with
most appropriate investigation because it per- hip pain. Frontal X-ray shows extensive erosion of the
mits, in most cases, a wider identification of the femoral neck and acetabulum with sclerotic margins
full extent of the disease (Fig. 14.1). (arrows) and maintained hip joint space

a b

Fig. 14.1 (a) Sagittal T1-weighted image without gado- T2-weighted images, hemosiderin deposition appears
linium shows an intra-articular hypointense mass (white more visible because of the blooming effect due to the
star) in the subtalar joint; (b) in sagittal gradient echo magnetic susceptibility (white arrows)
14 Pigmented Villonodular Synovitis 127

Fig. 14.3 Ultrasound examination of the medial side of

the knee shows a cystic image (circles) with echoes inside
emerging extra-articular from the pes anserine bursa
(arrow). T tibia
Fig. 14.4 Giant-cell tumor of the hand. Transverse US
scan of the palmar surface of the finger demonstrates a
solid, relatively homogeneous hypoechoic mass (*), fill-
The ultrasound pattern in PVNS is nonspe- ing the tendon sheath. Tendons (T) are peripherally
dislocated
cific but it is helpful to understand if the mass is
fluid or solid. It usually appears as hypoechoic
hypertrophic synovium, with a widespread Further Readings
villous thickening or with a nodular aspect,
corresponding to diffuse and localized type, Bianchi S, Mazzola CG, Martinoli C, Damiani S,
respectively, with or without joint effusion Derchi LE. Quiz case of the month. Eur Radiol.
(Fig. 14.3a, b). 1998;8(7):1275.
Bianchi S, Martinoli C. Ultrasound of the musculoskeletal
Color and power Doppler ultrasound tech- system. 1st ed. Berlin: Springer; 2007.
nique shows increased flow signals with a high Bravo SM, Winalski CS, Weissman BN. Pigmented villo-
degree of vessels in the mass. A pattern of nodular synovitis. Radiol Clin N Am. 1996;34:311–26.
increased flow may also be detected in the periph- Fałek A, Niemunis-Sawicka J, Wrona K, et al.
Pigmented villonodular synovitis. Folia Med Cracov.
eral zone of the synovial capsule. Tenosynovial 2018;58(4):93–104.
involvement by a giant-cell tumor most com- Martino F, Silvestri E, Grassi W, Garlaschi G.
monly appears as a single hypoechoic homoge- Musculoskeletal sonography. New York: Springer;
nous nodule, which tends to encircle and dislocate 2006.
Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC,
the affected tendon (Fig. 14.4). Flemming DJ, Walker EA. Pigmented Villonodular
Despite the fact that involvement of surround- synovitis: radiologic-pathologic correlation.
ing tissues is often extensive, when the tendon Radiographics. 2008;28:1493–518.
slides the mass does not move with it. Schvartzman P, Carrozza PV, Pascual T, Mazza L, Odesser
M, San Román JL. Radiological features of pigmented
Ultrasound can detect blood-stained effusions villonodular synovitis and giant cell tumor of the ten-
both in the joint and in the tendon sheath, which don sheath. Rev Argent Radiol. 2015;79(1):4–11.
might contain hemosiderin deposits in case of Yang PY, Wang CL, Wu CT, et al. Sonography of pig-
past bleedings. mented villonodular synovitis in the ankle joint. J Clin
Ultrasound. 1998;26:166–70.
 Shoulder Calcific Tendinopathy
15
Gianluigi Martino, Enzo Silvestri,
Davide Orlandi , Alessandro Muda,
and Fabio Martino

Contents
15.1 Introduction  129
15.2 Imaging of Calcifying Tendinitis  130
15.3 Complications: Subacromial Bursitis—Bone Involvement  132
Further Readings  136

15.1 Introduction It predominantly affects individuals aged

between 40 and 60 years, and 57–76.7% of
Calcific tendinitis of the shoulder is a relatively patients are women. Calcific tendinitis is charac-
common, painful disease, estimated to occur in terized by the presence of calcium salt deposits,
2.5–7.5% of adults. Although more common in primarily hydroxyapatite, in the substance of the
the right shoulder, at least a 10–25% incidence of rotator cuff tendons. Most calcification occurs in
bilaterality has been reported. the supraspinatus tendon. Calcification is
observed with decreasing frequency in the infra-
spinatus, teres minor, and subscapularis tendons.
More than one tendon may be involved.
The calcific deposit usually is described as
G. Martino
Institute of Radiology, University of Bari, being approximately 1–2 cm proximal to the ten-
Bari, Italy don insertion on the greater tuberosity. Calcifying
E. Silvestri tendinitis may be an incidental finding in 7.5–20%
Radiology, Alliance Medical, Genova, Italy of asymptomatic adults, or it may be the cause of
D. Orlandi shoulder pain. Symptomatic patients usually pres-
Department of Radiology, Ospedale Evangelico ent with impingement-type pain in the affected
Internazionale, Genova, Italy shoulder during overhead activity. Active and pas-
A. Muda sive range of motion is painful and restricted. The
Department of Radiology, IRCCS Policlinico San pain may seem to be out of proportion to any
Martino-IST, Genova, Italy
objective physical findings. The patient may
F. Martino (*) describe difficulty sleeping on the shoulder and
Radiology, Sant’Agata Diagnostic Center,
trouble falling asleep. Symptoms may last for a
Bari, Italy

© Springer Nature Switzerland AG 2022 129

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_15
130 G. Martino et al.

few weeks or a few months. The cause of calcify- phous calcium phosphate, and can be relatively
ing tendinitis is not known. It is generally agreed painless. This phase is followed by the resting
that it is not caused by trauma, and it rarely is part phase, which tends to be quiescent and may last
of a systemic disease. The pathophysiology of for months to years. The resorptive phase of cal-
calcifying tendinitis is controversial, and has been cific stage tends to be painful, as calcium crystals
attributed to cell-­mediated calcification and sub- are resorbed, inducing regional neoangiogenesis,
sequent spontaneous phagocytic resorption. beginning at the margin of the calcium deposit,
Based on the pathogenesis of histic hypoxia, and infiltration of phagocytes. The postcalcific
the hypoxic state produces a lack of irrigation of stage, which can be painless, is characterized by
the “critical area” near the insertion of the tendon the collagenization of the lesion by fibroblasts.
and induces calcified deposits. It is a self-limited
process in which the calcifications tend to resolve
after a period of worsening and intense pain. 15.2 Imaging of Calcifying
Therefore, many cases may resolve spontane- Tendinitis
ously and require no special treatment. Thus, it is
a dynamic process (Fig. 15.1) that evolves The first-line imaging modalities are X-ray and
through three distinct stages of the disease pro- ultrasound, as calcium deposits are readily identifi-
cess: the precalcific stage, characterized by the able on both. The evaluation of calcific tendinitis is
asymptomatic change of the tenocytes into chon- based mainly on radiography. It is cost effective
drocytes, and then fibrocartilage; the calcific and useful, not only for determining the presence
stage, which is subdivided into three phases— of calcium deposits but also for assessing their size,
formation, resting, and resorption; and the post- delineation, and density. Standard radiographic
calcific stage, characterized by an attempt by the evaluation of the shoulder should include internal
tendon to self-heal. The formation phase of cal- and external rotation anteroposterior views to help
cific stage is characterized by deposition of amor- visualize calcific deposits and their relationship to

Fig. 15.1 Clinic and pathologic evolution scheme of calcific shoulder tendinitis, in accord with Uhthoff stages
15 Shoulder Calcific Tendinopathy 131

a b

Fig. 15.2 Shoulder calcific tendinitis radiograph. (a) (arrowhead), with the shoulder internally rotated; also evi-
Shoulder externally rotated X-ray showing supraspinatus dent are subtle enthesophytic spurs of infraspinatus ten-
calcific tendinitis; (b) subscapularis calcific tendinitis don (arrows)

landmarks on the humeral head. External rotation size or morphology, although none of them guar-
consent to visualize the calcific tendinitis in the antee sufficient reliability and reproducibility, or
supraspinatus tendon profiles the greater tuberosity reliable correlation with the radiologic picture and
(Fig. 15.2a). Internal rotation of the humerus pro- clinical symptoms. Gärtner and Heyer proposed a
files the ­posterior aspect of the head on the lateral radiographic classification based on the morpho-
aspect of the radiograph and the anterior head logical appearance of the calcification, identifying
medially. Calcification in the infraspinatus tendon three types (Fig. 15.3a–c): (I) sharply defined and
profiles posteriorly on internal rotation (Fig. 15.2b). dense, (II) ill-defined/dense or sharply defined/
Calcification in the subscapularis profiles anteri- inhomogeneous-less radiodense, and (III) translu-
orly on internal rotation (Fig. 15.2b). The regions cent and cloudy appearance with vague border.
most affected by calcific tendinitis are the critical Calcifications with a well-defined, homoge-
zone of the supraspinatus tendon (80%), the lower neous contour are less likely to be symptomatic
side of the infraspinatus tendon (15%), and the pre- and may correlate with the formative or resting
insertional part of the subscapularis tendon (5%). phase. Deposits with fluffy, hazy, ill-defined
The radiographic appearance of calcific tendi- edges are often seen in patients with acute pain
nitis is as homogeneous, amorphous densities and may correlate with the resorptive phase of
without trabeculation, which allows for differen- calcific tendinitis. Ultrasound is useful in both
tiation from enthesopathic spurs or accessory detection of rotator cuff calcium deposits and
ossicles. Most calcifications are ovoid, and mar- therapeutic procedures, and is also beneficial in
gins may be smooth or ill-defined. Characterizing pre- and postoperative evaluation. Its diagnostic
the shape and contour of the calcific deposit is accuracy has been reported to be similar to that of
important to classify the pathology, in order to magnetic resonance imaging. Calcific plaque
determine the best possible treatment for the morphology and increased flow on power
patient. It is important to be able to reliably pre- Doppler were the most useful ultrasound find-
dict the consistency of the deposit and hereby the ings. Ultrasonography could also detect associ-
stage of the disease by characterizing the radio- ated conditions such as rotator cuff tears,
logical image in one of the classification systems subacromial–subdeltoid bursitis, and long head
in clinical use at present. Several radiological of the biceps pathology and allows us to perform
classifications have been proposed, based on the a dynamic evaluation to assess the subacromial
132 G. Martino et al.

a b c

Fig. 15.3 Shoulder calcific tendinitis radiograph. (a) or inhomogeneous structure; (c) type III calcification
Type I calcification is well defined, with dense and homo- appearing as hazy, ill-defined globular area, more or less
geneous structure; (b) type II calcifications are depicted transparent in structure, typically seen in acute symptom-
from less radiodense calcific deposits, with either sharp or atic patients
poorly defined border (as in this case), and homogeneous

impingement. All three of the main rotator cuff gesting resting or resorptive stage (Fig. 15.5).
tendons may be involved although the supraspi- Identifying the resorptive phase is important for
natus is the most common site of calcific depos- management as these deposits are nearly liquid
its. Tendon calcifications are visible as echogenic and can be successfully aspirated. MRI is now
foci usually accompanied by acoustic shadowing. not recommended as a first-line imaging modal-
With soft deposits the echogenicity may be more ity, because deposits appear hypointense in all
subtle and acoustic shadowing more variable. sequences, and can be missed, even though the
Various classifications were proposed for the development of new MR sequence such as
calcific plaques based on their location and susceptibility-­weighted imaging (SWI) seemed
appearance on ultrasound. Chiou et al. proposed to overcome this problem.
a classification of calcific deposits into four
shapes (Fig. 15.4a–d): (1) an arc shape (echo-
genic arc with clear shadowing); (2) a fragmented 15.3 Complications: Subacromial
or punctate shape (two or more echogenic Bursitis—Bone Involvement
plaques), with or without shadowing; (3) a nodu-
lar shape (cloudy echogenic nodule without A rare painful complication of calcifying tendini-
shadowing); and (4) a cystic shape (a bold echo- tis is the migration of calcium deposits from ten-
genic wall with an anechoic area, weak internal dons, usually the supraspinatus, into the
echoes, or layering content). subacromial–subdeltoid bursa or into the under-
There is a correlation between the ultrasound lying bone at the tendon attachment site
appearance of the calcified deposit, the clinical (Fig. 15.6). The pathomechanism is still
symptoms, and the three phases of histopatho- unknown, but seems to occur in the resorptive
logical findings of Uhthoff. Besides, there is an phase of the disease and seems to be mediated by
association with color Doppler ultrasonography aggressive inflammatory reaction and hyperemia
of the rotator cuff and the calcific stage/clinical at the tendon insertion and by rise of the intraten-
symptoms. In fact, during the resorptive phase, dinous pressure. This can lead to secondary
the deposits are surrounded by phagocytes and impingement resulting from the increased tendon
there was concomitant neoangiogenesis around size, and to rupture of the deposits into the sub-
the calcification. The combination of ultrasound acromial space or into the bursa. Rarely, calcific
and color Doppler appearance predicts more tendinopathy eventually causes focal resorption
accurately formative or resorptive stage. of adjacent cortical bone, and intraosseous migra-
Severe symptoms are associated with non- tion of calcic material might occur. These
arc-­shape calcifications, hypervascularity, and ­complications lead to severe shoulder pain and
widening of subacromial–subdeltoid bursa, sug- functional disability.
15 Shoulder Calcific Tendinopathy 133

a b

c d

Fig. 15.4 Shoulder calcific tendinitis ultrasound. (a) this case) acoustic shadowing; (c) nodular shape calcifi-
Arc-shaped calcification seen as well-defined echogenic cation that appears as ill-defined cloud-like echogenic
arc with deep acoustic shadowing (arrowheads) (“hard” nodule (arrows) without shadowing (“soft” calcification
calcification within the supraspinatus); (b) fragmented within the supraspinatus); (d) cystic shape calcification
shape calcification has the appearance of fragmented and (white asterisk) appearing as echogenic wall with weak
punctate echogenic profile (arrows) with or without (as in internal echoes

Fig. 15.5 Supraspinatus tendon calcifying tendinitis in

acute resorptive phase. The color Doppler ultrasound
shows hypervascularity in the subdeltoid bursa, distended
by fluid Fig. 15.6 Extratendinous calcification migration scheme:
(a) into the sub-bursal space; (b) into the subacromial–
subdeltoid bursa; (c) into the sub-insertional bone
134 G. Martino et al.

a b

Fig. 15.7 Shoulder extratendinous calcification migra- the bursa; (b) shoulder externally rotated X-ray clearly
tion. (a) Shoulder X-ray showing linear calcified deposit showing supraspinatus calcific tendinitis, and migration
(arrows), which surrounds the profile of the humeral of calcific deposits into the subacromial–subdeltoid bursa
trochlea, indicating the location between the tendon and (arrowheads)

Calcium deposit migration into the sub-bursal

space or into the subacromial–subdeltoid bursa
appears on radiograph as ill-defined calcifications
in the subacromial space (Fig. 15.7a and b). Often
it is not possible to assess their exact location,
whether intratendinous, sub-bursal, or intrabursal.
Ultrasound examination can visualize their
exact location. Della Valle reported that in cases
of intrabursal penetration of the calcification, at
sonography and MRI examinations, the subacro-
mial–subdeltoid bursa presents thickened walls
and appears filled with inhomogeneous fluid con-
taining calcium and debris (Fig. 15.8). Fig. 15.8 Shoulder extratendinous calcification migra-
If the calcific deposit has migrated into the tion. Bursal extrusion, showing complex fluid with calci-
sub-insertional bone, standard radiographs show fication inside the bursa, which presents thick walls.
focal erosions of the humeral head and a rounded Calcifications appear as cloud-like echogenic nodules
(asterisk) or minute scattered fragments (arrows)
sclerotic intraosseous lesion in the greater tuber-
osity (Fig. 15.9), which could be mistaken for
malignancy or infection. MRI and CT are considered the best methods
Ultrasound depicts intratendinous hyper- to demonstrate the involvement of bone marrow
echoic focal amorphous calcification adjacent to in calcific tendinopathy. CT is the gold standard
focal bone erosions of the greater tuberosity and imaging modality to depict cortical erosion of the
intraosseous calcification migration (Fig. 15.10). humeral head and a rounded well-defined lytic
15 Shoulder Calcific Tendinopathy 135

Fig. 15.9 Shoulder extratendinous calcification migra-

tion. Radiograph shows amorphous calcifications in the
subacromial space and cortical erosion, with an underly-
ing ovoid sclerotic lesion in the greater tuberosity
(arrowheads)

Fig. 15.11 Shoulder extratendinous calcification migra-

tion. Axial CT shows the subscapularis calcium deposit
migration into the sub-insertional bone. The arrow indi-
cates calcification, and the arrowhead indicates the sub-
cortical bone migration in the lesser tuberosity. Courtesy
of Prof. L.M. Sconfienza

Fig. 15.10 Shoulder extratendinous calcification migra-

tion. Ultrasonography in the long axis of the supraspinatus
tendon showing intratendinous calcification (arrows)
associated with focal bone erosion and intraosseous calci-
fication migration (arrowheads). Sonogram shows
anechoic fluid within enlarged subacromial–subdeltoid
bursa (white asterisk)

area located in the greater tuberosity (Fig. 15.11); Fig. 15.12 Shoulder extratendinous calcification migra-
it can also detect calcium deposit in its intraosse- tion. Coronal T2-weighted sequence shows low signal
ous location. MRI shows a cystic lesion in the intensity of the ovoid lesion in the greater tuberosity in
greater tuberosity and humeral osteitis related to keeping with sclerosis (arrowheads). There is a superficial
focus of fluid signal (white arrow) traversing the region of
typical reactive bone marrow edema surrounding cortical erosion. Ill-defined hyperintensity consistent with
the lytic lesion (Fig. 15.12). marrow edema (black arrows) surrounds the lesion
136 G. Martino et al.

Further Readings by ultrasonography: comparison between symptom-

atic and asymptomatic shoulders. Joint Bone Spine.
2010;77(3):258–63.
Bosworth BM. Calcium deposits in shoulder and sub-
Molè D, Kempf JF, Gleyze P, et al. Results of endoscopic
acromial bursitis: survey of 12,122 shoulders. JAMA.
treatment of non-broken tendinopathies of the rota-
1941;116:2477–82.
tor cuff. Calcifications of the rotator cuff. Rev Chir
Chianca V, Albano D, Messina C, Midiri F, Mauri G,
Orthop. 1993;79:532–41.
Aliprandi A, et al. Rotator cuff calcific tendinopa-
Moseley HF, Goldie I. The arterial pattern of the rota-
thy: from diagnosis to treatment. Acta Biomed.
tor cuff of the shoulder. J Bone Joint Surg Br.
2018;89(1-S):186–96.
1963;45(4):780–9.
Chiou HJ, Chou YH, Wu JJ, Hsu CC, Huang DY, Chang
Nogueira-Barbosa MH, Gregio-Junior E, Lorenzato
CY. Evaluation of calcific tendonitis of the rotator cuff:
MM. Retrospective study of sonographic findings in
role of color Doppler ultrasonography. J Ultrasound
bone involvement associated with rotator cuff calcific
Med. 2002;21(3):289–95.
tendinopathy: preliminary results of a case series.
Codman EA. The Shoulder. 3rd ed. Boston: Thomas
Radiol Bras. 2015;48(6):353–7.
Todd; 1934.
Nörenberg D, Ebersberger HU, Walter T, Ockert B,
Della Valle V, Bassi EM, Calliada F. Migration of cal-
Knobloch G, Diederichs G, Hamm B, Makowski
cium deposits into subacromial–subdeltoid bursa and
MR. Calcific tendonitis of the rotator cuff:
into humeral head as a rare complication of calcify-
susceptibility-­
weighted MR imaging. Radiology.
ing tendinitis: sonography and imaging. J Ultrasound.
2016;278(2):475–84.
2015;18:259–63.
Patte D, Goutallier D. Periarthritis of the shoulder.
De Palma AF, Kruper JS. Long-term study of shoulder
Calcifications. Rev Chir Orthop. 1988;74:277–8.
joints afflicted with and treated for calcific tendinitis.
Porcellini G, Paladini P, Campi F, Paganelli
Clin Orthop. 1961;20:61–72.
M. Arthroscopic treatment of calcifying tendonitis of
Flemming DJ, Murphey MD, Shekitka KM, et al.
the shoulder: clinical and ultrasonographic findings at
Osseous involvement in calcific tendinitis: a retro-
two to five years. J Shoulder Elb Surg. 2004;13:503–8.
spective review of 50 cases. AJR Am J Roentgenol.
Speed CA, Hazelman BL. Calcific tendinitis of the shoul-
2003;181:965–72.
der. N Engl J Med. 1999;340:1582–4.
Gärtner J, Heyer A. Calcific tendinitis of the shoulder [in
Uhthoff HK, Sarkar K, Maynard JA. Calcifying tendinitis:
German]. Orthopade. 1995;24(3):284–302.
a new concept of its pathogenesis. Clin Orthop Relat
Hamada J, Ono W, Tamai K, Saotome K, Hoshino
Res. 1976;118:164–8.
T. Analysis of calcium deposits in calcific periarthritis.
Uhthoff HK, Loehr JW. Calcific tendinopathy of the rota-
J Rheumatol. 2001;28:809–13.
tor cuff: pathogenesis, diagnosis, and management. J
Le Goff B, Berthelot JM, Guillot P, Glèmarec J, Maugars
Am Acad Orthop Surg. 1997;5(4):183–91.
Y. Assessment of calcific tendonitis of rotator cuff
 Frozen Shoulder
16
Enzo Silvestri, Davide Orlandi ,
Alessandro Muda, and Fabio Martino

Contents
16.1 Introduction  137
16.2 Diagnostic Imaging  138
Further Readings  141

16.1 Introduction and restricted. At patient inspection, a tendency

towards a winged scapula can be seen. During
Frozen shoulder (FS), also known as adhesive resisted muscle tests, reduction of movements in
capsulitis, is a debilitating clinical syndrome external rotation, internal rotation, and abduction
characterized by insidious onset of shoulder pain, is appreciated; another test evaluates the impos-
and gradual restriction of both active and passive sibility of abducting the humerus without lifting
motion of the glenohumeral joint, without docu- the shoulder when it exceeds 90° abduction. A
mented causes. It is a common inflammatory dis- differential diagnosis must be made with osteo-
order of the shoulder, mostly affecting females arthritis, subdeltoid bursitis, Parsonage-Turner
in 40–70 years’ group, with an incidence ranging syndrome, and rotator cuff tendons pathologies.
from 2% to 5%. More frequently the disease is Adhesive capsulitis is classified into two catego-
unilateral and the patients usually present with ries based on the absence or presence of concomi-
painful difficulty in overhead movements, getting tant shoulder disease: (1) primary, or idiopathic,
dressed, and moving the arm behind the back. refers to the disease process occurring without
Active and passive range of motion is painful an identifiable cause and (2) secondary, which is
clinically indistinguishable from idiopathic form,
E. Silvestri is associated with, or subsequent to, other shoul-
Radiology, Alliance Medical, Genova, Italy der pathologic states (trauma and immobilization,
D. Orlandi (*) calcific tendinitis with severe subdeltoid bursitis,
Department of Radiology, Ospedale Evangelico diabetes mellitus, hemiplegia, cervical arthritis,
Internazionale, Genova, Italy hyperthyroidism, Dupuytren disease). The etiol-
A. Muda ogy of adhesive capsulitis is not fully understood,
Department of Radiology, IRCCS Policlinico San but it is acclaimed as a cytokine-mediated inflam-
Martino-IST, Genova, Italy
matory and fibrotizing problem. It is character-
F. Martino ized by the presence of thickening and stiffness
Radiology, Sant’Agata Diagnostic Center, Bari, Italy

© Springer Nature Switzerland AG 2022 137

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_16
138 E. Silvestri et al.

of joint ­capsule, associated with synovitis that vide reliable imaging indicators of FS (Fig. 16.1a,
often affects also the tendon sheath of the long b), which include joint capsule and coracohumeral
head of the biceps brachii; the subdeltoid bursa ligament (CHL) thickening, presence of inflamma-
and the rotator cuff tendons may also be involved. tory tissue at the rotator interval that enhances after
FS is a self-limited process in which the disease intravenous gadolinium injection, and obliteration
tends to resolve after a period (12–18 months) of of the fat triangle due to edema surrounding the
worsening and intense pain, but recovery is gener- CHL at the level of the subcoracoid space.
ally not complete. Thus, it is a dynamic process However, X-ray and ultrasound are currently
that evolves through three distinct stages that considered the first-line imaging modalities.
can overlap: the acute stage (freezing or pain- Radiography will often appear normal. The role
ful stage), with pain at rest that increases at the of ultrasound is still debated; however the stud-
extremes of movements and interruption of night ies carried out indicate how there are structures
sleep (3–9 months); the adhesive stage (frozen involved in this disease that can be excellently
or transitional stage) with progressive reduc- evaluated with sonography. Commonly referred
tion of ROMs (up to 12 months); and the stage ultrasound findings in adhesive capsulitis are
of resolution (thawing stage), with progressive coracohumeral ligament (CHL) and joint cap-
pain relief and return to normal or close to normal sule thickening. The ultrasound examination is
range of movements (1–3.5 years). Management performed on patient’s shoulder placed in exter-
of capsulitis tends to be conservative, as most nal rotation and in 90° abducted position, with
cases resolve spontaneously, although a sub- forearm 90° flexed (Fig. 16.2a, b). In this position
set of patients progress to permanent disability. both CHL and joint capsule become stretched
Therefore, early and accurate diagnosis is crucial allowing the best thickness measurement. The
as adhesive capsulitis diagnosed in the later stages CHL can be shown by scanning on an oblique
is more difficult to manage. transverse plane using the coracoid as landmark;
the ligament originates from the coracoid and
ends on the rotator interval (Fig. 16.3a–c). The
16.2 Diagnostic Imaging average thickness of the CHL was significantly
greater in adhesive capsulitis (3 mm) than in the
Diagnosis is mainly based on clinical findings. asymptomatic shoulders (1.34 mm).
Imaging is not imperative to diagnose frozen Placing probe in axillary cavity allows us
shoulder. However, it may help confirm the correct to evaluate the joint capsule on longitudinal
diagnosis even excluding other problems in painful (when possible; if the axillary pouch stiffness
shoulder, such as a torn rotator cuff. MRI can pro- consent to be stretched and the shoulder to be

a b

Fig. 16.1 Left frozen shoulder in acute stage. Axial T2 capsulitis. H humerus, C coracoid, SSc subscapularis ten-
fat-sat magnetic resonance (MRI) scan (a) and corre- don, asterisk extended anterior recess edema, circles joint
sponding ultrasound (US) scan (b) of shoulder adhesive effusion
16 Frozen Shoulder 139

a b

Fig. 16.2 (a) Patient position, with 90° abducted arm and Probe (dotted line); coracohumeral ligament (blue); cap-
flexed forearm. (b) Probe position along the coracohu- sule profile (green)
meral ligament and under the capsule axillary pouch.

a b c

Fig. 16.3 Left frozen shoulder in adhesive stage (b) with and very limited external rotation of the affected shoulder.
respect to the normal contralateral side (a). The ultra- Part label (c) shows correct probe position. LT Lesser
sound evaluation shows the blurred thickening of the cor- tuberosity, SSC subscapularis tendon, Co coracohumeral
acohumeral ligament, in a patient with painful abduction ligament

abducted) (Fig. 16.4a–c) and transverse scans shoulder and correlates to MRI signs of adhesive
(more simple to place the probe) (Fig. 16.5a– capsulitis with high sensitivity and specificity.
c). The joint capsule thickness value is con- The main US Doppler sign of capsulitis is the
sidered a combination of capsular and synovial presence of hypoechoic and hyperemic synovial
thickness of the axillary pouch. It appears thickening around the biceps long head at rota-
as a thin hyperechoic band which surrounds tor cuff interval level (Fig. 16.6). A correct con-
humeral neck, and is represented with linear or duct of the examination requires to set the system
curved profile in longitudinal and axial views, with PRF <1 KHz and low wall filter to detect
respectively. small vessel flow signals, whose characteristics
In symptomatic patients the joint capsule resemble background noise. However, diagnostic
thickness greater than 2 mm measured by ultra- validity of this finding remains controversial due
sound can be considered indicative of frozen to the poor specificity.
140 E. Silvestri et al.

a b

Fig. 16.4 The sonographic evaluation of axillary pouch than normal right shoulder (b). The capsule thickness is
is conducted with longitudinal scan, as shown in the delimited by calipers (courtesy of M. Zappia M.D.)
model (a). The affected shoulder (c) appears thickened

a b c

Fig. 16.5 Same patient as in Fig. 16.2. The sonographic appears thickened and more hypoechoic than normal right
evaluation of axillary pouch is conducted with axial scan, shoulder (b). The capsule thickness is delimited by arrows
as shown in the model (a). The affected shoulder (c)
16 Frozen Shoulder 141

racy, noninvasiveness, and capability to provide

a dynamic comparison between the affected and
unaffected sides.

Further Readings
Bunker TD. Frozen shoulder: unravelling the enigma.
Ann R Coll Surg Engl. 1997;79:210–3.
Carrillon Y, Noel E, Fantino O, Perrin-Fayolle O, Tran-­
Minh VA. Magnetic resonance imaging findings in
idiopathic adhesive capsulitis of the shoulder. Rev
Rhum Engl Ed. 1999;66:201–6.
Fig. 16.6 Synovial thickening and hyperemia around the Cheng X, Zhang Z, Xuanyan G, Li T, Li J, Yin L, Lu
biceps long head, US transverse scan; T tendon, synovial M. Adhesive capsulitis of the shoulder: evaluation
effusion (asterisk); courtesy of E. LaPaglia M.D. with US-arthrography using a sonographic contrast
agent. Sci Rep. 2017;7:5551.
Cleland J, Durall CJ. Physical therapy for adhesive cap-
sulitis: systematic review. Physiotherapy. 2002;88:
However, the diagnosis of adhesive capsuli- 450–7.
tis still substantially relies on the radiologist’s Codman EA. Tendinitis of the short rotators. In: Cod-
observation of limited abduction or external man EA, editor. Ruptures of the supraspinatus tendon
rotation during dynamic shoulder ultrasound. and other lesions on or about the subacromial bursa.
Thomas Todd: Boston, Mass; 1934.
The dynamic test is indicative of capsulitis if, Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ.
positioning the probe on an oblique coronal
­ 2005;331:1453–6.
plane, using the margin of the acromion as the Emig E, Schweitzer M, Karasick D, Lubowitz J. Adhe-
medial reference, there is a difficulty in sliding sive capsulitis of the shoulder: MR diagnosis. AJR.
1995;164:1457–9.
the supraspinatus tendon and the overlying tis- Homsi C, Bordalo-Rodrigues M, da Silva JJ, Stump
sue plane above the bone plane during abduction. XMGRG. Ultrasound in adhesive capsulitis of the
A similar test can be performed during external shoulder: is assessment of the coracohumeral liga-
rotation movements by evaluating on a transverse ment a valuable diagnostic tool? Skeletal Radiol.
2006;35:673–8.
plane the sliding of the subscapularis tendon; a Jewell DV, Riddle DL, Thacker LR. Interventions asso-
decrease in the range of movement in symptom- ciated with an increased or decreased likelihood of
atic patients is indicative of capsulitis. pain reduction and improved function in patients with
A recent study proposed the role of strain adhesive capsulitis: a retrospective cohort study. Phys
Ther. 2009;89:419–29.
and shear-wave elastosonography of the supra- Kline CM. Adhesive capsulitis: clues and complexities.
spinatus and infraspinatus tendons as an aid in JAMA Online. 2007:2–9.
the diagnosis of adhesive capsulitis. The authors Lee G, Briggs L, Murrell G. Ultrasound measurement
verified that a greater rigidity of tendon struc- of shoulder capsule thickness for diagnosing frozen
shoulder. J Sci Med Sport. 2010;13(suppl 1):e75.
tures is possible in idiopathic adhesive capsulitis; Lee JC, Sykes C, Saifuddin A, Connell D. Adhesive
most of the pathologies of rotator cuff tendons, capsulitis: sonographic changes in the rotator cuff
such as tendinopathies, ruptures, and impinge- ­interval with arthroscopic correlation. Skeletal Radiol.
ment syndromes, lead to a loss of rigidity of the 2005;34(9):522–7.
Martino F, Silvestri E, Grassi W, Garlaschi G. Muscu-
tissue, while in idiopathic adhesive capsulitis a loskeletal sonography. Milan, Berlin, Heidelberg,
greater rigidity is observed, probably due to post-­ New York: Springer; 2006.
inflammatory fibrosis and response to immobili- Park GY, Park JH, Kwon DR, Kwon DG, Park J. Do the
zation and adaptation to muscle tension. findings of magnetic resonance imaging, arthrog-
raphy, and ultrasonography reflect clinical impair-
Currently, in symptomatic patients, sonogra- ment in patients with idiopathic adhesive capsulitis
phy is recommended as the preferred first-line of the shoulder? Arch Phys Med Rehabil. 2017;98:
imaging modality due to its diagnostic accu- 1995–2001.
142 E. Silvestri et al.

Park J, Chai JW, Kim DH, Cha SW. Dynamic ultra- Walmsley S, Rivett DA, Osmotherly PG. Adhesive cap-
sonography of the shoulder. Ultrasonography. sulitis: Establishing consensus on clinical identifiers
2018;37(3):190–9. for stage 1 using the Delphi technique. Phys Ther.
Ryu KN, Lee SW, Rhee YG, Lim JH. Adhesive capsulitis 2009;89:906–17.
of the shoulder joint: usefulness of dynamic sonogra- Yun SJ, Jin W, Cho NS, Ryu KN, Yoon YC, Cha JG,
phy. J Ultrasound Med. 1993;12(8):445–9. Park JS, Park SY, Choi NY. Shear-wave and strain
Sernik RA, Vidal Leão R, Bizetto EL, Sanford Dama- ultrasound elastography of the supraspinatus and
sceno R, Horvat N, Cerri GG. Ultrasound. 2019;27(3): infraspinatus tendons in patients with idiopathic
183–90. adhesive capsulitis of the shoulder: a prospective
Tandon A, Dewan S, Bhatt S, Jain AK, Kumari R. Sonog- case-control study. Korean J Radiol. 2019;20(7):
raphy in diagnosis of adhesive capsulitis of the shoul- 1176–85.
der: a case–control study. J Ultrasound. 2017;20: Zuckerman JD, Cuomo F. Frozen shoulder. In: Matsen FA,
227–36. Fu FH, Hawkins RJ, editors. The shoulder: a balance
Van Holsbeeck M, Vanderschueren J, Shoulder of mobility and stability. Rosemont, IL: American
WJ. Sonography in adhesive capsulitis. Chicago, Academy of Orthopaedic Surgeons; 1993. p. 253–67.
USA: 83rd Annual Meeting of the Radiological Soci-
ety of North America; 1997.
 Septic Arthritis
17
Alessandro Muda and Fabio Martino

Contents
17.1 Introduction  143
17.2 Diagnostic Imaging  144
Further Readings  147

17.1 Introduction bacterial arthritis, particularly following knee

and hip arthroplasty.
In general, infectious arthritis is classified as pyo- Septic arthritis can be theoretically caused by
genic (septic) or nonpyogenic. Septic arthritis is a any bacterium; however the most common etio-
serious type of joint infection and may represent logical agent of all septic arthritis cases is
a direct invasion of joint space by various micro- Staphylococcus aureus, which causes a destruc-
organisms, most commonly caused by bacteria. tive form of acute arthritis, representing a real
Nonpyogenic infective arthritis tends to be less medical emergency. Patients with a history of
aggressive and has a more chronic course, with intravenous drug abuse, elderly, or immunocom-
causative organisms including Mycobacterium promised people display a higher prevalence of
tuberculosis, fungi, viruses, and spirochetes. infection by gram-negative organisms. The most
Arthritis can develop indirectly as a result of common gram-negative organisms are
hematogenous seeding or extension from a con- Pseudomonas aeruginosa and Escherichia coli.
tiguous focus of infection. Bacterial arthritis can Infants and older adults are more likely to
also arise following direct introduction, can be develop septic arthritis. The knees are most com-
accidental from penetrating trauma (also from monly affected, but septic arthritis can also affect
human or animal bite or from a fingernail wound), the hips, shoulders, and other joints. Typically,
or can be iatrogenic by intra-articular injection. septic arthritis affects one large joint, such as the
Joint surgery has increasingly been a source of knee or hip, and only one. Less frequently, septic
arthritis can affect multiple joints simultaneously.
A. Muda The infection can quickly and severely injure
Department of Radiology, IRCCS Policlinico San the cartilage and bone within the joint, so prompt
Martino-IST, Genova, Italy diagnosis and antibiotic treatment are crucial,
F. Martino (*) also to prevent permanent damage to the joint. An
Radiology, Sant’Agata Diagnostic Center, acute onset of monoarticular joint pain, joint
Bari, Italy

© Springer Nature Switzerland AG 2022 143

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_17
144 A. Muda and F. Martino

swelling by effusion, erythema, heat, and

impaired range of movement, with fever and
chills, should raise suspicion of sepsis. Clinical
evaluation, laboratory workup, and joint fluid
aspiration are the primary means of diagnosing
septic arthritis. The role of imaging is to confirm
the diagnosis and establish the presence and
severity of joint damage.

17.2 Diagnostic Imaging

Conventional radiograph still remains as the ini- Fig. 17.1 Tibiotalar septic arthritis. Joint effusion
tial imaging approach, but it has low sensitivity appears inhomogeneously echogenic with turbid and
and specificity for acute infection. In early stages sand-like appearance (*) suggestive of septic fluid collec-
the simple radiograph can be normal and this tion. ti tibia, ta talus
does not rule out infection. With further develop-
ment of the conditions, the typical radiological joint effusion is found, sonography alone cannot
picture shows severe osteoporosis, destruction of distinguish with certainty between septic arthritis
joint cartilages with joint space narrowing, and and other types of synovitis. In fact, septic arthri-
serious damage to bones. Therefore, X-ray allows tis demonstrates great variability in ultrasound
to identify late stages of the disease, when bone presentation, depending on the patient age, etio-
tissue is already damaged, and it is no more use- logical agent, evolutionary stage, and affected
ful for therapeutic decision-making. Early recog- joint. The ultrasound appearance can range from
nition of the presence of intra-articular effusion mild echogenic articular effusion to joint destruc-
in affected joint is the primary objective of diag- tion (Figs. 17.1 and 17.2a–e).
nostic imaging, because the absence of a joint In pediatric age, septic arthritis is relatively
effusion essentially excludes septic arthritis. frequent, most commonly involving the hip joint,
Both ultrasound and MRI can detect a joint effu- and can have potentially serious consequences,
sion; however ultrasound is preferred for its being considered a medical emergency. Prompt
accessibility and patient acceptance. However diagnosis is of paramount importance to avoid a
MRI and bone scintigraphy may be warranted to disastrous outcome, which can lead to joint
rule out adjacent osteomyelitis. Therefore, when destruction when the therapy is delayed or inad-
the diagnosis of septic arthritis is presumed, equate. A classic clinical presentation of septic
ultrasonography may be mostly beneficial not arthritis is a sudden onset of the pain and joint
only for a diagnostic confirmation, but also for discomfort (frequently at hip), and the presence
simultaneous, ultrasound-guided arthrocentesis of Kocher criteria (non-weight-bearing status on
with aspiration of the purulent effusion. the affected side; fever >38.5°; erythrocyte sedi-
Ultrasonography is more sensitive for detecting mentation rate (ESR) >40 mm/h; increase in
effusions, particularly in challenging joints, such serum white blood cell (WBC) count >12,000/
as the hip. This ability is especially useful in the mm3). But sometimes distinguishing septic
early diagnosis of newborn septic arthritis, arthritis from transient synovitis or other types of
because of the frequent paucity of clinical signs arthritis of the hip in a limping child could be
and symptoms in these patients. Usually, when a challenging. In fact, in the early stage of disease
17 Septic Arthritis 145

a b c

d e

Fig. 17.2 Long-standing rheumatoid arthritis and osteo- Ultrasound (d, e). Note the septic fluid collection (*) sur-
myelitis. Hot and swollen ankle for 4 weeks in a 68-year-­ rounding both screw extremities [i.e., the head (arrow)
old male, who underwent ankle arthrodesis 5 years before. and the tip (arrowhead)] and appearing as an inhomoge-
Conventional radiography (a, b). Images acquired using neous area characterized by hyperechoic spots of different
different projections. The arrows and the arrowheads indi- size and shape distributed in a less echogenic fluid mate-
cate the parts of the screw displayed in the ultrasound rial. t tibia, tp tibialis posterior tendon (Images courtesy of
images. Radiographic detail (c): note soft-tissue swelling MD Cipolletta E, Ancona)
around the tibia (empty arrows), related to septic infiltrate.

their clinical presentation could be similar but may help to distinguish septic arthritis from other
treatment and prognosis are very different. In different types. For example, the echogenicity of
these cases, although they are unable to provide exudate is usually anechoic and homogeneous in
diagnostic certainty, some echographic features transient arthritis while in septic arthritis it often
146 A. Muda and F. Martino

a b

Fig. 17.3 (a, b) Septic arthritis of the hip in a limping sion is present (large white arrow). (b) X-ray in the same
3-year-old child with mild hip pain. (a) Longitudinal US patient confirms the soft-tissue swelling around the
scan reveals a small effusion with inhomogeneous echo- involved joint, suggestive of effusion (empty white
genicity and synovial thickening. Metaphyseal bone ero- arrows) and bone erosion (small white arrow)

shows a cloudy and inhomogeneous aspect echographic evaluation reveals a monoarticular

(Figs. 17.3a, b, and 17.4a–c). Synovium thicken- and homogeneously anechoic effusion, and a
ing is generally present in juvenile idiopathic minimal synovial thickening without hypervas-
arthritis (for hypertrophy), moderate in septic cularity, arthrocentesis is still mandatory if the
arthritis (for edema), and minimally evident or clinical and laboratory results evoke septic
absent in transient arthritis. As a rule, synovial involvement. Conversely, septic arthritis must
hyperemia is present at power Doppler evalua- always be excluded even in situations where the
tion in septic arthritis and juvenile idiopathic clinical presentation is atypical. In this way,
arthritis, while it is generally least or absent in sonography can play a useful role in differential
transient arthritis. diagnosis. In doubt, a precise and unmistakable
However, we must remember that septic diagnosis is only possible through arthrocentesis
arthritis is a great mimic. Therefore, even if the and isolation of the bacterium.
17 Septic Arthritis 147

a b

Fig. 17.4 (a–c) Transient synovitis in a 5-year-old child to-­bone distance (calipers) related to joint effusion and to
with similar clinical presentation to that of the patient in synovial thickening (*). (c) Power Doppler US demon-
Fig. 17.2. (a) Frontal radiograph shows capsular swelling strates absence of intrasynovial increased flow
(empty white arrows). (b) US detects increased capsule-­

Marchal GJ, Van Holsbeeck MT, Raes M, et al. Transient

Further Readings synovitis of the hip in children: role of US. Radiology.
1987;162:825–8.
Chin TWY, Tse KS. Clinical and radiological differen- Martino F, Silvestri E, Grassi W, Garlaschi
tiation of septic arthritis and transient synovitis of the G. Musculoskeletal sonography. Springer: Milan,
hip. Hong Kong J Radiol. 2017;20:41–6. Berlin, Heidelberg, New York; 2006.
Goldenberg DL. Septic arthritis. Lancet. Merino R, de Inocencio J, Garcia-Consuegra
1998;351:197–202. J. Differentiation between transient synovitis of the
Gordon JE, Huang M, Dobbs M, et al. Causes of false-­ hip with clinical and ultrasound criteria. An Pediatr
negative ultrasound scans in the diagnosis of sep- (Barc). 2010;73(4):189–93.
tic arthritis of the hip in children. J Pediatr Orthop. Nguyen A, Kan JH, Bisset G, Rosenfeld S. Kocher criteria
2002;22:312–6. revisited in the era of MRI: how often does the Kocher
148 A. Muda and F. Martino

criteria identify underlying osteomyelitis? J Pediatr Taylor-Robinson D, Keat A. Septic and aseptic arthritis: a
Orthop. 2017;37(2):e114–9. continuum? Baillieres Best Pract Res Clin Rheumatol.
Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial 1999;13:179–92.
joint infections in England and Wales: analysis of bac- Zamzam MM. The role of ultrasound in differentiating
terial isolates over a four year period. Br J Rheumatol. septic arthritis from transient synovitis of the hip in
1997;36:370–3. children. J Pediatr Orthop. 2006;15:418–22.
Shirtliff ME, Mader JT. Acute septic arthritis. Clin Zieger MM, Dörr U, Schulz RD. Ultrasonography of hip
Microbiol Rev. 2002;15(4):527–44. joint effusions. Skelet Radiol. 1987;16:607–11.
Strouse PJ, DiPietro MA, Adler RS. Pediatric hip effu-
sions: evaluation with power Doppler sonography.
Radiology. 1998;206:731–5.
 Hemophiliac Arthropathy
18
Alessandro Muda and Fabio Martino

Contents
18.1 Introduction  149
18.2 Diagnostic Imaging  150
Further Readings  153

18.1 Introduction Hemorrhagic events may occur starting from

the first years of life, particularly when children
Hemophilia is an X-linked recessive bleeding start to walk (this demonstrates the importance of
disorder, caused by the deficiency or absence of mechanical forces in triggering the bleed).
blood-clotting factor VIII in hemophilia A or fac- In patients affected by hemophilia, bleeding
tor IX in hemophilia B. It is a disease that affects may be spontaneous or may follow a trauma. The
almost exclusively males. Based on the residual most common type of hemorrhage is the intra-­
coagulation factor activity level, the disease is articular one, which can take place anywhere,
classified as severe (<1%), moderate (1–5%), or but the most affected areas are the large synovial
mild (5–40%). joints of the knees, elbows, and ankles. The pre-
The most common presentation is an increased dilection for these sites is probably related to the
bleeding tendency; recurrent hemarthrosis is the abundant vascularization of synovial tissue and
distinctive sign of severe hemophilia and may to the combination between deficiency of clotting
lead to hemophilic arthropathy, a disease caus- factors and intensive mechanical forces.
ing pain and affecting the patients’ quality of After a single bleed, alterations seem to be
life. Women are asymptomatic carriers and may transient, except for vascular changes that are
rarely have acquired hemophilia (immunological probably irreversible and increase the risk of
origin). recurrent bleeding. Therefore, in case of repeated
bleedings, the synovial cleaning capacity might
be damaged, resulting in iron accumulation
A. Muda with deposits of hemosiderin. This event gener-
Department of Radiology, IRCCS Policlinico San ates hemoglobin-mediated inflammation, neo-­
Martino-IST, Genova, Italy angiogenesis, synovial hyperplasia, and bone
F. Martino (*) degeneration. The latter alterations are related to
Radiology, Sant’Agata Diagnostic Center, degenerative arthropathy and are characterized
Bari, Italy

© Springer Nature Switzerland AG 2022 149

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_18
150 A. Muda and F. Martino

by the development of cysts, osteophytes, sub- have been shown to be particularly effective in
chondral sclerosis, epiphyseal enlargement, and detecting early changes in soft and osteochon-
osteoporosis. dral tissue in patients with hemophilia, before
Conservative treatment and orthopedic such changes become evident on physical exam-
approach are the only therapeutic options for ination or simple radiographs. However, MRI
hemophilic arthropathy. For this reason, with the is not easily accessible and may require seda-
purpose of recognizing early changes in joints tion in young children. The pathological condi-
and preventing the progression of this disease-­ tions that can be demonstrated with sonography
related arthropathy, periodic US monitoring of are synovial hyperplasia, hemarthrosis, bursal
the joint has been recommended. bleeding (Fig. 18.1), joint effusion, erosions of
the articular cartilage (where visible), changes
in the bone surface, muscle hematoma, and
18.2 Diagnostic Imaging pseudotumor.
Spontaneous bleeding into the muscle occurs
Clinical confirmation of hemarthrosis and between 10% and 23% of hemorrhagic episodes
changes in synovial and osteochondral structures in the musculoskeletal system, and may involve
is essential for the selection process among the any muscle, even in the absence of trauma. The
options available for the treatment of patients forearm, quadriceps, calf, and iliopsoas are most
with hemophilia. Even when the presence of often involved, the latter having particularly
a muscle hematoma is suspected, it is essential severe clinical presentation (Fig. 18.2a–c).
to demonstrate its presence, undertake the most When muscle hemorrhage is suspected, con-
appropriate therapy, and avoid complications. firmation should be obtained by imaging. Hence,
Given the absence of biomarkers or other labo- immediate enhanced on-demand hematologi-
ratory results that could help diagnose muscu- cal treatment must be started until the complete
loskeletal abnormalities in hemophilic patients, disappearance of the hematoma. If untreated,
imaging techniques are used to provide objective muscle bleeding can cause complications such
information on joint status and improve the effi- as nerve injury, compartment syndrome, myositis
cacy and timeliness of treatment. ossificans, pseudotumor, and even infection.
X-rays are widely available and may cap- Recurrent hemarthrosis can induce early vil-
ture advanced joint changes but are insensitive lous hyperplasia of the synovium and, subse-
to early change and unreliable for cartilage and quently, a characteristic hemophilic arthropathy.
soft-tissue evaluation. X-ray grading systems/ Ultrasound is useful to detect early stages of
scores include the Arnold–Hilgartner score hemophilic arthropathy, as opposed to conven-
(progressive, soft-tissue assessment included) tional radiology that is not able to show synovial
and widely used Pettersson score (additive, soft proliferation and initial cartilaginous damage.
tissue excluded). Instead, MRI and ultrasound Ultrasound is also crucial to monitor the hem-

Fig. 18.1 Young male

with severe hemophilia.
Longitudinal US scan of
the anterior aspect of the
hip demonstrating
enormous distention of
the iliopectineal bursa
(calipers) by echogenic
effusion (asterisks) due
to recent intra-bursal
bleeding
18 Hemophiliac Arthropathy 151

b c

Fig. 18.2 (a–c) Patient with severe hemophilia. (a) of the muscle hemorrhage (*). (c) Echographic control
Transverse non-contrast computed tomography (CT) scan just after sudden recurrence of pain shows the presence of
detected an old iliopsoas hemorrhage, evident as an intra- recent rebleeding (empty white arrow), which appears
muscular area of hypodensity (*). (b) Transverse sono- echogenic and easy to discriminate from the mostly reab-
gram in the same patient depicts the echo-free appearance sorbed previous hemorrhage (*)

orrhage and to investigate the response to treat- Synovial hyperplasia can be observed as the
ment. An acute bleeding appears echogenic on presence of solid formations bulging in the syno-
sonography, because of the high reflectivity of vial cavities (Fig. 18.4a, b). Ultrasound may also
fresh blood; another sign of acute bleeding is detect hemosiderin deposits that can be seen as
capsular distension (Fig. 18.3a, b). hypoechoic areas in the context of the hypertro-
152 A. Muda and F. Martino

phied synovium, but when deposition of hemo- sporadic hypervascular “spots” indicating a mod-
siderin is bland it is difficult to distinguish it from erate vascularization of this condition.
the synovium. Given these considerations, the Doppler
Color and power Doppler ultrasound is used in technique has low sensitivity in evaluating the
some chronic inflammatory arthropathies to esti- vascular asset in this disease; this determines
mate disease activity by demonstrating hypervas- a marginal role of this technique in predict-
cular patterns. However, in hemophilic patients it ing recurrent bleeding, in orienting therapeutic
is uncommon to observe Doppler positivity, with choices, and in patient management in general.
Hemarthrosis can lead to excessive distension
of the joint capsule, exerting compression against
a
adjacent tissues; at elbow it may result in cubi-
tal tunnel syndrome by compression of the ulnar
nerve (Fig. 18.5).
In the knee, hemarthrosis leads to joint capsule
distension, mainly of the suprapatellar recess.

Fig. 18.3 Ultrasound view of the knee joint of 15-year-­

old patient with severe hemophilia. Note the acute hemar- Fig. 18.5 Ultrasound of the elbow cubital tunnel show-
throsis (a) characterized by the hyperechoic effusion ing capsular swelling (arrows) by chronic hemarthrosis
(asterisks). A check performed after 7 days (b) shows the and consequent compression and dislocation of the ulnar
anechoic aspect of joint bleeding (circles) nerve (U)

a b

Fig. 18.4 Recurrent hemarthrosis in hemophilic patients. synovial recess which appears distended from abundant
(a) Sagittal posterior scan of the elbow shows capsular anechoic effusion (asterisk), related to previous hemar-
swelling, filled by synovial polypoid tissue (asterisk). (b) throsis. Synovial villous thickening is also depicted
Transverse US scan of the knee depicts the suprapatellar (arrows) (Image courtesy of MD Martella L, Lecce)
18 Hemophiliac Arthropathy 153

At the beginning, the articular cartilage Further Readings

changes are characterized only by a decrease in
its natural echogenicity, and then the persistence Debkowska MP, Cotterell IH, Riley AJ. Case report: acute
cubital tunnel syndrome in a hemophiliac patient.
of the damaging insult results in loss of thick- SAGE Open Med Case Rep. 2019;7:1–3.
ness. When the cartilage is almost completely Di Minno MND, Pasta G, Airaldi S, Zaottini F, Storino A,
reabsorbed, initial subchondral bone alterations Cimino E, Martinoli C. Ultrasound for early detection
might become evident. Ultrasound can detect of joint disease in patients with hemophilic arthropa-
thy. J Clin Med. 2017;6(8):77.
superficial alterations in subchondral bone, such Doria AS, Keshava SN, Mohanta A, Jarrin J, Blanchette V,
as osteophytes, surface irregularities, and cysts. Srivastava A, et al. Diagnostic accuracy of ultrasound
Bone erosions and cysts are different; the for- for assessment of hemophilic Arthropathy: MRI cor-
mer are in continuity with the bone surface, and relation. AJR. 2015;204(3):W336–47.
Klukowska A, Czyrny Z, Laguna P, Brzewski M, Serafin-­
the latter instead have no contact with it and can Krol MA, Rokicka-Milewska R. Correlation between
be peripheral or central. Ultrasound emerges as clinical, radiological and ultrasonographical image
the most efficient tool for the early detection of knee joints in children with haemophilia. Haemo-
of arthropathy, and the HEAD-US score (scor- philia. 2001;7:286–92.
Martino F, Silvestri E, Grassi W, Garlaschi G. Muscu-
ing method for Haemophilia Early Arthropathy loskeletal sonography. Milan, Berlin, Heidelberg,
Detection with Ultrasound) can be used for the New York: Springer; 2006.
consistent assessment of hemophilic joints opti- Martinoli C, Della Casa Alberighi O, Di Minno G, et al.
mizing the management of destructive changes. Development and definition of a simplified scanning
procedure and scoring method for Haemophilia early
A simplified scanning and scoring method of this Arthropathy detection with ultrasound (HEAD-US).
procedure was proposed by Martinoli (2013). Thromb Haemost. 2013;109:1170–9.
Sonography has technical limitations in detect- Soliman M, Daruge P, Dertkigil SSJ, De Avila FE, Negrao
ing most of the central subchondral cysts, and in JR, de Aguiar Vilela MS, et al. Imaging of haemo-
philic arthropathy in growing joints: pitfalls in ultra-
investigating the medullary bone and the surfaces sound and MRI. Haemophilia. 2017;23(5):660–72.
deep in the joint cavity. Van Vulpen LFD, Holstein K, Martinoli C. Joint disease
These weaknesses make ultrasound less in haemophilia: pathophysiology, pain and imaging.
comprehensive than MR imaging; nevertheless, Haemophilia. 2018;24(Suppl. 6):44–9.
Zhang CM, Zhang JF, Xu J, Guo YL, Wang G, Yang
echography has several advantages: it is faster LH. Musculoskeletal ultrasonography for arthropa-
and less expensive, it can evaluate multiple thy assessment in patients with hemophilia: a single-­
joints in the same session thanks to its quick- center cross-sectional study from Shanxi Province.
ness, it avoids ferromagnetic interactions and China Medicine (Baltimore). 2018;97(46):e13230.
claustrophobia problems, it can be adapted to
patients with movement limitations, and it allows
dynamic study.
 Part III
Ultrasound Pathologic Findings
in Orthopedic Diseases
 Bone Trauma
19
Luca Cavagnaro, Davide Orlandi , Enzo Silvestri,
Armanda De Marchi, and Elena Massone

Contents
19.1 Introduction  157
19.2 Fractures  158
19.3 Stress Fractures  160
Further Readings  161

19.1 Introduction

The use of ultrasound (US) in musculoskeletal

medicine has evolved rapidly over the last two
decades. This is due to the advantage of having
introduced high-resolution linear broadband
multifrequency probe and the clinical collabora-
tion which allows an accurate management of the
traumatic patient. However, despite this, US is
not routinely used for fracture detection.
L. Cavagnaro The normal bone appears like a hyperechoic
Ortopedia e Traumatologia 2- Joint Replacement,
Unit/Bone Infection Unit, Ospedale Santa Corona, line with posterior acoustic shadow due to the
Pietra Ligure, Italy complete reflection of the US waves. This straight
D. Orlandi (*) regular interface separates the bone from the soft
Department of Radiology, Ospedale Evangelico tissues allowing a clear distinction between the
Internazionale, Genova, Italy two structures. A fracture is visualized as a break
E. Silvestri of the echogenic surface of the bony cortex. The
Radiology, Alliance Medical, Genova, Italy modifications of peripheral soft tissue depend on
A. De Marchi the time when the fracture occurred (Fig. 19.1).
Radiologia CIDIMU: Centro Italiano di Diagnostica One cadaver study showed that US can be
Medica Ultrasonica, Torino, Italy used to accurately detect cortical disruption as
E. Massone small as 1 mm. US is noninvasive; it can pro-
Department of Radiology, Ospedale Santa Corona, vide both real-time and dynamic multiple plane
Pietra Ligure (SV), Italy

© Springer Nature Switzerland AG 2022 157

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_19
158 L. Cavagnaro et al.

a b

Fig. 19.1 Longitudinal (a) and transverse (b) scan of a rib. A focal disruption in the cortex line is evident (circles) with
a small amount of hematoma in the soft tissue (stars)

images and does not emit ionizing radiation.

The ultrasonography is performed with a high-­
frequency transducer 10–18 MHz for the superfi-
cial bone (e.g., metatarsal shaft) and with a lower
frequency transducer (5–10 MHz) for bones
with deeper localization (e.g., femur), in two-­
dimensional mode. This modality is particularly
useful in vulnerable population such as children
and pregnant women who are particularly sensi-
Fig. 19.2 Longitudinal US scan of the extensor region of
ble to such radiation. The clinical data like pain, the third finger of the hand shows a small avulsed bony
swelling, ecchymosis, and/or deformity represent fragment (calipers)
the important starting point in ultrasonographic
examination. The probe is placed perpendicular nose the majority of fractures and assess the dis-
to the region and studies each bone in ­longitudinal location of bony ends. In particular, in complex
and axial planes. Some authors noted that the anatomical areas diagnosis and fracture exten-
evaluation method involving more planes allows sion determination can be performed with CT. US
a circumferential view of each bone, reducing the may be useful for patients with persistent local-
risk of not detecting the fractures. ized pain, 2–3 weeks after trauma, with negative
In some difficult anatomical regions it is use- initial radiographic examination.
ful to perform a comparative image to use as a Ultrasonography is able to visualize irregular-
reference. In fact in some traumatic cases, it is ity, defect, and discontinuity in the cortical mar-
hard to differentiate nonpathological marginal gin as well as small bone fragment avulsion
irregularities, osteophytes, or vascular channels (Fig. 19.2).
from fractures. One of the most common bone defects is the
Hill-Sachs lesion, an irregular depression in the
posterolateral aspect of the humeral head due to
19.2 Fractures anterior shoulder dislocation. US is also an effi-
cient modality to assess the bone size and depth
In acute trauma, ultrasonography does not repre- in a Hill-Sachs lesion (Fig. 19.3).
sent the first imaging modality for diagnosing Compared to surgery, US has 96% sensitivity,
bone fractures. Standard radiographs can diag- 100% specificity, and 97% accuracy in the diag-
19 Bone Trauma 159

nosis. Several reports have described the useful- uncomplicated torus and greenstick pediatric
ness of US in diagnosing nondisplaced fractures forearms, investigators achieved 100% sensitiv-
that are difficult to see on standard radiographs ity and specificity in the identification of these
such as ribs, scaphoid, metatarsus, clavicle, orbit, fractures. In recent literature, in emergency
femur, and humerus. In the chest, US can also department the sensitivity and specificity of dis-
help to differentiate rib fractures from metasta- tal forearm bone fractures compared with radiog-
ses. Several articles have pointed out the utility of raphy were 94.4% and 96.8%, respectively.
US for detecting fractures in pediatric population As known in literature and as proved in
in particular in bone diagnosis of long bone frac- another study conducted in the same emergency
tures in children, those of the distal forearm, with condition US is extremely efficient also in other
good sensitivity and specificity in comparison anatomical sites in detecting the long bone frac-
with radiographs. In a previous study of 26 tures, with 100% sensitivity in humerus and fem-
oral mid-shaft fractures. This can confirm what
some authors have already suggested in previous
studies that bedside US is highly specific in the
detection of bone fractures. US is particularly
useful for detecting fractures in the immature
skeleton of children. In young sportsmen an avul-
sion fracture is frequently recognized when the
growth plate of an apophysis is injured due to a
sudden and forceful contraction of the attaching
musculotendinous unit (Fig. 19.4).
Adolescents are those who usually sustain
these injuries, and there is a significant male pre-
ponderance. However, in many of these studies,
US was more effective in detecting fractures of
Fig. 19.3 Longitudinal scan of the humerus head: Hill-­
Sachs fracture shows a cortical depression in the posterior-­
large bones. In addition US was less reliable for
superior portion of the humeral head (white arrows) compound injuries and fractures adjacent to joint,

a b

Fig. 19.4 Longitudinal scan of the anterior inferior iliac spine. (a) Normal US aspect (open arrow) and (b) avulsion
(white arrow) of the anterior inferior iliac spine
160 L. Cavagnaro et al.

a b

Fig. 19.5 (a) Longitudinal scan of the distal radius evidences a bulging of the cortex in “torus fracture” involving the
distal radial metaphysis (white line). (b) Corresponding X-ray confirming the “torus fracture”

lesions of the small bone of the hand and foot, fracture is not suspected because no history of
and undisplaced epiphyseal fractures. A cortical injury is recalled may complain pain in a swollen
discontinuity after a direct or indirect trauma has area. In these cases the sonographic evaluation
an important diagnostic value in the management targeted to the tender area can show a soft-tissue
of pediatric and adult patients. The sonography thickening, a focal periosteal reaction, or a corti-
can illustrate bone alignment, which is crucial cal discontinuity and local hematoma. Also corti-
also during treatment avoiding multiple attempts cal irregularities and hypertrophic changes may
with conventional radiographic techniques. The be visualized before they are seen on plain radio-
sonographic monitoring can provide real-time graphs or MRI.
observation that can guide and confirm the closed The lower limbs, in particular foot and ankle,
reduction of extra-articular distal radial fractures are body areas that are most commonly exposed
(Fig. 19.5a, b). to trauma. US can be helpful in assessing early
metatarsal stress fractures. In addition according
to the results of a recent paper US has high sensi-
19.3 Stress Fractures tivity, high specificity, negative predictive value
of about 100%, and favorable likelihood ratios in
Stress fractures are caused by repetitive force, the diagnosis of metatarsal fractures. However,
often from overuse in sportsmen: fatigue frac- the tibia is the most commonly implicated in run-
tures. These can also develop from the normal ners besides metatarsal bone. In this setting, the
use of a bone that is weakened by a condition US diagnosis of tibia stress fractures has only
such as osteoporosis: insufficiency fractures. been reported in a few cases.
In stress fractures the standard radiography is In the upper limbs, literature shows that in
negative and the fracture can only be seen once about 20–25% of patients with a scaphoid frac-
the reparative calcified callus is formed. A clini- ture initial radiographs are negative leading to a
cal history focused on the length, time, and delayed diagnosis. The diagnostic accuracy when
mechanism of injury must be stressed. The pos- performing US examination always depends on a
sibility to localize and limit the examination to good knowledge of the normal US anatomy. In
the site of injury represents the advantage of the fact, concerning the scaphoid trauma, a focal US
US over CT and MRI. irregularity of the cortex can show the normal
With the development of high-resolution aspect of tuberosity.
probes US is providing an excellent method for The ultrasound may help in the diagnosis
detecting occult fracture. Patients in whom a showing indirect signs of traumatic lesions like
19 Bone Trauma 161

a b

Fig. 19.6 (a) US longitudinal image obtained over the MRI T2 axial image shows bone marrow edema (white
diaphysis of the metatarsal shows a non-displaced fracture star) of the third metatarsal bone with surrounding perios-
(black arrow) and hyperechogenicity of the surrounding teal and soft-tissue reaction
soft tissue with periosteal thickening (white circles). (b)

an articular fluid effusion. A particular site fre- movement of the patient due to pain, and the
quently negative on radiographs is the sternal absence of significant displacement. Early diag-
region where fractures are visible in 8–10% of nosis in this case depends on MRI or on bone
patients with blunt trauma in the chest. The diag- scan scintigraphy, which is considered to be the
nosis of sternal radiography is often delayed. “gold standard.” The high cost of these imaging
Sonography is easy to perform on a patient who modalities, the poor accessibility of MRI, and the
is lying down. Even if several reports have exposure to ionizing radiation of the scintigraphy
described the usefulness of US in diagnosing make US the chosen imaging modality. The
sternal fractures some authors think that com- sonographic findings correlated well with
puted tomography represents the best imaging MRI. In stress fractures, US offers dynamic
modality and is superior to sonography in sternal images in a noninvasive, fast, and inexpensive
evaluation. In this setting, the differences in the manner. With high-quality equipment, experi-
US imaging aspect of bone injuries could be due ence, and academic ability of ultrasound opera-
to the different qualities of US devices used. tors, US can become an important and useful
In more recent literature the bone stress lesion advantageous tool in the evaluation of fractures
has showed different US aspects depending on and occult injuries.
the age, gender, history of repetitive sport activ-
ity, and anatomical region involved. In the site of
pain the hyperechogenicity of the surrounding
Further Readings
soft tissue indicates edema and inflammatory
reaction without cortical alteration. The thicken- Arni D, et al. Insufficiency fracture of the calcaneum: sono-
ing of the periosteum, the cortical disruption, and graphic findings. J Clin Ultrasound. 2009;37:424–7.
an increased periosteal color Doppler flow in the Backhaus M, et al. Guidelines for musculoskel-
bone lesion sites are evident signs of bone injury etal ultrasound in rheumatology. Ann Rheum Dis.
2011;60:641–9.
(Fig. 19.6). Banal F, et al. Sensitivity and specificity of ultrasonog-
Stress fractures are especially prominent in raphy in early diagnosis of metatarsal bone stress
individuals who suddenly increase physical fractures: a pilot study of 37 patients. J Rheumatol.
activity. It is important to diagnose stress frac- 2009;36:1715–9.
Banal F, et al. Ultrasound ability in early diagnosis of
tures early to prevent bone remodeling, nonunion stress fracture of metatarsal bone. Ann Rheum Dis.
injuries, and loss of function. It is well known 2006;65(7):977–8.
that radiographs have oftentimes yielded nega- Betrame V, et al. Sonographic evaluation of bone frac-
tive results until one callus is formed, for several tures: a reliable alternative in clinical practice? Clin
Imaging. 2012;36:303–8.
reasons: the small size of the fracture, the limited
162 L. Cavagnaro et al.

Bodner G, et al. Sonographic findings in stress fractures Lazovic D, et al. Ultrasound of diagnosis of apophy-
of the lower limb: preliminary findings. Eur Radiol. seal injuries. Knee Surg Sport Traumatol Rtrosc.
2005;15:356–9. 1996;3:234–7.
Canagasabey MD, et al. The sonographic Ottawa Foot and Marshburn TH, et al. Goal-directed ultrasound in
Ankle Rules study (the SOFAR study). Emerg Med J the detection of long-bone fractures. J Trauma.
EMJ. 2011;28(10):838–40. 2004;57:329–32.
Cho KH, et al. Sonography of bone and bone-related McNeil CR, et al. The accuracy of portable ultrasonogra-
diseases of the extremities. J Clin Ultrasound. phy to diagnose fractures in an austere environment.
2004;32:511–21. Prehosp Emerg Care. 2009;13:50–2.
Cicak N, et al. Hill-Sachs lesion in recurrent shoulder Mohsen E, et al. Diagnostic accuracy of ultrasonogra-
dislocation: sonographic detection. J Ultrasound Med. phy in diagnosis of metatarsal bone fracture: a cross-­
1998;17:557–60. sectional study. Arch Acad Emerg Med. 2019;7(1):e49.
Engin G, et al. US versus conventional radiography Nicholson JA, et al. What is the role of ultrasound in frac-
in the diagnosis of sternal fractures. Acta Radiol. ture management? Diagnosis and therapeutic poten-
2000;41:296–9. tial for fractures, delayed unions, and fracture-related
Environmental Protection Agency. Radiation protection. infection. Bone J Res. 2019;8(7):304–12.
2013. http://www.cdc.gov/rpdweboo/health_effects. Pancione L. Diagnosis of Hill-Sachs lesion of the shoul-
html. Accessed 1 Feb 2013. der. Comparison between ultrasonography and arthro-
Galletebeitia Laka I, et al. The utility of clinical ultraso- ­CT. Acta Radiol. 1997;38:523–6.
nography in identifying distal forearm fractures in the Papalada A, et al. Ultrasound as a primary evaluation tool
pediatric emergency department. Eur J Emerg Med. of bone stress injuries in elite track and field athletes.
2019;26(2):118–22. Am J Sports Med. 2012;40:915–9.
Graif M, et al. Sonographic detection of occult bone frac- Patel DS, et al. Stress fracture: diagnosis, treatment, and
ture. Pediatr Radiol. 1988;18:383–5. prevention. Am Fam Physician. 2011;83:39–46.
Greaney RB, et al. Distribution and natural history of Patten RM, et al. Nondisplaced fractures of the greater
stress fractures in U.S. Marine recruits. Radiology. tuberosity of the humerus: sonographic detection.
1983;146(2):339–46. Radiology. 1992;182:201–4.
Grechenig W, et al. Scope and limitation of ultrasonogra- Pohl M, et al. Biomechanical predictors of retrospec-
phy in the documentation of fractures-an experimental tive tibial stress fractures in runners. J Biomech.
study. Arch Ortop Trauma Surg. 1998;117:368–71. 2008;41:1160–5.
Griffith JF, et al. Sonography compared with radiography Romani WA, et al. Identification of tibial stress fractures
in revealing acute rib fracture. AJR Am J Roentgenol. using therapeutic continuous ultrasound. J Orthop
1999;173:1603–9. Sports Phys Ther. 2000;30:442–52.
Hamer D-d, et al. Ultrasound for distal forearm fractures: Sayed A, et al. Ultrasonography of occult fractures: a pic-
a systematic review and diagnostic meta-analysis. torial essay. Can Assoc Radiol J. 2001;52(5):312–21.
PLoS One. 2016;11:e0155659. Sofka CM. Imaging of stress fractures. Clin Sport Med.
Hills MW, et al. Sternal fracture: associated injuries and 2006;25:53–62.
management. J Trauma. 1993;35:55–60. Tai-Chang C, et al. Sonography of monitoring closed
Hodgkinson DW, et al. Scaphoid fracture: a new method reduction of displaced extra-articular distal radial
of assessment. Clin Radiol. 1993;48:398. fractures. J Bone Joint Surg Am. 2002;84(2):194–203.
Hubner U, et al. Ultrasound in the diagnosis of fractures in Warden S, et al. Stress fractures: pathophysiology, epi-
children. J Bone Joint Surg Br. 2000;82:1170–3. demiology, and risk factors. Curr Osteoporos Rep.
Hurley ME, et al. Is ultrasound really helpful in the detec- 2006;4:103–9.
tion of rib fractures? Injury. 2004;35:562–6. Weinberg ER, et al. Accuracy of the clinician performed
Jones SL, Phillips M. Early identification of foot and point of care ultrasound for the diagnosis of fractures
lower limb stress fractures using diagnostic ultraso- in children and young adults. Injury. 2010;41:862–8.
nography: a review of three cases. Foot Ankle Online Williamson D, et al. Ultrasound imaging of forearm frac-
J. 2010;3:3. tures in children: a viable alternative? J Accid Emerg
Khy V, et al. Bilateral stress fracture of the tibia diag- Med. 2000;17:22–4.
nosed by ultrasound: a case report. J Ultrasound. Wook Jin MD, et al. Diagnostic value of sonography for
2012;15:130–4. assessment of sterna fractures compared with conven-
Krestan C, Hojreh A. Imaging of insufficiency fractures. tional radiography and bone scan. J Ultrasound Med.
Eur J Radiol. 2009;71(3):398–405. 2006;25:1263–8.
 Muscle Injury
20
Giulio Pasta, Davide Orlandi , Enzo Silvestri,
Biagio Moretti, Lorenzo Moretti, Davide Bizzoca,
Piero Volpi, and Gian Nicola Bisciotti

Contents
20.1 Introduction  163
20.2 Imaging of Muscle Injuries  164
20.3 Classification of Muscle Injuries  168
20.3.1   Injuries from Direct Trauma  169
20.3.2   Injuries from Indirect Trauma  170
20.3.2.1 Nonstructural Muscle Injuries  171
20.3.2.2 Structural Muscle Injuries  172
20.3.3   Complications  173
Further Readings  175

20.1 Introduction

G. Pasta Muscle injuries are frequently related to sport

Specialista in Radiologia e Diagnostica per Immagini, activities but also to daily and working life.
Studio Associato di Radiologia Dr. Pasta,
Muscle injuries represent the most common trau-
Emilia-Romagna, Italy
matic event in the field of sports medicine, which
D. Orlandi (*)
account for up to 30% of all sports-related pathol-
Department of Radiology, Ospedale Evangelico
Internazionale, Genova, Italy ogy. For example, considering professional foot-
ball players, the most frequently affected
E. Silvestri
Radiology, Alliance Medical, Genova, Italy anatomical area by “time-loss injuries” (e.g., all
those accidents that force the athlete to stop prac-
B. Moretti · L. Moretti · D. Bizzoca
Orthopedic & Trauma Unit, Department of Basic ticing the sport, causing a significant impact on
Medical Sciences, Neuroscience and Sense Organs, the team) is the thigh (with hamstrings being the
University of Bari “Aldo Moro”, AOU Consorziale most commonly involved muscle group), fol-
“Policlinico”, Bari, Italy
lowed by the knee, ankle, and groin.
P. Volpi When facing a muscle injury, a diagnostic
IRCCS Humanitas Research Hospital, Milano, Italy
hypothesis could be formulated looking at the
G. N. Bisciotti clinical data (patient history and physical exami-
Kinemove Rehabilitation Centers, Pontremoli (SP),
nation). Then, a complete patient history collec-
Italy

© Springer Nature Switzerland AG 2022 163

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_20
164 G. Pasta et al.

tion (symptoms, mechanism of trauma, previous lacked subgroups and therefore muscle lesions
accidents) and a thorough physical examination with different etiology, clinics, treatment, and
(ecchymosis and swelling, muscle palpation, and prognosis were classified into the same group.
positivity to clinical tests), together with proper If on the one hand the Maffulli-Chan classifi-
diagnostic imaging, allow to reach a precise cation was important because of its anatomical
diagnosis. accuracy (that allows to discriminate between the
Considering the high incidence of muscle different locations of lesions and therefore under-
injuries in sports, efforts have been made in order stand that, for example, a lesion in the proximal
to reduce the number of these accidents. The first third of the hamstrings is more severe than a
step in this direction has been the attempt to lesion in the distal third and requires a longer
establish an unequivocal, universally recognized recovery time), on the other hand it could have
classification of muscle injuries. the limitation of not being very clinical, while the
In the last century, several classifications were Munich classification is very precise in clinical,
proposed: but not anatomical, terms.
Hence, the I.S.Mu.L.T. decided to integrate
• O’Donoghue, 1962. these two classifications to produce a classifica-
• Ryan, 1969. tion that in the near future could be universally
• American College of Sports Medicine,1980. recognized as an aid to the diagnostic and thera-
• Takebayashi, 1995. peutic process and:
• Stoller, 2007.
• Allows a faster return to activity.
Nowadays, especially in Italy, the most com- • Reduces complications.
monly used classification is the one proposed in • Minimizes relapses.
2000 by the Isokinetic group of Dr. Nanni, which
is very practical, functional, and schematic, based If we look at this new I.S.Mu.L.T. classifica-
on the pathogenesis, clinics, and imaging. tion from an ultrasound imaging point of view,
However, by the end of 2012 some new clas- muscular lesions are divided into two broad cat-
sifications emerged that revolutionized the field egories depending on the mechanism of injury
of muscular injury classifications. (Table 20.1):
The first classification, proposed by Maffulli-­
Chan, is more anatomy-oriented and based on • From direct trauma.
echo-MR imaging, allows to accurately define • From indirect trauma.
the anatomical site of the injury, and therefore is
more precise in terms of prognosis and healing
times, which is extremely important for profes- 20.2 Imaging of Muscle Injuries
sional sports teams (although it is advisable to
integrate imaging with clinical data). The authors The two main techniques used for studying mus-
believe that imaging is important not only to cular lesions are ultrasound (US) and magnetic
understand which athletes can be submitted to resonance imaging (MRI). These two techniques
surgical intervention in case of high-grade mus- should be considered complementary and not
culotendinous lesions, but also to anticipate when mutually exclusive; however, it is clear that being
the athlete will be able to return to the field. able to always perform both is utopic, especially
Later in 2012, the so-called Munich consensus in the world of nonprofessional sports. Therefore,
classification was proposed, similarly based on the best way forward is to use ultrasound as the
echo-MRI. This classification, more clinically ori- first-level examination, considering MRI when
ented than the previous one, divides muscle lesions US is inconclusive, when there is a mismatch
into various subgroups based on clinical and imag- between clinical examination and US, and for the
ing features. The relevance of this classification assessment of severe injuries with tendon
lies in the fact that the previous classifications involvement.
20 Muscle Injury 165

Table 20.1 Classification of muscle injuries according to the I.S.Mu.L.T guidelines

Injury Division Type Classification Definition US/MRI
Indirect Nonstructural I: Muscle 1A: Fatigue Sore, circumscribed Ultrasound negative or
injury disorder related induced increase of tone with hypo/hyperechogenic
to overexertion 1B: DOMS within a muscle. zone that disappears after
(delayed-onset 1B: Widespread 3–5 days and negative
muscle soreness) increase in muscle power Doppler. MRI
Il: 2A: tone and pain that negative or with limited
Neuromuscular Neuromuscular appears a few hours edema
disorder related to vertebral after physical activity
column disorders
and/or pelvis
2B:
Neuromuscular
related to muscle
Structural III: Partial 3A: Minor partial Injury of one or more Positive for fiber ruptures.
injury muscle injury injury primary bundles Intramuscular hematoma
within a secondary
bundle
3B: Moderate Injury of at least one Positive for significant
partial injury secondary bundle, fiber rupture, including
with an area of probable retractions.
rupture involving Lesions of the fascia and
<50% of the muscle intermuscular hematoma
surface
IV: (sub)total 4: Subtotal or total Lesion involving Subtotal or total
muscle injury injury or tendon >50% of the muscle musculotendinous
avulsion surface (subtotal) or discontinuity. Possible
involving the whole retraction and wavy tendon
muscle (total) or the morphology.
osteotendinous Lesions of the fascia and
junction intermuscular hematoma
Direct Contusion Mild: >1/2 ROM Direct trauma that Diffuse or circumscribed
Moderate: <1/2 causes diffuse or hematoma of variable size
and > 1/3 ROM limited hematoma and
Severe: <1/3 ROM causes pain and
decreased ROM
Tear

Ultrasound is a valid tool in the identifica- These problems are solved with MRI, because
tion and staging of muscle lesions, in the of its intrinsic advantages:
assessment of their evolution, and in the detec-
tion of complications thanks to its intrinsic • Multiparametricity (there are multiple
characteristics (cheap, quick, repeatable, best sequences and in this case sequences with a
anatomical detail of superficial structures, real- high intrinsic contrast (fluid sensitive) are of
time dynamic imaging, easy vascularity particular importance, for example STIR and
assessment). T2 that allow to discriminate even minor
However, US also suffers from some alterations).
disadvantages: • Sensitivity of 92%, compared to 76% of US.
• Panoramic view, based on the possibility to
• Limited view (some sites are inaccessible have a wider view on the affected area, also
because they are too deep or hidden or their allowing exploration of sites that were inac-
morphology is difficult to study). cessible with US.
• Early assessment of tears is limited by a sig-
nificantly reduced sensibility. Even the current literature lacks consensus
• Minor lesions could be undetectable. on which of the two exams is the gold standard
166 G. Pasta et al.

and when is the best moment to perform imag- best moment to perform muscle tear imaging is
ing, also considering that MRI tends to overesti- thought to be between 24 and 48 h from the
mate the muscle tear assessment in its early trauma.
phase and moreover that it is a static exam that Another advantage of US is the possibility to
cannot directly assess muscle tear stability. On use color and power Doppler. Doppler US is a
the contrary, US slightly underestimates muscle technique that allows to visualize the main blood
tear size but is able to perform a dynamic assess- vessels and to study their blood flow thanks to
ment of the injury by performing a direct com- real-time association of a bidimensional US
pression on the patient skin or asking to perform image with a pulsed Doppler signal.
an active contraction of the affected muscle. Essentially, color Doppler allows us to visual-
This is essential, since it allows to examine the ize the movement of blood inside the venous and
separation and dislocation of tertiary bundles arterial vessels and estimate how much blood
and to evaluate the true extension of the lesion reaches a certain structure or organ.
(Fig. 20.1). Power Doppler is similar to color Doppler but
Generally speaking, considering that the it measures the energy of the frequency of the
edematous-hemorrhagic fluid collection is great- examined structures, therefore producing a more
est after 24 h and starts to decrease after 48 h, the sensitive signal (Fig. 20.2).

a b

Fig. 20.1 Third-degree lesion at the proximal myotendi- an increase in the gap. (b) Appearance of the injured thigh
nous junction (MTJ) of the left hamstring. (a) US per- after a fall during an enduro race
formed during muscle relaxation and contraction, showing

a b

Fig. 20.2 Use of color Doppler for monitoring a second-degree lesion of the right proximal adductor longus. Notice
the hypervascularization of the injured area (a) compared with the contralateral side (b)
20 Muscle Injury 167

Also sonoelastography (USE) can be useful in USE image based on the degree of dislocation
the follow-up of a structural lesion, even though with a range varying in a specific color which can
this technique is still under development and the be selected by the operator (e.g., from red (soft
studies performed until now are still experimen- tissues) to blue (hard tissues)) (Fig. 20.3).
tal and preliminary. Let us see some examples of US examination
USE measures tissue distortion in response to an in different types of muscle injuries:
external force, assuming that the distortion will be
less in harder tissues compared to softer tissues. • Nonstructural injury. US findings are nega-
This technique is based on the comparison of tive or at most we can observe a slightly
ultrasound radio-frequency waves obtained hyperechoic area due to edematous imbibition
before and after a slight tissue compression with or a hypoechoic and suffused area, which dis-
a normal probe. Color pixels are assigned to the appears in 3–5 days (Fig. 20.4).

a b

Fig. 20.3 Fibrosis of the semimembranosus. B-mode US scan (a) and corresponding real-time sonoelastography (b)

a b

Fig. 20.4 US of a nonstructural alteration of the right semimembranosus (a). Note the increased echogenicity of the
affected muscle fibers (asterisk) compared to the healthy contralateral muscle (b)
168 G. Pasta et al.

a b

Fig. 20.5 Longitudinal (a) and transverse (b) US scan showing a small intramuscular anechoic area (asterisk) due to a
minor partial lesion (3A) of the biceps femoris muscle

a b

Fig. 20.6 Longitudinal (a) and transverse (b) US scan showing a moderate partial lesion (3B) of the rectus femoris
muscle (asterisk)

• Structural injury. The ultrasound study 20.3 Classification of Muscle

shows the discontinuity of the muscle bundles, Injuries
reactive edema, and hematoma. In case of
complete rupture of the muscular belly, the As previously mentioned, it is becoming increas-
retracted muscle bundles appear on the ultra- ingly important to have a common terminology,
sound with the typical bell-clapper image, sur- which should be as international and as shared as
rounded by a hypoanechoic hematoma possible, and should start from the classification
(Figs. 20.5, 20.6 and 20.7). of accidents and eventually help to establish a
20 Muscle Injury 169

a b

Fig. 20.7 Transverse (a) and longitudinal (b) US scan of toma (asterisk). Appearance of the injured thigh after a
a complete lesion (grade 4) of the proximal musculotendi- fall during a water-ski race
nous junction of the semimembranosus with a large hema-

clear diagnosis, a precise prognosis, and an Table 20.2 Classification of muscle injuries from direct
appropriate therapy. trauma (ROM: range of motion)
The classification should therefore be precise, Contusion Mild: >1/2 Direct trauma that
complete, and accessible also, and above all, by physiological causes diffuse or
ROM circumscribed
those who are not familiar with dealing with Moderate: <1/2 hematoma, pain, and
these accidents. We hereby consider the new and >1/3 decreased ROM
I.S.Mu.L.T. classification for the next paragraph physiological
(Table 20.1). ROM
Severe: <1/3
physiological
ROM
20.3.1 Injuries from Direct Trauma Tear

Injuries from direct trauma are caused by an

external force acting against the muscle. The Lacerations are not classified into subgroups;
thigh muscles are most frequently affected (for the necessary therapy is surgical suturing and
example vastus intermedius muscle). They recovery times depend on the extent and depth of
include (Table 20.2): the lesion (Fig. 20.8).
Contusions are classified as mild, moderate, or
• Contusion, very common in athletes, caused severe (Fig. 20.9) depending on the functional
by an external compressive force applied impotence that derives from them, which is assessed
against the muscle (for example impact with as the ability to actively perform a movement at the
an opponent). level of the corresponding joint (the knee for the
• Laceration, rare in athletes, caused by a quadriceps, the hip for the gluteus maximus, etc.). It
direct cut injury (impact against a structure is worth mentioning that the athlete must be re-
with sharp edges, against opponent’s soccer examined after 24 h to better evaluate the injury,
studs, etc.) involving the epimysium and the because often, immediately after a contusion, the
underlying muscle. pain is so disabling that there would be the risk of
classifying them all as severe contusions.
170 G. Pasta et al.

a b

Fig. 20.8 (b) B-mode US scan of a submuscular and fascial skin laceration of the left rectus femoris (asterisk) com-
pared with the contralateral side (a)

a b

Fig. 20.9 Longitudinal (a) and transverse (b) US scan showing severe contusion of the left vastus intermedius muscle
with a large hematoma (asterisk)

20.3.2 Injuries from Indirect Trauma of high-speed contraction fibers (hamstrings, rec-
tus femoris).
Injuries from indirect trauma derive from an intrin- They are divided into two broad categories:
sic force generated by a sudden energetic muscle
contraction. These accidents occur without contact • Nonstructural muscle injuries.
with the opponent or other blunt structures or • Structural muscle injuries.
equipment: the athlete hurts himself/herself.
The most frequently affected muscles are the In the former, there are no anatomical lesions
biarticular ones and those with a greater amount of the muscle fibers, and they are divided into
20 Muscle Injury 171

four subgroups. The latter are instead character- strate a limited edema. The gold standard
ized by a true anatomical lesion of muscle fibers, examination is MRI because it often allows to
even if small, and they are classified into three detect even mild edema; this means that the
subgroups. sensitivity for these lesions goes from 76% of
ultrasound to 92% of MRI. It is important in
20.3.2.1 Nonstructural Muscle this sense to use the appropriate intrinsic high-
Injuries contrast sequences.
In this type of injury there is no muscle fibers Subgroup 1A is caused by fatigue and favored
damage. They are the most numerous category, by continuous changes in the type of exercise or
but also the most insidious one to diagnose and playing surfaces or by training with excessive
treat. In football, they make up 70% of muscle workloads.
injuries and, while not presenting any muscle Subgroup 1B is caused by an excessive number
lesion, they are responsible for over 50% of of exercises and eccentric stresses (Fig. 20.10).
absences from sports due to muscle injuries. Subgroup 2A is caused by problems of the
If neglected they can result in structural inju- spine that may be difficult to diagnose, such as
ries. They are divided into four subgroups minor intervertebral defects (MID) that irritate
(Table 20.3): the corresponding spinal nerve causing an altered
US is often negative or, at most, shows a control of the tone on the “target” muscle. In
transient hyperechogenicity or hypoecho- these cases, the resolution of the muscle lesion
genicity (3–5 days). Power Doppler is negative. also depends on the treatment of the spine
MRI is often negative or sometimes can demon- problem.

Table 20.3 Classification of nonstructural muscle injuries

Nonstructural I: Muscle disorder 1A: Fatigue-induced Sore, circumscribed increase of tone
injury related to overexertion 1B: DOMS (delayed-onset within a muscle.
muscle soreness) 1B: Widespread increase in muscle
II: Neuromuscular 2A: Neuromuscular related to tone and pain that appears a few hours
disorder vertebral column and/or pelvis after physical activity
disorders
2B: Neuromuscular related to
muscle

a b

Fig. 20.10 (b) B-mode US scan of a type 1B nonstructural injury of the medial gastrocnemius (asterisk) compared
with the contralateral side (a)
172 G. Pasta et al.

Subgroup 2B arises from an imbalance in neu- less than 50% of the section surface of the
romuscular control, especially of the mechanism muscle in that location
of reciprocal inhibition originating from muscle • 4: Subtotal injury, i.e., injury greater than 50%
spindles. Keep in mind that muscle tone is mainly of the section surface of the muscle at that
under the control of the gamma circuit (stretch location, or total injury, i.e., injury with rup-
reflex) and the activation of alpha motor neurons is ture of the entire muscle or bone-tendon
mainly under the control of the descending motor junction.
pathways. Sensory information from the muscle is
carried by ascending pathways to the brain. The The classification of structural injuries also
afferent signals enter the spinal cord through the includes defining the location where the injury
alpha motor neurons of the associated muscle, but occurs in the muscle: proximal (P), medium (M),
they also give off branches capable of stimulating or distal (D). In fact, the lesions that occur at the
interneurons in the spinal cord that inhibit the proximal level of the hamstring and rectus femo-
alpha motor neurons of the antagonist muscles. ris have a more severe prognosis than those of the
A dysfunction of these neuromuscular control same size that occur in other areas of the
mechanisms can lead to significant impairment muscle.
of normal muscle tone and can cause muscle dis- As regards the triceps surae, instead, injuries
orders, especially when the inhibition of antago- that occur distally have a more severe prognosis
nist muscles is altered (e.g., decreased) and the compared to those with proximal involvement.
agonist contracts excessively to compensate. The classification of these structural muscle
injuries is based, as we can see, on the anatomical
20.3.2.2 Structural Muscle Injuries extent of the lesion. It is not easy to distinguish a
They are divided into three subgroups according minor partial lesion from a small moderate one,
to the extent of the anatomical lesion within the and MRI can overestimate the extent of the
muscle (Table 20.4): lesion. Ultrasound and MRI are therefore still not
precise enough in determining structural damage;
• 3A: Minor partial injury: injury of one or more often, for example, the liquid seen on the MRI
primary fascicles within a secondary fascicle can lead to an overestimation of the damage, so
• 3B: Moderate partial injury: injury of at least this will be one of the most important topics to
one secondary fascicle with an area of rupture continue studying in the upcoming years.

Table 20.4 Classification of structural muscle injuries

• Partial minor injury 3A: The ultrasound, in
Nonstructural III: 3A: Minor Injury of one or the acute phase, shows a slightly hyperechoic
injury Partial partial more primary
muscle injury fascicles within
area which then turns into a nonhomoge-
injury a secondary neously hypoechoic area with initial echo-
fascicle structural subversion, in the context of which
3B: Injury of at least a small intramuscular anechoic focal area is
Moderate one secondary
demonstrated (Fig. 20.11).
partial fascicle with an
injury area of rupture • Moderate partial injury 3B: The acute-­
<50% of the phase ultrasound shows a hyperechoic area
muscle surface that transforms into a very uneven area with
in that location
evident structural subversion, in the context of
IV: 4: Subtotal Injury of >50%
(Sub) or total of the muscle which a large intra- and intermuscular
total injury or surface anechoic area is demonstrated (Fig. 20.12).
muscle tendon (subtotal) or of • Partial subtotal or total injury 4: In the
injury avulsion the entire acute phase, ultrasound shows a highly disor-
muscle (total)
or of the ganized iso-hyperechoic area, which turns
tendon-bone into a very inhomogeneous area with evident
junction structural alterations, bell-shaped stump
20 Muscle Injury 173

a b

Fig. 20.11 B-mode US scan of a minor partial injury (3A) of the right femoral biceps at rest (a) and during contraction
(b) showing only minor instability at the injury site (calipers)

a b

Fig. 20.12 B-mode US scan of a moderate partial injury (3B) of the hamstring at rest (a) and during contraction (b)
showing clear instability at the injury site (calipers)

retraction, and a large anechogenic intra- and fore for identifying any complications. In this
intermuscular area (Fig. 20.13). chapter we will only deal with the acute compli-
cations, namely intermuscular fluid collections
and serum-blood cysts.
20.3.3 Complications
• Intermuscular fluid collection: a fluid col-
Ultrasound is very important not only for the lection, mostly bloody, that occurs between
identification of muscle lesions and for their clas- two muscle groups a few days after direct or
sification but also for monitoring them and there- indirect trauma. Most often they develop
174 G. Pasta et al.

Fig. 20.14 Fluid collection (asterisk) between medial

gastrocnemius and soleus muscles

Fig. 20.13 Fourth-degree injury of the muscle-tendon

junction of the semimembranosus (calipers) with a large
hematoma

a b

Fig. 20.15 Longitudinal (a) and transverse (b) US scan showing a serohemorrhagic cyst of the biceps femoris

between the rectus femoris and the vastus reabsorbed, is encapsulated by fibrous tissue
intermedius or between the medial gastrocne- and the blood collection remains fluid.
mius and the soleus, where the muscle fasciae • It is encountered most frequently in the calf
are robust and not very extensible (Fig. 20.14). muscles and it can be the consequence of
• Serohemorrhagic cyst: complication that blunt trauma or treatment errors in the acute
occurs when the hematoma, not completely phase (Fig. 20.15).
20 Muscle Injury 175

Further Readings Itoh A, Ueno E, Tohno E, et al. Breast disease: clini-

cal application of US elastography for diagnosis.
Radiology. 2006;239:341–50.
Askling C, Tengvar M, Saartok T, et al. Sports related
Kolouris G, Connell D. Evaluation of the hamstring
hamstring strains – two cases with different eti-
muscle complex following acute injury. Skelet Radiol.
ologies and injury sites. Scand J Med Sci Sports.
2003;32:582–9.
2000;10(5):304–7.
Maffulli N, Nanni G, Pasta G, et al. I.S.Mu.L.T. Guidelines
Bisciotti GN, Volpi P, Alberti G. Italian Consensus
for muscle injuries. MLTJ. 2013;3(4):241–9.
Statement (2020) on return to play after lower
Megliola A, Eutropi F, Scorzelli A, et al. Ultrasound and
limb muscle injury in football (soccer). BMJ Open
magnetic resonance imaging in sports-related muscle
Sport Exerc Med. 2019;5(1):e000505. https://doi.
injuries. Radiol Med. 2006;111:836–45. https://doi.
org/10.1136/bmjsem-­2018-­000505.
org/10.1007/s11547-­006-­0077-­5.
Bisciotti GN, Volpi P, Amato M, et al. Italian consensus
Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, et al.
conference on guidelines for conservative treatment
Terminology and classification of muscle injuries in
on lower limb muscle injuries in athlete. BMJ Open
sport: the Munich consensus statement. Br J Sports
Sport Exerc Med. 2018;4(1) https://doi.org/10.1136/
Med. 2013;47(6):342–50.
bmjsem-­2017-­000323.
Noonan TJ, Garrett WE. Muscle strain injury: diagnosis
Bryan DJ. Gastrocnemius vs. soleus strain: how to dif-
and treatment. J Am Acad Orthop Surg. 1999;7:262–9.
ferentiate and deal with calf muscle injuries. Curr Rev
Pasta G, Manara M. Diagnostic imaging in muscle injury.
Musculoskelet Med. 2009;2(2):74–7.
Muscle Injuries Sports Med J. 2013;3:97–134.
Chan O, Del Buono A, Best TM, Maffulli N. Acute
Peter B, Sydney KK. Brukner & Khan’s clinical sports
muscle strain injuries: a proposed new classifica-
medicine. 2nd ed. Australia: McGraw-Hill; 2002.
tion system. Knee Surg Sports Traumatol Arthrosc.
Rubin SJ, Feldman F, Staron RB, et al. Magnetic reso-
2012;20(11):2356–62.
nance of muscle injury. Clin Imaging. 1995;19:263–9.
Corazza A, Orlandi D, Baldari A, et al. Thigh muscles
Speed C. A systematic review of shockwave therapies
injuries in professional soccer players: a one year
in soft tissue conditions: focusing on the evidence.
longitudinal study. Muscles Ligaments Tendons
Br J Sports Med. 2014;48(21):1538–42. https://doi.
J. 2013;3(4):331–6. http://www.ncbi.nlm.nih.gov/
org/10.1136/bjsports-­2012-­091961.
pubmed/24596698. Accessed 19 Jan 2020
Takebayashi S, Takasawa H, Banzai Y, et al. Sonographic
De Smet AA. Magnetic resonance findings in skeletal
findings in muscle strain injury: clinical and MR imag-
muscle tears. Skelet Radiol. 1933;22:479–84.
ing correlation. J Ultrasound Med. 1995;14:899–905.
Dierking JK, Bemben MG, Bemben DA, et al. Validity of
Volpi P. Medico del calcio: Il manuale. Edra spa, 2018.
diagnostic ultrasound as a measure of delayed onset mus-
Wohlfahrt M, Ekstrand J, Orchard J, et al. Terminology
cle soreness. J Orthop Sports Phys Ther. 2000;30:116–22.
and classification of muscle injuries in sport: the
Fornage BD. Muscular trauma. Clin Diagn Ultrasound.
Munich consensus statement. Br J Sports Med.
1995;30:1–10.
2012;47:342–50.
Hashimoto BE, Kramer DJ, Wiitala L. Applications
of musculoskeletal ultrasound. J Clin Ultrasound.
1999;27:293–318.
 Tendon Trauma
21
Umberto Viglino, Davide Orlandi ,
Alberto Aliprandi, and Elena Massone

Contents
21.1 Introduction  177
21.2 Tendinosis  177
21.3 Enthesopathy  178
21.4 Tendon Rupture  180
21.5 Tendon Dislocations  182
Further Readings  184

21.1 Introduction The etiological factors of these conditions could

be intrinsic (sex, age, biomechanics) or extrinsic
Tendon injuries include multiple conditions from (sports or occupational functional overload,
acute rupture to chronic tendon degeneration. repetitive traumatism, etc.) but a combination of
Inflammatory conditions usually affect the peri- both is very common. Such conditions can be
tenon of anchoring tendons (paratenonitis), the classified as acute (<6 weeks), subacute
synovial sheath of sliding tendons (tenosynovi- (6–12 weeks), and chronic (>12 weeks).
tis), or the osteotendinous junction (enthesitis).

21.2 Tendinosis
U. Viglino
Postgraduate School of Radiology, Genoa University, Tendinosis is a degenerative condition of anchor-
Genova, Italy ing and sliding tendons, usually associated with
D. Orlandi (*) mild painful symptoms.
Department of Radiology, Ospedale Evangelico The tendinosis process is characterized by fibro-
Internazionale, Genova, Italy
blast activation with production of high-­molecular-­
A. Aliprandi weight collagen and proteoglycans, which can
Responsabile Servizio di Radiologia, Istituti Clinici
Zucchi, Monza (MB), Italy
contain a lot of water with consequent diffuse
edema. Necrosis and fibrinous exudation show up
E. Massone
Department of Radiology, Ospedale Santa Corona,
progressively with possible fibrocartilaginous
Pietra Ligure (SV), Italy metaplasia and precipitation of calcium deposits.

© Springer Nature Switzerland AG 2022 177

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_21
178 U. Viglino et al.

Fig. 21.1 Low-grade tendinosis. Note the typical fibrillar

echogenicity fragmentation (*)

Fig. 21.2 Achilles tendinosis. The tendon appears thick-

In this setting, diagnostic imaging has an ened, diffusely dishomogeneous with wide focal
essential value for diagnostic evaluation because hypoechoic area (*), expression of focal mucoid
degeneration
a complete and realistic assessment of tendinous
condition could not be based on anamnesis and
clinic exam only. Ultrasound (US) can detect
very early tendon alterations, showing mild ten-
don thickening and fragmentation of normal
fibrillar echogenicity as first US signs of tendino-
sis (Fig. 21.1).
The typical early tendinosis US pattern is rep-
resented on long-axis scans by complete altera-
tion of tendon echogenicity with fusiform tendon
thickening, at which corresponds a “rounding”
aspect on short-axis scans, with typical ventral
concavity loss.
Fig. 21.3 Transverse scan of Achilles tendon. The ten-
In severe tendinosis appear focal hypoechoic don is thickened and dishomogeneous in a case of tendi-
areas and expressions of mucoid degeneration nosis with a small site of osseous calcification (asterisk)
(Fig. 21.2) with disorganization of collagen
fibers and with micro- or macro-calcifications There are some biomechanical and anatomic
(hyperechoic spots). Large calcifications have predisposing conditions to the developing of ten-
posterior acoustic shadow and are expression of dinosis. Giving an example, the presence of a
focal intratendinous osseous-calcific metaplasia megalic posterior-superior calcaneal tubercle
(Fig. 21.3). (Haglund syndrome) can cause friction with the
Color or power Doppler evaluation could be preinsertional aspect of the Achilles tendon caus-
useful in order to highlight vascular signal spots ing subsequent tendinopathy. In these cases,
within the degenerative site, which could be ultrasound shows the presence of flogistic and
expression of angiogenetic activation, with degenerative alterations, with tendon thickening
potential restoring of the damaged area. The and loss of fibrillar echotexture, frequently asso-
absence of vascular signal within these areas, on ciated with precalcaneal and retrocalcaneal bursi-
the contrary, could indicate the evolution of the tis (Fig. 21.5a, b).
degenerated area toward necrosis. However in
daily clinical practice there are frequent cases of
simultaneous presence of degenerative (tendi- 21.3 Enthesopathy
nosis) and flogistic (paratenonitis) alterations,
characterized by complex color and power Enthesopathy or insertional tendinopathy is a
Doppler patterns which anyway can increase the flogistic-degenerative condition affecting the
accuracy and reliability of B-mode US osseous-tendinous junctions and is typical of
(Fig. 21.4a, b). anchoring tendons subjected to intense and repet-
21 Tendon Trauma 179

a b

Fig. 21.4 (a) Longitudinal US scan of Achilles tendon. Doppler shows a concomitant hypervascularity caused by
The tendon appears thickened, dishomogeneous, with the hyperemic-flogistic condition
fibrillar structure loss due to tendinosis; (b) power

a b

Fig. 21.5 Haglund syndrome. (a) The longitudinal US intratendinous vascular signals at power Doppler exami-
scan shows thickening and dishomogeneity of preinser- nation (*). (b) MR exam (GE T2w sequence) in the same
tional tract of Achilles tendon with retrocalcaneal bursitis patient confirms ultrasound alterations and shows in addi-
and concomitant hypervascularity with flogistic peri-­ tion the megalic posterior-superior calcaneal tubercle (T)

itive mechanical stress, being directly related Tendon structural dishomogeneity with focal
with functional overload. hypoechoic areas and insertional calcification
The most commonly affected structures are may be present, and these are expressions of
Achilles and patellar tendon (e.g., jumper’s knee) intratendinous myxoid degeneration typical of
and the common extensor and flexor tendons of severe infection (Fig. 21.6). Frequently associ-
the elbow (e.g., tennis elbow). ated are the flogistic reaction of the adjacent
Normal enthesis is formed by the combination bursae and the presence of erosions and irregu-
of tendon fibers and fibrocartilage. Blood vessels larities of the cortical surface in the insertional
are present but, because of low blood speed and area.
flow, are detectable only with the most advanced US appearance of bone erosions is repre-
microvascular power Doppler tools. sented by discontinuity of the echogenic profile
The first detectable anatomic-pathologic alter- of the bony surface; however, MRI evaluation is
ations in enthesopathies are enthesis thickening essential for a complete evaluation of advanced
with local hyperemia and neoangiogenesis; cases of enthesopathy because it is the only
Doppler evaluation can show the early increment technique that can detect the presence of bone
of tendon vascularity without actual altered col- marrow edema using high-contrast sequences
lagen matrix. (Fig. 21.7).
180 U. Viglino et al.

persistent, can progressively induce partial or

complete tears inside the degenerate tendon
structure. Frequently, these ruptures are incom-
plete but they can alter the tendon homogeneity,
continuity, and function with different degrees of
severity.
At US evaluation, the rupture is represented
by a hypo/anechoic gap that interrupts the fibril-
lar continuity of the tendon (Fig. 21.8a, b). In
complete ruptures US can show the fiber discon-
tinuity with diastasis of tendon stumps and blood
Fig. 21.6 Longitudinal scan of Achilles tendon (T) in a
case of enthesopathy. Note the diffuse alteration of inner effusion. In these cases, dynamic evaluation is
tendon echostructure with insertional calcifications important for a more precise description of the
(arrowheads) and thickening of precalcaneal soft tissues site and extension of rupture.
(asterisk). C calcaneus In some anatomical locations tendon rupture
evaluation needs a more precise classification.
This is particularly evident when evaluating rota-
tor cuff tendons; tears can be divided, using
extension and site criteria, into the following:

• Partial tear, which can be divided into bursal

sided when the tear is limited to the tendon
surface in contact with subacromial-­subdeltoid
bursa (Fig. 21.9); articular sided when it is
limited to the tendon surface in contact with
the glenohumeral articular surface; and intra-
tendinous. Intratendinous partial tear is char-
acterized by anechoic intra-substance tendon
delamination (Fig. 21.10).
• Full-thickness tear: when the full thickness of
the tendon is involved (mild, moderate, wide)
(Fig. 21.11), with possible stump diastasis, but
with part of the tendon still intact.
• Complete tear: when the whole tendon is
involved, with different grades of stump dias-
tasis (Fig. 21.12).

In wide complete tears with tendon stump

Fig. 21.7 MRI exam of the ankle, sagittal scan (fat-sat
retraction there is humeral head exposure and
technique) shows bone marrow edema of calcaneal bone subacromial space reduction which can progres-
in correspondence with Achilles tendon insertion (*) sively lead to a new pseudo-articulation between
humeral head and acromion (Fig. 21.13).
Tendon rupture repair is a gradual process that
21.4 Tendon Rupture needs from a few days to some months to obtain
the full tendon healing and it develops through a
Tendon rupture can be caused by acute trauma or three-step process: inflammatory phase (about a
can occur spontaneously as a complication of week, there is recruit of macrophages and tendon
tendinosis. Mechanic overload, if excessive and fibroblast by increased concentrations of cyto-
21 Tendon Trauma 181

a b

Fig. 21.8 (a) Longitudinal, (b) axial, and (c) extended field-of-view longitudinal US scan of a complete tear of the
Achilles tendon at its middle third. Arrowheads show the tendon stumps divided by a gap (asterisk). C calcaneus

Fig. 21.9 Partial tear (*) on the bursal side of supraspina-

tus tendon
Fig. 21.11 Full-thickness tear of supraspinatus tendon
(arrowheads) extending from the bursal to the articular
side of the tendon. SS supraspinatus tendon, D deltoid
muscle, G great tubercle of humerus

kines), proliferative phase (production of

­collagen), and remodeling phase (reorganization
of new collagen with correct orientation and
cross-­linkage of collagen fibers).
In this reparative remodeling process are
involved different cytotypes (including marrow-­
derived mesenchymal stem cells, fibroblasts, and
Fig. 21.10 Intratendinous partial tear (arrow) of supra- inflammatory cells) and many growth factors like
spinatus tendon platelet-derived growth factor (PDGF-BB), trans-
182 U. Viglino et al.

a b

Fig. 21.12 (a) Complete tear of supraspinatus tendon with moderate diastasis of tendon fibers (T) on a highly degener-
ate matrix. (b) MPR reconstruction shows rupture “from above” on a coronal plane. T tendon stumps

nels. The anatomical structures designated to keep

these structures in the correct position are retinac-
ula, transverse thickenings localized in the deep
muscular fascia and firmly fastened to bone emi-
nences. Their integrity is crucial to allow a solid
stabilization. When it is reduced, the tendon will
dislocate determining an instability condition.
There are different severity grades on tendon insta-
bilities: in mild conditions tendon dislocates only
following certain movements, and in more severe
conditions the subluxation and dislocation are
more frequent, and sometimes a fixed dislocation
could be observed. Moreover, in case of congenital
absence or retinacula hypoplasia, dislocation
could be spontaneous. In this setting high-resolu-
tion US, performed with dedicated dynamic
maneuvers, represents the “gold standard” tech-
Fig. 21.13 Chronic massive tear of the rotator cuff with
pseudo-articulation between humeral head (H) and acro- nique for the diagnosis of tendon instability.
mion (A) and concomitant joint effusion (*) Even though tendon instability is not a fre-
quent pathological condition, it could be fre-
forming growth factor β (TGF-β), vascular endo- quently associated with ligament sprains and its
thelial growth factor (VEGF), and basic fibroblast presence must be considered because early diag-
growth factor (bFGF). nosis is of key importance to prevent the develop-
ing of tendinosis or tendon rupture.
The tendons more prone to develop instability
21.5 Tendon Dislocations are the long head of biceps brachii (LHBB) at the
humerus biceps groove in the shoulder and the
Sliding tendons can have bending along their peroneal tendons at the peroneal groove in the
course with spatial misalignment as compared to ankle.
the normal functional axis of the muscle. To assure LHBB can dislocate following a rupture of
correct articular biomechanics, the anatomical transverse ligament or coracohumeral ligament
structures such as muscle belly and tendons, with and can be associated with the rupture of sub-
their corner points and lever fulcrums, must be in scapularis tendon. In addition, there are geneti-
the physiological position in osseous-­fibrous chan- cally predisposing anatomical conditions such as
21 Tendon Trauma 183

a flat bicipital groove that could lead to spontane- demonstrate the instability, a dynamic US evalu-
ous dislocation. ation of the LHBB performed with arm extra-­
US shows the empty bicipital groove and the rotation by 90° with flexed elbow could be
tendon dislocated medially, above or under the useful.
subscapularis tendon (Fig. 21.14). In order to In the ankle, peroneal tendons are held in
physiological position by superior and inferior
peroneal retinacula, located, respectively, over
and under the deflexion site at the level of the
peroneal groove of the lateral malleolus.
Traumatic instability is caused by the lesion of
the superior retinaculum with consequent ten-
dency to anterior dislocation of peroneal tendons
over peroneal malleolus. In addition, there are
genetically predisposing anatomical conditions
such as a flat peroneal groove that could lead to
peroneal instability.
US dynamic maneuver for peroneal instability
demonstration is performed placing the trans-
ducer on tendons’ short axis in correspondence
Fig. 21.14 Transverse scan of the shoulder that shows
of deflexion site and, during dorsiflexion of the
medial dislocation of long head biceps brachii tendon
(arrows) after subscapularis tendon rupture. Note the empty foot, observing the tendon dislocation over lat-
bicipital groove between humeral tuberosities (asterisk) eral malleolus (Fig. 21.15).

a b

Fig. 21.15 (a) Transverse scan of lateral compartment of MRI exam (axial scan, SE T1-weighted technique).
the ankle that shows peroneal tendon dislocation (arrows) Arrowhead = peroneal tendons
over peroneal malleolus (asterisk). (b) Same patient, the
184 U. Viglino et al.

Further Readings Martino F, Silvestri E, Grassi W, Garlaschi G. Ecografia

dell’apparato osteoarticolare Anatomia, semeiotica e
quadri patologici. Milan: Springer; 2006.
Bianchi S, Martinoli C. Ultrasound of the musculoskeletal
Scott A, Backman LJ, Speed C. Tendinopathy: update
system. Milan: Springer; 2007.
on pathophysiology. J Orthop Sports Phys Ther.
Freedman BR, Sarver JJ, Buckley MR, Voleti PB,
2015;45(11):833–41.
Soslowsky LJ. Biomechanical and structural response
Silvestri E, Muda A, Sconfienza LM. Normal ultrasound
of healing Achilles tendon to fatigue loading following
anatomy of the musculoskeletal system a practical
acute injury. J Biomech. 2014;47(9):2028–34. https://
guide. Milan: Springer; 2012.
doi.org/10.1016/j.jbiomech.2013.10.054.
Thomopoulos S, Parks WC, Rifkin DB, Derwin
Maffulli N, Wong J, Almekinders LC. Types and epi-
KA. Mechanisms of tendon injury and repair. J Orthop
demiology of tendinopathy. Clin Sports Med.
Res. 2015;33:832–9. John Wiley and Sons Inc. https://
2003;22(4):675–92.
doi.org/10.1002/jor.22806.
 Superficial Interosseous Ligament
Injury
22
Enzo Silvestri, Davide Orlandi , Elena Massone,
and Ernesto La Paglia

Contents
22.1 Introduction  185
22.2  uperficial Interosseous Ligament Injuries 
S 186
22.2.1 Stener Lesion  186
22.2.2 Scapholunate Ligament Disruption  186
22.2.3 Coracohumeral Ligament  188
22.2.4 Coracoclavicular Ligaments  188
22.2.5 Ankle Interosseous Ligaments  188
Further Readings  191

22.1 Introduction with high-­frequency linear probe. Depending

on the biomechanics with which the trauma
Interosseous ligaments are connective and occurs, we may have pure ligamentous lesions
fibrous reinforcing and stabilizing structures of or lesions with avulsions of the ligament inser-
the joint capsule with hyperechogenic fibrillar tion bone bract and consequent instability of
ultrasound pattern. Since they are superficial the reference joint. The former result in an
structures their optimal evaluation is obtained ultrasound picture of loss of the regular fibrillar
echostructure with possible diastasis of the
stumps and with various degrees of edematous
hemorrhagic infarction of the peri-­ligamentous
E. Silvestri soft tissues, and the others associate these find-
Radiology, Alliance medical, Genova, Italy
ings with the presence of parcellar detachment
D. Orlandi (*) of cortical bone tract from the cortical profile
Department of Radiology, Ospedale Evangelico
Internazionale, Genova, Italy ligament insertion. Dynamic ultrasound imag-
ing can also provide additional information
E. Massone
Department of Radiology, Ospedale Santa Corona, about ligament dislocation and joint diastasis
Pietra Ligure (SV), Italy during stressful maneuvers. Ultrasonography
E. La Paglia also affords quick comparative imaging of the
Department of Radiology, Humanitas Cellini, uninjured side.
Torino, Italy

© Springer Nature Switzerland AG 2022 185

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_22
186 E. Silvestri et al.

22.2 Superficial Interosseous In addition to being noninvasive, cost effec-

Ligament Injuries tive, and less time consuming, ultrasound has
been shown to have from 83% to 100% sensitiv-
The main upper and lower limb superficial inter- ity and specificity in discerning between non-­
osseous ligament lesion sites will be examined. displaced and displaced tears, showing the
anatomic relationship of the UCL as it pertains to
adductor aponeurosis. The appearance of a Stener
22.2.1 Stener Lesion lesion on ultrasound has been called the “tadpole
sign” or yo-yo on a string sign. Ridley et al. note,
A Stener lesion is a complete tear of the ulnar “The head of the tadpole is formed by the
collateral ligament from the thumb proximal pha- retracted proximal fragment of the UCL which
lanx at the level of the metacarpophalangeal joint displaces to be adjacent to the head of the meta-
with its dislocation superficial to the adductor carpal. The tail of the tadpole is formed by the
pollicis aponeurosis, leading to interposition of adductor aponeurosis which is often thickened
the aponeurosis between the UCL and the MCP and lies deep to the retracted UCL fibers.”
joint. The distal dislocation of the UCL and its The “yo-yo on a string sign” appearance pres-
interposition beneath the adductor aponeurosis ents by the small mass displaced superficial to the
distinguish the Stener lesion from other UCL adductor pollicis from the torn ligament fibers
injuries and it is particularly important as it that retracted proximally (Fig. 22.3).
impedes healing, thereby conducting patient to
surgery (Figs. 22.1 and 22.2).
Biomechanics leading to Stener injury is 22.2.2 Scapholunate Ligament
hyperabduction and hyperextension of the first Disruption
MCP joint (typically an acute lesion occurs from
a fall onto the ground with an abducted thumb The interosseous scapholunate ligament extends
with a ski pole in hand, but the same mechanism from the lunate to the scaphoid bones and, espe-
can also occur from sports such as hockey, soc- cially the dorsal band which is the thickest and
cer, handball, basketball, and volleyball). functionally most important part, contributes to

a b c d

Fig. 22.1 (a) Normal aspect of ulnar collateral complex tion; (d) Stener lesion as a complete tear of the ulnar col-
of the thumb; (b) middle third partial ulnar collateral liga- lateral ligament from the thumb proximal phalanx at the
ment lesion without any dislocation vs. the adductor apo- level of the metacarpophalangeal joint with its dislocation
neurosis; (c) avulsion lesion of distal insertion of ulnar superficial to the adductor pollicis aponeurosis
collateral ligament with cortical bone fragment’s produc-
22 Superficial Interosseous Ligament Injury 187

a b c d

Fig. 22.2 US longitudinal view of the thumb (a, b), ana- ment with cortical bone fragment’s production at the basis
tomical Scheme (c), and T1w coronal MRI (d) showing an of the thumb proximal phalanx at the level of metacarpo-
avulsion lesion of distal insertion of ulnar collateral liga- phalangeal joint (red arrowheads)

a b

Fig. 22.3 Stener lesion appearance on ultrasound (a) and which displaces to be adjacent to the head of the metacar-
corresponding anatomical Scheme (b) showing the so-­ pal. The tail of the tadpole is formed by the adductor apo-
called tadpole sign. The head of the tadpole is formed by neurosis which is often thickened and lies deep to the
the retracted proximal fragment of the UCL (arrowheads) retracted UCL fibers

the stability of the interposed segment of the order to get an early diagnosis and minimize the
carpus. potential for inappropriate or delayed treatment.
A disruption of this ligament may lead to a The injury mechanism most commonly
dorsal or volar instability of interposed segment involves a combination of hyperextension and
which can be demonstrated with a complete radial deviation stresses with an impact on the
radiological approach (standard radiographs— thenar eminence. The intact dorsal band of the
four views) associated with an US examination in SLL appears as an echogenic fibrillar structure
188 E. Silvestri et al.

(mean thickness 1.1 mm and mean length 22.2.4 Coracoclavicular Ligaments

4.2 mm) in the scapholunate interval. The evalu-
ation with a high-frequency linear probe (15– The coracoclavicular ligaments (trapezoid and
18 MHz) and dynamic maneuvers can lead to the conoid) are responsible for acromioclavicular
demonstration of a discontinuity of the dorsal joint (ACJ) stability and are known as suspen-
band of the ligament in neutral position or a non-­ sory ligament of the shoulder: the trapezoid lig-
visualization of the ligament with an increased ament leads from the inferior aspect of the
width of the scapholunate space in ulnar inclina- clavicular epiphysis to the superior aspect of the
tion of the wrist. coracoid while the conoid ligament extends
Ancillary findings are cortical disruption, sub- from the inferior aspect of the conoid tubercu-
periosteal hematoma, radiocarpal joint effusions, lum at the clavicular diaphysis to the basis of the
and carpal ganglion cysts arising from the ante- coracoid.
rior band of the scapholunate ligament. When a ACJ injuries’ etiology is a fall with direct
lesion is suspected, second-level imaging such as impact to the shoulder, while the arm is adducted.
MRI arthrography should be performed. The Rockwood classification is based on the
radiographic analysis of the ACJ and leads from a
normal aspect with no displacement (grade 1) to
22.2.3 Coracohumeral Ligament displacement of >100% of the height of the ACJ
and clavicle displaced inferiorly and anteriorly
Bicipital pulley is a capsuloligamentous complex with trapezius and deltoid muscles’ damage
which stabilizes the long head of bicipital tendon (grade 6).
in the bicipital groove and the whole anatomical Ultrasound can be combined with radiography
space is known as the rotator interval: the coraco- for the diagnostic workup of ACJ injuries in the
humeral ligament—the roof of the rotator inter- acute phase. Ultrasound can be performed in the
val—is an interosseous band which, together neutral position as it is better tolerated by patients.
with the superior glenohumeral ligament (the The lesion of the ACJ can be associated with
floor of the rotator interval) forms a sling around the lesion of the coracoclavicular ligaments rang-
the long head of biceps tendon. ing from normal coracoclavicular ligaments
When performing a shoulder US examination (grade 1) to distended coracoclavicular liga-
a complete approach to the evaluation of the rota- ments, enlarged and with loss of echogenic
tor interval should be achieved by the use of appearance on US (grade 2), to ruptured coraco-
dynamical tests obtained while intra- and extra-­ clavicular ligaments and ligament stump located
rotation of the forearm while keeping the elbow at bone insertion (grade 3).
flexed. Habermeyer classified various types of
bicipital pulley disruption involving also the sub-
scapularis tendon and the supraspinatus tendon. 22.2.5 Ankle Interosseous Ligaments
Isolated pulley injuries with the only involvement
of the coracohumeral ligament (type 1 Ankle is the most commonly injured major joint
Habermeyer) lead to 7.1% of the cases. in the body and ankle ligamentous sprains are
Dynamic maneuvers performed during ultra- extremely common in biomechanics of eversion
sonography show, as an indirect sign of lesion of (85%) and inversion (15%) with respective
the SGHL and integrity of CHL, an empty bicipi- involvement of ligamentous bands of lateral
tal groove and the long head of bicipital tendon complex, medial/deltoid complex, and
dislocated close to the subscapularis insertion of syndesmosis.
the CHL (Fig. 22.4). The ankle ligaments are best evaluated with
When a lesion is suspected, second-level high-frequency transducers (preferably from 15
imaging such as MRI arthrography should be to 18 MHz) in the long axis, with short-axis
performed (Fig. 22.5). imaging for problem-solving. Similar to other
22 Superficial Interosseous Ligament Injury 189

a b

c d

Fig. 22.4 Axial and sagittal US scan of the bicipital pul- superior glenohumeral ligament lesion. Arrowhead: sub-
ley and bicipital groove (a–c) and fat-sat T2w axial MRI scapularis tendon; bright gray curved line: bicipital
(d) of the same site showing a dislocation of the bicipital groove; TN: lesser tuberosity of the humerus; TR: greater
tendon (asterisk) close to the subscapularis insertion of tuberosity of the humerus; white arrow: vertical portion of
the CHL (dark gray curved line) as an indirect sign of the long head of the biceps brachii tendon (LHBBT)

ligaments, the ankle ligaments should appear as Acute full-thickness ligament tears typically
echogenic with a more compact fibrillar structure present as discontinuity, non-visualization of the
than tendons, most commonly connecting two ligament, or visualization of hypoechoic or het-
osseous structures. erogeneous material representing a torn ligament
A general consideration regarding patient and hemorrhage (Fig. 22.7).
positioning is that the ligament should be slightly A chronic injury may appear as ligamentous
taut during evaluation to eliminate redundancy. thickening, attenuation, or non-visualization.
The transducer should be angled so that the liga- Avulsion injuries may show tiny echogenic shad-
ment fibers are perpendicular to the sound beam owing fragments of bone. Dynamic US may
to eliminate anisotropy. show lack of normal tendon tightening during
Normal thickness of the ankle ligaments stress maneuvers in complete tears: in the evalu-
ranges from 2 to 5 mm. Some general principles ation of anterior talo-fibular ligament the anterior
apply when it comes to the US appearance of drawer test is useful to distinguish a partial from
ligament injuries. Acute partial-thickness liga- a complete tear by placing the patient prone with
ment tears typically appear as hypoechoic thick- the foot hanging over the edge of the examination
ening with preservation of some continuous table while pulling the forefoot anteriorly when
fibers (Fig. 22.6). in plantar flexion and inversion. When the
190 E. Silvestri et al.

a b c

d e f

Fig. 22.5 MR arthrography of the shoulder showing rior glenohumeral ligament (red circles). Note the empty
(from a to f) dislocation of the bicipital tendon close to the bicipital groove (asterisk) on the fourth axial image (d)
subscapularis insertion of the CHL and disruption of supe-

Fig. 22.7 Acute full-thickness tear of the anterior talo-­

Fig. 22.6 Acute partial-thickness tear of the anterior fibular ligament (ATFL) showing ligament fibers’ discon-
talo-fibular ligament (ATFL) showing hypoechoic thick- tinuity (asterisk) with surrounding hemorrhage and edema
ening of the ligament (arrowheads) and surrounding (circles). F fibula, T talus
edema (asterisks). F fibula, T talus
(CFL); by full dorsiflexion of the foot this liga-
l­igament is torn, the anterior shift of the talus ment becomes taut and peroneal tendons are lifted
against the fibula will open the gap in the sub- up. Lack of elevation of the peroneal t­ endons with
stance of the ligament. dorsiflexion is an indirect indicator of a CFL tear.
Dynamic US may also be useful to better eval- Complete CFL tears may be accompanied by
uate the integrity of calcaneo-fibular ligament fluid in the overlying peroneal tendon sheath.
22 Superficial Interosseous Ligament Injury 191

Further Readings Mattox R, et al. Sonographic diagnosis of an acute Stener

lesion: a case report. J Ultrasound. 2016;19(2):149–52.
Meyer P, et al. Imaging of wrist injuries: a standardized
Alves T, et al. Normal and injured ankle ligaments on
US examination in daily practice. J Belg Soc Radiol.
ultrasonography with magnetic resonance imaging
2018;102(1):9.
correlation. J Ultrasound Med. 2019;38:513–28.
Morvan G, et al. Ultrasound of the ankle. Eur J Ultrasound.
Baumann B, et al. Arthroscopic prevalence of pulley
2001;14:73–82.
lesions in 1007 consecutive patients. J Shoulder Elb
Nakata W, et al. Bicipital pulley: normal anatomy and
Surg. 2008;17(1):14–20.
associated lesions at MR arthrography. Radiographics.
Bilfeld MF, et al. US of the coracoclavicular ligaments in
2011;31(3):791–810.
the acute phase of an acromioclavicular disjunction:
Peetrons P, et al. Sonography of ankle ligaments. J Clin
comparison of radiographic, ultrasound and MRI find-
Ultrasound. 2004;34:491–9.
ings. Eur Radiol. 2017;27:483–90.
Ridley LJ, et al. Tadpole sign: Stener lesion. J Med
Ebrahim FS, et al. US diagnosis of the UCL tears of the
Imaging Radiat Oncol. 2018;62(Suppl 1):162.
thumb and Stener lesions: technique, pattern-based
Rockwood C, et al. Acromioclavicular injuries. In:
approach and differential diagnosis. Radiographics.
Fractures in adults. Philadelphia, PA: Lippincott-­
2006;26(4):1007–20.
Raven; 1996. p. 1341–413.
Hung CY, et al. Gamekeepers thumb (skiers, ulnar col-
Sconfienza LM, et al. Dynamic high-resolution US
lateral ligament tear). Treasure Island (FL): StatPearls
of ankle and midfoot ligaments: normal anatomic
Publishing; 2019.
structure and imaging technique. Radiographics.
Lucerna A, Rehman UH. Stener lesion. Treasure Island
2015;35:164–78.
(FL): StatPearls Publishing; 2019. PMID: 31082048
Tauber M. Management of acute acromioclavicular joint
Martinoli C, et al. Musculoskeletal ultrasound: technical
dislocations: current concepts. Arch Orthop Trauma
guidelines. Insights Imaging. 2010;1:99–141.
Surg. 2013;133(7):985–95.
 Peripheral Entrapment
Neuropathies
23
Salvatore Guarino, Davide Orlandi ,
Enzo Silvestri, and Marcello Zappia

Contents
23.1 Introduction  194
23.2  ntrapment Neuropathies of Upper Limb 
E 194
23.2.1 .Suprascapular Nerve  194
23.2.2 .Musculocutaneous Nerve  196
23.2.3 .Axillary Nerve  196
23.2.4 .Radial Nerve  196
23.2.4.1 Spiral Groove Syndrome  197
23.2.4.2 Posterior Interosseus Syndrome  197
23.2.5 .Ulnar Nerve  198
23.2.5.1 Cubital Tunnel Syndrome  199
23.2.5.2 Guyon’s Canal Syndrome  200
23.2.6 .Median Nerve  200
23.2.6.1 Carpal Tunnel Syndrome  201
23.3  ntrapment Neuropathies of Lower Limb 
E 202
23.3.1 .Lateral Femoral Cutaneous Nerve Entrapment  202
23.3.2 .Sciatic Nerve  203
23.3.2.1 Deep Gluteal Syndrome  203
23.3.3 .Common Peroneal Nerve  203
23.3.4 .Superficial Peroneal Nerve  204
23.3.5 .Deep Peroneal Nerve  205
23.3.5.1 Anterior Tarsal Tunnel Syndrome  205
23.3.6 .Tibial Nerve  206

S. Guarino
Department of Radiology, Monaldi Hospital,
M. Zappia
AORN Ospedali dei Colli, Naples, Italy
Musculoskeletal Radiology Unit, Istituto Diagnostico
D. Orlandi (*) Varelli, Napoli, Italy
Department of Radiology, Ospedale Evangelico
Dipartimento di Medicina e Scienze della Salute,
Internazionale, Genova, Italy
Università degli Studi del Molise (CB),
E. Silvestri Campobasso, Italy
Radiology, Alliance Medical, Genova, Italy [email protected]

© Springer Nature Switzerland AG 2022 193

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_23
194 S. Guarino et al.

23.3.6.1  arsal Tunnel Syndrome (Posterior Tibial Nerve) 

T 206
23.3.6.2 Jogger’s Foot (Medial Plantar Nerve)  206
23.3.6.3 Baxter Neuropathy (Inferior Calcaneal Nerves)  207
23.3.7 .Interdigital Nerves  207
23.3.8 .Medial Proper Plantar Digital Nerve  208
Further Readings  208

23.1 Introduction

Entrapment neuropathies are a group of mono-

neuropathy syndromes due to compression/
impingement of a single peripheral nerve.
Regardless of the cause of compression, the
nerves react to this irritative stimulus with the
same characteristics and the ultrasound (US)
appearance of the entrapped nerve has constant
features:

• Crushing of the nerve at the compression site,

associated with its focal thickening proxi- Fig. 23.1 Suprascapular notch. Transverse US image of
suprascapular nerve (white arrows) in suprascapular
mally to the pathological site, due to edema notch (or superior incisura) of the scapula. The nerve
and vascular congestion. passes in the suprascapular notch, beneath the superior
• Loss of the normal “honeycomb” fascicular transverse scapular ligament (black arrows). In the supe-
pattern of the nerve, which shows a homoge- rior incisura the suprascapular artery (arrowhead) runs
outside this tunnel. SSP supraspinatus muscle
neously hypoechoic internal aspect.
• Swelling of the fascicles.
• Intraneural echogenic fibrotic areas in chronic tions from the C5 and C6 nerve roots and incon-
entrapments. stantly the C4 nerve root. The nerve runs
• Hypoechoic appearance due to the edema of posteriorly to the clavicle to the superior border
the epineurium with poorly defined margins of of the scapula, where it passes into the suprascap-
the nerve. ular notch, a variable depression on the superior
• Echogenic concentric or asymmetric halo, border of the scapula. Through this notch, the
representing a thickening of the outer nerve SSN traverses the upper border of the scapula
sheath. under the superior transverse scapular ligament
• Increasing vascularity, at color/power Doppler (Fig. 23.1). The nerve then runs roughly medially
evaluation. to the posterior glenoid rim entering in the spino-
• Hyperechoic aspect with reduction of the glenoid notch where it passes, with the adjacent
mass of the innervated muscles. artery, under the spinoglenoid (inferior transverse
scapular) ligament (Fig. 23.2). Before entering in
the spinoglenoid notch the SSN most commonly
23.2 Entrapment Neuropathies supplies two motor branches to the supraspinatus
of Upper Limb muscle and, exiting from the spinoglenoid notch,
supplies two branches to the infraspinatus mus-
23.2.1 Suprascapular Nerve cle. The SSN also supplies up to 70% of the sen-
sation of the shoulder, with nerve branches to the
The suprascapular nerve (SSN) arises from the glenohumeral joint, acromioclavicular joint, and
upper trunk of the brachial plexus with contribu- coracoacromial ligament as well as to the skin.
23 Peripheral Entrapment Neuropathies 195

Fig. 23.2 Spinoglenoid notch. Transverse US image of

suprascapular nerve (white arrows) in spinoglenoid notch
(or inferior incisura) of the scapula. The nerve passes in
the spinoglenoid notch, beneath the inferior transverse Fig. 23.3 Glenoid paralabral cyst. Transverse US image
scapular ligament (black arrows). In the inferior incisura of posterior glenohumeral recess shows a large paralabral
the suprascapular artery (arrowhead) runs inside this tun- cyst (white arrows) occupying the spinoglenoid notch. A
nel. ISP infraspinatus muscle HH humeral head thin amount of fluid (arrowheads) shows the cyst com-
munication with the joint cavity due to the SLAP injury.
The suprascapular nerve (black arrow) is not well identifi-
The SSN entrapment may occur at three lev- able as it is compressed between the cyst and the notch
floor. ISP infraspinatus muscle, L labrum, H humeral
els: the suprascapular notch (also known as scap-
head, D deltoid muscle
ular notch or supraspinous notch or superior
incisura), the spinoglenoid notch (inferior inci-
sura), and along its course in the osteofibrous
tunnel located in subfascial position between the
two incisurae.
Numerous bony morphological variants of the
suprascapular (superior) notch have been described.
In the less frequent SSN entrapment in the
spinoglenoid notch, potential predisposing mor-
phological features have been evocated:
V-shaped, narrow, or “deep” suprascapular
notch; a band-shaped, bifurcated, or completely
ossified superior transverse scapular ligament;
and particular arrangements of the suprascapu-
lar nerve and vessels at the suprascapular notch.
Fig. 23.4 Infraspinatus muscle atrophy. Transverse US
These morphologies are assessable during US image of posterior cuff muscles shows the atrophy of
examination. infraspinatus (ISP) due to suprascapular nerve entrap-
The spinoglenoid (inferior) notch is the most ment. The infraspinatus muscle appears hyperechoic with
common site of SSN entrapment. Usually the respect to the teres minor (TM) muscle with the “black
and white” effect. D deltoid muscle, S scapula
nerve is compressed from a ganglion paralabral
cyst due to a SLAP lesion. US well depict the
paralabral cysts as round or oval hypoechoic US scan of the posterior rotator cuff muscles
lesions with well-defined margins within the is also helpful in identifying the compression
spinoglenoid notch. The cyst may contain hyper- site. Isolated atrophy of the infraspinatus muscle
echoic areas due to the gas bubbles within it. The indicates SSN compression within or at the exit
continuity of the cyst with a defect in the poste- of the spinoglenoid notch (Fig. 23.4). Conversely,
rior labrum can be identified (Fig. 23.3). if both the supraspinatus and the infraspinatus
196 S. Guarino et al.

muscles are involved, the compression is located ness to palpation and teres minor, and deltoid
proximal to the notch. denervation. These symptoms are typically exac-
erbated in abduction and external rotation
position.
23.2.2 Musculocutaneous Nerve The most common cause of compression of
the axillary nerve is the presence of a fibrous
The musculocutaneous nerve (MCN) is one of band within the quadrilateral space, but paral-
the main terminal branches of the brachial plexus abral cysts, bony spurs/fragments, and benign
and it supplies the muscles of the anterior com- tumors have also been reported.
partment of the arm (the coracobrachialis, biceps Although the axillary nerve can be identified,
brachii, and brachialis muscles) and the skin on the nerve compression remains difficult to
the lateral aspect of the forearm. Typically, the directly assess with US. Otherwise, the denerva-
MCN arises from the lateral cord of the brachial tion of teres minor muscle often allows the first
plexus; it pierces the coracobrachialis muscle and sign for QSS diagnosis. Atrophy of the teres
it descends distally between the biceps brachii minor can be easily assessed by comparing the
and brachialis muscle. Just below the elbow, it US appearance of this muscle with that of the
pierces the deep fascia lateral to the biceps adjacent infraspinatus.
tendon. Dilated posterior circumflex humeral artery at
US can identify the MCN from its origin from the quadrilateral space can be another important
the lateral cord in the axilla, to the distal third of sign for quadrilateral space diagnosis.
the arm. The MCN mean cross-sectional area at Paralabral cysts or other space-occupying
the level of the arm is 2.5 ± 0.4 mm2. lesions in quadrilateral space can be identified,
Most of the mechanical MCN neuropathies too.
are due to trauma or stretching microtraumas.
Entrapment MCN neuropathies are rare.
Neuropathy after excessive exercises and after 23.2.4 Radial Nerve
long head biceps tenotomy has been described.
The radial nerve is the largest nerve in the upper
limb. It is a branch of the brachial plexus arising
23.2.3 Axillary Nerve from the posterior cord with fibers originating
from the C5, C6, C7, C8, and T1 roots. After
The axillary nerve originates from the spinal cord entering the axillary region, it runs distally, in the
at the C5 and C6 levels with occasional contribu- posterior aspect of the upper arm, passing in a
tion from C4. It is derived from the posterior cord spiral groove found in the posterior cortex of the
of the brachial plexus and travels below the cora- humerus. Anterior to the lateral epicondyle, the
coid process, obliquely along the anterior surface radial nerve divides into superficial and deep
of the subscapularis, and then travels posteriorly, branches.
adjacent to the inferomedial capsule passing The superficial branch is purely sensory and
through the quadrilateral space. The quadrilateral its entrapment syndrome at proximal wrist (called
space is delimited by the long head of the triceps Wartenberg’s syndrome) is uncommon.
medially, the humeral shaft laterally, the teres The deep, purely motor, branch of the radial
minor muscle superiorly, the teres major and nerve is called posterior interosseous nerve
latissimus dorsi muscles inferiorly, and the sub- (PIN) and it runs between the two heads of the
scapularis muscle anteriorly. This is the anatomi- supinator muscle, innervates it, then enters the
cal main region of compression of the axillary forearm, and supplies the majority of the fore-
nerve. arm and hand extensors. In its most proximal
First described by Cahill and Palmer in 1983, part the supinator muscle forms a fibrous arc
the quadrilateral space syndrome (QSS) can lead called arcade of Fröhse, which is a common site
to poorly localized shoulder pain, discrete tender- of PIN compression.
23 Peripheral Entrapment Neuropathies 197

23.2.4.1 Spiral Groove Syndrome

Spiral groove syndrome is often caused by a
fracture of the humerus at this level. Radial palsy
can be caused by (1) the injury of the nerve that
passes adjacent to the cortical bone; (2) entrap-
ment of the nerve between the skeletal segments
or in the callus; (3) impingement between radial
nerve and screws; and (4) entrapment of the
nerve between the humerus and the surgical
hardware. US is recommended in the algorithm
for the management of radial nerve palsy associ-
ated with the fracture of the shaft of the humerus.
In case of radial nerve palsy after a surgically Fig. 23.6 Radial nerve entrapment in a fixation screw
treated humeral fracture, US is useful in deter- spiral after surgical osteosynthesis of humeral shaft frac-
mining the type of nerve damage. In case of ture. Transverse US image shows the radial nerve (white
injury, at US the nerve may appear thickened and arrows) entrapped and partially injured by the lightly
extruded surgical screw (black arrows). H humerus
hypoechoic or interrupted (Fig. 23.5). In case of
fractures, the radial nerve appears displaced by
the bone fragments or pinched between them. In
the postoperative period, the radial nerve may be
found stretched over or pinched by the orthope-
dic hardware used for osteosynthesis (Figs. 23.6
and 23.7).

Fig. 23.7 Radial nerve entrapment under the hardware

after surgical osteosynthesis of humeral shaft fracture. In
the longitudinal US image the radial nerve (arrows)
appears pinched between humeral cortex and osteosyn-
thesis hardware (arrowheads) with hourglass aspect of the
nerve. H humerus

23.2.4.2 Posterior Interosseus

Syndrome
The posterior interosseus syndrome, also called
supinator syndrome or radial tunnel syndrome, is
a rare compression neuropathy of the upper limb
affecting the deep branch of the radial nerve.
Supinator syndrome appears in two forms, a
truly neurogenic, paralytic form and a painful
Fig. 23.5 Radial nerve injury. Transverse US image form. The painful form is often difficult to distin-
shows the radial nerve (white arrows) hypoechoic and guish from lateral epicondylitis.
swollen due to the direct trauma of the previous humeral
fracture (arrowhead). No nerve entrapment is visible. H The true neurogenic form is different from a
humerus lesion of the main trunk of the radial nerve,
198 S. Guarino et al.

a b

Fig. 23.8 (a, b) Posterior interosseus nerve (PIN) entrap- arcade (arrowhead). The PIN appears hypoechoic and
ment in the arcade of Fröhse. Longitudinal (a) and trans- swelling (between calipers) just proximally to the com-
verse (b) US images demonstrate the PIN (arrows) pression site
compressed by the hyperechoic and thickened Fröhse’s

because there are no sensory symptoms and the

patient has usually a finger drop rather than the
wrist drop of a radial neuropathy because the
extensor carpi radialis muscle is spared, although
this clinical feature is not constant.
PIN syndrome can be caused by extrinsic
effects, such as compression on the PIN from
adjacent structures, or by intrinsic lesions of
the nerve. The arcade of Fröhse is the most
common cause of extrinsic compression. The
arcade of Fröhse can be classified as tendinous Fig. 23.9 Posterior interosseus nerve (PIN) entrapment.
and membranous and the tendinous type is con- Longitudinal US image demonstrates the PIN compressed
between a lipoma of deep head and superficial head of
sidered a significant risk factor for PIN syn- supinator muscle (shS). The PIN (arrows) shows hour-
drome. Repeated pronation and supination glass aspect. The patient was suffering from isolated fin-
could be aggravated by the compression, as the ger drop of the index
nerve is “fixed” in the supinator muscle, result-
ing in its elongation and rotation during these PIN is usually found distally to the Fröhse arcade
movements. Compression and proximal (Fig. 23.10)
hypoechoic swelling of the PIN at the entrance
into the supinator canal are typically US appear-
ance in Fröhse arcade compression cases 23.2.5 Ulnar Nerve
(Fig. 23.8a, b).
The PIN may also be compressed by soft-­ Potential ulnar nerve entrapment can occur at five
tissue masses (such as lipomas, deep ganglia, sites around the elbow: the arcade of Struthers,
and synovitis), radial head fracture, and the medial intermuscular septum, the medial epi-
Monteggia fracture-dislocation (Fig. 23.9). In condyle, the cubital tunnel, and the deep flexor
addition, the nerve in that area is more suscepti- pronator aponeurosis. The most common site of
ble to post-­traumatic injuries and swelling of the entrapment is the cubital tunnel.
23 Peripheral Entrapment Neuropathies 199

23.2.5.1 Cubital Tunnel Syndrome acquired, including an anconeus-epitrochlearis

Cubital tunnel syndrome involves compression muscle, bone deformities, ganglion cysts, and
and irritation of the ulnar nerve at the elbow, other space-occupying lesions.
where the nerve passes through the cubital tunnel To begin the US examination, it is useful to
under Osborne’s ligament. It is considered the keep the elbow extended and the probe posi-
second most common upper extremity nerve tioned immediately posterior to the medial epi-
entrapment after carpal tunnel syndrome. condyle (identifiable by palpation). The ulnar
Compression of the nerve at this level can be nerve appears hypoechoic, surrounded by
caused by numerous causes both congenital and hyperechoic fat, and it can be ovoid or have a
bilobed, bifid, or trifid appearance. The mean
cross-­sectional area of the ulnar nerve in the
cubital tunnel was approximately 6.6 mm and
slight enlargement of the nerve at the epicon-
dyle compared to ulnar nerve area at the level
of the upper arm proximally could be normal.
In the cubital tunnel syndrome, the ulnar
nerve appears thickened and hypoechoic proxi-
mal to the tunnel and may flatten or remain
thickened within it (Fig. 23.11a–c). It is useful
to identify the causes of nerve compression,
Fig. 23.10 Posterior interosseus nerve (PIN) injury. such as joint effusion, synovitis and osteophytes
Transverse US image demonstrates a hypoechoic and (Fig. 23.12). The presence of an anconeus-epi-
swollen PIN (arrows) distally to the Fröhse’s arcade after
trauma. ECRL extensor carpi radialis longus, BR brachio- trochlearis muscle may represent another possi-
radialis, shS superficial head of supinator muscle, R radius ble cause of ulnar nerve entrapment, which

a b

Fig. 23.11 (a–c) Cubital tunnel syndrome. Longitudinal just before entering the cubital tunnel. In the tunnel the
(a) and transverse (b) US images just proximally and at nerve appears normal in dimension (arrow in c). ME
the cubital tunnel level (c). The ulnar nerve (arrows) medial epicondyle, O olecranon
appears swollen and hypoechoic (arrowheads in a and b)
200 S. Guarino et al.

artery pseudoaneurysms, or abnormal muscles

are the main causes of this syndrome. Clinically
it differs from that of the cubital tunnel because
the sensitivity of the dorsum of the middle half
of the fourth and fifth fingers is preserved.

23.2.6 Median Nerve

Fig. 23.12 Cubital tunnel syndrome. Transverse US The median nerve originates from the medial and
image shows the ulnar nerve compressed by an olecranic
lateral cords of the brachial plexus, receiving
spur (arrowhead). The ulnar nerve (arrows) appears
pinched with hyperechoic and irregular margins. ME innervation from C6, C7, C8, and T1. After its
medial epicondyle, O olecranon origin, the median nerve and brachial artery run
along the medial aspect of the arm towards the
elbow. The anterior interosseous nerve (AIN)
a
emerges 5–8 cm distally to the lateral epicondyle
on the posterior surface of the median nerve.
Rare entrapment sites of the median nerve are
located near the elbow.
The supracondylar process syndrome is
caused by the presence of the supracondylar pro-
cess which is a beak-shaped bony process on the
anteromedial aspect of the distal humerus. The
b ligament of Struthers’ is a fibrous band usually
extending from the tip of the process to the
medial epicondyle.
The median nerve could be entrapped under
the ligament of Struthers’ or directly compressed
by the bony process (Fig. 23.14).

Fig. 23.13 (a, b) Transverse (a) and longitudinal (b) US

images at the cubital tunnel level show the ulnar nerve
(arrows) entrapped between an accessory muscle called
anconeus epitrochlearis (AE) and the medial epicondyle
humerus (ME). A focal nerve swelling (arrowhead in b) is
noted just proximally to the compression site. ME medial
epicondyle, O olecranon

occurs just proximal to the true cubital tunnel. It

is visible with US as a muscle superficially to
the ulnar nerve (Fig. 23.13a, b).

23.2.5.2 Guyon’s Canal Syndrome

Guyon’s canal represents an additional site of
Fig. 23.14 Transverse US image of the anterior aspect of
entrapment of the ulnar nerve, although this the middle third of the arm. Note the supracondylar pro-
pathology is quite rare. Space-occupying cess (SP) that dislocates the median nerve (arrows)
lesions such as lipomas, cystic ganglia, ulnar deforming it. H humerus
23 Peripheral Entrapment Neuropathies 201

In the pronator syndrome patients have pain nosis of CTS to be a cost-effective strategy in the
and paresthesia in the volar aspect of the elbow hands of a specialist.
and forearm and in the first, second, and third The US diagnosis of STC includes several
digits and radial half of the ring finger. US is very semiotic features. The most commonly used are
useful to detect the compression site. The Kiloh-­ median nerve thickening and evaluating the dif-
Nevin syndrome is characterized by an extrinsic ference in cross-sectional area between the
compression of the AIN that determines the dif- nerve in the carpal tunnel and proximally at the
ficulty in performing the OK sign with the pronator quadratus muscle level in the distal
affected hand. forearm (Δ >2 mm2 is pathologic). The severity
Clinical and US detection of muscle atrophy grading is defined as mild when Δ is ≤6 mm2,
often represents the first step in diagnosing these moderate when it is ≤9 mm2, and severe when it
rare forms of entrapment. is >9 mm2. Distal flattening of the median nerve
and palmar bulging of the flexor retinaculum
23.2.6.1 Carpal Tunnel Syndrome (>2 mm beyond line joining the hamate-pisi-
Carpal tunnel syndrome (CTS) is the most com- form to the trapezium/scaphoid) are other
mon entrapment neuropathy and consists of important US features for the diagnosis of
compression of the median nerve in the name- CTS. Power Doppler evaluation is also used by
sake tunnel. The median nerve in the carpal some authors in combination of nerve swelling
tunnel lies between the flexor retinaculum measurements to increase the diagnostic accu-
superiorly and the flexor tendons and carpal racy of US in patients with clinically suspected
bones (scaphoid and trapezium) inferiorly. The CTS (Figs. 23.15a, b, and 23.16a, b).
CTS is characterized first by intermittent noc- Even if usually the CTS is congenital, US can
turnal paresthesia and pain. Subsequently there assess the possible causes of compression: thick-
is a loss of sensation followed by motor symp- ening of the flexor retinaculum, tenosynovitis,
toms such as weakness and thenar muscle ganglion cysts, radiocarpal synovitis, or muscles’
atrophy. anatomic variants.
Current recommendations by the American Anatomical variants of median nerve at wrist
Academy of Orthopaedic Surgeons (AAOS) are level include accessory branches proximal to the
to obtain a confirmatory test in patients for whom carpal tunnel; accessory branches in the distal
carpal tunnel surgery is being considered. Several carpal tunnel; thenar branch course variation; and
authors today are in agreement to use US as a high divisions of the median nerve (or bifid
first-line test for confirmation of a clinical diag- median nerve). The incidence of bifid median

a b

Fig. 23.15 (a, b) Carpal tunnel syndrome. Two trans- 8 mm2 in (a) and 14 mm2 in (b) with a Δ of 6 mm2, indi-
verse US images at the level of the distal third of pronator cating high-grade carpal tunnel syndrome. PQ pronator
quadratus muscle (a) and at carpal tunnel level (b). The quadratus muscle, C carpus, FCR flexor carpi radialis
cross-sectional area of the median nerve (outlined) is tendon
202 S. Guarino et al.

a b

Fig. 23.16 (a, b) Carpal tunnel syndrome. Transverse (a) distally (white arrows). Note the palmar bowing of the
and longitudinal (b) US images at carpal tunnel level. The flexor retinaculum (black arrows) and the increase of
median nerve appears swollen and hypoechoic just proxi- nerve vascularization at power Doppler
mally to the carpal tunnel (arrowheads) and flattening

nerves was found to be 2.8% and it can be present

with a persistent median artery (Fig. 23.17).
Evaluation of the cross-sectional area implies
summing the areas of the two branches of the
median nerve with a new cutoff Δ value of 4 mm2
instead of 2 mm2.

23.3 Entrapment Neuropathies

of Lower Limb Fig. 23.17 Bifid median nerve. Transverse US image at
carpal tunnel level shows a bifid median nerve (arrows)
with a persistent median artery (arrowhead)
23.3.1 L
 ateral Femoral Cutaneous
Nerve Entrapment
inguinal ligament with pain, numbness, pares-
The lateral femoral cutaneous nerve (LFCN) is a thesia, or burning sensation in the anterolateral
pure sensory nerve providing sensation to the thigh. Causes of entrapment are abdominal
anterolateral aspect of the thigh. The LFCN bulging over the inguinal ligament in preg-
arises from the L2 and L3 nerve roots, courses nancy and ­ obesity with compression of the
lateral to the psoas muscle, crosses the iliacus nerve at the lateral end of the inguinal liga-
muscle, and exits the pelvis running below or in a ment, ascites, tight clothing, seat belts, limb
split of the lateral end of the inguinal ligament, length discrepancy, avulsion fracture of the
medially to the anterior superior iliac spine ASIS, proximal sartorius enthesopathy, and
(ASIS). Soon after crossing the ligament, the local soft-tissue masses. Recently, smartphone
LFCN passes over or medially to the sartorius worn on the belt or tablet rested too frequently
muscle into the thigh, where it divides into an on a patient’s lap has been found to cause
anterior and a posterior branch, providing sen- LFCN entrapment.
sory innervation to the anterior and the lateral The main US findings of LFCN neuropathy
thigh, respectively. are nerve flattening under the inguinal ligament
Meralgia paresthetica is an entrapment neu- with hypoechoic nerve swelling proximal to the
ropathy of the LFCN where it crosses the area of entrapment (Fig. 23.18a, b).
23 Peripheral Entrapment Neuropathies 203

a b

Fig. 23.18 (a, b) Meralgia paresthetica. Transverse (a) arrows). The nerve shows coalescence of fascicles and
and longitudinal (b) US images show the entrapment of hyperechoic outer nerve sheath (white arrows). IM iliac
the lateral femoral cutaneous nerve between anterior muscle
superior iliac spine (ASIS) and inguinal ligament (black

23.3.2 Sciatic Nerve fossa, coursing along the border of the biceps
femoris muscle. CPN then travels superficially
The sciatic nerve (SN), the largest nerve in the and wraps around the fibular head/neck, before
body, originates from the L4 through S3 nerve entering the anterior compartment musculature
roots, forming a single nerve within pelvis, and of the leg through the peroneal tunnel, formed by
exits the pelvis posteriorly through the greater sci- the proximal fibula and peroneus longus muscle,
atic foramen inferior to the piriformis muscle. where it divides into the superficial and deep
Distally to the piriformis muscle, SN is covered peroneal nerves.
by gluteus maximus and runs halfway between Compression neuropathy of CPN at fibular
the ischial tuberosity and the greater trochanter. head is the most common neuropathy of the
After curving around the ischial spine, SN has a lower limb, presenting clinically with foot drop
close relationship with hamstrings, descending or motor weakness of ankle dorsiflexion. At the
lateral to their proximal origin and running behind fibular head level the CPN is relatively fixed,
them in the proximal thigh. SN provides motor located superficially and closely to the underly-
fibers to the posterior thigh muscles and almost all ing bone of the fibula, making it particularly sus-
sensory and motor functions below the knee. ceptible to injury. A remarkable predisposing
factor for CPN neuropathies at fibular head is a
23.3.2.1 Deep Gluteal Syndrome recent weight loss, because it is associated with
This syndrome is caused by entrapment of SN loss of subcutaneous fat, increasing the suscepti-
occurring from gluteal region. The most common bility of the nerve to compression at this level.
causes of SN entrapment are fibrovascular band, Furthermore, anatomic variations of lateral gas-
piriformis syndrome, ischiofemoral impinge- trocnemius, distal biceps femoris tendon, and
ment, proximal hamstring tendon injury, femoral fibular head may predispose to compression of
fracture, hip fracture dislocation, and total hip CPN.
arthroplasty. In these cases US may reveal a focal Other causes of CPN neuropathy at fibular
increase in the nerve size, loss of the fascicular head/neck include space-occupying lesions,
echotexture, and hypoechoic pattern of SN. thickening of a surrounding fascia, traction- or
contusion-nerve injuries during knee trauma (iso-
lated or in association with fibular head fracture),
23.3.3 Common Peroneal Nerve and postsurgical scar tissue. Another less com-
mon cause is entrapment of the nerve by fabella,
The common peroneal nerve (CPN), receiving in close anatomical relation with CP (Fig. 23.19).
contributions from the L4 through S2 nerve roots, Compression of the deep peroneal nerve at the
takes off from SN at the apex of the popliteal peroneal tunnel is less common.
204 S. Guarino et al.

a b

Fig. 23.19 (a, b) Common peroneal nerve impingement thickened and hypoechoic; the fabella (F) is noted. In (b),
with fabella. Two transverse US images of common pero- with the knee in typical position of the legs crossed, the
neal nerve (CPN) at lateral femoral condyle level, with CPN (arrows) appears compressed and deformed by the
extended knee in (a) and flexed knee with external rota- fabella (F)
tion of the foot in (b). In (a) the CPN (arrows) appears

a b

Fig. 23.20 (a, b) Common peroneal nerve entrapment. Transverse (a) and longitudinal (b) US images show the com-
mon peroneal nerve (arrows) compressed and dislocated by the below fibular head (FH).

The main US findings of CPN neuropathy 23.3.4 Superficial Peroneal Nerve

are an evident fibular-CPN impingement,
increased cross-sectional area (>11 mm2), and After its origin from CPN in the peroneal tunnel,
flexion of its course at the fibular head, the superficial peroneal nerve (SPN) courses
hypoechogenicity, loss of normal fascicular between the peroneus longus and extensor digito-
pattern, and sometimes hypervascularization rum longus muscles. About 5 cm above the ankle
on color or power Doppler (Fig. 23.20a, b). In joint SPN pierces the deep fascia, the most com-
cases of doubt on the direct ultrasound evalua- mon site of mechanical entrapment, to enter the
tion of the nerve, it may be useful to confirm subcutaneous compartment, where it divides into
the compromise of the only muscles innervated its terminal sensory branches.
by the PCN to exclude other pathologies SPN provides motor innervation to the pero-
(Fig. 23.21). neus longus and brevis muscles and sensory
23 Peripheral Entrapment Neuropathies 205

Fig. 23.21 Common peroneal nerve entrapment: Muscle and healthy side (on the right). On the left the tibialis ante-
atrophy. Transverse US images of anterior proximal third rior (TA) and the extensor digitorum longus (EDL) mus-
of the leg show the difference in echogenicity of the cles appear hyperechoic due to the peroneal nerve
anterolateral muscles between the affected (on the left) entrapment

innervation to the lower two-thirds of the antero- 23.3.5.1  nterior Tarsal Tunnel
A
lateral leg and the dorsum of the foot. Syndrome
The most common site of entrapment is the At the ankle level the nerve becomes superficial
exit from the deep fascia and the generally and enters the anterior tarsal tunnel, containing
reported symptoms are pain and sensory changes the extensor tendons of the foot, dorsalis pedis
over the dorsum of the foot. Causes of SPN artery and veins, and DPN. Just inferior or under
entrapment are repetitive plantar flexions and the inferior extensor retinaculum, DPN divides
ankle inversions, scarring or fibrous bands, gan- into lateral and medial branches.
glion cyst, and muscle hernia through a fascial Entrapment of DPN and its branches may
defect. occur more commonly in three sites: deep to the
US is fundamental in assessing SPN, because, inferior extensor retinaculum; deep to the exten-
in addition to identifying the classic signs of sor hallucis longus tendon at the level of the talo-
entrapment neuropathy, it allows to detect any navicular joint; and deep to the extensor hallucis
fascial defects and muscle hernias through a brevis muscle at the first and second tarsal-­
dynamic exam during muscle contraction. metatarsal articulation levels (medial branch).
Generally, patients report sensory changes and
pain across the top of the foot going into the
23.3.5 Deep Peroneal Nerve space between the first and the second toe.
US may easily evaluate the nerve in its more
After its origin from CPN in the peroneal tun- superficial locations and detect entrapment
nel, the deep peroneal nerve (DPN), accompa- causes.
nied by the anterior tibial artery, courses distally Causes of DPN entrapment neuropathy are
along the anterior surface of interosseous mem- thickening or injury to the extensor retinaculum,
brane, providing motor innervation to extensor synovitis, and osteophytosis at talo-navicular,
muscles of the foot and sensory innervation to navicular-cuneiform or tarso-metarsal joints
tibiotalar joint. Impingement of the proximal (Fig. 23.22), os intermetatarseum, fractures, ice
course of the nerve within the proximal leg is skate or ski boot wear, high-heeled or tight-fitting
uncommon. running shoes, ganglia originating from neigh-
206 S. Guarino et al.

containing PTN, posterior tibial artery and veins,

posterior tibialis, and flexor tendons.
Excessive tension, compression, and entrap-
ment of PTN in the tarsal tunnel may be due to
valgus hindfoot, traumatic scar, talocalcaneal
coalition, hypertrophic and accessory muscles,
hypertrophic or inflamed tendons, and space-­
occupying lesions.
Symptoms of tarsal tunnel syndrome include
pain and paresthesia along the plantar foot.
Fig. 23.22 Deep peroneal nerve. Transverse US images US of TN at the tarsal tunnel is very specific,
show synovitis (asterisks) of tarso-metatarsal joints with being able to identify the causes of tarsal tunnel
entrapment of superior deep peroneal nerve (arrow). T tar- syndrome and direct findings of entrapment neu-
sus, a artery
ropathy, such as loss of nerve fascicular pattern,
hypoechoic nerve enlargement proximal to the
boring joints, extensor tenosynovitis, anterior area of entrapment with flattening or disappear-
tibial or dorsalis pedis artery aneurysms, throm- ance of the nerve at the site of entrapment, and
bosed dorsalis pedis vein, and prosthesis. acute and pathologic angle changes in the path of
the nerve or “kinking” (Fig. 23.23).

23.3.6 Tibial Nerve 23.3.6.2 J ogger’s Foot (Medial

Plantar Nerve)
The tibial nerve (TN) receives contributions from The medial plantar nerve (MPN) is the larger ter-
the L4 through S2 nerve roots. In the posterior minal branch of TN, providing motor innervation
knee TN takes off from SN at the apex of the pop- to the deep muscles of the plantar side of the foot
liteal fossa and runs through the popliteal fossa and sensation from the respective side of the sole
accompanied by popliteal artery and vein. This of the foot. MPN is most commonly entrapped
neurovascular bundle passes deep to the tendi- between the abductor hallucis muscle and the
nous arch of the soleus muscle and, after yielding “Henry’s knot,” that is, the crossing of the flexor
the peroneal artery, travels superficial to the tibi- digitorum longus tendon over the flexor hallucis
alis posterior muscle to reach the tarsal tunnel. longus tendon in the plantar aspect of the mid-
At the ankle level, TN, now known as poste-
rior tibial nerve (PTN), trifurcates into its termi-
nal branches (medial plantar, lateral plantar, and
medial calcaneal nerves) proximally, within or
distally to the tarsal tunnel, the fibro-osseous tun-
nel in the posteromedial aspect of the ankle pos-
terior to the medial malleolus, and deep to the
flexor retinaculum.
The main compression neuropathies of TN
and its branches include tarsal tunnel syndrome,
jogger’s foot, and Baxter neuropathy.

23.3.6.1 Tarsal Tunnel Syndrome

(Posterior Tibial Nerve) Fig. 23.23 Tarsal tunnel syndrome. Transverse US
image of tarsal tunnel shows hypertrophy of the medial
Tarsal tunnel syndrome is a compression neurop- process of the talus. The bony spur (arrowhead) creating
athy of PTN within the fibro-osseous tarsal tun- impingement with the tibial posterior nerve (arrows). A
nel on the posteromedial aspect of the ankle, artery
23 Peripheral Entrapment Neuropathies 207

of the foot, and weakness of the abductor digiti

minimi. US is useful to assess the nerve and
detect space-occupying lesions, other causes of
external compression, as well as a denervation
atrophy, but MRI appears to be more sensitive to
identify the abductor digiti minimi muscle
atrophy.

Fig. 23.24 Jogger’s foot. Transverse US image of the

posteromedial aspect of the ankle at calcaneal level shows 23.3.7 Interdigital Nerves
hypertrophy of sustentaculum tali (ST) of calcaneus
related to talocalcaneal coalition. The medial plantar The interdigital nerves (IN) originate from the
nerve (arrows) results entrapped between the sustentacu-
lum tali and superficial fascia. Note the lateral plantar medial and lateral plantar nerves at the level of
nerve posteriorly (black arrows). FHL flexor hallucis lon- the metatarsal bases and course through a fibro-­
gus, FDL flexor digitorum longus, V veins, A artery osseous tunnel formed by the metatarsal heads
and intermetatarsal ligament, innervating the web
foot, leading to pain on the medial plantar aspect spaces.
of the foot. Tendinosis or tenosynovitis around IN are typically involved in Morton’s neu-
“Henry’s knot” may cause nerve irritation, par- roma, which is not a true neuroma, but an entrap-
ticularly in regular runners; for this reason this ment neuropathy, characterized by perineural
condition is also called as “jogger’s foot.” Other fibrosis of the interdigital nerve.
less common causes of entrapment are plantar It is caused by repetitive compressive trauma
muscle hypertrophy, bony abnormalities and of IN against the transverse intermetatarsal liga-
space occupying lesions (Fig. 23.24). ment resulting in local edema of the endoneu-
The “Henry’s knot” is an excellent landmark rium, axonal degeneration, neovascularization,
to identify the nerve at US exam that is able to and perineural fibrosis. Sometimes it may be
detect tendinosis or tenosynovitis around associated with intermetatarsal bursitis.
Henry’s, space-occupying lesions, and direct Morton’s neuroma most commonly affects
findings of entrapment neuropathy. women, likely due to wearing narrow shoes
inducing traction of IN. It is also observed in run-
23.3.6.3  axter Neuropathy (Inferior
B ners and dancers, typically caused by hyperex-
Calcaneal Nerves) tension of the metatarsophalangeal joints and
The inferior calcaneal nerve (ICN), or Baxter’s repetitive trauma to the metatarsals.
nerve, is the first branch of the lateral plantar The second and third intermetatarsal spaces
nerve, providing motor innervation to the abduc- are more commonly involved due to their smaller
tor digiti minimi muscle and sensory innervation dimensions and the larger dimensions of the third
to the anterior aspect of the calcaneus. IN, receiving contributions from both the medial
Entrapment of ICN is also known as Baxter and lateral plantar nerves.
neuropathy. The entrapment sites are where ICN Patients typically refer to burning or electric
travels between the abductor hallucis and medial pain and paresthesia in the affected web space
margin of the quadratus plantae muscles and and may report sensation of walking on a lump or
where ICN runs between calcaneus and flexor pebble.
digitorum brevis muscle-aponeurosis complex. US is a reliable tool in confirming the clinical
Causes of entrapment are plantar calcaneal enthe- diagnosis of Morton’s neuroma. The best tech-
sopathy, plantar fasciitis, bone spurs, muscle nique to visualize Morton’s neuroma is to place
hypertrophy, varicosities, and hyperpronation of the transducer on the plantar aspect of the web
the foot. The most common symptoms are heel space of clinical interest applying a “Mulder’s
pain, numbness along the lateral third of the sole test” maneuver. At US the Morton’s neuroma
208 S. Guarino et al.

Ay S, Bektas U, Yilmaz C, Diren B. An unusual supra-

condylar process syndrome. J Hand Surg Am.
2002;27:913–5.
Balalis K, Topalidou A, Balali C, et al. The treatment
of Morton’s neuroma, a significant cause of meta-
tarsalgia for people who exercise. Int J Clin Med.
2013;4:19–24.
Bäumer P, Kele H, Xia A, et al. Posterior interosseous
neuropathy: Supinator syndrome vs fascicular radial
neuropathy. Neurology. 2016;87:1884–91.
Baxter DE, Thigpen CM. Heel pain—operative results.
Foot Ankle. 1984;5:16–25.
Fig. 23.25 Morton’s neuroma Transverse US image of Beltran LS, Bencardino J, Ghazikhanian V, Beltran
third intermetatarsal space during Mulder’s test shows the J. Entrapment neuropathies III: lower limb. In:
so-called Morton’s neuroma as hypo-isoechoic mass (out- Seminars in musculoskeletal radiology. Semin
lined) between the third and fourth metatarsal heads (Mt) Musculoskelet Radiol .Thieme Medical Publishers.
2010;14:501–11.
Bencardino J, Rosenberg ZS, Beltran J, et al. Morton’s
appears as a rounded or ovoid, hypoechoic nod- neuroma: is it always symptomatic? Am J Roentgenol.
ule in the intermetatarsal space. It is reported that 2000;175:649–53.
Bianchi S, Martinoli C. Ultrasound of the musculoskele-
the mean size of the measured neuromas on US tal system. Switzerland: Springer Science & Business
was 4.9 ± 1.45 mm (range: 4–9 mm) (Fig. 23.25). Media; 2007.
The US Tinel sign, consisting of the evocation of Bignotti B, Assini A, Signori A, et al. Ultrasound versus
pain with the pressure exerted by the transducer, MRI in common fibular neuropathy. Muscle Nerve.
2017;55:849–57.
may also be present and help in diagnosing Bignotti B, Cadoni A, Assini A, et al. Fascicular involve-
Morton’s neuroma. ment in common fibular neuropathy: evaluation with
ultrasound. Muscle Nerve. 2016;53:532–7.
Bignotti B, Signori A, Sormani MP. Ultrasound ver-
sus magnetic resonance imaging for Morton neu-
23.3.8 M
 edial Proper Plantar Digital roma: systematic review and meta-analysis. Eur
Nerve Radiol. 2015;25(8):2254–62. https://doi.org/10.1007/
s00330-­015-­3633-­3.
Bodner G, Bernathova M, Galiano K, et al. Ultrasound of
The medial proper plantar digital nerve, also
the lateral femoral cutaneous nerve: normal findings
known as the medial hallucal digital nerve, is the in a cadaver and in volunteers. Reg Anesth Pain Med.
most medial branch of the medial plantar nerve 2009;34:265–8.
and is located at the medial plantar aspect of the Bodner G, Buchberger W, Schocke M, et al. Radial
nerve palsy associated with humeral shaft fracture:
hallux adjacent to the medial sesamoid bone, pro-
evaluation with US—initial experience. Radiology.
viding sensory innervation to the medial aspect 2001;219:811–6.
of the hallux. Focal irritation of the nerve may Bowley MP. Entrapment neuropathies of the lower
result in the formation of a neuroma known as extremity. Med Clin North Am. 2018;103(2):371–82.
https://doi.org/10.1016/j.mcna.2018.10.013.
Joplin neuroma, which may be visualized at US
Boykin RE, Friedman DJ, Higgins LD, Warner
as a small area of hypoechoic focal thickening. JJP. Suprascapular neuropathy. JBJS.
2010;92:2348–64.
Cahill BR, Palmer RE. Quadrilateral space syndrome. J
Hand Surg Am. 1983;8:65–9.
Further Readings Carro LP, Hernando MF, Cerezal L, et al. Deep gluteal
space problems: piriformis syndrome, ischiofemo-
Abreu E, Aubert S, Wavreille G, et al. Peripheral tumor ral impingement and sciatic nerve release. Muscles
and tumor-like neurogenic lesions. Eur J Radiol. Ligaments Tendons J. 2016;6:384.
2013;82:38–50. Chari B. Nerve entrapment in ankle and foot. Ultrasound
Allagui M, Maghrebi S, Touati B, et al. Posterior inter- Imag. 2018;22:354–63.
osseous nerve syndrome due to intramuscular lipoma. Chihlas CN, Ladocsi LT, Sholley MM, et al. Position of
Eur Orthop Traumatol. 2014;5:75–9. the fabella relative to the path of the common pero-
Amin MF, Berst M, El-Khoury GY. An unusual cause of neal nerve across the lateral head of the gastrocnemius
the quadrilateral space impingement syndrome by a muscle. Clin Anat Off J Am Assoc Clin Anat Br Assoc
bone spike. Skeletal Radiol. 2006;35:956–8. Clin Anat. 1993;6:163–6.
23 Peripheral Entrapment Neuropathies 209

Chipman JN, Mott RT, Stanton CA, Cartwright Hochman MG, Zilberfarb JL. Nerves in a pinch: imag-
MS. Ultrasonographic tinel sign. Muscle Nerve Off J ing of nerve compression syndromes. Radiol Clin.
Am Assoc Electrodiagn Med. 2009;40:1033–5. 2004;42:221–45.
Cho D, Saetia K, Lee S, et al. Peroneal nerve injury Hung C-Y, Chang K-V, Chen P-T, et al. Sonoelastography
associated with sports-related knee injury. Neurosurg for the evaluation of an axillary schwannoma in a
Focus. 2011;31:E11. case of quadrilateral space syndrome. Clin Imaging.
Chundru U, Liebeskind A, Seidelmann F, et al. Plantar 2014;38:360–3.
fasciitis and calcaneal spur formation are associated Ikiz ZAA, Ucerler H, Uygur M. Dimensions of the ante-
with abductor digiti minimi atrophy on MRI of the rior tarsal tunnel and features of the deep peroneal
foot. Skeletal Radiol. 2008;37:505–10. nerve in relation to clinical application. Surg Radiol
Claessen FMAP, Peters RM, Verbeek DO, et al. Factors Anat. 2007;29:527–30.
associated with radial nerve palsy after operative treat- Jacobson JA, Fessell DP, Lobo LDG, Yang
ment of diaphyseal humeral shaft fractures. J Shoulder LJ-S. Entrapment neuropathies I: upper limb (carpal
Elb Surg. 2015;24:e307–11. tunnel excluded). Semin Musculoskelet Radiol. ©
Cruz-Martinez A, Arpa J, Palau F. Peroneal neuropathy Thieme Medical Publishers. 2010;14:473–86.
after weight loss. J Peripher Nerv Syst. 2000;5:101–5. Jacobson JA, Wilson TJ, Yang LJ. Sonography of com-
Damarey B, Demondion X, Boutry N, et al. Sonographic mon peripheral nerve disorders with clinical correla-
assessment of the lateral femoral cutaneous nerve. J tion. J Ultrasound Med. 2016;35:683–93.
Clin Ultrasound. 2009;37:89–95. Kang PB, Preston DC, Raynor EM. Involvement of super-
Davidson JJ, Bassett FH, Nunley JA. Musculocutaneous ficial peroneal sensory nerve in common peroneal neu-
nerve entrapment revisited. J shoulder Elb Surg. ropathy. Muscle Nerve Off J Am Assoc Electrodiagn
1998;7:250–5. Med. 2005;31:725–9.
Duparc F, Coquerel D, Ozeel J, et al. Anatomical basis of Karwa KA, Do DP, Tavee JO. Journal of the Neurological
the suprascapular nerve entrapment, and clinical rel- Sciences Smart device neuropathy. J Neurol
evance of the supraspinatus fascia. Surg Radiol Anat. Sci. 2016;370:132–3. https://doi.org/10.1016/j.
2010;32:277–84. jns.2016.09.040.
Felci GRS. Delayed radial nerve palsy due to entrapment Katirji B. Peroneal neuropathy. Neurol Clin.
of the nerve in the callus of a distal third humerus frac- 1999;17:567–91.
ture. Turk Neurosurg. 2008;18:194–6. Kim Y, Ha DH, Lee SM. Ultrasonographic find-
Feng S-H, Hsiao M-Y, Wu C-H, Özçakar L. Ultrasound-­ ings of posterior interosseous nerve syndrome.
guided diagnosis and management for quadrilateral Ultrasonography. 2017;36:363.
space syndrome. Pain Med. 2017;18:184–6. Kim S-J, Hong SH, Jun WS, et al. MR imaging map-
Ferkel E, Davis WH, Ellington JK. Entrapment neu- ping of skeletal muscle denervation in entrapment
ropathies of the foot and ankle. Clin Sports Med. and compressive neuropathies. Radiographics.
2015;34:791–801. https://doi.org/10.1016/j. 2011;31:319–32.
csm.2015.06.002. Klauser AS, Buzzegoli T, Taljanovic MS, et al. Nerve
Flynn LS, Wright TW, King JJ. Quadrilateral space syn- entrapment syndromes at the wrist and elbow by
drome: a review. J shoulder Elb Surg. 2018;27:950–6. sonography. Semin Musculoskelet Radiol. 2018;22
Foresti M, Foresti M. Superficial peroneal nerve compres- Thieme Medical Publishers:344–53.
sion due to peroneus brevis muscle herniation. J Radiol Klauser AS, Faschingbauer R, Jaschke WR. Is sono-
Case Rep. 2019;13:10–7. https://doi.org/10.3941/jrcr. elastography of value in assessing tendons? Semin
v13i11.3757. Musculoskelet Radiol Thieme Medical Publishers.
Fowler JR, Maltenfort MG, Ilyas AM. Ultrasound as a 2010;14:323–33.
first-line test in the diagnosis of carpal tunnel syn- Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tun-
drome: a cost-effectiveness analysis. Clin Orthop nel syndrome assessment with US: value of additional
Relat Res. 2013;471:932–7. cross-sectional area measurements of the median
Gamil AM, Shalaby MH, Shehata KA, El Deeb AM. Value nerve in patients versus healthy volunteers. Radiology.
of grayscale and power doppler high-resolution ultra- 2009;250:171–7.
sound in assessment of patients with clinically sus- Kotani H, Miki T, Senzoku F, et al. Posterior interosse-
pected carpal tunnel syndrome. J Ultrasound Med. ous nerve paralysis with multiple constrictions. J Hand
2020;39:1155–62. Surg Am. 1995;20:15–7.
Garwood ER, Duarte A, Bencardino JT. MR imaging Kroonen LT. Cubital tunnel syndrome. Orthop Clin.
of entrapment neuropathies of the lower extrem- 2012;43:475–86.
ity. Radiol Clin NA. 2018;56:997–1012. https://doi. La Rocca VR, Rosenberg ZS, Kiprovski K. MRI of the
org/10.1016/j.rcl.2018.06.012. distal biceps femoris muscle: normal anatomy, vari-
Grant TH, Omar IM, Dumanian GA, et al. Sonographic ants, and association with common peroneal entrap-
evaluation of common peroneal neuropathy in patients ment neuropathy. Am J Roentgenol. 2007;189:549–55.
with foot drop. J Ultrasound Med. 2015;34:705–11. Łabętowicz P, Synder M, Wojciechowski M, et al.
Hobson-webb LD, Juel VC. Common entrapment neurop- Protective and predisposing morphological fac-
athies. Continuum (Minneap Minn). 2017;23:487–511. tors in suprascapular nerve entrapment syndrome:
210 S. Guarino et al.

a ­fundamental review based on recent observations. Molina AEP, Bour C, Oberlin C, et al. The posterior inter-
Biomed Res Int. 2017;2017:4659761. osseous nerve and the radial tunnel syndrome: an ana-
Lau JTC, Daniels TR. Tarsal tunnel syndrome: a review of tomical study. Int Orthop. 1998;22:102–6.
the literature. Foot Ankle Int. 1999;20:201–9. Musson RE, Sawhney JS, Lamb L, et al. Foot & Ankle
Lee M, Kim S, Song H, et al. Morton neuroma: evalu- International. Los Angeles, CA: Sage Publishing;
ated with ultrasonography and MR imaging. Korean J 2014. https://doi.org/10.3113/FAI.2012.0196.
Radiol. 2007;8(2):148–55. Nagano A. Spontaneous anterior interosseous nerve palsy.
Lee S, Shin K, Gil Y, et al. Anatomy of the lateral femoral J Bone Joint Surg Br. 2003;85:313–8.
cutaneous nerve relevant to clinical findings in meral- Nakasa T, Fukuhara K, Adachi N, Ochi M. Painful os
gia paresthetica. Muscle Nerve. 2017;55:646–50. intermetatarseum in athletes: report of four cases and
Lenchik L, Brigido MK, Shahabpour M, Marcelis review of the literature. Arch Orthop Trauma Surg.
S. Normal anatomy and compression areas of 2007;127:261–4.
nerves of the foot and ankle: US and MR imag- Ng I, Vaghadia H, Choi PT, Helmy N. Ultrasound imag-
ing with anatomic correlation. Radiographics. ing accurately identifies the lateral femoral cutaneous
2015;35:1469–82. nerve. Anesth Analg. 2008;107:1070–4.
Letters C. Clinical letters. 2016–2018. 2017. Ozturk E, Sonmez G, Colak A, et al. Sonographic appear-
Lucchetta M, Briani C, Liotta GA, et al. Ultrasonographic ances of the normal ulnar nerve in the cubital tunnel. J
Tinel sign: comment. Muscle Nerve Off J Am Assoc Clin Ultrasound. 2008;36:325–9.
Electrodiagn Med. 2010;41:570–1. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome:
Ma H, Van Heest A, Glisson C, Patel S. Musculocutaneous clinical features, diagnosis, and management. Lancet
nerve entrapment: an unusual complication after Neurol. 2016;15:1273–84.
biceps tenodesis. Am J Sports Med. 2009;37:2467–9. Palmer BA, Hughes TB. Cubital tunnel syndrome. J Hand
Malek E, Salameh JS. Common entrapment neuropathies. Surg Am. 2010;35:153–63.
Semin Neurol. 2020;39(5):549–59. Park BJ, Joeng ES, Choi JK, Kang S. Ultrasound-guided
Marciniak C. Fibular (peroneal) neuropathy electrodi- lateral femoral cutaneous nerve conduction study. Ann
agnostic features and clinical correlates. Phys Med Rehabil Med. 2015;39:47–51.
Rehabil Clin NA. 2013a;24:121–37. https://doi. Paul L, Lakshmi GV, Alex L. A cadaveric study of
org/10.1016/j.pmr.2012.08.016. the Arcade of Frohse. Indian J Clin Anat Physiol.
Marciniak C. Fibular (peroneal) neuropathy: electrodi- 2020;7:195–200.
agnostic features and clinical correlates. Phys Med Peters PG, Adams SB, Schon LC. Interdigital neuralgia.
Rehabil Clin. 2013b;24:121–37. Foot Ankle Clin. 2011;16:305–15.
Martin HD, Shears SA, Johnson JC, et al. The endo- Pham M, Bäumer P, Meinck H-M, et al. Anterior inter-
scopic treatment of sciatic nerve entrapment/deep osseous nerve syndrome: fascicular motor lesions of
gluteal syndrome. Arthrosc J Arthrosc Relat Surg. median nerve trunk. Neurology. 2014;82:598–606.
2011;27:172–81. Polguj M, Sibiński M, Grzegorzewski A, et al. Variation
Martinoli C, Bianchi S, Pugliese F, et al. Sonography in morphology of suprascapular notch as a fac-
of entrapment neuropathies in the upper limb (wrist tor of suprascapular nerve entrapment. Int Orthop.
excluded). J Clin Ultrasound. 2004;32:438–50. 2013;37:2185–92.
Martinoli C, Miguel-Perez M, Padua L, et al. Imaging Polguj M, Sibiński M, Grzegorzewski A, et al.
of neuropathies about the hip. Eur J Radiol. Morphological and radiological study of ossified
2013;82:17–26. superior transverse scapular ligament as potential risk
Masakado Y, Kawakami M, Suzuki K, et al. Clinical neu- factor of suprascapular nerve entrapment. Biomed Res
rophysiology in the diagnosis of peroneal nerve palsy. Int. 2014;2014:613601.
Keio J Med. 2008;57:84–9. Pomeroy G, Wilton J, Anthony S. Entrapment neuropa-
Masear VR, Hill JJ Jr, Cohen SM. Ulnar compression thy about the foot and ankle: an update. JAAOS.
neuropathy secondary to the anconeus epitrochlearis 2015;23:58–66.
muscle. J Hand Surg Am. 1988;13:720–4. Puig S, Turkof E, Sedivy R, et al. Sonographic diagno-
McDonagh C, Alexander M, Kane D. The role of ultra- sis of recurrent ulnar nerve compression by ganglion
sound in the diagnosis and management of carpal cysts. J Ultrasound Med. 1999;18:433–6.
tunnel syndrome: a new paradigm. Rheumatology. Safran MR. Nerve injury about the shoulder in athletes,
2015;54:9–19. part 1: suprascapular nerve and axillary nerve. Am J
Melendez MM, Glickman LT, Dellon AL. Peroneal nerve Sports Med. 2004;32:803–19.
compression in figure skaters. Clin Res Foot Ankle. Samarawickrama D, Therimadasamy AK, Chan
2013;1:102. YEEC, et al. Nerve ultrasound in electrophysi-
Miller SL, Gill J, Webb GR. The proximal origin of the ologically verified tarsal tunnel syndrome. Muscle
hamstrings and surrounding anatomy encountered Nerve. 2016;53(6):906–12. https://doi.org/10.1002/
during repair: a cadaveric study. JBJS. 2007;89:44–8. mus.24963.
Miller MD, Thompson SR. DeLee & Drez’s Orthopaedic Sanders TG, Tirman PFJ. Paralabral cyst: an unusual
Sports Medicine E-Book. Elsevier Health Sciences, cause of quadrilateral space syndrome. Arthrosc J
Amsterdam; 2014. Arthrosc Relat Surg. 1999;15:632–7.
23 Peripheral Entrapment Neuropathies 211

Shamrock AG, Das JM. Radial tunnel syndrome. In: Tawfik EA, El Zohiery AK, Abouelela AAKH. Proposed
StatPearls [Internet]. Treasure Island, FL: StatPearls sonographic criteria for the diagnosis of idiopathic
Publishing; 2020. tarsal tunnel syndrome. Arch Phys Med Rehabil.
Shon H-C, Park J-K, Kim D-S, et al. Supracondylar pro- 2016;97(7):1093–9. https://doi.org/10.1016/j.
cess syndrome: two cases of median nerve neuropa- apmr.2015.11.012.
thy due to compression by the ligament of Struthers. J Toms AF, Rushton LA, Kennedy NR. Muscle herniation
Pain Res. 2018;11:803. of the peroneus longus muscle triggering superficial
Sirico F, Castaldo C, Baioccato V, et al. Prevalence fibular nerve paresthesia. Sonography. 2018;5:36–40.
of musculocutaneous nerve variations: Systematic Torriani M, Kattapuram SV. Dynamic sonography of
review and meta-analysis. Clin Anat. 2019;32:183–95. the forefoot: the sonographic Mulder sign. Am J
Spinner RJ, Dellon AL, Rosson GD, et al. Tibial intraneu- Roentgenol. 2003;180:1121–3.
ral ganglia in the tarsal tunnel: is there a joint connec- Visser LH, Hens V, Soethout M, et al. Diagnostic value
tion? J foot ankle Surg. 2007;46:27–31. of high-resolution sonography in common fibu-
Still GP, Fowler MB. Joplin’s neuroma or compression lar neuropathy at the fibular head. Muscle Nerve.
neuropathy of the plantar proper digital nerve to the 2013;48:171–8.
hallux: clinicopathologic study of three cases. J Foot Weiss C, Imhoff AB. Sonographic imaging of a spinogle-
Ankle Surg. 1998;37:524–30. noid cyst. Ultraschall der Medizin. 2000;21:287–9.
Tagliafico AS, Bignotti B, Martinoli C. Elbow US: anat- Weng W-C, Wei Y-C, Huang W-Y, et al. Risk factor analy-
omy, variants, and scanning technique. Radiology. sis for meralgia paresthetica: a hospital-based study in
2015;275:636–50. Taiwan. J Clin Neurosci. 2017;43:192–5.
Tagliafico AS, Michaud J, Marchetti A, et al. US imag- Yates B, Merriman LM. Merriman’s assessment of the
ing of the musculocutaneous nerve. Skeletal Radiol. lower limb. Amsterdam: Elsevier Health Sciences;
2011;40:609–16. 2009.
Tagliafico A, Serafini G, Lacelli F, et al. Ultrasound-­ Yoshida N, Tsuchida Y. Posterior interosseous nerve
guided treatment of meralgia paresthetica (lateral palsy due to Bado type-III Monteggia fracture. Case
femoral cutaneous neuropathy) technical description Reports. 2018;2018:bcr2018226254.
and results of treatment in 20 consecutive patients. J Yücesoy C, Akkaya T, Özel Ö, et al. Ultrasonographic
Ultrasound Med. 2011;30:1341–6. evaluation and morphometric measurements of the
Takebe K, Hirohata K. Peroneal nerve palsy due to fabella. suprascapular notch. Surg Radiol Anat. 2009;31:409.
Arch Orthop Trauma Surg. 1981;99:91–5.
 Part IV
Ultrasound in Healing Evaluation
and in Therapy Monitoring
 Bone Fracture Healing
24
Armanda De Marchi, Davide Orlandi ,
Enzo Silvestri, Luca Cavagnaro,
and Alessandro Muda

Contents
24.1 Introduction  215
24.2 Ultrasound Evaluation of Bone Fracture Healing  216
Further Readings  217

24.1 Introduction has different steps involving nonosseous tissue

components like cartilage and blood vessels until
The reparative process after bone fracture the complete repair.
depends on several conditions: mechanism of Bone fracture repair is generally assessed
injury, site of lesions, kind of fracture, and meth- using ionizing radiation-based imaging modali-
ods of fracture treatment. The healing process ties such as plain films, fluoroscopy, and com-
puted tomography (CT).
Signs of fracture healing using plain films and
fluoroscopy are not normally evident until after
A. De Marchi 6–8 weeks of recovery when the callus has
Radiologia CIDIMU: Centro Italiano di Diagnostica
Medica Ultrasonica, Torino, Italy become sufficiently calcified to be visible on
X-ray; in fact their main limitation is the low sen-
D. Orlandi (*)
Department of Radiology, Ospedale Evangelico sitivity for the healing process during the early
Internazionale, Genova, Italy phase. In addition, when dealing with fractures
E. Silvestri treated by metal hardware, radiographic evalua-
Radiology, Alliance Medical, Genova, Italy tion is also limited by the presence of the latter.
L. Cavagnaro CT is really useful for investigating cortical
Ortopedia e Traumatologia 2- Joint Replacement, bone fractures and soft-tissue calcifications, due to
Unit/Bone Infection Unit, Ospedale Santa Corona, the good contrast between tissues, and also for the
Pietra Ligure (SV), Italy evaluation of the healing process but is affected by
A. Muda some limitations such as the presence of metal
Department of Radiology, IRCCS Policlinico San hardware artifacts and a very poor sensitivity in
Martino-IST, Genova, Italy
the detection of trabecular bone involvement. In
© Springer Nature Switzerland AG 2022 215
F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_24
216 A. De Marchi et al.

this setting MRI could be considered the gold stan- was used, depending on the skin accessibility
dard, being able to perform a detailed assessment within the Ilizarov frame, and was begun at either
of bone and soft-tissue involvement. Nowadays, 7 or 15 days after surgery and at 4 and 6–8 weeks.
thanks to metallic artifact reduction sequences The authors confirmed that new bone formation
(MARS) MRI could also be performed in patients appears like some hyperechoic spots until the
treated by metal hardware or prosthesis. development of a dense hyperechoic line.
Such information may provide valuable prog-
nostic information for the early assessment of
24.2 Ultrasound Evaluation fracture healing and the related need for second-
of Bone Fracture Healing ary operative procedures.
It is possible also with ultrasound to predict
Ultrasound (US) provides a safe and noninvasive the future repair process to identify healing com-
monitoring of the first steps of bone-healing pro- plications as early as possible like hematoma and
cess, improving the current subjective clinical cyst, which can hinder the new bone production.
fracture assessment [8, 9]. US represents an effi- Compared to X-ray ultrasound could substan-
cient diagnostic imaging modality to visualize tially improve the monitoring of fracture repair
and assess the first step of bone healing, which is by allowing earlier detection of bridging callus,
the soft-tissue reparation stage. At this stage nonunion lesions, and complications.
ultrasound is able to detect simultaneously the US imaging is performed with linear or convex
bony surface and the incoming soft callus before probes in the peripheral region of the fracture
its transformation in a dense calcific callus. In encompassing almost the total circumference of the
this way US has been used successfully to evalu- long bone across the entire length of the fracture
ate also what is assumed to be callus production. site. Instead of conventional 2D ultrasound, some
An animal study indicates that a direct corre- authors have highlighted the use of 3D freehand
lation exists between this “presumed to be callus” ultrasound in complex fractures where 3D details of
tissue seen with US and actual fracture callus as fracture site and bone fragment are important.
determined by histological examination. Bone growth depends on the rapid growth of
In a study where an external limb-lengthening new capillaries; conventional color Doppler
distraction device (Ilizarov frame) was used, modalities can obtain information about these
Young et al. studied the value of sonography in the vessels (Fig. 24.1).
evaluation of new bone production at the distrac- Caruso et al. also used color Doppler ultraso-
tion site to determine whether it could be used to nography in tibial fracture patients with delayed
image the new bone before it became visible on fracture healing, detecting the lack of blood flow
plain radiography. In this study the sonographic signals and persistence of high resistance indices.
evaluation with linear and/or sector transducers 3D power Doppler ultrasound (PDU) used in

a b

Fig. 24.1 Contrast-enhanced ultrasound evaluation (a) and color Doppler (b) performed during callus formation
4 weeks after fracture treatment showing few vessels in the gap of the fracture (asterisks)
24 Bone Fracture Healing 217

another study on fracture healing in a rat model is niques (e.g., SMI) able to display very-low-­
not yet used for the clinical assessment of frac- velocity blood flows, allowing imaging of
ture cases. As a precondition of osteogenesis, microvessels without any contrast agent.
neovascularization plays a crucial role in the However, in a recent paper some authors com-
whole process and directly affects bone activity. pared the performances of CEUS and SMI in the
In this field contrast-enhanced ultrasound evaluation of bone healing, showing that SMI
(CEUS) represents a noninvasive imaging modal- neovascularity detection sensitivity is lower than
ity, which is able to evaluate the angiogenesis at CEUS.
the site of bone fracture. The US contrast agents’ In conclusion, the monitoring of the fracture
property to remain within the vessels is very use- repair is crucial; therefore, a noninvasive diag-
ful to detect a true microvascular pattern. nostic method such as US could help the tradi-
Regarding the use of CEUS in bone fracture tional X-ray modalities to reveal the progress of
healing evaluation literature highlights a lack of a the biologic processes during fracture healing.
standardized timing for US contrast medium pro-
cedure in this setting. In this pilot study for the
early diagnosis of fracture, healing was at 6 and 9
weeks postoperatively. In recent papers CEUS Further Readings
examination was performed at a 12-week follow-
Augat P, et al. Imaging techniques for the assessment of
­up to capture the vascularization of soft callus fracture repair. Injury. 2014;45(Suppl 2):S16–22.
formation, which begins after the initial inflam- Augat P, et al. Quantitative assessment of experimental
matory phase and slows down before the hard fracture repair by peripheral computed tomography.
Calcif Tissue Int. 1997;60(2):194–9.
callus formation or remodeling phase in tibial
Caruso G, et al. Monitoring of fracture callus with
nonunion fractures. color Doppler sonography. J Clin Ultrasound.
In another recent study CEUS was performed 2000;28(1):20–7.
15 days before the treatment and 7 days and 4 and De Marchi A, et al. Perfusion pattern and time of vas-
cularization with CEUS increase accuracy of differ-
8 weeks after treatment in noninfected long bone
entiating between benign and malignant tumours in
nonunion fractures. 216 musculoskeletal soft tissue masses. Eur J Radiol.
As evidenced in this recent literature, the neo- 2015;84:142–50.
angiogenesis in graft bone increased from the 3rd De Marchi A, et al. Study of neurinomas with ultra-
sound contrast media: review of a case series to iden-
to 14th day and then gradually decreased by days
tify characteristics imaging patterns. Radiol Med.
21–28. 2011;116:634–43.
The different operative and nonoperative Den Boer F. Quantification of fracture healing with three-­
treatments represent the cause for no standard- dimensional computed tomography. Arch Orthop
Trauma Surg. 1998;117:345–50.
ized imaging procedure to early detect the bone
Firoozabadi R, et al. Qualitative and quantitative assess-
formation. ment of bone fragility and fracture healing using
CEUS is also a useful method in monitoring conventional radiography and advanced imaging tech-
the healing process in long bone noninfected nologies – focus on wrist fracture. J Orthop Trauma.
2008;22(8 Suppl):S83–90.
nonunion fractures. Krammer et al. reported that
Fischer C, et al. Dynamic contrast enhanced sonography
an early evaluation of success recovery after tib- and dynamic contrast-enhanced magnetic resonance
ial nonunion can be realized with CEUS. In imaging for preoperative diagnosis of infected non-
another recent paper authors showed that a com- unions. J Ultrasound Med. 2016;35:933–42.
Fleicher AC. Sonographic depiction of tumor vascularity
bination of CEUS and peripheral cytokine
and flow; from in vivo models to clinical applications.
expression analysis is a promising novel tool in J Ultrasound Med. 2000;19(1):55–61.
the early prediction of the outcome of the non- Giannoudis PV, et al. The diamond concept—open ques-
union therapy. tions. Injury. 2008;39(Suppl 2):S5–8.
Hamblen D, Simpson AH. Outline of fractures. 12th ed.
Recently, following the technological devel-
London, UK: Churchill Livingstone; 2007.
opment of ultrasound machines, different brands Haubruck P, et al. A preliminary study of contrast-­
have developed microvascular imaging tech- enhanced ultrasound (CEUS) and cytokine expression
218 A. De Marchi et al.

analysis (CEA) as early predictors for the outcome Müller S, et al. Assessment of bone microcirculation
of tibial nonunion therapy. Diagnostics (Basel). by contrast-enhanced ultrasound (CEUS) and posi-
2018;8:55. tron emission tomography/computed tomography in
Hijazy A, et al. Quantitative monitoring of bone heal- free osseous and osseocutaneus flaps for mandibular
ing process using ultrasound. J Franklin Inst. 343(4– reconstruction: preliminary results. Clin Hemorheol
5):495–500. Proceedings of the First International Microcirc. 2016;49:115–28.
Conference on Modeling, Simulation and Applied Orlandi D, et al. Advances power Doppler technique
Optimization, Sharjah, U.A.E. 2005; February 1–3 increase synovial vascularity detection in patients
Kang M-L, et al. Vascular endothelial growth factor with rheumatoid arthritis. Ultrasound Med Biol.
transfected adipose-derived stromal cells enhance 2017;43:1880–7.
bone regeneration and neovascularization from bone Park AY, et al. An innovative ultrasound technique for
marrow stromal cells. J Tissue Eng Regen Med. evaluation of tumor vascularity in breast cancers:
2017;11:3337–48. superbmicro-vascular imaging. J Breast Cancer.
Krammer D, et al. Contrast enhanced ultrasound quanti- 2016;19:210–3.
fies the perfusion within tibial non unions and predicts Pozza S, et al. Technical and clinical feasibility of
the outcome of revision surgery. Ultrasound Med Biol. contrast-enhanced ultrasound evaluation of long
2018;44:1853–9. bone non-infected nonunion healing. Radiol Med.
Leunig M, et al. Quantitative assessment of angiogenesis 2018;123:703–9.
and osteogenesis after transplantation of bone: com- Colier R, Donarski R. “Non-invasive method of measur-
parison of isograft and allograft bone in mice. Acta ing the resonant frequency of a human tibia in vivo”,
Orthop Scand. 1999;70:374–80. part 1 & 2. J Biomed Eng. 1987;9:321–31.
Jin L, et al. MD Studies of superb microvascular imaging Ross EF. 3D ultrasound for imaging components of mus-
and contrast-enhanced ultrasonography in the evalu- culoskeletal system. PhD thesis; 2009.
ation of vascularization in early bone regeneration. J Sun MH, et al. Three-dimensional high frequency power
Ultrasound Med. 2019;38:2963–71. Doppler ultrasonography for the assess-ment of micro-
Moed BR, et al. Ultrasound for the early diagnosis of frac- vasculature during fracture healing in a rat model. J
ture healing after interlocking nailing of the tibia with- Orthop Res. 2012;30(1):137–43.
out reaming. Clin Orthop. 1995;310:137–44. Blokhuis T, et al. The reliability of plain radiography
Moed BR, et al. Ultrasound for the early diagnosis of in experimental fracture healing. Skelet Radiol.
tibial fracture healing after static inter- locked nailing 2001;30:151–6.
without reaming: clinical results. J Orthop Trauma. Tall M. Treatment of aseptic tibial shaft nonunion
1998;12(3):206–13. without bone defect. Orthop Traumatol Surg Res.
Moed BR, et al. Ultrasound for the early diagnosis of 2018;104:S63–9.
tibial fracture healing after static interlocked nailing Yung JW, et al. Sonographic evaluation of bone produc-
without reaming: histologic correlation using a canine tion at distraction site in Ilizarov limb-lengthening pro-
model. J Orthop Trauma. 1998;12:200–5. cedures. AJR Am J Roentgenol. 1990;154(1):125–8.
 Tendon and Muscle Rupture
Repair
25
Giovanni Rusconi, Giulio Pasta, Davide Orlandi ,
Enzo Silvestri, and Francesco Di Pietto

Contents
25.1 Introduction  219
25.2  ealing After Muscle Injury 
H 220
25.2.1 Skeletal Muscle Healing Process  220
25.2.2 Hematoma and Scar Tissue  220
25.3  uscle Healing Process Complications 
M 222
25.3.1 Cyst  222
25.3.2 Calcific Myonecrosis  222
25.3.3 Myositis Ossificans  223
25.3.4 Muscle Hernia  224
25.3.5 Morel-Lavallée Lesion  225
25.4 Ultrasound After Tendon Surgery Repair  226
Further Readings  230

25.1 Introduction

The main objectives of ultrasound after a diagno-

sis of muscle injury are the control of the evolu-
tion of the lesion for a timely and safe return to
play, the early recognition of possible complica-
G. Rusconi · F. Di Pietto
Dipartimento di Diagnostica per Immagini “Pineta tions, the prevention of recurrences, or the detec-
Grande Hospital”, Castel Volturno (CE), Italy tion of those cases which deserve surgical
G. Pasta therapy.
Specialista in Radiologia e Diagnostica per Immagini, Ultrasound is a useful tool to evaluate the
Studio Associato di Radiologia Dr. Pasta, aspects of muscle healing and offers higher spa-
Emilia-Romagna, Italy
tial resolution than magnetic resonance imaging.
D. Orlandi (*) In addition to these features, the possibility of a
Department of Radiology, Ospedale Evangelico
color Doppler analysis and a dynamic study
Internazionale, Genova, Italy
should be considered. Serial ultrasound evalua-
E. Silvestri
tions of muscle injury may reduce the recurrence
Radiology, Alliance Medical, Genova, Italy

© Springer Nature Switzerland AG 2022 219

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_25
220 G. Rusconi et al.

rate of strains and allow for a standardized return-­ 3. Remodeling phase, during which the matura-
to-­play criteria. tion of the regenerated myofibers, the con-
It has been suggested that between 2 and 48 h traction and reorganization of the scar tissue,
after injury is the ideal timing of examination. If and the recovery of the functional capacity of
the examination is performed too early post-­ the muscle occur. Repair and remodeling
injury then the hematoma may not have had ade- phases are usually closely associated or
quate time to fully form and there may be a risk overlapping.
of false-negative examination, or underapprecia-
tion of the severity of the injury.
25.2.2 Hematoma and Scar Tissue

25.2 Healing After Muscle Injury Hematoma is a localized collection of blood that
forms secondary to trauma or surgery but sponta-
25.2.1 S
 keletal Muscle Healing neous formation is also not uncommon, espe-
Process cially in patients with coagulation disorders or on
anticoagulant therapy.
The healing of a skeletal muscle after contusion, The physical consistency of the collection var-
strain, or laceration injury is usually divided into ies according to its phase, from a hyperacute to a
a three-phase process: chronic stage. In the very first hours after the
trauma, the hematoma can still be diffuse, not
1. Destruction phase, in which there is the rup- collected, with hyperechoic aspect at ultrasound
ture and necrosis of the myofibers, the conse- examination. For these reasons it could be diffi-
quent inflammatory reaction, and the cult to clearly identify it in a very early phase. In
formation of a hematoma between the rup- the subsequent phase (after 2–3 days), the clot
tured muscle stumps. dissolves and the collection becomes to appear as
2. Repair phase, characterized by the phagocyto- a cystic, purely liquid collection characterized by
sis of the necrotized tissue, the regeneration of low echogenicity or complete anechogenicity at
the myofibers, and the capillary ingrowth into US (Fig. 25.1).
the injured area, resulting in the production of As healing progresses, after some days or
a connective tissue scar. weeks, the hematoma will begin to organize and

a b c

Fig. 25.1 Ultrasound examination performed at 3 h (b), vastus intermedius has hyperechoic appearance. At 72-h
reassessed at 72 h (c), after direct blunt trauma. At the 3-h evaluation the hematoma becomes hypo/anechoic. (a)
evaluation the large hematoma of the muscle belly of the Corresponding healthy contralateral side
25 Tendon and Muscle Rupture Repair 221

a b

Fig. 25.2 Ultrasound examination 3 days after trauma femoris muscle. At 20 days (b) the hematoma is largely
(a) showing hypoechoic hematoma with full-thickness reabsorbed and becomes echoic due to organization and
tear of the proximal myotendinous junction of the biceps partial scarring of the fibers

in the chronic phase it could have a solid mass or formation until 8 weeks after injury, which grad-
a mixed cystic-solid appearance, characterized ually decreases at 12-week ultrasound follow-up
by septa formation and calcification, due to after injury (Fig. 25.3).
chronic hemoglobin degradation products While hematoma is mainly observed in the
(Fig. 25.2). initial phases of injury, in the subsequent remod-
The presence and extent of hematoma should eling phase there is progressive scar formation.
be assessed in both short and long axis imaging Fibrotic scars are hyperechoic linear zones within
planes. As mentioned above, 48 h post-injury is the muscle after a trauma and sometimes the
the ideal time for initial examination; if it is per- healing process may lead to an excessive scar tis-
formed prior to this time, consider to repeat sue formation, especially in larger lesions and
examination within a few days to document any when the return to play is too early (Fig. 25.4).
additional hematoma that may not have been They cause few symptoms if the patient is
optimally visualized at the initial examination. In well aware of their presence and warms his/her
many cases hematomas may decrease in dimen- muscles adequately before a competition and
sion and resolve spontaneously, but US-guided stretches his/her muscles deeply after the compe-
percutaneous aspiration may be considered when tition. Usually, scar thickness is significantly
there is a significant hematoma or in those cases larger at 8 and 12 weeks compared with 4 weeks
in which chronic hematomas do not resolve in and it has been reported that fibrous tissues
time, in order to drain the fluid collected and pro- remained at 1-year follow-up after injury
mote the healing process. Other possible indica- (Fig. 25.5).
tions to drainage are those patients with severe There is a risk of recurrent injury associated to
pain or elite athletes, to achieve an early return to the extent of residual fibrous scar tissue in the
play. muscle belly. Dynamic ultrasound examination
Power Doppler imaging can be a useful tool in can help in its assessment by revealing the differ-
the evaluation of a muscle injury because it can ences in muscle contraction in the scar areas
add information about neovascularization. In through contralateral comparison.
fact, it has been reported that there is new vessel
222 G. Rusconi et al.

a b

Fig. 25.3 Indirect strain injury (grade I) at the myotendi- cess. (b) 1-month follow-up of the same patient. Reduction
nous junction of the indirect tendon of the rectus femoris. of peritendinous vascular signals at power Doppler
(a) US at 7 days shows peritendinous hyperemia at power analysis
Doppler analysis, expression of an ongoing repair pro-

a b

Fig. 25.4 Scar tissue at the site of a previous distal myofascial tear of the medial head of the gastrocnemius (arrows)
(a). Corresponding healthy contralateral side (b)

25.3  uscle Healing Process

M 25.3.2 Calcific Myonecrosis
Complications
Calcific myonecrosis refers to a rare disease
25.3.1 Cyst occurring as a very late sequela after a closed
fracture or trauma, often associated to compart-
Cysts result from an incomplete resorption of a ment syndrome. The symptoms of calcific myo-
hematoma after a muscle trauma and appear as necrosis appear, on average, 37 years following
well-defined lesions with anechoic content and the initial injury (range: 10–64 years).
consequent posterior acoustic enhancement. It involves almost exclusively the lower limb
They may be intermuscular (Fig. 25.6) or and typically the anterior muscles of the leg, even
­intramuscular (Fig. 25.7) and the most common if it has been occasionally reported at other sites.
location is the calf. Biggest ones causing mass It is a benign lesion, characterized by the for-
effect may need percutaneous needle mation of a dystrophic enlarging mass; in partic-
evacuation. ular, the injured muscle is replaced by a complex
25 Tendon and Muscle Rupture Repair 223

mass consisting of a central cystic core contain- hypoechoic area, but in many cases other imag-
ing necrotic muscle, fibrin, and cholesterol, with ing modalities are needed. The main differential
peripheral plaque-like amorphous calcifications. diagnosis of calcific myonecrosis is the more
US is often the first imaging method to evalu- common myositis ossificans (MO), but its aspect
ate the lesion and demonstrates extensive, shad- and its enlargement could mimic soft-tissue sar-
owing, echogenic foci, consistent with comas. US may also help to guide the aspiration
calcifications, with a central complex of the central fluid component to help the heal-
ing process, and to guide the biopsy for a histo-
logic diagnosis.

25.3.3 Myositis Ossificans

Myositis ossificans (MO) is a benign process

characterized by heterotopic ossification usually
within large muscles, involving most commonly
the extremities, the thigh, and the anterior side of
the arm.
Despite the term “myositis”, it is not an
inflammatory condition and several hypotheses
have been proposed about the pathophysiology.
The lesion is thought to develop through inappro-
priate differentiation of fibroblasts into osteo-
Fig. 25.5 Follow-up of a grade III injury of the adductor genic cells after traumatic muscle injury, resulting
longus. Distal retraction of the muscle belly (arrows) with
in extraosseous bone formation.
extensive scar tissue at the myotendinous junction
(arrowheads)

Fig. 25.6 Large cystic interfascial collection between medial head of the gastrocnemius (MG) and soleus (S) after a
distal myofascial junction tear of the medial head of the gastrocnemius (asterisk)
224 G. Rusconi et al.

a b

Fig. 25.7 Intramuscular cyst after a grade II injury of the semimembranosus (white arrows). (a) Long-axis ultrasound
scan showing hypoechoic aspect of the cyst. (b) Coronal FSE T2 MRI of the same patient

As MO occurs as a result of a severe contusion irregularity of the peripheral rim and may regress
trauma, the most affected population is young in size, disappearing spontaneously in approxi-
adults. Another group of patients especially prone mately 30% of cases.
to MO are paraplegics, in which recognized epi- Peripheral calcification is a peculiar feature
sodes of trauma are often absent, and the disease of myositis ossificans and makes this condition
frequently occurs around knees and hips. more easily diagnosed with X-ray, even if US
It is considered a skeletal so-called “don’t can detect the ossification process approximately
touch lesion”, which is important to recognize 2 weeks earlier than plain radiographs (Fig. 25.8).
because it can mimic malignant lesions. For
example, osteosarcoma has a histologically simi-
lar appearance, and this may lead to inappropri- 25.3.4 Muscle Hernia
ate management.
MO clinically presents as a painful, tender Muscle hernias represent a focal defect in the mus-
mass, and histologically is characterized by a cle fascia with protrusion of muscle through the
zonal organization: a peripheral, well-organized defect. They are most commonly found in the lower
mature lamellar bone zone, an intermediate oste- extremities, typically the tibialis anterior muscle.
oid region, and a proliferating fibroblast central They are often asymptomatic, but can cause
zone, with granulation tissue and localized areas cramping sensations or pain during or after activ-
of hemorrhage. ity. They may also present as a palpable mass,
MO also has a typical “maturation” pattern and be referred for imaging with suspicion of
and imaging findings change according to an neoplasia.
early, a subacute, and a mature phase. In particu- Ultrasound is the modality of choice in the
lar, at US examination, early MO lesions are het- evaluation of suspected muscle hernia, although
erogeneous hypoechoic soft-tissue masses, with MRI may be required if there are uncertain US
a focal hyperechoic central area. As the lesion findings. The hernia is often hypoechoic to the
matures, after 4 weeks, the center develops dif- surrounding muscle and may assume a mush-
fuse reflective areas and a peripheral lamellar cal- room shape as it protrudes through the fascial
cification, leading to posterior acoustic defect (Fig. 25.9).
shadowing. It is also possible to detect increased The mass may not be palpable when the
vascularity at color Doppler analysis. After about patient is relaxed, which is a clinical clue to the
2 months, mature calcified mass may present diagnosis; therefore a dynamic US evaluation is
25 Tendon and Muscle Rupture Repair 225

a b

Fig. 25.8 US short (a) and long (b) axis scan of myositis the proximal third of the muscle belly of the
ossificans. Macroscopic shell calcification with posterior semimembranosus
acoustic shadowing after traumatic injury at the level of

a b

Fig. 25.9 Wide defect in the superficial fascia of the muscle belly of the tibialis anterior with secondary herniation of
its fibers. (a) Short-axis scan. (b) Long-axis scan. Margins of the muscle hernia (arrows) are clearly identified

recommended to properly depict the hernia, This lesion typically occurs when the skin and
asking the patient to contract the muscle. When subcutaneous fatty tissue traumatically and
the hernia is not clinically evident, it is also abruptly separate from the underlying fascia as a
important to decrease the pressure on the probe result of shearing forces acting on the subcutane-
in order to avoid the accidental reduction of the ous tissues.
hernia. The potential space created superficial to the
fascia is filled by various types of fluid, ranging
from serous fluid to frank blood, due to the rupture
25.3.5 Morel-Lavallée Lesion of the vessels perforating the fascia layers and con-
sequent bleeding. It classically occurs in the thigh
Morel-Lavallée lesions are closed degloving and the most frequent site is over the greater tro-
injuries associated with severe trauma.
226 G. Rusconi et al.

Fig. 25.10 Morel-Lavallée lesion. Post-contusive anechoic collection (arrows), with serohematic content and well-­
defined margins, located superficially to the iliotibial band (arrowheads) in the lateral region of the thigh

chanter of the femur, although it can be seen in the also be increased or decreased. This could be a
lumbar region, over the scapula, or over the knee. problem because the US criteria to diagnose a
At US examination, acute lesions may appear tendon tear include abnormal hypoechogenicity,
as thin heterogeneous hyperechoic collections loss of the normal fibrillar echotexture, and
due to debris such as necrotic fat lobules. Then, reduction of the tendon thickness.
the collection may spontaneously resolve or Generally, normal operated tendons are larger
become persistent. than native ones. Progressive thickening starts
In a chronic phase, the collection becomes between 3 and 6 months after the intervention
fusiform, the fluid tends to become more homo- and is irreversible. Some intratendinous Doppler
geneous and anechoic, and local inflammatory signals can be identified and can even increase
reaction promotes the development of a fibrous between the first and third months after surgery.
pseudocapsule (Fig. 25.10). It usually decreases after 6 months. At US fol-
However, it is difficult to establish the age of low-­up beyond 6 months after surgery, detection
the lesion, as rebleeding of a chronic lesion may of tendon thinning, a liquid collection in or
confer a persistent heterogeneous hyperechoic around the tendon, and persistent intratendinous
appearance. Doppler signals suggest inadequate healing or re-­
rupture. The diagnosis of a recurrent full-­
thickness tendon tear after surgery also takes
25.4 Ultrasound After Tendon advantage of dynamic US imaging, by evaluating
Surgery Repair active and passive tendon motion.
Some of the most involved tendons that
While injured muscle fibers have the ability to undergo surgery repair are rotator cuff, distal
heal, even though with the formation of a scar biceps brachii, peroneal and Achilles tendons.
tissue, tendons usually require a surgical repair. Their peculiar postoperative aspects and more
The sonographic appearance of the postoperative frequent complications after surgery will be dis-
tendon is very variable, ranging from hyper- cussed hereafter.
echoic to hypoechoic appearance. Moreover, the Rotator cuff: Common indications for rotator
normal fibrillar echotexture may be present or cuff repair include a full-thickness tear or a high-­
completely absent and the tendon thickness may grade partial-thickness tear for which conserva-
25 Tendon and Muscle Rupture Repair 227

Fig. 25.11 US follow-up after surgical reinsertion of the

supraspinatus tendon. At the level of the greater tuberosity
(GT), a depression of the cortical contour (arrowheads)
produced by the orthopedic surgeon in the anchor implant Fig. 25.12 Ultrasound examination after surgical rein-
site (white arrow) is visible sertion of the supraspinatus tendon, which has inhomoge-
neous echostructure, due to a hyperechoic linear streak
referable to the suture thread (arrowhead) attached to the
tive management has failed. Although greater tuberosity (GT) by means of an anchor (*)
symptomatic smaller partial-thickness tears may
be treated with just debridement, higher grade tendon translation across the repair site with
partial-thickness (>50% tendon thickness) and associated tendon retraction is diagnostic for a
full-thickness tears are commonly repaired by full-thickness tendon tear.
attaching the torn tendon fibers onto the osseous Distal biceps brachii tendon (DBBT): In
footprint of the humeral greater tuberosity. At most individuals, the DBBT is composed of two
US, hyperechoic suture material within the separate components. The first derives from the
­tendon substance and hyperechoic anchors at the long head of the biceps muscle, originating at the
bone cortex may be observed (Fig. 25.11). They supraglenoid tuberosity, whereas the second is
both may produce posterior acoustic shadowing issued from the short head, originating at the cor-
and they can also displace in subdeltoid bursa. acoid process. Although partial tears are usually
Postoperative rotator cuff tendons can have a treated conservatively, complete tears require
highly variable imaging appearance, with a het- surgical repair, with a high satisfaction rate
erogeneous echotexture at US exam which lasts reported. Hyperechoic fibrillar structure becomes
for years after surgery (Fig. 25.12). heterogeneous because of small hypoechoic
Initially, the tendon may have a thick or thin areas around the suture material or small calcare-
aspect and is hypoechoic with loss of the normal ous deposits (Fig. 25.13). Decreased mobility
fibrillar architecture; it becomes more echogenic and elasticity of the tendon may also be observed
with time. Peribursal soft tissues may demon- within the first few months.
strate persistent inhomogeneous echogenicity, Most frequent postoperative complications
and fluid in the subacromial bursa is also a nor- related to DBBT repair are heterotopic ossifica-
mal finding in a postoperative setting. tion, nerve injury, and tendon re-rupture, occur-
An irregularity of the tendon surface is not so ring in 15–40% of patients.
important in the postoperative patient, as it is a Heterotopic ossification may develop within
common finding in asymptomatic patients in the several weeks after surgery and US can identify it
follow-up after surgery; however careful clinical earlier than does radiography, showing hyper-
correlation is always needed. echoic nodules or streaks with posterior acoustic
With regard to the recurrent rotator cuff tears, attenuation within muscles. Nerve lesions and
many of them are massive, with resultant com- tendon re-rupture are considered major compli-
plete absence of the tendons in the physiological cations and should be diagnosed as soon as pos-
location. Furthermore, at dynamic US, lack of sible. Dynamic US evaluation of nerves’
228 G. Rusconi et al.

a b

c d

Fig. 25.13 US examination after surgical reinsertion of chial artery. The arrowhead indicates the hyperechoic
the distal biceps brachii tendon. (a) Short-axis US scan, metal anchor characterized by posterior acoustic rever-
(b) long-axis US scan. The reinserted tendon (white beration artifact. (c) Axial FSE PD MRI and (d) FSE T2
arrows) is thickened and inhomogeneous with some intra- MRI examination of the same patient. Note the magnetic
tendinous vascular signals at power Doppler, suggesting susceptibility artifact caused by the metal anchor (arrow-
ongoing reparation process. The asterisk indicates the bra- head) in MRI

relationship with orthopedic material is helpful in plex, which is composed of the peroneus brevis
determining a nerve abnormal structure or possi- (PB) and peroneus longus (PL) muscles and ten-
ble conflict. dons, PT sheaths, and superior and inferior
Re-rupture usually occurs within 3 weeks peroneal retinacula. First approach for peroneal
after surgery and is typically the result of too tenosynovitis, tendinopathy, and partial tears is
early or excessive rehabilitation. MR imaging is classically a conservative management, includ-
also very sensitive for diagnosing complete tears ing pharmacological therapy, physiotherapy,
after surgery, but it is less sensitive in detecting and immobilization, with relief expected in
partial tears. Moreover, MRI is complicated by 4–6 weeks.
the patient difficulty in achieving correct Operative intervention may be indicated when
­positioning of the elbow after surgery or by the conservative treatments fail or in tendon disloca-
presence of metal orthopedic material. tion/subluxation and high-grade symptomatic
Peroneal Tendon Tears: The peroneal ten- and full-thickness tendon tear, especially in
dons (PT) are part of the peroneal tendon com- patients with high functional demands. Peroneal
25 Tendon and Muscle Rupture Repair 229

a b

c d

Fig. 25.14 Distal (a, b) and proximal (c, d) US scan of intratendinous hyperechoic strikes with posterior acoustic
surgical suture repair of the Achilles tendon. The tendon shadowing, referable to the suture threads (white arrows)
appears thickened and inhomogeneous, characterized by

tendon tears are characteristically longitudinal There are immediate and late complications
(split lesions) rather than transverse, and pero- of peroneal tendon surgery. Immediate compli-
neus brevis tears are much more common than cations include intratendinous and/or peritendi-
those of the peroneus longus. When evaluating nous hematoma and infections. Late
tendon injuries, it is important to investigate for complications include recurrent degeneration or
frequently associated damage of the anterolateral tears, dislocations, and peritendinous adhesions.
ligament complex of the ankle. Most important Patients with postoperative hematoma and
postoperative findings to report after surgery are infection usually have pain and swelling with
the viability of the remaining tendon, any complex collection detected at US imaging.
­recurrent or residual tear of one or both peroneal Presence of fluid associated with retracted ten-
tendons, underlying tendinopathy, and extent of don ends or nonvisualization of the tendon, dis-
changes within the tendon. lodged suture anchor, and broken suture are
At US examination, the echogenicity for signs of tendon recurrent tear. A dynamic ultra-
repaired tendons varies from hyperechoic to sound study to evaluate tendon movement by
hypoechoic, with changes of the normal fibrillar moving the extremity can be used to confirm a
pattern due to varying degrees of granulation tis- tendon tear. Complications of peroneal tendon
sue or scar remodeling. Hypoechoic defects and groove refashioning include redislocation,
Doppler spots of vascularization within a tendon decreased range of motion, sural nerve injury,
repair site caused by the granulation tissue may and friction of the tendon after repair leading to
persist for several years and mimic recurrent tear. recurrent tendinosis and tear. Calcifications and
230 G. Rusconi et al.

suture granuloma are other possible but uncom- tendon and the peritendinous soft tissues. A
mon complications. dynamic US evaluation during dorsiflexion and
Achilles tendon: The Achilles tendon is the plantar flexion movements is necessary to reveal
most commonly injured of all the ankle tendons. discontinuity of the tendon. It should also be con-
Predisposing factors include overuse injury, dia- sidered that sometimes the gliding of the tendon
betes, peripheral vascular disease, inflammatory is prevented by the scar tissue around the repair
and degenerative changes, and obesity. Some site. In fact, although initial formation of scars
drugs are also associated to an increased risk of provides continuity at the repair site, an excessive
tendinopathy and tear (glucocorticoids, oral con- production has to be considered pathological. In
traceptives). The middle third of the tendon is the this case, at US it may be difficult distinguishing
most prone to rupture because it is known to be the margins of the tendon from the surrounding
the less vascularized zone of the tendon. tissue and there are hypoechoic areas around the
Different surgery techniques can be performed repaired tendon. Other possible complications
according to the degree of lesion. If tendon ends include infection, calcifications, and suture gran-
are still closely approximated, primary end-to-­ uloma, as may happen after surgical repair of
end repair is usually feasible. When severe retrac- other tendons.
tion is present and the gap is too large to reattach
the tendon ends, then either a tendon graft or a
synthetic augmentation can be used. Grafts from Further Readings
the plantaris, flexor hallucis longus, and peroneal
tendons are commonly used to add mechanical Amin NH, Volpi A, Lynch TS, et al. Complications of
strength to the repair. distal biceps tendon repair: a meta-analysis of single-­
The repaired tendon is normally larger and/or incision versus double-incision surgical technique.
Orthop J Sports Med. 2016;4(10):2325967116668137.
wider than normal and maintains the increased Batz R, Sofka CM, Adler RS, et al. Dermatomyositis and
thickness for at least 2 years after surgery. At US calcific myonecrosis in the leg: ultrasound as an aid in
examination, heterogeneous echotexture with management. Skelet Radiol. 2006;35(2):113–6.
loss of the internal fibrillary structure and pres- Beltran LS, Bencardino JT, Steinbach LS. Postoperative
MRI of the shoulder. J Magn Reson Imaging.
ence of surgical material within the tendon are 2014;40(6):1280–97.
considered as normal aspects after surgery Brodsky J, Toppins A. Postsurgical imaging of the
(Fig. 25.14). Fluid collections, irregular contours, peroneal tendons. Semin Musculoskelet Radiol.
and extensive intratendinous calcifications should 2012;16(03):233–40.
Chun KA, Cho KH. Postoperative ultrasonography
be considered pathologic aspects. of the musculoskeletal system. Ultrasonography.
At Doppler imaging there might be a subtle 2015;34(3):195–205.
increase during the initial healing process that Cohen MJ. US imaging in operated tendons. Ultrasound.
regresses as the scar matures, but increased vas- 2012;15(1):69–75.
Counsel P, Breidahl W. Muscle injuries of the lower leg.
cularity signals at 2 years after surgery may sug- Semin Musculoskelet Radiol. 2010;14(2):162–75.
gest tendinopathy or reinjury. Creteur V, Madani A, Sattari A, et al. Ultrasonography
Variations of peritendinous vascularization of complications in surgical repair of the dis-
are considered less important than intratendinous tal biceps Brachii tendon. J Ultrasound Med.
2019;38(2):499–512.
one. Devilbiss Z, Hess M, Ho GWK. Myositis Ossificans
Dynamic US evaluation shows a physiologic in sport: a review. Curr Sports Med Rep. 2018
reduction of the tendon’s mobility in the first few Sep;17(9):290–5.
months after surgery. Di Pietto F, Chianca V, Zappia M, et al. Articular and peri-­
articular hip lesions in soccer players. The importance
Post-traumatic re-rupture is the main compli- of imaging in deciding which lesions will need surgery
cation after surgical treatment of the Achilles ten- and which can be treated conservatively? Eur J Radiol.
don rupture. Although clinical symptoms could 2018;105:227–38.
be clear, sonographic diagnosis may not be obvi- Drakonaki EE, Sudoł-Szopińska I, Sinopidis C, et al.
High resolution ultrasound for imaging complications
ous, due to the altered echostructure of both the
25 Tendon and Muscle Rupture Repair 231

of muscle injury: is there an additional role for elas- Kwee RM, Kwee TC. Calcified or ossified benign soft
tography? J Ultrason. 2019;19(77):137–44. tissue lesions that may simulate malignancy. Skelet
Garon MT, Greenberg JA. Complications of biceps distal Radiol. 2019;48(12):1875–90.
repair. Orthop Clin N Am. 2016;47:435–44. LiMarzi GM, Scherer KF, Richardson ML, et al. CT
Gilat R, Atoun E, Cohen O, et al. Recurrent rotator cuff and MR imaging of the postoperative ankle and foot.
tear: is ultrasound imaging reliable? J Shoulder Elb Radiographics. 2016;36(6):1828–48. Review
Surg. 2018;27(7):1263–7. Lungu E, Michaud J, Bureau NJ. US assessment
Gitto S, Draghi AG, Bortolotto C, et al. Sonography of of sports-related hip injuries. Radiographics.
the Achilles tendon after complete rupture repair: 2018;38(3):867–89.
what the radiologist should know. J Ultrasound Med. Möller M, Kälebo P, Tidebrant G, et al. The ultrasono-
2016;35(12):2529–36. graphic appearance of the ruptured Achilles tendon
Grasset W, Mercier N, Chaussard C, et al. The surgi- during healing: a longitudinal evaluation of surgical
cal treatment of peroneal tendinopathy (excluding and nonsurgical treatment, with comparisons to MRI
­subluxations): a series of 17 patients. J Foot Ankle appearance. Knee Surg Sports Traumatol Arthrosc.
Surg. 2012;51:13–9. 2002;10:49–56.
Guermazi A, Roemer FW, Robinson P, et al. Imaging Orlandi D, Corazza A, Arcidiacono A. Ultrasound-guided
of muscle injuries in sports medicine. Radiology. procedures to treat sport-related muscle injuries. Br J
2017; Radiol. 2016;89(1057):20150484.
Hall MM. Return to play after thigh muscle injury: util- Peetrons P. Ultrasound of muscles. Eur Radiol.
ity of serial ultrasound in guiding clinical progression. 2002;12:35–43.
Curr Sports Med Rep. 2018 Sep;17(9):296–301. Pierce JL, Nacey NC, Jones S, et al. Postoperative shoul-
Hollawell S, Baione W. Chronic Achilles tendon rup- der imaging: rotator cuff. Labrum and Biceps Tendon
ture reconstructed with Achilles tendon allograft Radiographics. 2016;36:1648–71.
and xenograft combination. J Foot Ankle Surg. Tyler P, Saifuddin A. The imaging of myositis Ossificans.
2015;54(6):1146–50. Semin Musculoskelet Radiol. 2010;14(2):201–16.
Jacobson JA, Lax MJ. Musculoskeletal sonography of the Yoshida K, Itoigawa Y, Maruyama Y. Healing process
postoperative orthopedic patient. Semin Musculoskelet of gastrocnemius muscle injury on ultrasonography
Radiol. 2002;6(1):67–77. Review using B-mode imaging, power Doppler imaging,
Kumar Y, Farmazalian A, Shivani A, et al. Peroneal ten- and shear wave Elastography. J Ultrasound Med.
don pathology: pre- and post-operative high resolution 2019;38(12):3239–46.
US and MR imaging. Eur J Radiol. 2017;92:132–44.
 Therapy Efficacy Evaluation
in Synovitis
26
Marina Carotti, Emilio Filippucci , Fausto Salaffi,
and Fabio Martino

Contents
26.1 Introduction  233
26.2  usculoskeletal Ultrasound Scoring Methods 
M 234
26.2.1 Ultrasound Scoring Systems  234
26.2.2 Examined Joints  237
26.2.3 Color and/or Power Doppler Ultrasound Methods  239
26.2.4 Doppler Quantitative Assessment of Synovial Blood Flow  241
26.3  ole of CEUS in the Assessment of Inflammatory Arthritis 
R 241
26.3.1 Quantitative Analysis of CEUS  242
26.3.2 Applications of Quantitative Analysis of CEUS
in Inflammatory Arthritis  242
26.3.3 Clinical Application of CEUS in Therapeutic Monitoring
in Inflammatory Arthritis  244
26.3.4 Limitations  244
Further Readings  246

26.1 Introduction

In chronic inflammatory joint diseases, synovial

tissue is the major site of inflammation. Latest
reports indicate that ultrasonography may be an
important imaging technique to determine the
M. Carotti degree of synovitis in inflamed joints of patients
Clinica di Radiologia, Dipartimento di Scienze with chronic inflammatory arthritis. Furthermore,
Radiologiche – Azienda Ospedali Riuniti di Ancona
Universita’ Politecnica delle Marche, Ancona, Italy the use of power Doppler technique with high-­
frequency probes allows for a sensitive detection
E. Filippucci · F. Salaffi
Clinica Reumatologica, Dipartimento di Scienze of synovial proliferation with abnormal blood
Cliniche e Molecolari, Università Politecnica delle flow, especially in the small joints of the hands
Marche, Jesi (Ancona), Italy and feet.
F. Martino (*) Power Doppler technique analyzes Doppler
Radiology, Sant’Agata Diagnostic Center, Bari, Italy changes induced by the moving red blood cells

© Springer Nature Switzerland AG 2022 233

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_26
234 M. Carotti et al.

and is particularly helpful for the quantification of Recently, the EULAR-OMERACT (European
low blood flows at synovial tissue level. Contrast- League Against Rheumatism-Outcome Measures
enhanced ultrasound (CEUS) may be a promising in Rheumatology) group for musculoskeletal
tool to evaluate inflammatory arthritis, because of ultrasound has agreed on the use of a four-grade
its ability to provide dynamic imaging, and high semiquantitative scoring system for both
sensitivity for angiogenesis. Angiogenesis is B-mode-detected and Doppler-detected synovi-
emerging as a key player in the pathogenesis of tis, which have demonstrated good multi-­
many chronic inflammatory arthritis. A number of examiner intra-observer and inter-observer
scoring systems, improving reliability and conse- reliability in RA patients.
quently the responsiveness of US in clinical trials, In 2003, Szkudlarek et al. developed a four-­
have been proposed. However, there is still a lack step semiquantitative US grading system for joint
of an expert-derived consensus, especially on the effusion, synovial thickening, and power Doppler
core set of joints to scan. We have attempted to signal at synovium level in five preselected small
summarize the emerging B-mode ultrasound, joints of patients with RA: second and third
color/power Doppler ultrasound, and CEUS metacarpophalangeal joints, second proximal
imaging techniques and their applications in interphalangeal joint, and first and second meta-
quantifying synovial inflammation. tarsophalangeal joints. Joint effusion was defined
as a compressible anechoic intracapsular area
and the amount of fluid semiquantitatively scored
26.2 Musculoskeletal Ultrasound as follows: grade 0: no effusion; grade 1: minimal
Scoring Methods amount; grade 2: moderate amount (without dis-
tension of the joint capsule); and grade 3: exten-
In patients with rheumatoid arthritis, sonographic sive amount (with distension of the joint capsule).
findings of synovial inflammation were found Synovial thickening was defined as a non-­
predictive for irreversible joint damage (i.e., bone compressible hypoechoic intracapsular area
erosions), and they can be significantly changed scored as follows: grade 0: none; grade 1: mini-
by disease-modifying antirheumatic drugs. Color mal synovial thickening filling the angle between
and power Doppler techniques have shown to be the periarticular bones, without bulging over the
of diagnostic value in the detection of vascularity line linking tops of the bones; grade 2: synovial
in intra-articular synovial tissue and provide a thickening bulging over the line linking tops of
measure of neovascularization within the syno- the periarticular bones without extension along
vial lining of tendons and within tendons them- the bone diaphysis; and grade 3: synovial thick-
selves. The ultrasound quantification of synovial ening bulging over the line linking tops of the
inflammation is essential for at least three rea- periarticular bones with extension to at least one
sons: (i) for diagnosing active synovitis, (ii) for of the bone diaphysis. Semiquantitative grading
therapy monitoring, and (iii) as a predictive fac- of the PD signal in the synovium was described
tor for relapse in patients in remission. as follows: grade 0: no flow; grade 1: single-­
vessel signals; grade 2: confluent vessel signals
in less than half of the area of the synovium; and
26.2.1 Ultrasound Scoring Systems grade 3: vessel signals in more than half of the
area of the synovium (Figs. 26.1 and 26.2).
Several semiquantitative scoring systems using In 2000, Wakefield et al. described the first
grayscale findings and power Doppler signals semiquantitative scoring system for the assess-
have been proposed (Table 26.1). In most of the ment of bone erosions. A bone erosion was
published studies, grayscale and Doppler find- defined as an interruption of the bony cortex with
ings have been graded independently and each an irregular floor documented in longitudinal and
elementary component had its dedicated scoring transverse planes. The size of the definite bone
system. erosion was measured using its maximal diame-
26 Therapy Efficacy Evaluation in Synovitis 235

Table 26.1 Main ultrasound scoring systems for synovitis listed in chronological order
No. of Joint
Author Year Pathologies patients Grade Examined joints region
Wakefield 2000 Bone erosion 100 0–3 Unilateral MCP II-V Ulnar,
et al. radial,
palmar,
and dorsal
Szkudlarek 2003 Joint effusion, synovial 30 0–3 Unilateral MCP II, III, Dorsal
et al. thickening, PD activity PIP II, MPT I and II
Scheel et al. 2005 Effusion/synovial 46 0–3 Unilateral MCP II–V, Palmar,
hypertrophy PIP II–V, assessment dorsal
Naredo 2005 Joint effusion, synovial 49 0–3 sum of bilateral Dorsal
et al. thickening, PD activity 60-, 18-, 16-, 12-,
10-, and 6-joint
score
Backhaus 2009 Synovitis, 120 0–3; 0–1 for Unilateral wrist, MCP Dorsal,
et al. tenosynovitis, tenosynovitis and II, III PIP II, III, MPT palmar,
paratendonitis, PD erosion II, V lateral
activity, bone erosions
Ellegaard 2010 PD activity 109 0–3 Unilateral wrist Dorsal
et al.
Dougados 2010 Synovitis 76 0–3; 0–1 for Bilateral 28 joints vs. Dorsal,
et al. tenosynovitis 38 joints (28 + MTPs) plantar
vs. 20 joints (20
MCPs + 20 MTPs)
Hammer 2011 Synovitis, 20 0–3 Bilateral 78 joints vs. Dorsal
et al. tenosynovitis PD 44 joints, 28 joints, 12
activity, bursitis joints, and 7 joints
Kawashini 2011 Synovitis, bursitis 24 0–3 Bilateral elbows, wrists, Dorsal,
et al. knees, and ankles palmar
Bachkaus 2012 Synovitis, 432 0–3 Sum of wrist, MTP Dorsal,
et al. tenosynovitis, II-V, MCP/PIP II and III plantar
paratendonitis, bone
erosions
Ohmdorf 2012 Synovitis, 6 0–3 Dominant wrist, MCP II Dorsal,
et al. tenosynovitis, and III, PIP II–V, MPT radial, and
paratendonitis, bone II and V plantar
erosions
Harlung 2012 Synovitis, 199 0–3 Shoulder, elbow, hip, Dorsal,
et al. tenosynovitis PD and knee ventral,
activity and lateral
Yoshimi 2014 PD activity 234 0–3 Wrists, knees, MCP I-V, Dorsal,
et al. PIP II and III palmar
Aga et al. 2015 GSUS and PDUS 439 0–3 7-joint/2 tendon (MCP, Dorsal,
scores PIP, MTP), radiocarpal, palmar,
elbow, tibialis plantar
Luz et al. 2016 Synovitis, 48 0–3; 0–1 for Wrist, MCP II and III, Dorsal,
tenosynovitis PD tenosynovitis PIP II and III palmar
activity, bone erosions
Janta et al. 2016 Synovitis, 47 0–3 12-joint (wrist, hand, Dorsal,
tenosynovitis, PD ankle, MTP); B-mode, palmar
activity PD, tenosynovitis
Sun et al. 2017 Synovitis, PD activity 235 0–3 Bilateral wrists, MCP Dorsal
I-V, PIP I-V
236 M. Carotti et al.

Synovial effusion Synovial hypertrophy Synovial hyperemia

Grade 0

Grade 1

Grade 2

Grade 3

Fig. 26.1 Ultrasound semiquantitative scoring scheme of dorsal longitudinal scan. Red dotted line = tangent line to
synovial effusion, synovial hypertrophy, and synovial tops of joint bones; asterisk = dorsal plate; arrow = cap-
hyperemia assessing synovitis grade at MCP joint using sule profile

a In a recent study by Hurnakova J et al., carti-

lage damage of the metacarpal head was assessed
in patients with rheumatoid arthritis and in
patients with osteoarthritis using a very-high-­
frequency probe (up to 22 MHz) and the follow-
ing five-grade semiquantitative scoring system:
0 = normal hyaline cartilage; 1 = loss of the
sharpness of the cartilage superficial margin;
b 2 = partial-thickness defect of the cartilage layer;
3 = full-thickness defect of the cartilage layer
with normal subchondral bone profile; and
4 = complete loss of the cartilage layer and sub-
chondral bone damage (Fig. 26.4).
For tenosynovitis and tendon damage a task-
force of the OMERACT US group agreed on a
Fig. 26.2 Rheumatoid arthritis. Active synovitis detected four-grade semiquantitative scoring system (i.e.,
using a longitudinal dorsal scan at metacarpophalangeal grade 0, normal; grade 1, minimal; grade 2, mod-
joint level. Both images (a) and (b) show representative erate; grade 3, severe). Both longitudinal and
examples of synovitis grade 3 using grayscale scoring
system. Using power Doppler assessment grade 2 and transverse planes should be used to assess both
grade 3 can be assigned, respectively, to (a) and (b). p inflammatory findings and tendon ruptures.
proximal phalanx, m metacarpal bone The data acquired by all scoring systems
depend on both acquisition and interpretation
ter and the following scoring system was pro- processes and the following practical tips are fun-
posed: small erosion: <2 mm; moderate erosion: damental to consider, especially when a compari-
2–4 mm; and large erosion: >4 mm (Fig. 26.3). son between a previous or future ultrasound
26 Therapy Efficacy Evaluation in Synovitis 237

sure which is essential for therapy monitoring.

Thus, ultrasound examination should not be lim-
ited to placing the probe in a selected number of
scanning planes, but it should entail the movement
of the probe from one side of the anatomic site
under examination to the other side, to look for the
maximal expression of synovial inflammation.
Interpretation of ultrasound findings indica-
tive of synovitis for therapy monitoring must
consider the following main issues: intra- and
inter-observer reliability and sensitivity to
change. In fact, interpretation based only on pres-
ence/absence is likely to provide a higher degree
of intra- and inter-observer agreement, but it may
miss early improvements due to treatment; con-
versely adopting a semiquantitative scoring sys-
tem allows for a more sensitive-to-change method
which distinguishes different grades of synovitis.
In other words, presence/absence approach
misses the benefit obtained by a treatment induc-
ing a change from synovitis grade 3 at baseline to
grade 1 at follow-up examination, because it
requires the complete disappearance of the ultra-
sound findings indicative of synovial inflamma-
tion to record an improvement.

26.2.2 Examined Joints

Fig. 26.3 Rheumatoid arthritis. Second metacarpopha-

Several core sets of joints have been proposed to
langeal joint on longitudinal radial scan. Representative assess rheumatoid arthritis activity with ultra-
examples showing bone erosions with different sizes. p sound; however, to date, there is no clear consen-
proximal phalanx; m metacarpal bone sus on the optimal joint count to use in daily
clinical practice. To include ultrasound in the
examination is, respectively, requested or clinical routine, it is of major importance to scan
planned. the lowest number of joints and tendons that is
As regards the acquisition process, it may be able to give relevant information on the inflam-
based on anatomic or pathologic references: in matory process at patient level.
other words, the sonographer may save the Hammer et al. published a study, in which a
images using standard scanning planes described comprehensive US score including 78 joints was
using fixed anatomic landmarks, or according to compared with reduced joint counts (7-, 12-, 28-,
the maximal expression of synovitis. and 44-joint scores) at different time points, dur-
The images acquired using standard scans are ing biologic agent treatment. They found high
easily compared, but they may underestimate or correlation between the reduced joint scores and
completely miss synovitis; conversely the method the 78-joint score at all examination time points
based on pathologic findings may lead to the for power Doppler ultrasound.
acquisition of images with different anatomic In the development of scoring system, Scheel
backgrounds, but they display the outcome mea- et al. examined semiquantitatively (0–3) and quan-
238 M. Carotti et al.

a b

c d

Fig. 26.4 Rheumatoid arthritis. Metacarpal head on lon- layer. (d) Full-thickness defect of the cartilage layer with
gitudinal dorsal scan. Representative examples of differ- normal subchondral bone profile. (e) Complete loss of the
ent grades of cartilage damage. (a) Normal hyaline cartilage layer and subchondral bone damage. p proximal
cartilage. (b) Loss of the sharpness of the cartilage super- phalanx; m metacarpal bone
ficial margin. (c) Partial-thickness defect of the cartilage

titatively synovitis in the clinically most affected reduced number of joints is preferable, in view of
metacarpophalangeal and proximal interphalan- the shorter examination time required.
geal joints of the hands of rheumatoid patients. Naredo et al. investigated the validity of
They found no significant differences between reduced joint counts including large and small
semiquantitative scores and quantitative measure- joints on both sides. A 12-joint score including
ments and concluded that the examination of a bilateral wrist, metacarpophalangeal and proxi-
26 Therapy Efficacy Evaluation in Synovitis 239

mal interphalangeal joints of the second and third To date the seven-joint US composite scoring
fingers, and knees was used to determine effu- system proposed by Backhaus et al. represents the
sion, synovitis, and PD activity. Such a scoring most comprehensive (not only joints are included
system correlated highly with a corresponding but also tendons; not only inflammatory findings
60-joint score. In fact, 12-joint score reflected the are evaluated, but also bone erosions) and vali-
overall joint inflammation in patients with RA dated (not only in cross-sectional studies in com-
and is therefore useful for monitoring treatment. parison with clinical and other imaging data, but
Luz et al. proposed a novel ultrasound scoring also in longitudinal studies testing its responsive-
system for hand and wrist joints for evaluation of ness) approach for assessing patients with rheu-
patients with early RA. Such a scoring system matoid arthritis. This accounts for its being the
involved the assessment of the wrist and second most used score in rheumatological clinical prac-
and third metacarpophalangeal and proximal tice. From a practical point of view, its main limi-
interphalangeal joints. The score consisted of tation lies on the fact that it is based on a fixed set
inflammation parameters (synovial proliferation, of anatomic structures to scan (Table 26.2). Since
power Doppler signal, and tenosynovitis) and the anatomic structures are frequently affected
joint damage parameters (bone erosion and carti- joints in rheumatoid arthritis, this score works
lage damage). The method proved to be a useful very well when assessing a cohort of patients with
tool for monitoring inflammation and joint dam- rheumatoid arthritis. However, in a specific single
age in patients with early RA, demonstrating sig- patient it may miss the most clinically involved
nificant correlations with longitudinal changes in joints. Thus, a possible solution in daily clinical
disease activity and functional status. practice could be to scan the seven joints indi-
More recently, 705 patients with definite RA cated by Backhaus et al. together with the most
were investigated and a selection of eight joints clinically inflamed joint at the time of the visit.
(bilateral wrist and metacarpophalangeal joints
of second, third, and fifth fingers) was found sim-
ple and efficient to detect synovitis in daily 26.2.3 C
 olor and/or Power Doppler
practice. Ultrasound Methods
In 2009, Backhaus et al. proposed a seven-­
joint US composite scoring system, including Color and/or power Doppler ultrasound tech-
wrist, metacarpophalangeal and proximal inter- niques have gained importance because of their
phalangeal joint of the second and third fingers, ability to assess abnormal blood flow at synovial
and metatarsophalangeal joint of the second and tissue level, a key feature of the inflammatory
fifth toes. The joints were examined by B-mode process in patients with chronic arthritis. Apart
and power Doppler ultrasound for synovitis, from the outcome measure for monitoring dis-
tenosynovitis/paratendonitis, and erosions ease activity during treatment (Fig. 26.5),
(Table 26.2). Doppler findings have been proposed as predic-
B-mode ultrasound synovitis was scored tors for relapse in patients in clinical remission
semiquantitatively according to Scheel et al., and have been found able to predict erosive pro-
while the power Doppler signal was assessed gression both in patients with early RA and in
using the scoring system of Szkudlarek et al. patients with low disease activity or remission.
Tenosynovitis/paratendonitis and bone erosions Color and/or power Doppler ultrasound tech-
in B-mode ultrasound were recorded on a binary niques are operator- and machine-dependent tech-
basis (presence/absence). The authors concluded niques. The following practical aspects should be
that the use of this score would provide a fast considered during a Doppler examination of joint
overview of disease activity in daily clinical prac- and periarticular structures. First, the patient must
tice and would be helpful in monitoring find a comfortable position during the scanning to
treatment. avoid an increase of pressure at the anatomic site
240 M. Carotti et al.

Table 26.2 B-mode ultrasound (US) and power Doppler (PD) US assessing synovitis, tenosynovitis/paratendonitis,
and bone erosions from the dorsal, palmar, and ulnar aspects of the wrist, metacarpophalangeal (MCP), proximal inter-
phalangeal (PIP), and metatarsophalangeal (MTP) joints
Wrist Fingers Toes
Synovitis Dorsal + PD MCP II, III MPT II, V
Palmar + PD Palmar + PD Dorsal + PD
Ulnar + DP Dorsal-only PD
PIP II, III
Palmar + PD
Dorsal-only PD
Paratendonitis/ Dorsal + PD MCP II,
tenosynovitis Palmar + PD IIIDorsal + PD
Ulnar + PD Palmar + PD

Bone erosions MCP II, III MTP II, V

Dorsal, palmar Dorsal, plantar
MCP II MTP V
Radial Lateral
PIP II, III
Dorsal, palmar

1 joint 4 joints 2 joints 7 joints

under examination and consequent false-negative • Doppler frequency: 6 MHz for large joints,
findings. Second, the sonographer should reduce i.e., knee; 9 MHz for smaller joints, i.e., wrist;
as much as possible the compression on the tis- and 11 MHz for very small joints and superfi-
sues with the probe. Third, the Doppler parame- cial structures, i.e., distal interphalangeal
ters should be set to obtain the maximal sensitivity joints and tendons of the fingers and toes.
for the detection of synovial blood flow. Although • Pulse repetition frequency (PRF): ranging
they may vary using different ultrasound systems, from 750 Hz to 1.3 KHz.
the mean values of the main Doppler parameters • Doppler gain: the highest value not generating
can be the following: random noise artifacts.
26 Therapy Efficacy Evaluation in Synovitis 241

a ing systems include the count of color pixels or

the color pixel intensity, in a region of interest
(ROI), outlined by the sonographer, in synovial
tissue, inside the joint capsule, using dedicated
post-processing software and spectral Doppler
analysis with measurement of the resistive index
(RI) (Fig. 26.6).
Spectral Doppler analysis can be used to
obtain a quantitative estimation of the grade of
b the synovial perfusion. The normal flow at the
level of soft tissues is characterized by high resis-
tance (i.e., high values of RI), because the dia-
stolic velocity has been considered to be zero.
Conversely, the inflammatory process is charac-
terized by an increased perfusion and permeabil-
ity of vessels together with neovascularization,
c and consequently an increase of the diastolic
velocity and low values of RI indicate an inflam-
mation process.
Thus, RI value allows quantitative measure-
ments of the synovial blood flow providing an
estimation of the synovial activity in patients
with chronic arthritis: the lower the value of RI,
the higher the grade of synovitis.
Fig. 26.5 Rheumatoid arthritis. Wrist synovitis.
Ultrasound changes induced by intra-articular steroid
injection assessed using a dorsal longitudinal view. (a) 26.3 Role of CEUS
Baseline assessment showing active wrist synovitis. (b) in the Assessment
Two weeks after the injection the same view allows the
detection of the disappearance of ultrasound signs of of Inflammatory Arthritis
synovitis. (c) One month after the injection, the image
shows the persistent absence of ultrasound signs of syno-
Contrast-enhanced US (CEUS) consists of a sus-
vitis. ca capitate bone, lu lunate bone, ra radius, t common
pension of stabilized gas-filled spheres, which
extensor tendons of the fingers
once introduced into the bloodstream, intrave-
nously, generate high-intensity signals which can
26.2.4 Doppler Quantitative be detected by the transducer. These tiny micro-
Assessment of Synovial bubbles are smaller than red blood cells, which
Blood Flow thereby can be introduced into the vascular sys-
tem, and keep stable during the whole process of
Using different machines, Doppler modalities, examination. CEUS microbubbles are “blood
and settings may have a considerable influence pool” contrast agents because once injected
on the quantification of inflammation by ultra- inside the vessels, they remain inside the lumen
sound in patients with chronic arthritis, and this and do not diffuse in the extra-arterial tissue or in
must be taken into account when a follow-up the cells, showing the exact vascular patterns and
examination is performed. Semi- or fully auto- neoangiogenesis in the inflamed synovium. This
mated software tools for quantitative assessment is important because angiogenesis is reported to
of active synovitis may help reducing the inter-­ be the earliest sign of rheumatoid arthritis and
observer variability. Quantitative Doppler scor- other inflammatory rheumatic diseases.
242 M. Carotti et al.

Fig. 26.6 Spectral

Doppler analysis, with
automatic calculation of
the resistive index (RI).
Abnormal
vascularization, with
decreased value of RI,
due to persistent flow
during the diastole, can
be observed at the level
of inflamed synovial
tissue of the wrist in a
patient with RA

The more recent type of US contrast agents lated by the software, representative of the perfu-
consists of stabilized microbubbles of a sulfur sion kinetics, and therefore they allow a detailed
hexafluoride gas (SonoVue®, Bracco, Milan, evaluation and quantification of synovial inflam-
Italy). The use of CEUS improves the sensitivity mation. Another approach of quantitative CEUS
of CDUS and PDUS in the identification of analysis of the vascular perfusion of synovium is
abnormal vascularization in joint inflammation, pixel-based level and in a study a linear relation-
allowing a more exact measurement of the syno- ship was discovered between the parameters of
vitis and a better characterization of the pannus, quantitative CEUS and the frequencies of some
in terms of differentiation between hypervascu- interleukins in patients with psoriatic arthritis.
larity, hypovascularity, and avascularity. This
method has been shown to correlate with the his-
topathological quantitative and morphologic esti- 26.3.2 Applications of Quantitative
mation of microvascular proliferation in synovial Analysis of CEUS
tissue. in Inflammatory Arthritis

Many studies have demonstrated that CEUS may

26.3.1 Quantitative Analysis of CEUS be an excellent tool in the early diagnosis in
inflammatory diseases, such as rheumatoid
After an intravenous injection of the contrast arthritis, psoriatic arthritis, and ankylosing spon-
microbubbles, a time-intensity curve (TIC) in the dylitis, as well as in degenerative disorders. Most
region of interest (ROI) is displayed by the soft- of these studies have been performed in patients
ware, showing an S-shaped wash-in and a nearly with rheumatoid arthritis. The capacity of CEUS
exponential washout (Fig. 26.7). The enhance- compared to that of B-mode and power Doppler
ment curves can be compared to those built with ultrasound for detection of vascularity in joints of
gadolinium DTPA in magnetic resonance studies. rheumatoid patients was evaluated by the
After the bolus injection, the slope of the ascend- International Arthritis Contrast Ultrasound
ing and descending curve, the time to peak, the (IACUS) study group in a multicenter trial of five
maximum intensity, and the area under the TIC European centers. CEUS has been found more
curve are the most common parameters calcu- sensitive than color and power Doppler ultra-
26 Therapy Efficacy Evaluation in Synovitis 243

Fig. 26.7 Example of the time-intensity curve in patients with RA at baseline (a, b) and after 3 months of treatment
with biologic agents (c, d)
244 M. Carotti et al.

sound in the differentiation between active and patients with inflammatory arthritis and imaging
inactive synovitis. CEUS significantly improves findings contribute to estimating synovial inflam-
the detection of synovial vascularization at the mation activity. In the EFSUMB (European
knee in rheumatoid patients and the area under Federation of Societies for Ultrasound in
the curve correlates with the clinical and labora- Medicine and Biology) guidelines, CEUS is
tory findings of disease activity and with the described as a method whose findings may
degree of knee inflammation, being significantly change as a result of adequate treatment. A num-
higher in patients with clinically active synovitis ber of studies confirmed that CEUS can play a
compared with those with inactive synovitis. role in the therapeutic monitoring in inflamma-
Apart from synovitis, CEUS was found to be use- tory arthritis and in the evaluation of true remis-
ful in the detection of pathologic intra- and peri- sion (Table 26.3). CEUS has been shown to be
tendinous vascularity associated with able to detect changes in synovial perfusion after
tenosynovitis; in the evaluation of vascularized intra-articular steroid injection in patients with
erosive lesions, which are a sign of progressive RA and in patients treated with tumor necrosis
active disease; and in the demonstration of vascu- factor alpha (TNFα) inhibitors. In these patients,
larized synovial lining of the inflamed bursa. CEUS was found to be useful in the short-term
Similar results have been found in patients with follow-up, as it seems to provide an indication of
spondylarthritis. It has been demonstrated that the presence or absence of residual disease
the perfusion kinetics of CEUS, such as refilling activity.
time, peak intensity, regional blood flow, and
slope, are associated with vascular synovial pat-
tern in patients with psoriatic arthritis. There is 26.3.4 Limitations
also evidence confirming that the hypervascular-
ity can be shown in the inflamed sacroiliac joints Apart from the advantages, some drawbacks
with spondylarthritis. must be considered when using CEUS to assess
synovitis for therapy monitoring in clinical prac-
tice. In fact, CEUS imaging allows the assess-
26.3.3 C
 linical Application of CEUS ment of only one joint per each dose of contrast
in Therapeutic Monitoring medium administered intravenously which limits
in Inflammatory Arthritis the examination to one or very few target dis-
tricts. Moreover, the contrast agent administra-
The quantification of synovitis is a key aspect to tion involves an increase in the running costs, and
support therapy decisions in daily practice in carries a risk, albeit minimal, of side effects.
26 Therapy Efficacy Evaluation in Synovitis 245

Table 26.3 Main studies focusing on the role of CEUS in therapeutic monitoring in inflammatory arthritis listed in t3.1
chronological order
Quantification
Author Year Disease Therapy method Results
Carotti 2002 RA Intra-articular injection Time-intensity curve The mean values of the
et al. of glucocorticosteroids parameters underlying time-intensity
curves differed between
patients with active and those
with inactive synovitis
Salaffi 2005 RA Intra-articular injection Median values of the Synovitis activity was highly
et al. of triamcinolone area underlying associated with changes of
hexacetonide time-intensity curves the value of the area
underlying time-intensity
curves. The values are also
correlated with CRP and
index score of synovitis
activity
Klauser 2005 RA Conventional synthetic Enhancement and CEUS improved the
et al. drugs semiquantitative differentiation of active
assessment versus inactive synovitis
Song 2008 RA and SpA Intra-articular injection The slope values by A significant improvement of
et al. of glucocorticosteroids time-intensity clinical and CEUS
analysis parameters in patient 1, and
elevated parameters in patient
2
Klauser 2010 Tenosynovitis Not done Extent of vascularity CEUS was significantly more
et al. in RA, still on semiquantitative sensitive in the detection of
disease, SSc, assessment vascularization, compared to
SpA power Doppler ultrasound
Ohmdorf 2011 RA Anti-TNF-alpha agents Enhancement slope CEUS showed the best
et al. and semiquantitative sensitivity in detecting the
assessment changes after the treatment
with anti-TNF-alpha among
all the imaging techniques
applied in the study
Stramare 2013 RA Anti-TNF-alpha agents Enhancement and CEUS might be useful in the
et al. semiquantitative short-term follow-up of
assessment patients with RA
Mouterde 2014 Nonsteroidal The slope values by CEUS improved the
et al. SpA anti-­ time-intensity analysis detection of
inflammatory enthesitis in SpA
drugs patients
Bonifati 2014 Anti-TNF-alpha The count of swollen A significant
et al. PsA agents (ACR 66), tender (ACR reduction of all
68), and active inflamed clinical variables,
joints including CEUS
Cozzi 2015 PsA Mud-bath treatment, The count of swollen A significant appearance
et al. anti-TNF-alpha agents (ACR 66, tender delay and faster washout
(ACR 68), and active were observed in the
inflamed joints therapeutic group
Tamas 2015 Early arthritis Conventional synthetic Peak, slope, area Peak and area underlying
et al. drugs underlying time-intensity curve
time-intensity significantly decreased during
the treatment with the
remission of the symptoms
CEUS contrast-enhanced ultrasound, PsA psoriatic arthritis, RA rheumatoid arthritis, SpA spondylarthritis, SSc sys-
temic sclerosis
246 M. Carotti et al.

Further Readings joints in rheumatoid arthritis patients and healthy sub-

jects. Eur J Radiol. 2012;81:1834–8.
D'Agostino MA, Terslev L, Aegerter P, Backhaus
Albrecht K, Grob K, Lange U, Müller-Ladner U, Strunk
M, Balint P, Bruyn GA, Filippucci E, Grassi W,
J. Reliability of different Doppler ultrasound quantifi-
Iagnocco A, Jousse-Joulin S, Kane D, Naredo E,
cation methods and devices in the assessment of thera-
Schmidt W, Szkudlarek M, Conaghan PG, Wakefield
peutic response in arthritis. Rheumatology (Oxford).
RJ. Scoring ultrasound synovitis in rheumatoid
2008;47(10):1521–6.
arthritis: a EULAR-­ OMERACT ultrasound task-
Ammitzbøll-Danielsen M, Janta I, Torp-Pedersen force-part 1: definition and development of a stan-
S, Naredo E, Østergaard M, Terslev L. Three-­ dardised, consensus-based scoring system. RMD
dimensional Doppler ultrasound findings in healthy Open. 2017;3(1):e000428. https://doi.org/10.1136/
wrist and finger tendon sheaths - can feeding vessels rmdopen-­2016-­000428. eCollection
lead to misinterpretation in Doppler-detected tenosy- Filippucci E, Cipolletta E, Mashadi Mirza R, Carotti M,
novitis? Arthritis Res Ther. 2016;18:70. Giovagnoni A, Salaffi F, Tardella M, Di Matteo A, Di
Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus Carlo M. Ultrasound imaging in rheumatoid arthritis.
TM, Hartung W, Sattler H, Albrecht K, Kaufmann Radiol Med. 2019;124:1087–100.
J, Becker K, Sörensen H, Meier L, Burmester GR, Filippucci E, Di Geso L, Grassi W. Progress in imaging in
Schmidt WA. Evaluation of a novel 7-joint ultrasound rheumatology. Nat Rev. Rheumatol. 2014;10:628–34.
score in daily rheumatologic practice: a pilot project. Filippucci E, Salaffi F, Carotti M, Grassi W. Doppler ultra-
Arthritis Rheum. 2009;61(9):1194–201. https://doi. sound imaging techniques for assessment of synovial
org/10.1002/art.24646. inflammation. Rep Med Imaging. 2013;6:83–91.
Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda https://doi.org/10.2147/RMI.S32950.
K, Peterfy CG, et al. An explanation for the apparent Fiocco U, Cozzi L, Chieco-Bianchi F, Rigon C, Vezzù
dissociation between clinical remission and contin- M, Favero E, et al. Vascular changes in psoriatic knee
ued structural deterioration in rheumatoid arthritis. joint synovitis. J Rheumatol. 2001;28:2480–6.
Arthritis Rheum. 2008;58:2958–67. Fiocco U, Stramare R, Coran A, Grisan E, Scagliori E,
Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy Caso F, Costa L, Lunardi F, Oliviero F, Bianchi FC,
CG, Hensor E, Wakefield RJ, O'Connor PJ, Emery Scanu A, Martini V, Boso D, Beltrame V, Vezzù M,
P. Presence of significant synovitis in rheumatoid Cozzi L, Scarpa R, Sacerdoti D, Punzi L, Doria A,
arthritis patients with disease-modifying antirheu- Calabrese F, Rubaltelli L. Vascular perfusion kinetics
matic drug-induced clinical remission: evidence from by contrast-enhanced ultrasound are related to syno-
an imaging study may explain structural progression. vial microvascularity in the joints of psoriatic arthritis.
Arthritis Rheum. 2006;54:3761–73. Clin Rheumatol. 2015;34:1903–12.
Bruyn GA, Iagnocco A, Naredo E, Balint PV, Gutierrez Fiocco U, Stramare R, Martini V, Coran A, Caso F, Costa
M, Hammer HB, Collado P, Filippou G, Schmidt WA, L, et al. Quantitative imaging by pixel-based contrast-­
Jousse-Joulin S, Mandl P, Conaghan PG, Wakefield enhanced ultrasound reveals a linear relationship
RJ, Keen HI, Terslev L, D'Agostino MA, OMERACT between synovial vascular perfusion and the recruit-
Ultrasound Working Group. OMERACT defini- ment of pathogenic IL-17A-F IL-23+ CD161 + CD4+
tions for Ultrasonographic pathologies and elemen- T helper cells in psoriatic arthritis joints. Clin
tary lesions of rheumatic disorders 15 years on. J Rheumatol. 2017;36:391–9.
Rheumatol. 2019;46:1388–93. Foltz V, Gandjbakhch F, Etchepare F, Rosenberg C,
Bruyn GAW, Hanova P, Iagnocco A, et al. Ultrasound def- Tanguy ML, Rozenberg S, et al. Power Doppler ultra-
inition of tendon damage in patients with rheumatoid sound, but not low-field magnetic resonance imaging,
arthritis. Results of a OMERACT consensus-based predicts relapse and radiographic disease progression
ultrasound score focusing on the diagnostic reliability. in rheumatoid arthritis patients with low levels of dis-
Ann Rheum Dis. 2014;73:1929–34. ease activity. Arthritis Rheum. 2012;64:67–76.
Carotti M, Galeazzi V, Catucci F, Zappia M, Arrigoni Freeston JE, Wakefield RJ, Conaghan PG, Hensor EM,
F, Barile A, Giovagnoni A. Clinical utility of eco-­ Stewart SP, Emery P. A diagnostic algorithm for
color-­power Doppler ultrasonography and contrast persistence of very early inflammatory arthritis: the
enhanced magnetic resonance imaging for interpre- utility of power Doppler ultrasound when added
tation and quantification of joint synovitis: a review. to conventional assessment tools. Ann Rheum Dis.
Acta Biomed. 2018;89(1-S):48–77. 2010;69:417–9.
Carotti M, Salaffi F, Manganelli P, Salera D, Simonetti B, Hammer HB, Kvien TK. Comparisons of 7- to 78-joint
Grassi W. Power Doppler sonography in the assess- ultrasonography scores: all different joint combina-
ment of synovial tissue of the knee joint in rheumatoid tions show equal response to adalimumab treatment in
arthritis: a preliminary experience. Ann Rheum Dis. patients with rheumatoid arthritis. Arthritis Res Ther.
2002;61:877–82. 2011;13:R78.
Carotti M, Salaffi F, Morbiducci J, Ciapetti A, Bartolucci Hurnakova J, Filippucci E, Cipolletta E, Di Matteo A,
L, Gasparini S, et al. Colour Doppler ultrasonography Salaffi F, Carotti M, Draghessi A, Di Donato E, Di
evaluation of vascularization in the wrist and finger Carlo M, Lato V, Horvath R, Komarc M, Pavelka K,
26 Therapy Efficacy Evaluation in Synovitis 247

Grassi W. Prevalence and distribution of cartilage ing of rheumatoid arthritis patients. Ultraschall Med.
damage at the metacarpal head level in rheuma- 2011;32(Suppl 2):E38–44.
toid arthritis and osteoarthritis: an ultrasound study. Piscaglia F, Nolsøe C, Dietrich CF, Cosgrove DO, Gilja
Rheumatology (Oxford). 2019;58(7):1206–13. https:// OH, Bachmann Nielsen M, Albrecht T, Barozzi L,
doi.org/10.1093/rheumatology/key443. Bertolotto M, Catalano O, Claudon M, Clevert DA,
Kaiser MJ, Hauzeur JP, Blacher S, Foidart JM, Deprez Correas JM, D'Onofrio M, Drudi FM, Eyding J,
M, Rossknecht A, Malaise MG. Contrast-enhanced Giovannini M, Hocke M, Ignee A, Jung EM, Klauser
coded phase-inversion harmonic sonography of knee AS, Lassau N, Leen E, Mathis G, Saftoiu A, Seidel
synovitis correlates with histological vessel density: G, Sidhu PS, ter Haar G, Timmerman D, Weskott
2 automated digital quantifications. J Rheumatol. HP. The EFSUMB guidelines and recommendations
2009;36:391–400. on the clinical practice of contrast enhanced ultra-
Klauser A, Demharter J, De Marchi A, et al. The IACUS sound (CEUS): update 2011 on non-hepatic applica-
study group. Contrast enhanced gray-scale sonogra- tions. Ultraschall Med. 2012;33(1):33–59.
phy in assessment of joint vascularity in rheumatoid Reece RJ, Canete JD, Parsons WJ, Emery P, Veale
arthritis: results from the IACUS study group. Euro DJ. Distinct vascular patterns of early synovitis in
Radial. 2005;15(12):2404–10. psoriatic, reactive, and rheumatoid arthritis. Arthritis
Klauser A, Halpern EJ, Frauscher F, Gvozdic D, Duftner C, Rheum. 1999;42:1481–4.
Springer P, Schirmer M. Inflammatory low back pain: Ribbens C, Andre B, Marcelis S, et al. Rheumatoid hand
high negative predictive value of contrast-enhanced joint synovitis: gray-scale and power Doppler US
color Doppler ultrasound in the detection of inflamed quantifications following anti-tumor necrosis factor-
sacroiliac joints. Arthritis Rheum. 2005;53:440–4. ­a treatment: pilot study. Radiology. 2003;229:562–9.
Löffler C, Sattler H, Uppenkamp M, Bergner R. Contrast-­ Salaffi F, Carotti M, Manganelli P, Filippucci E,
enhanced ultrasound in coxitis. Joint Bone Spine. Giuseppetti GM, Grassi W. Contrast-enhanced power
2016;83:669–74. https://doi.org/10.1016/j. Doppler sonography of knee synovitis in rheumatoid
jbspin.2015.10.012. arthritis: assessment of therapeutic response. Clin
Luz KR, Pinheiro MM, Petterle GS, Dos Santos MF, Rheumatol. 2004;23:285–90.
Fernandes AR, Natour J, Furtado RN. A new mus- Salaffi F, Ciapetti A, Gasparini S, Carotti M, Filippucci
culoskeletal ultrasound scoring system (US10) of the E, Grassi W. A clinical prediction rule combining
hands and wrist joints for evaluation of early rheuma- routine assessment and power Doppler ultrasonogra-
toid arthritis patients. Rev Bras Rheumatol Engl Ed. phy for predicting progression to rheumatoid arthritis
2016;56(5):421–31. from early-onset undifferentiated arthritis. Clin Exp
Mouterde G, Aegerter P, Correas JM, Breban M, Rheumatol. 2010;28(5):686–94.
D'Agostino MA. Value of contrast-enhanced ultra- Sarzi-Puttini P, Filippucci E, Adami S, et al. Clinical,
sonography for the detection and quantification of ultrasound, and predictability outcomes following
enthesitis vascularization in patients with spondyloar- Certolizumab Pegol treatment (with methotrexate) in
thritis. Arthritis Care Res (Hoboken). 2014;66:131–8. patients with moderate-to-severe rheumatoid arthri-
Mouterde G, Carotti M, D'Agostino MA. Contrast-­ tis: 52-week results from the CZP-SPEED study. Adv
enhanced ultrasound in musculoskeletal diseases. J Ther. 2018;35:1153–68.
Radiol. 2009;90(1 Pt 2):148–55. Scheel AK, Hermann KG, Kahler E, et al. A novel ultra-
Naredo E, D'Agostino MA, Wakefield RJ, Möller sonographic synovitis scoring system suitable for
I, Balint PV, Filippucci E, Iagnocco A, Karim analyzing finger joint inflammation in rheumatoid
Z, Terslev L, Bong DA, Garrido J, Martínez- arthritis. Arthritis Rheum. 2005;52:733–43.
Hernández D, Bruyn GA, OMERACT Ultrasound Simpson E, Hock E, Stevenson M, Wong R, Dracup
Task Force*. Reliability of a consensus-based ultra- N, Wailoo A, Conaghan P, Estrach C, Edwards C,
sound score for tenosynovitis in rheumatoid arthri- Wakefield R. What is the added value of ultrasound
tis. Ann Rheum Dis. 2013;72(8):1328–34. https:// joint examination for monitoring synovitis in rheu-
doi.org/10.1136/annrheumdis-­2012-­202092. Epub matoid arthritis and can it be used to guide treatment
2012 Sep 14 decisions? A systematic review and cost-effectiveness
Naredo E, Gamero F, Bonilla G, et al. Ultrasonographic analysis. Health Technol Assess. 2018;22:1–258.
assessment of inflammatory activity in rheumatoid Stramare R, Coran A, Faccinetto A, Costantini G,
arthritis: comparison of extended versus reduced joint Bernardi L, Botsios C, Perissinotto E, Grisan E,
evaluation. Clin Exp Rheumatol. 2005;23:881–4. Beltrame V, Raffeiner B. MR and CEUS monitoring of
Naredo E, Monteagudo I. Applications of Doppler patients with severe rheumatoid arthritis treated with
techniques in rheumatology. Clin Exp Rheumatol. biological agents: a preliminary study. Radiol Med.
2014;32(Suppl. 80):S12–9. 2014;119:422–31.
Ohrndorf S, Hensch A, Naumann L, Hermann KG, Sun X, Deng X, Geng Y, Ji L, Xie W, Zhang X, Zhang
Scheurig-Münkler C, Meier S, Burmester GR, Z. A simplified and validated ultrasound scoring sys-
Backhaus M. Contrast-enhanced ultrasonography tem to evaluate synovitis of bilateral wrists and hands
is more sensitive than grayscale and power Doppler in patients with rheumatoid arthritis. Clin Rheumatol.
ultrasonography compared to MRI in therapy monitor- 2018;37(1):185–91.
248 M. Carotti et al.

Szkudlarek M, Court-Payen M, Jacobsen S, et al. Torp-Pedersen S, et al. Power and color Doppler ultra-
Interobserver agreement in ultrasonography of the sound settings for inflammatory flow. Impact on scor-
finger and toe joints in rheumatoid arthritis. Arthritis ing of disease activity in patients with rheumatoid
Rheum. 2003;48:955–62. arthritis. Arthritis Rheumatol. 2015;67(2):386–95.
Taylor PC, Steuer A, Gruber J, Cosgrove DO, Blomley MJ, Torp-Pedersen ST, Terslev L. Settings and artefacts rel-
Marsters PA, et al. Comparison of ­ultrasonographic evant in colour/power Doppler ultrasound in rheuma-
assessment of synovitis and joint vascularity with tology. Ann Rheum Dis. 2008;67(2):143–9.
radiographic evaluation in a randomized, placebo-­ Wakefield RJ, Gibbon WW, Conaghan PG, et al. The
controlled study of infliximab therapy in early rheu- value of sonography in the detection of bone ero-
matoid arthritis. Arthritis Rheum. 2004;50:1107–16. sions in patients with rheumatoid arthritis: a compari-
Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus son with conventional radiography. Arthritis Rheum.
M, Balint P, Bruyn GAW, Iagnocco A, Jousse-Joulin S, 2000;43:2762–70.
Schmidt WA, Szkudlarek M, Conaghan PG, Filippucci Zhao CY, Jiang YX, Li JC, Xu ZH, Zhang Q, Su N,
E, D'Agostino MA. Scoring ultrasound synovitis in Yang M. Role of contrast-enhanced ultrasound in
rheumatoid arthritis: a EULAR-OMERACT ultrasound the evaluation of inflammatory arthritis. Chin Med J.
taskforce-part 2: reliability and application to mul- 2017;130:1722–30.
tiple joints of a standardised consensus-based scoring
system. RMD Open. 2017;3(1):e000427. https://doi.
org/10.1136/rmdopen-­2016-­000427. eCollection 2017
 Part V
Generalities in Ultrasound-guided
Procedures
 Introduction
27
Carlo Faletti, Davide Orlandi , and Enzo Silvestri

Contents
27.1 Introduction  251
Further Readings  252

27.1 Introduction interventional procedures such as injections,

arthrocentesis, and biopsies.
One of the most important issues of medicine is, All of these procedures cannot be performed
having established the location and the possible safely and effectively without the precise iden-
cause of a pathology, to identify its treatment tification of the affected area and constant con-
with less discomfort for the patient. trol of the procedural path. Nowadays,
Certainly, in the modern progression of thera- diagnostic imaging and especially ultrasound
peutic possibilities, taking advantage of what have proven to be excellent tools for a precise
technology is able to provide, the need and will- guidance of needles within soft tissues and
ingness are to treat the greatest number of pathol- joints, for use in a wide range of procedures.
ogies through the less invasive technical Moreover ultrasound is also able to perform
approach. In this setting, among the musculo- dynamic evaluations of soft tissues related to
skeletal and orthopedic panorama, we mention the musculoskeletal system, and without patient
exposure to ionizing radiation, allowing the cli-
nician’s technological and professional skills to
play a fundamental role both in diagnostic and
C. Faletti therapeutic terms.
Direttore tecnico Radiodiagnostica Centro This chapter describes, in a complete and
Diagnostico Cernaia, Asti Direttore scientifico Master
MSK di II livello, Università degli studi di Torino, timely manner, the various ultrasound-guided
Turin, Italy interventional procedures with prevalent refer-
D. Orlandi (*) ence to the musculoskeletal system and periph-
Department of Radiology, Ospedale Evangelico eral nerves.
Internazionale, Genova, Italy
E. Silvestri
Radiology, Alliance Medical, Genova, Italy

© Springer Nature Switzerland AG 2022 251

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_27
252 C. Faletti et al.

Further Readings part III, nerves of the upper limb. Eur Radiol.
2020;30(3):1498–506.
Sconfienza LM, Adriaensen M, Albano D, et al. Clinical
Obradov M, Gielen L. Image-guided Intra- and Extra-­
indications for image-guided interventional proce-
articular musculoskeletal interventions. Switzerland
dures in the musculoskeletal system: a Delphi-­based
AG: Springer Nature; 2018.
consensus paper from the European Society of
Sconfienza LM, Adriaensen M, Albano D, et al. Clinical
Musculoskeletal Radiology (ESSR)-Part II, elbow and
indications for image-guided interventional proce-
wrist. Eur Radiol. 2020 Apr;30(4):2220–30.
dures in the musculoskeletal system: a Delphi-­based
Sconfienza LM, Serafini G, Silvestri E. Ultrasound-­
consensus paper from the European Society of
guided musculoskeletal procedures. The upper limb.
Musculoskeletal Radiology (ESSR)-part I, shoulder.
Springer Verlag: Milan; 2012.
Eur Radiol. 2020;30(2):903–13.
Silvestri E, Martino F, Puntillo F. Ultrasound-Guided
Sconfienza LM, Adriaensen M, Albano D, et al.
Peripheral Nerve Blocks. Switzerland AG: Springer
Clinical indications for image guided interven-
Nature; 2018.
tional procedures in the musculoskeletal system: a
Enzo S, Sconfienza LM, Orlandi D. Ultrasound-guided
Delphi-based consensus paper from the European
musculoskeletal procedures. The lower limb. Milan:
Society of Musculoskeletal Radiology (ESSR)-
Springer Verlag; 2015.
 Joint and Bursal Infiltration
28
Marina Carotti, Emilio Filippucci , Fausto Salaffi,
Fabio Martino, Enzo Silvestri,
and Davide Orlandi

Contents
28.1 Generalities in Ultrasound-­Guided Procedures in Rheumatology 253
28.2 Viscosupplementation: Technique and Indications 258
 Further Readings 263

28.1 Generalities in Ultrasound-­

Guided Procedures
in Rheumatology

Synovial fluid aspiration and intra- and periartic-

ular injection treatment are part of the standard
M. Carotti diagnostic and therapeutic armamentarium in
Clinica di Radiologia,
Dipartimento di Scienze Radiologiche – Azienda
rheumatological clinical practice.
Ospedali Riuniti di Ancona The obtainment of synovial fluid sample
Università Politecnica delle Marche, allows its analysis which provides several diag-
Ancona, Italy nostic information including the definition of its
E. Filippucci · F. Salaffi inflammatory nature, the detection of crystals,
Clinica Reumatologica, and the identification of bacteria. Moreover, in
Dipartimento di Scienze Cliniche e Molecolari,
Università Politecnica delle Marche, Jesi (Ancona),
case of acutely and significantly swollen joint
Italy due to a variable, but usually important, amount
F. Martino (*)
of synovial fluid, its aspiration can highly con-
Radiology, Sant’Agata Diagnostic Center, tribute to joint pain relief.
Bari, Italy Steroid or hyaluronic acid injection represents
E. Silvestri an alternative or adjunctive therapeutic option to
Radiology, Alliance Medical, Genova, Italy the systemic treatment in many rheumatic disor-
D. Orlandi ders (Table 28.1).
Department of Radiology, Ospedale Evangelico In Finland the intra-articular steroid injection
Internazionale, Genova, Italy is a recognized important part of the treatment

© Springer Nature Switzerland AG 2022 253

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_28
254 M. Carotti et al.

Table 28.1 The most commonly injected anatomic structures in rheumatological daily practice
Anatomic
site Anatomic target Rheumatic disorder
Shoulder Glenohumeral joint Chronic inflammatory arthritis
Acromion-clavicular joint Polymyalgia rheumatica
Subdeltoid bursa CPPD
Long head of the biceps tendon synovial sheath Regional pain syndrome
Elbow Elbow joint Chronic inflammatory arthritis
Olecranon bursa Gout
Cubital bursa Lateral and medial
epicondylitis
Wrist Radio-carpal joint Chronic inflammatory arthritis
Inter-carpal joint Carpal tunnel syndrome
Distal radioulnar joint CPPD
Trapeziometacarpal joint Thumb carpometacarpal joint
OA
Compartments of the extensor tendons on the dorsal aspects of the
radius
Common finger flexor tendon synovial sheath
Flexor carpi radialis tendon synovial sheath
Hand Metacarpophalangeal joint Chronic inflammatory arthritis
Proximal interphalangeal joint
Distal interphalangeal joint
Digital synovial sheath of the finger flexor tendons
Hip Hip joint Chronic inflammatory arthritis
Iliopsoas bursa Hip OA
Trochanteric bursa Polymyalgia rheumatica
Knee Knee joint Chronic inflammatory arthritis
Prepatellar bursa Knee OA
Infrapatellar deep bursa CPPD
Gout
Ankle Tibiotalar joint Chronic inflammatory arthritis
Subtalar joint
Tibialis posterior tendon synovial sheath
Peroneal tendon synovial sheath
Foot Metatarsophalangeal joint Chronic inflammatory arthritis
Plantar fascia Gout
OA osteoarthritis, CPPD calcium pyrophosphate dihydrate crystal deposition disease

scheme in rheumatoid arthritis (RA) patients, their treatment during the observation period.
and traditionally rheumatologists inject all Furthermore, in patients with early RA, US
swollen joints in patients with early RA unless resulted to be useful in the identification of the
in the presence of contraindications. Moreover, joints which would obtain the maximal clinical
the results of a recent study indicate that neglect- benefit from a steroid injection, with moderate
ing intra-articular glucocorticoid injections is Doppler activity being the best predictor of
associated with lower remission rates, higher treatment success in both swollen and not-swol-
disease activity, and lower quality of life in RA len joints.
patients with early stages of the disease. On the According to the latest Osteoarthritis
other end injecting small joints of the hands and Research Society International (OARSI) guide-
wrists with persistent synovitis was found effec- lines for the nonsurgical management of knee,
tive for up to 12 weeks after the US-guided ste- hip, and polyarticular osteoarthritis, both intra-
roid injection in RA patients who did not change articular steroid and hyaluronic acid injections
28 Joint and Bursal Infiltration 255

are recommended for patients with knee osteo- scientific societies conducted in 2012, in most of
arthritis (OA). the European countries less than 10% of the rheu-
These procedures are normally carried out matologists routinely use US to guide arthrocen-
using anatomical landmarks with a variable suc- tesis and joint injection in their clinical practice.
cessful rate mainly depending on both the degree US-guided injections can be carried out using
of anatomical complexity and the size of the tar- two main methods.
get area. In the first method the sonographer uses US
In particular the traditional non-imaging-­ imaging to obtain the relevant information to
guided approach may result to be inadequate place the tip of the needle at the target area:
when the target area is far from the skin and/or detection of the target area, identification of the
small in size or when a dry joint has to be injected. entrance point at skin level, and measurement of
In fact, both efficacy and side effects of an the distance between them.
injection largely depend on the correct placement In the second method the needle progression
of the tip of the needle at the target area avoiding from the skin surface to the target area is directly
direct contact with nerves, tendons, articular car- visualized under real-time US scanning. In par-
tilage, and blood vessels. ticular, this method includes the following steps:
There is evidence revealing that conventional
joint injections are often inaccurate. In fact, based 1. Preliminary US examination aimed at detect-
on the experience of Jones et al. (1993), injec- ing the target area and confirming the clinical
tions performed in different anatomic sites using indication to perform the injection therapy.
a mixture of steroid and radiographic contrast 2. Identification of the US scanning plan to visu-
medium were judged accurately by conventional alize the needle progression from the skin to
radiography in only 56 (52%) out of 108 rheu- the target area.
matic patients. The percentage of successful 3. Disinfection of the skin area defined as point
placement reduces to 37% at shoulder level due of entrance of the needle and covering of the
to the inherent anatomical complexity. probe using a glove or a condom.
It is now well established that steroid injec- 4. Placement of a thin amount of sterile gel on
tions guided by US were significantly more accu- the skin surface where to put the probe.
rate than those guided by clinical examination in 5. Real-time visualization of the needle progres-
patients with inflammatory arthritis. Difference sion through the soft tissues until the tip of the
in the number of joints accurately injected is par- needle reaches the target area.
ticularly higher at shoulder, hip, elbow, and ankle 6. Visual confirmation of the synovial fluid aspi-
level, suggesting that US may be especially help- ration if present and of the drug spreading into
ful in guiding injections in joints with complex the target area during the injection (Fig. 28.1).
anatomy.
While there is still very little evidence sup- As well as for conventional approach,
porting the superior clinical benefit of US-guided US-guided procedures should be performed after
versus palpation-guided steroid injection, espe- obtaining a patient informed consent and both
cially to treat tenosynovitis, accurate placement patient and operator should gain a comfortable
of the tip of the needle is obviously fundamental position during all the procedure.
for the efficacy of the hyaluronic acid joint The best US visualization of the needle
injection. requires a perpendicular insonation angle. Once
Although the use of ultrasound (US) to guide the patient position and the needle progression
synovial fluid aspiration and injections reduces pathway are defined, such an angle value is
the number of incorrect placements of the tip of obtained with manual (i.e., moving the probe)
the needle, this imaging technique is still not sys- and/or electronic (i.e., beam steering, virtual con-
tematically integrated into rheumatological prac- vex) changing of the US beam direction. Under
tice. According to a survey of experts and perpendicular insonation the needle appears as a
256 M. Carotti et al.

a b

c d

Fig. 28.1 Rheumatoid arthritis. Knee exudative synovi- the synovial fluid. (d) Injection of the steroid, appearing
tis. Anterior transverse suprapatellar view. (a) as an echoic material spreading into the suprapatellar
Identification of the target area. (b) Placement of the tip pouch. * synovial fluid, f femur
of the needle (arrow) at the target area. (c) Aspiration of

sharply defined hyperechoic band with strong shortens the needle pathway to reach the target
posterior reverberations on longitudinal view and area which results to be particularly helpful to
as a small hyperechoic round spot on transverse reach deep targets.
view. Confirmation of the needle’s correct placement
The longitudinal view allows the in-plane nee- can be obtained visualizing the spreading of ste-
dle US imaging. This technique allows the real-­ roid (appearing echoic), hyaluronic acid (appear-
time visualization of the needle tip and shaft ing anechoic or hypoechoic), or air (appearing
while proceeding from the superficial level at one hyperechoic) within the target area or under color
of the two upper corners of the screen to the tar- or power Doppler control (while injected the com-
get area in the deeper central part of the US field pound is visualized as a colored spot).
(Figs. 28.2 and 28.3). The in-plane US imaging is Peri-tendinous intrasynovial injection therapy
the one used in the great majority of the cases in with steroid has a well-established role in patients
rheumatology. with chronic arthritis and tenosynovitis. A suc-
The out-of-plane needle US visualization uses cessful technique requires a correct positioning
the transverse view. Such an approach requires of the tip of the needle inside the tendon sheath
advanced scanning skills to ascertain the position avoiding the contact between the needle and the
of the tip of the needle during the procedure and tendon.
28 Joint and Bursal Infiltration 257

a b

c d

Fig. 28.2 Psoriatic arthritis. Hip exudative synovitis. the needle (arrow) is passing through the hip joint cavity.
Anterior longitudinal view. (a) Identification of the target (d) Injection of sterile air, appearing as a hyperechoic
area. (b) The tip of the needle appears at the upper right material spreading inside the joint cavity, just before the
corner of the screen and is directed to the target area in the steroid. * synovial fluid, f femur
deeper central part of the ultrasound field. (c) The tip of

The steroid injection within a widened syno- allows confirmation of the diagnosis and needle
vial tendon sheath under US control appears to be guidance to aspirate synovial fluid and inject
very effective in minimizing the risk of damaging steroid.
the tendon. The progression of the needle can be US is very useful for the detection of popliteal
steadily monitored until the tip of the needle is cysts and for detailed visualization of their
properly placed within the tendon sheath and the content.
steroid accurately injected into the peritendinous Inner structure of the cyst is important to
synovial space (Fig. 28.4). guide needle aspiration of the synovial fluid.
Bursitis is a very common condition in rheu- Moreover, US control is critical to avoid puncture
matological practice. Steroid injection is an wounds of nerves and/or blood vessels and to
effective and safe treatment in patient ensure the correct position of the tip of the needle
­nonresponders to other conservative therapeutic especially in patients with loculated cysts
options, including rest, local application of ice, (Fig. 28.5).
and anti-inflammatory medication. In patients In conclusion, the US guidance should be con-
with clinical suspicion of bursitis, US approach sidered under the following main conditions:
258 M. Carotti et al.

• To inject sites with a complex anatomy that

a are at risk to be injected inaccurately using the
conventional approach (i.e., shoulder and
ankle).
• If the anatomy is distorted by pathology or the
anatomic landmarks are less accessible due to
obesity or pathology.
• When hyaluronic acid is injected to provide
visual feedback of its intra-articular spreading.
• In patients with previous failure of palpation-­
guided injection.

28.2 Viscosupplementation:
b Technique and Indications

Conservative treatment of OA includes weight

loss, physical therapy, oral anti-inflammatory and
analgesic medications, and intra-articular injec-
tions of steroids. Viscosupplementation, consist-
ing of intra-articular injection of hyaluronic acid
(HA) derivatives, is the main local treatment of
mild or moderate OA.
The administration of hyaluronic acid with
ultrasound-guided intra-articular injection has
been demonstrated to be effective in moderate
c and severe osteoarthritis treatment. The aim of
such a procedure is to reduce patients’ disability
and pain restoring the physiological properties of
synovial fluid and improving articular function
and recovery of working and social activity.
The intra-articular administration of hyal-
uronic acid has a role not only to restore the vis-
coelastic properties of synovial fluid (pure
mechanical effect), but also to stimulate the
endogenous production of hyaluronic acid by
articular chondrocytes and synoviocytes by prod-
Fig. 28.3 Rheumatoid arthritis. Third metacarpophalan- ucts based on hyaluronic acid.
geal joint. Proliferative synovitis. Dorsal transverse view. Hyaluronic acid is a polysaccharide of the
(a) Identification of the target area: the joint cavity. (b) group of glycosaminoglycans, which is a poly-
Placement of the tip of the needle (arrow) at the target mer with very high molecular weight (million
area. (c) Injection of the steroid, appearing as an echoic
material spreading into the joint cavity. * synovial fluid, Dalton), formed by repeating units of
arrowhead synovial hypertrophy, et finger extensor ten- N-acetylglucosamine and glucuronic acid linked
don, m metacarpal head together by glycosidic bonds.
28 Joint and Bursal Infiltration 259

a b c

Fig. 28.4 Psoriatic arthritis. Third finger dactylitis. Volar at the target area. (c) Injection of the steroid, appearing as
longitudinal view showing finger flexor tendon tenosyno- an echoic material spreading into the synovial tendon
vitis. (a) Identification of the target area: the synovial ten- sheath. Arrowhead synovial hypertrophy, ft. finger flexor
don sheath. (b) Placement of the tip of the needle (arrow) tendons, mp middle phalanx, pp. proximal phalanx

a b c

d e f

Fig. 28.5 Knee osteoarthritis. Popliteal cyst depicted on roid injection (f) were guided using the longitudinal view.
transverse (a) and longitudinal (b) views showing syno- (c) Placement of the tip of the needle (arrow) at the target
vial fluid (*) and small areas of synovial hypertrophy area. (d, e) Aspiration of the synovial fluid. (f) Injection of
(arrowhead). Aspiration of synovial fluid (c–e) and ste- the steroid

It is present in the superficial layer of the hya- • High molecular weight (>di 4000 kDA).
line cartilage, the intracellular matrix of the joint
capsule, the synovial tissue and the synovial fluid. Molecular weight is related with different
It is highly absorbent with viscoelastic properties: effects; low-molecular-weight HA has a greater
viscosity (lubrication) in case of static compres- penetration in the tissues, allowing a greater con-
sive strength and elastic (shock-absorbing) in case centration of the product around the cell surface
of dynamic shear and compressive forces. and producing an increased pharmacological
You can divide HA in terms of molecular weight: response of chondrocytes, being able to slow
down Fas gene-induced apoptosis.
• Low molecular weight (from 500 to The stabilization of aggregates at high density
1000 kDA). and high molecular weight (>2000 kDa) results
• Average molecular weight (from 1000 to in reduced motility of single molecules of HA
4000 kDA). and thus they will not be able to be rapidly
260 M. Carotti et al.

degraded by the synovial cells that are able to and uniformly echogenic structure. Of note, in
swallow only free molecules of HA. The patients with advanced OA, anatomy of this joint
­preparation thus prolonged half-life within the can be relatively different, and joint components
joint (approximately 4 weeks), allowing you to may not be identified easily.
get a single-injection result in long-term treat- Using a caudo-cranial approach with the artic-
ment of OA. ular joint space centered in the middle of the
Ultrasound is an ideal technique for guiding screen, a 20 G spinal needle is inserted laterally
the needle during the joint infiltration procedure to the distal side of the probe with a caudal-­
and avoiding the extra-articular injection of hyal- cranial direction. According to the patient’s habi-
uronic acid in particular for deep and challenging tus, the depth of the joint may vary, and thus the
locations such as the hip. angle of needle insertion has to be adjusted; gen-
Intra-articular injection at the level of the hip erally, the angle of needle insertion ranges from
is generally more complex when compared to 30° to 60°. This procedure can also be performed
other joints (e.g., shoulder, knee) for its deep with the cranial-caudal approach. Power Doppler
location and the relative contiguity of the femoral module can also be switched on to monitor the
neurovascular bundle. flow of the drug within the capsule during
We hereby describe the standardized injection.
ultrasound-­guided hip injection technique. Less experienced operators may take advan-
Lateral (in-plane) approach allows a direct tage of a metallic needle guide that can be
and continuous visualization of the needle along attached to the ultrasound probe. With this
the whole path in soft tissues, while out-plane approach, the whole path of the needle can be
approach may be preferred for being shorter and visualized in real time, and slight corrections of
less painful, but needle visibility is remarkably the direction can be made. The needle tip can be
decreased. inserted in within the whole joint capsule.
The patient lies in supine position. Slight However, inserting the needle exactly in the joint
internal rotation of the leg (about 15°–20°) may space may result in a very painful injection pro-
help to decrease joint capsule tension and cedure. The best area to put the needle tip is at the
improve tolerability of the procedure. The neuro- femoral head-neck junction. Once the joint space
vascular bundle can be visualized with an axial is reached, the syringe is connected to the needle,
scan at the level of the groin to detect possible and the drug is injected (Fig. 28.6). Of note, in
vascular or neural anatomic variations and avoid case of high resistance to injection, the needle
accidental punctures. Then, the probe is rotated should be minimally retracted.
about 135° and shifted laterally in order to reach In case of arthrosynovitis and/or if iliopsoas
an anterior sagittal-oblique scanning plane over bursitis is present, an ultrasound-guided aspira-
the hip joint. A correct scanning plane should tion could be performed during the same proce-
visualize the femoral neck, the femoral head cov- dure just before the intra-articular drug injection
ered by hyaline cartilage, the acetabular labrum, (Fig. 28.7).
the osseous component of the acetabulum, the Using the coaxial approach (Fig. 28.8) the
joint capsule, and, superficially, the iliopsoas articular joint space is centered on the screen,
muscle belly. The articular cortex of the femoral and a 20 G spinal needle is inserted at the cen-
head appears as a curve echogenic line and the ter of the longer side of the probe, with a very
cortical surface of the anterior acetabular rim as a slight lateral-to-medial angulation (about 5°) to
triangular echogenic structure just distal to this reach the joint space visualized in the scanning
line. The fibrocartilaginous anterior acetabular plane. Along its path, the needle tip is visual-
labrum may be seen as a well-defined, triangular, ized indirectly, by means of slight movements
28 Joint and Bursal Infiltration 261

a b

c d e

Fig. 28.6 Didactic scheme, probe, and patient position to probe (c) and needle (e) during acid hyaluronic injection
perform long-axis US-guided intra-articular hip injection (PS iliopsoas muscle, Ac acetabulum, F femur, asterisk
(a, b) with US long-axis view (d) and position of the US labrum, arrowheads joint capsule)

of superficial soft tissues; when the joint space After the US-guided hyaluronic acid injection
is reached, the needle tip should be visible as a the needle can be removed and a plaster should
hyperechoic dot under the articular capsule. Of be applied. Then, patients are usually kept under
note, this procedure is less painful for patients observation for about 15 min. Pain may occur
but requires longer experience in US-guided after treatment and can be managed with a short
procedures. course of oral NSAIDs.
262 M. Carotti et al.

a b

c d

Fig. 28.7 Arthrosynovitis in femur-acetabular conflict d). Bursa fluid collection evacuation should always be
with fluid distention of all capsular recesses and the ilio- associated with joint US-guided treatment. US-guided
psoas bursa (a, b). Resolution of exudative distention of bursa evacuation must be obtained with attention in avoid-
the iliopsoas bursitis following arthrocentesis and cycle of ing femoral artery (red oval) which runs superficially and
US-guided infiltration with PRP and hyaluronic acid (c, anteriorly to the bursa
264 M. Carotti et al.

Donato E, Tardella M, Di Matteo A, Di Carlo M, tal study and practical applications in rheumatology.
Grassi W. Ultrasound-guided procedures in rheuma- Clin Exp Rheumatol. 2005;23:373–8.
tology daily practice: feasibility, accuracy and safety Kumar N, Newmon RJ. Complications of intra and
issues. J Clin Rheumatol. 27(6):226–31. peri-articular steroid injections. Br J Gen Pract.
Conrozier T. Is the addition of a polyol to hyaluronic acid 1999;49:465–6.
a significant advance in the treatment of osteoarthritis? Kuusalo LA, Puolakka KT, Kautiainen H, Alasaarela
Curr Rheumatol Rev. 2018;14(3):226–30. EM, Hannonen PJ, Julkunen HA, Kaipiainen-
Cunnington J, Marshall N, Hide G, Bracewell C, Isaacs Seppänen OA, Korpela MM, Möttönen TT, Paimela
J, Platt P, Kane D. A randomized, double-blind, con- LH, Peltomaa RL, Yli-Kerttula TK, Leirisalo-Repo
trolled study of ultrasound-guided corticosteroid M, Rantalaiho VM, NEO-RACo Study Group.
injection into the joint of patients with inflammatory Intra-articular glucocorticoid injections should not
arthritis. Arthritis Rheum. 2010;62(7):1862–9. be neglected in the remission targeted treatment
D’Agostino MA, Schmidt WA. Ultrasound-guided injec- of early rheumatoid arthritis: a post hoc analysis
tions in rheumatology: actual knowledge on efficacy from the NEO-RACo trial. Clin Exp Rheumatol.
and procedures. Best Pract Res Clin Rheumatol. 2016;34:1038–44.
2013;27:283–94. Legre V, Boyer T, Fichez O. Gestes locaux en pathologie
De Luigi AJ, Saini V, Mathur R, Saini A, Yokel sportive: anesthésiques, glucocorticoïdes. Rev Rhum.
N. Assessing the accuracy of ultrasound-guided nee- 2017;74:602–7.
dle placement in sacroiliac joint injections. Am J Phys Luc M, Pham T, Chagnaud C, Lafforgue P, Legré
Med Rehabil. 2019;98:666–70. V. Placement of intraarticular injection veri-
Di Geso L, Filippucci E, Meenagh G, Gutierrez M, Ciapetti fied by the backflow technique. Osteoarthr Cartil.
A, Salaffi F, Grassi W. CS injection of tenosynovitis in 2006;14:714–6.
patients with chronic inflammatory arthritis: the role Lussier A, Civino AA, McFarlane CA, Olzinski WP,
of US. Rheumatology (Oxford). 2012;51:1299–303. Potasner WJ, De Medicic R. Viscosupplementation
Eustace JA, Brophy DP, Gibney RP, Bresnihan B, with hylan for the treatment of osteoarthritis: find-
FitzGerald O. Comparison of the accuracy of ste- ings from clinical practice in Canada. J Rheumatol.
roid placement with clinical outcome in patients with 1996;23:1579–85.
shoulder symptoms. Ann Rheum Dis. 1997;56:59–63. Luz KR, Furtado RN, Nunes CC, Rosenfeld A, Fernandes
Glattes RC, Spindler KP, Blanchard GM, Rohmiller MT, AR, Natour J. Ultrasound-guided intra-articular injec-
McCarty EC, Block J. A simple, accurate method to tions in the wrist in patients with rheumatoid arthri-
confirm placement of intra-articular knee injection. tis: a double-blind, randomised controlled study. Ann
Am J Sports Med. 2004;32:1029–31. Rheum Dis. 2008;67:1198–200.
Gutierrez M, Di Matteo A, Rosemffet M, Cazenave T, Makhlouf T, Emil NS, Sibbitt WL Jr, Fields RA, Bankhurst
Rodriguez-Gil G, Diaz CH, Rios LV, Zamora N, AD. Outcomes and cost-effectiveness of carpal tunnel
Guzman Mdel C, Carrillo I, Okano T, Salaffi F, Pineda injections using sonographic needle guidance. Clin
C, Pan-American League against Rheumatisms Rheumatol. 2014;33:849–58.
(PANLAR) Ultrasound Study Group. Short-term Mandl P, Naredo E, Conaghan PG, D’Agostino MA,
efficacy to conventional blind injection versus Wakefield RJ, Bachta A, et al. Practice of ultrasound-­
ultrasound-­guided injection of local corticosteroids in guided arthrocentesis and joint injection, includ-
tenosynovitis in patients with inflammatory chronic ing training and implementation, in Europe: results
arthritis: a randomized comparative study. Joint Bone of a survey of experts and scientific societies.
Spine. 2016;83:161–6. Rheumatology. 2012;51:184–90.
Hoeber S, Aly AR, Ashworth N, Rajasekaran Naredo E, Cabero F, Beneyto P, Cruz A, Mondéjar B,
S. Ultrasound-guided hip joint injections are more Uson J, Palop MJ, Crespo M. A randomized com-
accurate than landmark-guided injections: a sys- parative study of short term response to blind injec-
tematic review and meta-analysis. Br J Sports Med. tion versus sonographic-guided injection of local
2016;50:392–6. corticosteroids in patients with painful shoulder. J
Johal H, Devji T, Schemitsch EH, Bhandari Rheumatol. 2004;31:308–14.
M. Viscosupplementation in knee osteoarthritis: evi- Naredo E, Rull M. Aspiration and injection of joints and
dence revisited. JBJS Rev. 2016;4(4):e11–111. periarticular tissue and intralesional therapy. Hochberg
Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Rheumat. 6th ed. Section 4, Chapter 69. 2015.
Doherty M. Importance of placement of intra-articular Nordberg LB, Lillegraven S, Aga AB, Sexton J, Lie E,
steroid injections. Br Med J. 1993;307:1329–30. Hammer HB, Olsen IC, Uhlig T, van der Heijde D,
Kane D, Koski J. Musculoskeletal interventional proce- Kvien TK, Haavardsholm EA. The impact of ultra-
dures: with or without imaging guidance? Best Pract sound on the use and efficacy of intraarticular glu-
Res Clin Rheumatol. 2016;30:736–50. cocorticoid injections in early rheumatoid arthritis:
Koski JM, Saarakkala SJ, Heikkinen JO, Hermunen secondary analyses from a randomized trial examining
HS. Use of air-steroid-saline mixture as contrast the benefit of ultrasound in a clinical tight control regi-
medium in greyscale ultrasound imaging: experimen- men. Arthritis Rheumatol. 2018;70:1192–9.
28 Joint and Bursal Infiltration 265

Sconfienza LM, Orlandi D, Silvestri E. Ultrasound-­ Wang S, Wang X, Liu Y, Sun X, Tang Y. Ultrasound-­
guided musculoskeletal procedures: the lower limb. guided intra-articular triamcinolone acetonide injec-
New York: Springer; 2015. tion for treating refractory small joints arthritis of
Legré-Boyer V. Viscosupplementation: technique, rheumatoid arthritis patients. Medicine (Baltimore).
indications, results. Orthop Traumatol Surg Res. 2019;98:e16714.
2015;101:S101–8.
 Tendon Infiltrative
and Regenerative Treatments
29
Davide Orlandi , Elena Massone,
and Enzo Silvestri

Contents
29.1   Introduction  267
29.2   Tendon Infiltrative Treatments  268
29.2.1   Tendon Synovial Sheath Injection  268
29.2.2   High-Volume Injection  268
29.3   Tendon Regenerative Treatments  269
29.3.1   Tendon Scarification (Dry Needling)  269
29.3.2   Platelet-Rich Plasma (PRP)  270
29.3.3   Adipose-Derived Mesenchymal Stem Cells (ASCs)  271
Further Readings  271

29.1 Introduction their action (such as flexor or extensor tendons of

the wrist and foot).
Tendinopathy is generally referred to as a condi- Inflammatory and degenerative tendinopa-
tion causing pain and swelling of a tendon but thy of anchoring tendons is characterized by
depending on biomechanical characteristics, the degenerative-­structural changes in collagen fibers
tendons may be affected by various diseases. associated with fibrotic phenomena and noncon-
Tendons can be distinguished into anchoring stant presence of inflammatory signs, both intra-
tendons which are coated with peritoneum alone tendinous and of the peritoneum.
(such as the Achilles tendon) and sliding tendons This condition may affect the tendon enthe-
covered with a synovial sheath that facilitates sis or the preinsertional tendon portion, result-
ing in a fusiform thickening of the tendon belly
D. Orlandi (*) with focal areas of intratendinous degeneration
Department of Radiology, Ospedale Evangelico depending on the degree of tendinopathy. When
Internazionale, Genova, Italy the degenerative disease chronically affects the
E. Massone tendon enthesis it is often associated with the
Department of Radiology, Ospedale Santa Corona, presence of bony spurs and intratendinous enthe-
Pietra Ligure (SV), Italy
sopathic lamellar calcifications.
E. Silvestri
Radiology, Alliance Medical, Genova, Italy

© Springer Nature Switzerland AG 2022 267

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_29
268 D. Orlandi et al.

Sliding tendons are susceptible to tenosyno- At the end of the procedure a plaster is applied
vitis, with or without inflammatory or degenera- and the patient is asked to consume NSAIDs for
tive pathology of the underlying tendon. Acute up to 5 days in case of post-procedural pain.
tenosynovitis is characterized by a fluid effusion
within the compartment or the tendon sheath,
while in chronic tenosynovitis there is synovial 29.2.2 High-Volume Injection
thickening or proliferation.
Many studies have focused on non-insertional
tendinopathy of the Achilles tendon, a condition
29.2 Tendon Infiltrative that mainly affects runners and in which conser-
Treatments vative treatments such as anti-inflammatory drugs
and eccentric exercises have limited efficacy.
US guidance is used in the treatment of tendi- High-volume injection procedure is based on
nopathies to guide the injection of steroid anti-­ the peritendinous injection of a large amount (up
inflammatory drugs, low molecular-weight to 40 ml) of several substances (isolated or in
hyaluronic acid, or saline solution into the space combination) such as saline solution, local anes-
between the synovial sheath and the tendon or in thetic, corticosteroid, or hyaluronates in cases
the peritenonium. of inflammatory tendinopathy with high intra-­
peritendinous vascularity.
In this setting, all the previous substances
29.2.1 Tendon Synovial Sheath injected into the peritoneum have been shown
Injection to significantly reduce pain and improve tendon
functionality in the short and medium terms. The
US-guided treatment of tenosynovitis is per- rationale of the procedure would be due to the
formed injecting steroid anti-inflammatory drugs stretching, rupture, or occlusion of the nerves and
or low-molecular-weight hyaluronic acid into vessels responsible for inflammation causing the
the space between the synovial sheath and the patient pain.
tendon; it is very important to avoid intratendi-
nous steroid injection as it is associated with an Procedure
increased risk of tendon rupture. A 21-gauge needle is inserted from the lateral
A special treatment is reserved for ste- aspect of the tendon under real-time US guid-
nosing tenosynovitis, where inflammation is ance between the deep aspect of the Achilles
partly sustained by the rubbing of the tendon tendon and Kager’s fat pad. Then, 5 ml of local
with thickened stabilization structures such anesthetic and up to 40 ml of saline solution
as retinaculum or pulleys. In this case, a first are injected. Finally 1 ml of long-acting ste-
intra-sheath steroid injection could be fol- roid could be injected in the same space. At the
lowed by a 1–2-week-­d elayed forced injection end of the procedure a plaster and ice pack are
of low-weight hyaluronic acid into the syno- applied.
vial sheath, performing a mechanical stretch- Patients are allowed to walk on the injected
ing and release of the stabilization structures. leg immediately, but are advised strictly to refrain
from high-impact activity, such as running or
Procedure jumping, for 72 h.
US-guided synovial sheath injection is generally After 72 h, patients are instructed to restart
performed using small-caliber needles (27–29 heavy eccentric loading under the guidance of a
gauge) in order to minimize the pain perceived chartered physiotherapist.
by the patient during the procedure (Fig. 29.1).
29 Tendon Infiltrative and Regenerative Treatments 269

a b

c d

Fig. 29.1 US-guided treatment of peroneal tenosynovitis on a and (c) US image of needle insertion within peroneal tendon
short axis. (a) Probe and patient position to perform US-guided sheath, C calcaneus, T tibia, F fibula, P peroneal tendons,
treatment of peroneal tenosynovitis. (b) Anatomical scheme arrow needle tip. (d) Steroid injection (asterisks)

erative treatment of Achilles tendinopathy and

29.3 Tendon Regenerative plantar fasciitis.
Treatments

The rationale of regenerative treatments of intra- 29.3.1 T

 endon Scarification (Dry
tendinous tendinopathies is to speed up the phys- Needling)
iological tissue regeneration tendon. This could
be obtained by a direct bleeding of the tendon Dry needling is an US-guided procedure for
induced by scarification (dry needling), by intra- the treatment of anchoring tendons consisting
tendinous injection of platelet-rich plasma (PRP), of multiple fenestration of the affected tendon
or by adipose-derived mesenchymal stem cells which could be performed alone or combined
(ASCs). The latter should participate directly in with simultaneous intratendinous PRP injection.
the process of tendon regeneration, being able to The purpose of the treatment is to cause local
differentiate into different types of cells. hyperemia and bleeding into the tendon, thus
All these treatments have recently been shown promoting post-procedural platelet-induced
to be safe in the orthopedic setting for the regen- recovery phenomena.
270 D. Orlandi et al.

Procedure 3. Pure platelet-rich fibrin (P-PRF): preparation

A 20 G needle is inserted under in-plane ultra- without leukocytes and with a high-density
sound guidance in the affected portion of the fibrin network
tendon to be treated. Anesthetic (up to 5 ml) is
injected along the path of the needle and in the Procedure
peritendinous soft tissues avoiding intratendi- The most frequently used PRP preparation in
nous injection which could slow the regenerative orthopedics and sports medicine is L-PRP with
action of the procedure. 5–8 more platelets and leukocytes than periph-
The US-guided procedure consists of per- eral blood. The preparation may be obtained by
forming 15–20 small punctures along the entire using disposable kit (with predetermined PRP
thickness of the tendon and, when the enthesis is concentration, almost no risk of contamination
involved, also hitting the periosteum in order to but higher cost) or obtained from the transfu-
promote a mild bleeding. sion medicine service of the hospital. The sec-
At the end of the procedure a plaster and ice ond method of preparation starts by collecting
pack are applied and the patient is asked to con- a whole venous blood sample (40–50 ml) from
sume paracetamol in case of pain within 48 h and a patient usually from the cubital vein, and it is
to reduce his/her sports activity for 1–2 weeks. mixed with citrate to prevent early clotting. Then,
it is centrifuged for about 15 min (depending on
the centrifugation method), and a small sample
29.3.2 Platelet-Rich Plasma (PRP) is taken in order to determine the absence of
contamination. The centrifugation separates and
PRP is a platelet-rich preparation obtained from concentrates platelets and, depending on the type
the centrifugation of peripheral blood. Nowadays of preparation, leukocytes from other blood com-
PRP is applied in various clinical settings includ- ponents. In the end, usually 4–10 ml of PRP solu-
ing sports medicine where it has been proposed tion is gained. Unactivated PRP must be injected
for the treatment of muscle and tendon injuries, in the site of fiber injury as soon as possible after
tendinopathies, ligamentous injuries, periph- centrifugation in order to prevent gelification and
eral neuropathies, and plantar fasciitis. A recent will be activated by the contact with collagen and
meta-­analysis emphasized that PRP was associ- other tissue factors.
ated with a significant pain reduction at 2 months Sometimes the release of platelet granules is
compared with hyaluronic acid (HA), but no induced by using exogenous substances such as
differences were observed at 6- and 12-month the simultaneous injection of 1–2 ml of calcium
follow-up. gluconate solution by a two-way syringe.
The rationale behind PRP use is the ability In our experience we recommend the use
to stimulate the process of tissue regeneration of inactivated PRP in larger lesions and/or in
through angiogenesis, innervation, and release of particular involving the epimysium and/or the
multiple GFs and cytokines from platelets while fascial planes, where up to 10 ml of PRP may
the local immune response and fibrinogenesis are be injected seeking endogenous physiological
modulated. activation through its contact with collagen and
The most common PRP types are: other inflammatory mediators into the site of the
injury while exogenously activated 2–6 ml of
1. Pure PRP (P-PRP) with low content of PRP may be used in particular in small, focal
leukocytes intramuscular strain, where its potential role
2. Leukocyte- and platelet-rich plasma (L-PRP): in the promotion of the fibrin clot may help to
preparation with leukocyte and with low-­ speed up the regenerative process (Fig. 29.2).
density fibrin network, with greater concen- After the procedure a plaster and an ice pack
tration of platelets than P PRP are applied.
29 Tendon Infiltrative and Regenerative Treatments 271

a b

Fig. 29.2 US-guided PRP treatment of Achilles tendi- tendon tear; white arrow needle tip. (b) Corresponding
nopathy (a). A Achilles tendon, C calcaneus; asterisk dis- sagittal MRI GE-STIR sequence showing Achilles tendi-
tended deep retrocalcaneal bursa; circles longitudinal nopathy with longitudinal tendon tear (black arrow)

Finally, early rehabilitative mobilization pro- micro-fractured lipoaspirate. The disrupted por-
tocol should be considered in order to promote tion of the tissue, including the SVF, is then cen-
the mechanical stimuli which are essential to the trifuged for 10 min at 400 g. In the last stage of
optimal injury recovery (myogenesis stimula- preparation 4 ml of ASCs with SVF is transferred
tion, correct alignment of new fibers, and proper into a syringe ready to be injected.
innervation promotion). A 20 G needle is then inserted under in-plane
ultrasound guidance in the affected portion of the
structure to be treated. Anesthetic (up to 5 ml) is
29.3.3 Adipose-Derived injected along the path of the needle and in the
Mesenchymal Stem Cells peritendinous soft tissues avoiding intratendi-
(ASCs) nous injection which could slow the regenerative
action of the procedure. Care must be taken to
In non-insertional tendinopathy of the Achilles inject SVF into the thickest part of the affected
tendon studies agree on the reduction of pain after structure, covering the entire degenerated area.
regenerative treatments, but still have discrepan- After treatment, the patient is advised to walk
cies on the pathogenic mechanisms; it seems that on crutches for 24 h and to use paracetamol in
in the initial stages there is a treatment-­induced case of pain within 48 h.
local inflammation with regional hyperemia and No specific physical therapy is prescribed
mild thickening of the tendon and then, after a after the treatment and patients are allowed to
few months, a thickness reduction of the regener- progressively resume their normal life and sports
ated tendon. activities after 1–2 weeks.
The purpose of ASC tendon treatment is to
participate directly in the process of tendon
regeneration, being able to differentiate into dif-
Further Readings
ferent types of cells.
ASC preparation and injection procedure: Albano D, Messina C, Usuelli FG, et al. Magnetic reso-
A small amount of subcutaneous adipose tis- nance and ultrasound in achilles tendinopathy: pre-
sue (50 ml) is manually lipoaspirated with a blunt dictive role and response assessment to platelet-rich
plasma and adipose-derived stromal vascular fraction
19 cm, 13 G aspiration cannula. injection. Eur J Radiol. 2017;95:130–5.
The adipose tissue is then processed with a Callegari L, Spanò E, Bini A, et al. Ultrasound-guided
dedicated kit, resulting in 10–12 cc of autologous injection of a corticosteroid and hyaluronic acid: a
272 D. Orlandi et al.

potential new approach to the treatment of trigger fin- procedures to treat sport-related muscle injuries. Br J
ger. Drugs R D. 2011;11:137–45. Radiol. 2016;89:20150484.
Corazza A, et al. Thigh muscles injuries in professional Orlandi D, Corazza A, Fabbro E, et al. Ultrasound-guided
soccer players: a one year longitudinal study. Muscles, percutaneous injection to treat de Quervain’s disease
Ligaments Tendons J. 2013;3(4):331–6. using three different techniques: a randomized con-
D’Addona A, Maffulli N, Formisano S, Rosa D. Inflam- trolled trial. Eur Radiol. 2015;25(5):1512–9.
mation in tendinopathy. Surgeon. 2017;15(5): Orlandi D, Corazza A, Silvestri E, et al. Ultrasound-­
297–302. guided procedures around the wrist and hand: how to
Ferrero G, Fabbro E, Orlandi D, et al. Ultrasound-guided do. Eur J Radiol. 2014;83(7):1231–8.
injection of platelet rich plasma in chronic Achilles and Sconfienza LM, Serafini G, Silvestri E, editors.
patellar tendinopathy. J Ultrasound. 2012;15:260–6. Ultrasound-guided musculoskeletal procedures. Italia:
Maffulli N, Sharma P, Luscombe KL. Achilles tendi- Springer-Verlag; 2011.
nopathy: aetiology and management. J R Soc Med. Tagliafico A, Russo G, Boccalini S, et al. Ultrasound-­
2004;97:472–6. guided interventional procedures around the shoulder.
Maffulli N, Spiezia F, Longo UG, et al. High volume Radiol Med. 2014;119:318–26.
image guided injections for the management of Uygure E, Aktas B, Ozkut A, Erinç S, Yılmazoglu
chronic tendinopathy of the main body of the Achilles EG. Dry needling in lateral epicondylitis: a prospec-
tendon. Phys Ther Sport. 2013;14:163–7. tive controlled study. Int Orthop. 2017;41(11):2321–5.
Orlandi D, Corazza A, Arcidiacono A, Messina C,
Serafini G, Sconfienza LM, et al. Ultrasound-guided
 Shoulder Calcific Tendinitis
Treatment
30
Massimo De Filippo, Fabio Martino,
and Francesco Pagnini

Contents
30.1   Introduction  273
30.2   Therapeutic Options and Clinical Indications  274
30.3   How to Do  274
30.3.1 Pre-procedural Phase  274
30.3.2 Procedure  274
30.4   Clinical Outcome and Complications  276
Further Readings  277

30.1 Introduction Ultrasonography is preferable for the correct

assessment of the affected tendon, for guiding
The most reasonable diagnostic methods to eval- therapeutic procedures and for the post-­procedural
uate shoulder calcifications are X-ray and ultra- evaluation during the follow-up period. Both meth-
sonography. X-ray should be considered as the ods are also effective in evaluating the stage of the
first-line imaging modality, being a panoiramic, calcification process and to establish the timing for
fast, and cost-effective imaging modality for the its treatment, which is the most important criterion
assessment and characterization of the character- for the therapeutic success.
istic calcific deposit. Multiple classifications have been pro-
posed; among them the most used is the Farin
classification, which divides the calcifications
M. De Filippo
into three types on the basis of US appearance
Professor of Radiology, Department of Medicine and
Surgery, University of Parma, Parma, Italy (Fig. 30.1):
Director of Diagnostic an Interventional Unit, Azienda
Ospedaliero-Universitaria di Parma, Parma, Italy –– Type I: a hyperechoic focus with a well-­
defined shadow
F. Martino (*)
Radiology, Sant’Agata Diagnostic Center, Bari, Italy –– Type II: a hyperechoic focus with a faint
shadow
F. Pagnini
Radiologist, Diagnostic an Interventional Unit, Azienda –– Type III: a hyperechoic focus without an
Ospedaliero-Universitaria di Parma, Parma, Italy acoustic shadow

© Springer Nature Switzerland AG 2022 273

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_30
274 M. De Filippo et al.

a b c

Fig. 30.1 US appearance of shoulder calcifications: (a) a hyperechoic focus with a well-defined shadow; (b) a hyper-
echoic focus with a faint shadow; (c) a hyperechoic focus without an acoustic shadow

As mentioned in the previous chapters the elective treatment should be preferred. With very
resorptive phase is usually associated with the small calcifications (<5 mm) or migration into the
development of acute pain that can be very disabling bursal space the procedure is not indicated. Mild
(pseudoparalytic shoulder) and unresponsive to or moderate degeneration of the tendon or inflam-
conservative treatments such as nonsteroidal anti- matory conditions do not represent a contraindi-
inflammatory drugs (NSAIDs). It happens because cation to treatment because the “needling” of the
of hyperemia detectable with color Doppler ultra- tendon improves the healing process and usually
sonography, edema, and increased intratendinous the procedure is combined with a bursal injection
pressure with possible extravasation of calcium of local anesthetics and slow-release steroids in
crystals in the subacromial bursa. This is the order to relieve inflammation-related symptoms.
moment in which, according to the morphologic
type, the treatment can be more effective.
30.3 How to Do

30.2 Therapeutic Options 30.3.1 Pre-procedural Phase

and Clinical Indications
The patient should lie in semisupine position,
Therapeutic options are subacromial steroid with the arm of the affected shoulder completely
injections, arthroscopy, extracorporeal shock extended along the body, with an internal/exter-
waves, and percutaneous irrigation. Currently nal rotation according to the calcification’s loca-
ultrasound-guided percutaneous irrigation of tion and accessibility. Ordinary antisepsis, with
calcific tendinopathy (US-PICT), also known as iodopovidone or chlorhexidine, is sufficient to
“barbotage” and “lavage,” is accepted as the first-­ guarantee a safe procedure.
line treatment for safety and effectiveness, with
significant pain relief and significative improve-
ment in the shoulder function in the short and 30.3.2 Procedure
long terms. It is a procedure that does not require
hospitalization, performed under local anes- The procedure starts with the injection of a small
thesia, and that does not need post-procedural amount of local anesthetic (usually up to 10 ml of lido-
immobilization. The patient usually can go home caine) along the path of the needles, into the subacro-
approximately 30 min after the procedure and mial-subdeltoid bursa and around the calcification.
resume his/her daily activities the day after the The size of the needle needed to perform the
treatment without complications. procedure should be chosen in order to maxi-
US-PICT is always indicated in the resorptive mize calcium retrieval and to avoid obstruction;
phase, in the presence of soft or semifluid calci- in other published studies for RCCT treatment it
fications (type II or III). In case of hard calcifi- varies between 16 and 18 G. Every movement is
cation (type I) or mildly symptomatic patients, done under continuous US monitoring using a
30 Shoulder Calcific Tendinitis Treatment 275

freehand technique which is faster and that allows

a more flexible approach, or with needle guid-
ance kit, according to the operator’s experience.
The procedure can be done with a double-­
needle or a single-needle technique: in the double-­
needle technique (Fig. 30.2) the deeper needle
(the furthest from the probe) is first inserted to
avoid its own acoustic shadowing, taking care
to preserve the integrity of the calcific shell, and
then the second needle is inserted superficially.
Both needles should be as perpendicular as
possible to the US beam, with an angulation of the
needle’s tips of approximately 25–30° and with
both bevels facing each other. In this way anisot-
ropy artifacts are minimized and needles can be
seen entirely. Saline solution is normally injected
using a 20/40 ml syringe through one needle; the
plunger is pushed repeatedly, and when the calcifi-
cation starts to dissolve, water and calcium debris
Fig. 30.2 The double-needle technique. The deeper nee-
are drained from the second needle (Fig. 30.3).
dle (a) is positioned, and then the second needle (b) is
During the irrigation procedure needles can be inserted superficially with an angulation of approximately
rotated and displaced to increase calcium disag- 25–30° to the first one. In order to minimize anisotropy
gregation and fragmentation. The use of warm artifacts both needles should be positioned as perpendicu-
lar as possible to the US beam

a b

Fig. 30.3 The outflow of saline water and calcium debris, (a). After some minutes of rest the calcific debris tend to
injected from one needle and drained by the other, using form aggregates (b)
warm saline solution with the double-needle technique
276 M. De Filippo et al.

saline solution may shorten the procedure and an US-guided intrabursal injection of local anes-
improve calcification dissolution. thetics and slow-release steroids.
In the single-needle technique, after the needle A short course of oral nonsteroidal anti-­
placement, calcium retrieval is obtained alternat- inflammatory drugs (NSAIDs), a period of relative
ing the saline solution injection and the aspira- rest (~15 days), and physiokinetic therapy are sug-
tion of water and debris from the same needle. gested to improve the procedure’s outcome.
When the dissolved calcium is completely
removed and calcium debris is no longer
retrieved, the procedure can be considered fin- 30.4 Clinical Outcome
ished. An alternative option, especially useful for and Complications
type I and type II calcifications, is the approach
with a needle composed of a cutting sheet and In the short-term period the worsening of symp-
an inner stylet (Fig. 30.4): with this method the toms is frequent, but normally followed by a
needle tip is placed at the periphery of the cal- quick resolution (~48 h).
cification, and then the inner stylet is retracted Compared to patients who refused the treatment,
creating vacuum. many authors reported a greater reduction of pain,
The cutting sheet is subsequently inserted and a significant improvement of shoulder function
applying simultaneous rotations to break the in the middle and long-term periods, with reduction
calcification. The needle is completely retracted of the volume of calcification (Fig. 30.6).
before getting in touch with the distal side of the The overall complication rate is about 10%:
calcific shell, in order to retrieve calcium debris vasovagal reactions (2%) and seizures (0.2%) are
and to prevent tendon’s injury (Fig. 30.5). described as immediate reactions, for which it is
In order to improve the pain relief and to pre- important to keep an on-site observation period
vent complications the procedure is ended with of the patient (~30 min after the procedure) and

Fig. 30.4 A needle

composed of a cutting
a
sheet and an inner stylet
(a): the needle tip is
placed at the periphery
of the calcification and b
the inner stylet is
retracted creating
vacuum (b). The cutting
sheet is inserted while
rotating to penetrate and
break the calcification
(c). Before getting in
c
touch with the distal side
of the calcific shell, the
needle is retracted, in
order to retrieve calcium
debris and to prevent
tendon’s injury (d).
Repeating the operation
(a–d) for multiple times
d
the calcification is
completely emptied (e)

e
30 Shoulder Calcific Tendinitis Treatment 277

a b

Fig. 30.5 Calcific material retrieved after the procedure (a, b) in a type I calcification

a b

Fig. 30.6 An X-ray of the right shoulder before (a) and after (b) 3 months of the procedure representing the therapeutic
success

to have a prompt pharmacological support for Di Giacomo V, Trinci M, van der Byl G, Catania VD,
Calisti A, Miele V. Ultrasound in newborns and chil-
emergencies.
dren suffering from non-traumatic acute abdominal
Reported delayed reactions are bursitis (7%), pain: imaging with clinical and surgical correlation. J
as the most frequent, frozen shoulder (0.2%), Ultrasound. 2015;18:385–93.
and tenosynovitis of the bicipital long head Orlandi D, Mauri G, Lacelli F, Corazza A, Messina C,
Silvestri E, Serafini G, Sconfienza LM. Rotator cuff
(0.1%).
calcific tendinopathy: randomized comparison of
US-guided percutaneous treatments by using one or
two needles. Radiology. 2017;285(2):518–27.
Further Readings Oudelaar BW, Schepers-Bok R, Ooms EM, Huis In’t
Veld R, Vochteloo AJ. Needle aspiration of calcific
Barile A, La Marra A, Arrigoni F, et al. Anaesthetics, deposits (NACD) for calcific tendinitis is safe and
steroids and platelet-rich plasma (PRP) in ultrasound-­ effective: six months follow-up of clinical results and
guided musculoskeletal procedures. Br J Radiol. 2016; complications in a series of 431 patients. Eur J Radiol.
https://doi.org/10.1259/bjr.20150355. 2016;85:689–94.
Borchers J, Krey D, McCamey K. Tendon needling for Perrotta FM, Astorri D, Zappia M, Reginelli A, Brunese
treatment of tendinopathy: a systematic review. Phys L, Lubrano E. An ultrasonographic study of enthesis
Sportsmed. 2015;43(1):80–6. in early psoriatic arthritis patients naive to traditional
278 M. De Filippo et al.

and biologic DMARDs treatment. Rheumatol Int. itis: short-term and 10-year outcomes after two-needle
2016;36:1579–83. us-guided percutaneous treatment--nonrandomized
Sconfienza LM, Bandirali M, Serafini G, et al. Rotator controlled trial. Radiology. 2009;252:157–64.
cuff calcific tendinitis: does warm saline solution de Witte PB, Selten JW, Navas A, et al. Calcific tendi-
improve the short-term outcome of double-needle nitis of the rotator cuff: a randomized controlled
US-guided treatment? Radiology. 2012;262:560–266. trial of ultrasound-guided needling and lavage ver-
Sconfienza LM, Serafini G, Sardanelli F. Treatment of cal- sus subacromial corticosteroids. Am J Sports Med.
cific tendinitis of the rotator cuff by ultrasound-guided 2013;41:1665–73.
single-needle lavage technique. Am J Roentgenol. Zheng F, Wang H, Gong H, Fan H, Zhang K, Du L. Role
2011;197(2):W366. author reply 367 of ultrasound in the detection of rotator-cuff syn-
Serafini G, Sconfienza LM, Lacelli F, Silvestri E, drome: an observational study. Med Sci Monit.
Aliprandi A, Sardanelli F. Rotator cuff calcific tendon- 2019;25:5856–63.
 Peripheral Nerve Block
31
Giuseppe Sepolvere, Mario Tedesco,
and Davide Orlandi

Contents
31.1   Upper Limb Ultrasound-Guided Blocks: How to Do  279
31.1.1 Interscalene Block  280
31.1.2 Supraclavicular Block  280
31.1.3 Infraclavicular Block  280
31.1.4 Axillary Block  281
31.2   Lower Limb Ultrasound-Guided Blocks  282
31.2.1 Femoral Nerve Block  283
31.2.2 Obturator Nerve Block  285
31.2.3 Lateral Femoral Cutaneous Nerve Block  287
31.2.4 Saphenous Nerve Block  287
31.2.5 Sciatic Nerve Block  288
Further Readings  291

31.1  pper Limb Ultrasound-

U branches of the spinal roots from C5 to T1 with
Guided Blocks: How to Do variable contributions of C4 and T2 and extends
from the neck to the axilla.
The ultrasound-guided upper limb nerve blocks The roots merge into three main nerve trunks
allow to anesthetize the peripheral nerve struc- (interscalene block) moving between the scalene
tures of derivation of the brachial plexus (PB) muscles, subsequently above and laterally to the
(Fig. 31.1). The latter arises from the ventral subclavian artery; they are divided into two sec-
ondary trunks (supraclavicular block) and from
G. Sepolvere there pass under the clavicle and head towards
Department of Anesthesia and Cardiac Surgery the armpit group around the axillary artery to
Intensive Care Unit, San Michele Hospital, form the lateral, medial, and posterior cords
Maddaloni, Italy
(infraclavicular block); joints in the armpit divide
M. Tedesco into the terminal nerve branches: median nerve;
Department of Anesthesia and Intensive Care Unit
and Pain Therapy, Mater Dei Hospital, Bari, Italy
radial; ulnar; and cutaneous and axillary muscle
(axillary block).
D. Orlandi (*)
Department of Radiology, Ospedale Evangelico
Internazionale, Genova, Italy

© Springer Nature Switzerland AG 2022 279

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_31
280 G. Sepolvere et al.

The secondary trunks of the PB are identified

laterally to the subclavian artery and, keeping the
plexus central to the ultrasound image, the probe
is brought up along the sternocleidomastoid mus-
cle with the so-called trace-back technique to
observe three vesicles stacked like a traffic light
between the scalene muscles (Fig. 31.2a, c). The
approach is in lateromedial plane, and the injec-
tion of local anesthetic takes place between the
upper trunk and the middle trunk with a volume
equal to 10–20 ml (Fig. 31.2b).

Fig. 31.1 Brachial plexus scheme. AC lateral cord (from 31.1.2 Supraclavicular Block
anterior division), PC posterior cord (from posterior divi-
sion), MC medial cord (from posterior division). 1 Supraclavicular block is used for arm, forearm,
Suprascapular nerve; 2 lateral pectoral nerve; 3 musculo-
and hand surgery, defined as “spinal arm” for its
cutaneous nerve; 4 median nerve; 5 ulnar nerve; 6 medial
cutaneous nerve of forearm; 7 medial cutaneous nerve of effectiveness. The position of the patient and the
arm; 8 lower subscapular nerve; 9 thoracodorsal nerve; 10 probe is the same as that described for the inter-
medial pectoral nerve scalene block, in-plane needle approach
(Fig. 31.3a). The plexus is located at the top and
side of the subclavian artery, lies on the first rib,
Materials and at the top is delimited by the superficial cer-
• High-frequency linear probe >12 mHz vical fascia and omohyoid muscle. The injection
• 50 mm, 22G atraumatic needle of about 15–20 ml of local anesthetic takes place
• Neurostimulator, BSmart® (Injection between the secondary trunks, which appear as
Pressure Monitor) vesicles, and the angle between the subclavian
artery and the first “pocket corner” edge
(Fig. 31.3b).

31.1.1 Interscalene Block

31.1.3 Infraclavicular Block
The interscalene block is used for shoulder sur-
gery, alone or in combination with other Infraclavicular block has the same indications of
approaches (supraclavicular or infraclavicular) the supraclavicular; it is very useful if you decide
when surgery exceeds 1/3 proximal of the to place a perineural catheter for elbow surgery
humerus. rehabilitation. To make the blockage safer, the
Patient in supine position with rise under the patient’s arm must be abducted (Fig. 31.4); this
shoulders and head turned contralaterally allows to superficialize the axillary artery and
(Fig. 31.2a). The main trunks are searched by therefore the three ropes, which are all positioned
placing the probe on the supraclavicular sulcus laterally and behind the artery, and move them
(Fig. 31.2a). away from the pleura.
31 Peripheral Nerve Block 281

a b

Fig. 31.2 The interscalene groove in a trans-sectional middle scalene muscle. Long white arrow: needle direc-
view of the neck. (a) Patient position and needle entry tion and target point. (c) Anatomical scheme of the inter-
point. The yellow arrow allows the trajectory of “trace-­ scalene groove. TS superior trunk, TM middle trunk, TI
back method” scanning. (b) Sonoanatomy. SCM: sterno- inferior trunk, CA carotid artery, IJV internal jugular vein
cleidomastoid muscle; AS: anterior scalene muscle; MS:

The probe is positioned in the deltoid-pectoral 31.1.4 Axillary Block

sulcus (Fig. 31.5a), and the needle enters the
plane with direction towards the armpit. The Axillary block (Fig. 31.6) has similar indications
injection of anesthetic about 25–30 ml takes to the supra- and infraclavicular block; it can also
place laterally and posteriorly to the axillary be used as a rescue block when the more proxi-
artery (Fig. 31.5b) forming an anechoic bubble mal blocks do not guarantee adequate surgical
(double-bubble sign). coverage of some territories.
282 G. Sepolvere et al.

a b

Fig. 31.3 Supraclavicular block. (a) Patient position and pocket (yellow dashed lines). Long white arrow needle
needle entry point. Probe tilting (yellow arrows). (b) direction and target point
Sonoanatomy. first R first rib, A subclavian artery. Corner

ited superficially by skin and subcutaneous tis-

LC
MC sues, deeply by the triceps muscle, and above by
adducted arm the biceps muscle). The musculocutaneous nerve
A V
PC could be located outside the fascia, in the coraco-
brachialis muscle or between it and the biceps.
Around 5 ml of local anesthetic is injected
LC
around the musculocutaneous nerve (Fig. 31.8a,
A
c), then the needle is directed above and below
abducted arm
PC MC
V the axillary artery, and up to 20 ml of local anes-
thetic is injected (perivascular technique).

Fig. 31.4 The abduction of the arm shifts the three cords
of the brachial plexus laterally and posteriorly to the 31.2  ower Limb Ultrasound-
L
artery. MC medial cord, LC lateral cord, PC posterior Guided Blocks
cord, A axillary artery, V axillary vein

The ultrasound-guided blocks of the lower limb

The arm is abducted and the probe is posi- ensure anesthetization of the peripheral nervous
tioned transversely (Fig. 31.7a); an accurate structures that derive from the lumbar plexus
ultrasound scan is performed to identify an image (Fig. 31.9). The lumbar plexus originates from
in which all the nerves to be blocked with a single the anterior rami of spinal roots L1–L4 and gives
injection are perfectly visible. The needle is rise to the nervous structures responsible for the
introduced into the plane (Fig. 31.7b). sensory and motor innervation of the lower limbs.
Median, radial, and ulnar nerves are arranged It is therefore possible to achieve blocks of the
around the axillary artery contained in the nerve femoral, obturator, lateral femoral cutaneous,
vascular fascia (a triangular-shaped space delim- saphenous, and sciatic nerves.
31 Peripheral Nerve Block 283

a b

Fig. 31.5 Infraclavicular block (a) Patient position and nee- lary artery, V axillary vein, MC medial cord (yellow outlined),
dle entry point, with abducted arm. (b) Sonoanatomy. MaP LC lateral cord (yellow outlined), PC posterior cord (yellow
major pectoralis muscle, MiP minor pectoralis muscle, A axil- outlined). Long white arrow: needle direction and target point

Materials
• High-frequency linear probe >12 mHz
for femoral, obturator, and lateral femo-
ral cutaneous nerve blocks
• 6 mHz Convex probe for the sciatic
nerve block
• 80–100 mm, 22G atraumatic needle
• Neurostimulator, BSmart® (Injection
Pressure Monitor)

V
Bsh M
U
MC A 31.2.1 Femoral Nerve Block
R
Blh Tm
C Br
It is used in anterior thigh surgeries, in combina-
tion with obturator, lateral femoral cutaneous,
H and sciatic nerve blocks. The femoral nerves
originate from the posterior divisions of the ante-
Tr
rior rami of L2, L3, and L4, and are the most rep-
resented branch of the lumbar plexus. Below the
inguinal ligament, it divides into an anterior and
a posterior division.
The anterior division innervates the anterior
and medial cutaneous regions from the inguinal
Fig. 31.6 Anatomic slice of axillary area. Bsh biceps short ligament to the knee, and gives off motor branches
head muscle, Blh biceps long head muscle, CBr coracobra- to the sartorius and pectineus muscles.
chialis muscle, H humerus, Tm teres major muscle, Tr triceps
muscle, A axillary artery, V axillary vein, MC musculocuta-
neous nerve, M median nerve, U ulnar nerve, R radial nerve
284 G. Sepolvere et al.

a b

Fig. 31.7 Axillary block (a) Patient position and needle M median nerve, U ulnar nerve, R radial nerve, B biceps
entry point, with abducted arm. (b) Sonoanatomy of axil- muscle, CB coracobrachialis muscle, TeM teres major
lary area: A axillary artery, MC musculocutaneous nerve, muscle, T triceps muscle, H humerus

T12
a
L1

B
L2
C

L3
b
D

L4

L5
c
G H
I

Fig. 31.9 Simplified schema of lumbar plexus anatomy

(posterior nerves red painted): (a) Iliohypogastric nerve,
Fig. 31.8 (a) Musculocutaneous nerve block. Yellow (b) ilioinguinal nerve, (c) genitofemoral nerve, (d) lateral
musculocutaneous nerve. Red circle axillary artery. (b, c) femoral cutaneous nerve, (e) and (f) branches for psoas
“Perivascular technique” of axillary area nerve block. Red and iliacus muscles, (g) femoral nerve, (h) accessory
circle: axillary artery obturator nerve, (i) obturator nerve, (j) lumbosacral trunk
31 Peripheral Nerve Block 285

The posterior division innervates the medial nerve and vessels (Fig. 31.11a). Using an in-­
cutaneous region from the knee to the medial plane approach, the needle is introduced in a lat-
malleolus via the saphenous nerve, and gives off eromedial direction, past the iliac fascia, to reach
motor branches to the quadriceps muscles. It lies the femoral nerve. Then, about 15 ml of local
on top the iliopsoas muscles in close anatomical anesthetic is injected circumferentially around
relation to the femoral artery and vein. It runs the nerve (Fig. 31.11b).
within the iliac fascia, which is extremely impor-
tant for the achievement of the nerve block. The
iliac fascia envelopes the nerve and then runs 31.2.2 Obturator Nerve Block
medially below the femoral vessels (Fig. 31.10).
The patient is positioned supine and the high-­ It is used in surgeries that involve the medial thigh
frequency linear probe is placed below the ingui- region down to the knee, in association with femo-
nal ligament in order to visualize the femoral ral, lateral femoral cutaneous, and sciatic nerve
blocks. The obturator nerve originates from the pri-
mary anterior rami of the L2, L3, and L4 roots of
the lumbar plexus and descends into the pelvis
passing above the psoas at the sacroiliac joint. It
exits the pelvis through the obturator foramen and
divides into an anterior and a posterior branch
(Fig. 31.12a). The anterior branch innervates the
skin of the medial and inner thigh and gives off
motor branches to the adductor muscles. The pos-
terior branch passes through the adductor muscles
and gives rise to a motor branch that innervates
most of the adductor magnus, and a sensory branch
Fig. 31.10 A trans-sectional view of the thigh showing that innervates the knee joint (joint capsule, syno-
the adductor canal. IP iliopsoas muscle, P pectineus mus- vial membrane, cruciate ligaments). The anterior
cle, F femur, blue line FL fascia lata, IF iliac fascia, Fn branch runs in between the adductor longus and
with black arrow femoral nerve close to femoral artery
and vein adductor brevis muscles, while the posterior branch

a b

Fig. 31.11 Femoral nerve block. (a) Patient position and muscle, A femoral artery, V femoral vein, F femur. Long
needle entry point. (b) Sonoanatomy of the inguinal area. white arrow needle direction and target point
Fn femoral nerve, PS iliopsoas muscle, PE pectineus
286 G. Sepolvere et al.

runs in between the adductor brevis and the adduc- With the patient in supine position, let the high-­
tor magnus (Fig. 31.12b). frequency linear probe slide medially along the
At the inguinal level, the medial end of the inguinal ligament until you find the muscular and
pectineus muscle comes into strict anatomical nervous structures (Fig. 31.13a). Using an
relationship with the anterior branch of the nerve. ­in-­plane approach, introduce the needle in a lat-

a b

ON
ONpb

ONab

ONab ONpb
AL

P AB

AL
AB
AM AM
F

Fig. 31.12 Anatomic scheme in sagittal section (a) and ONab ON anterior branch, ONpb ON posterior branch, P
in transverse section (b) showing the course and distribu- pectineus muscle, AL adductor longus muscle, AB adduc-
tion in the thigh of obturator nerve. ON obturator nerve, tor brevis muscle, AM adductor magnus muscle, F femur

a b

Fig. 31.13 Obturator nerve block. (a) Patient position magnus muscle, P pectineus muscle, Oab anterior branch
and needle entry point. (b) Sonoanatomy medial aspect of and Opb posterior branch of obturator nerve. Double long
upper thigh showing in a transverse view AL adductor lon- white arrow needle direction and target points
gus muscle, AB adductor brevis muscle, AM adductor
31 Peripheral Nerve Block 287

eromedial direction until you encounter the ante-

rior and posterior branches of the nerve. Then,
inject 8 ml of local anesthetic (Fig. 31.13b).

31.2.3 L
 ateral Femoral Cutaneous
Nerve Block

It is used in association with the femoral, obtura- IL

tor, and sciatic nerve blocks. The lateral femoral
cutaneous nerve is exclusively sensory and origi- LFCN
nates directly from the L2 and L3 roots of the
lumbar plexus. It supplies sensory innervation to LFCN
the anterolateral area of the thigh and knee. It pb
runs underneath the anterior superior iliac spine
in between the sartorius and the tensor fasciae
latae. It then divides into an anterior and a poste-
LFCN
rior branch (Fig. 31.14). ab
With the patient in supine position, slide the
high-frequency linear probe laterally along the
inguinal ligament (Fig. 31.15a). Using an in-­plane
approach, introduce the needle in a lateromedial
direction until you reach the target nerve, and then
inject 5 ml of local anesthetic (Fig. 31.15b).

31.2.4 Saphenous Nerve Block

It is used in association with obturator, lateral

femoral cutaneous, and sciatic nerve blocks, or in Fig. 31.14 Anatomic scheme of the lateral femoral cuta-
neous nerve. IL inguinal ligament, LFCN lateral femoral
the management of postoperative pain in pros- cutaneous nerve, LFCNpb posterior branch, LFCNab
thetic knee replacement. The saphenous nerve is anterior branch
exclusively sensory and originates from the pos-
terior branch of the femoral nerve in the femoral
triangle. It innervates the medial aspect of the leg saphenous vein. Hunter’s canal is delimited supe-
from the knee to the medial malleolus. It runs lat- riorly by the sartorius, laterally by the vastus
eral to the femoral vessels inside the adductor medialis, and medially by the adductor longus
canal (Hunter’s canal). After exiting the subsarto- (Fig. 31.16).
rial canal, it divides into two branches: an With the patient in supine position, place the
infrapatellar branch, which supplies sensory
­ high-frequency linear probe along Hunter’s canal
innervation to the anteromedial aspect of the (Fig. 31.17a). Using an in-plane approach, intro-
knee, and a descending branch, which supplies duce the needle in a lateromedial direction to
the anteromedial aspect of the leg and ankle. reach the target nerve. Then, inject 10 ml of local
Below the knee, it follows the same route of the anesthetic (Fig. 31.17b).
288 G. Sepolvere et al.

a b

Fig. 31.15 Lateral femoral cutaneous nerve block. (a) cle, PE pectineus muscle, A femoral artery, V femoral
Patient position and needle entry point. (b) Sonoanatomy vein, F femur. Long white arrow needle direction and tar-
of the inguinal area. Fn femoral nerve, PS iliopsoas mus- get point

31.2.5 Sciatic Nerve Block

The sciatic nerve is the largest peripheral nerve

and the longest nerve in the human body, with a
diameter of about 2 cm. It supplies sensorimotor
innervation to the posterior aspect of the thigh
and to nearly the whole leg, with the exception of
the medial aspect of the foot that is innervated by
the saphenous nerve. It originates from the spinal
roots L4–L5 and S1–S3, then it exits the pelvis,
and at the gluteal and subgluteal level it comes in
close contact with the gluteus maximus, the piri-
formis, the quadratus femoris, the greater tro-
chanter laterally, and the ischial tuberosity
medially (Fig. 31.18).
With the patient in lateral decubitus, position a
convex probe at gluteal level between the greater
trochanter and the ischial tuberosity (Fig. 31.19a).
Using an in-plane approach, introduce the needle
in lateromedial direction to reach the target nerve
and inject 15 ml of local anesthetic circumferen-
tially to the nerve (Fig. 31.19b).
Fig. 31.16 Trans-sectional view of the thigh showing the Past the gluteal plane, the sciatic nerve
adductor canal. RF rectus femoris muscle, VL vastus late-
ralis muscle, VI vastus intermedius muscle, VM vastus
descends along the posterior aspect of the thigh
medialis muscle, SR sartorius muscle, A adductor longus to the popliteal fossa, where it divides into a tibial
muscle, F femur, S with black arrow saphenous nerve and a common fibular component. The tibial
31 Peripheral Nerve Block 289

a b

Fig. 31.17 Saphenous Nerve Block (a) Patient position medialis muscle, AL adductor longus muscle, A femoral
and needle entry point. (b) Sonoanatomy of the adductor artery, V femoral vein. Long white arrow needle direction
canal. Sn saphenous nerve, S sartorius muscle, VM vastus and target point

component continues to descend along the cen-

tral aspect of the leg, while the common fibular
component moves laterally. Along its posterior
route, the sciatic nerve comes in close anatomical
contact with the biceps femoris and the vastus
lateralis muscles laterally, with the semitendino-
sus and semimembranosus medially and with the
adductor magnus anteriorly (Fig. 31.18). At the
level of the popliteal fossa, it is possible to per-
form a sciatic nerve block by placing the patient
in prone position (Fig. 31.20a). With a high-­
frequency linear probe and in-plane approach,
introduce the needle in lateromedial direction
until you reach the target nerve. Subsequently,
inject 15 ml of local anesthetic in circumferential
fashion (Fig. 31.20b).
An alternative approach through the medio-­
femoral region is described by Sepolvere-­
Tedesco. The patient is placed supine and a
convex probe is placed between the vastus latera-
lis and the biceps femoris muscles (Fig. 31.21a).
The needle is introduced in-plane in lateromedial
direction to reach the target nerve, where 15 ml
of local anesthetic is injected circumferentially
(Fig. 31.21b).

Fig. 31.18 Schema of sciatic nerve anatomy. S sciatic

nerve, GM gluteus maximus muscle, P piriform muscle,
BF biceps femoris muscle, ST semitendinosus muscle
290 G. Sepolvere et al.

a b

Fig. 31.19 Sciatic nerve block. (a) Patient position and dratus femoris muscle, IT ischial tuberosity. Long white
needle entry point. (b) Sonoanatomy. S sciatic nerve, GT arrow needle direction and target point
greater trochanter, GM gluteus maximus muscle, QF qua-

a b

Fig. 31.20 Sciatic nerve block at the popliteal fossa. (a) teal nerve, vein, and artery. F femur, ST semitendinosus
Patient position and needle entry point. (b) Sonoanatomy muscle, SM semimembranosus muscle, P popliteal sciatic
in a transverse section of popliteal region showing popli- nerve. Long white arrow needle direction and target point
31 Peripheral Nerve Block 291

a b

Fig. 31.21 Sciatic nerve block through the medio-­ muscle, VL vastus lateralis muscle, AM adductor magnus,
femoral region. (a) Patient position and needle entry F femur. Long white arrow needle direction and target
point. (b) Sonoanatomy of a lateromedial axial section at point
mid-shaft of femur. S sciatic nerve, BF biceps femoris

Kirkpatrick JD, Sites BD, Antonakakis JG. Preliminary

Further Readings experience with a new approach to performing an
ultrasound-guided saphenous nerve block in the
Bendtsen TF, Moriggl B, Chan V, Børglum J. Basic mid- to proximal femur. Reg Anesth Pain Med.
topography of the saphenous nerve in the femoral tri- 2010;35:222–3.
angle and the Adductor Canal. Reg Anesth Pain Med. Sahin L, Sahin M, Isikay N. A different approach to
2015;40(4):391–2. an ultrasound-guided saphenous nerve block. Acta
Dolan J. Ultrasound-guided anterior sciatic nerve block Anaesthesiol Scand. 2011;55:1030–1.
in the proximal thigh: an in-plane approach improv- Silvestri E, Martino F, Puntillo F. Ultrasound-­ guided
ing the needle view and respecting fascial planes. Br J peripheral nerve blocks. Milan, Berlin, Heidelberg,
Anaesth. 2013;110:319–20. New York: Springer; 2018.
Franco CD, Williams JM. Ultrasound-guided Interscalene Snaith R, Dolan J. Ultrasound-guided interfascial injec-
block: reevaluation of the “stoplight” sign and clinical tion for peripheral obturator nerve block in the thigh.
implications. Reg Anesth Pain Med. 2016;41(4):452–9. Reg Anesth Pain Med. 2010;35:314–5.
Fredrickson MJ, Wolstencroft P. Evidence-based medi- Taha AM. Brief reports: ultrasound-guided obturator
cine supports ultrasound-guided infraclavicular block nerve block: a proximal interfascial technique. Anesth
over the corner pocket supraclavicular technique. Reg Analg. 2012;114:236–9.
Anesth Pain Med. 2011;36(5):525–6. Tedesco M, Sepolvere G, Cibelli M. Ultrasound-guided
Galluccio F, Arnay EG, Salazar C, Altinpulluk EY, lateral, mid-shaft approach for proximal sciatic nerve
Capassoni M, Garcia DS, Espinoza K, Olea MS, Perez block. Reg Anesth Pain Med. 2019;7:100657. https://
MF. Ultrasound-guided block of the axillary nerve: doi.org/10.1136/rapm-­2019-­100657.
a prospective, randomized, single-blind study com- Tran DQ, Charghi R, Finlayson RJ. The “double bubble”
paring Interfascial and perivascular injections. Pain sign for successful infraclavicular brachial plexus
Physician. 2020;23(1):E61–70. blockade. Anesth Analg. 2006;103(4):1048–9.
Goffin P, Lecoq JP, Ninane V, Brichant JF, Sala-Blanch Wong WY, Bjørn S, Strid JMC, Børglum J, Bendtsen
X, Gautier PE, et al. Interfascial spread of Injectate TF. Defining the location of the Adductor Canal using
after Adductor Canal injection in fresh human cadav- ultrasound. Reg Anesth Pain Med. 2017;42(2):241–5.
ers. Anesth Analg. 2016;123(2):501–3.
 Fluid Collection Evacuation
32
Ernesto La Paglia, Enzo Silvestri,
and Davide Orlandi

Contents
32.1 Introduction  293
32.2 Abscess  293
32.3 Hematoma  294
Further Readings  295

32.1 Introduction is clear. Typically needle drainage is chosen for

smaller abscesses and catheter drainage is pre-
One of the most important prognostic factors in ferred for the drainage of multiloculated abscesses
patients with musculoskeletal fluid collection is and for larger ones. This technique avoids unnec-
the delay in establishing therapy, both in order to essary catheter insertions into sterile fluid collec-
get a diagnosis of septic process which requires tion such as lymphoceles and hematomas.
analysis of fluid and in order to avoid compart-
ment syndrome. Ultrasonography is a rapid,
portable, sensitive technique for fluid collection 32.2 Abscess
management. The study can be easily repeated
for follow-up of lesions. US allows real-time guidance of fluid aspiration and
Fluid collection must be completely aspirated can reduce the risk of contaminating other anatomic
and the cavity is irrigated with a volume of saline compartments, especially in the hands, wrists, and
that is half of the aspirated fluid volume and the feet. Radiography provides complementary infor-
irrigation is continued until the aspirated fluid mation and should be performed in conjunction
with US. US is the imaging modality of choice
for diagnosis of superficial abscesses. Dynamic
E. La Paglia
Department of Radiology, Humanitas Cellini, compression with the US probe and color Doppler
Torino, Italy imaging can facilitate the detection of superficial
E. Silvestri abscesses. US may help in the early diagnosis of
Radiology, Alliance Medical, Genova, Italy osteomyelitis by demonstrating subperiosteal or
D. Orlandi (*) juxtacortical fluid collections and by providing
Department of Radiology, Ospedale Evangelico guidance for aspiration of these collections.
Internazionale, Genova, Italy

© Springer Nature Switzerland AG 2022 293

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4_32
294 E. La Paglia et al.

Abscesses may have different features at ous involvement, which would not be available
US. The lesion may appear as an anechoic or with US (Fig. 32.2).
diffusely hypoechoic mass which increases Ultrasound-guided drainage of soft tis-
through transmission or may be hyperechoic sues’ abscesses is a safe and effective treatment
or isoechoic relative to surrounding tissues and approach. Needle drainage is the most common
lack mass effect. The margins may be well cir- first-line treatment approach because of the sim-
cumscribed or blend in with the surrounding tis- plicity of the procedure, improved patient com-
sues. Sometimes, an echogenic rim is seen. Septa fort, and reduced costs. Catheter drainage will
may be present, as well as internal echoes, which be reserved for large multiloculated abscesses.
represent debris or gas. Power or color Doppler Follow-up US may show that a repeat puncture
imaging may be used to demonstrate hyperemia and drainage are necessary. Most drainage proce-
at the periphery of the mass and absence of flow dures are performed without any anesthesia and
in the center (Fig. 32.1). apart from minor discomfort during the drainage
Dynamic evaluation of the soft-tissue area procedure and the subsequent indwelling cath-
by palpation or gentle compression with the US eter period, there were no serious complications
probe is useful to reveal the motion of the liq- related to the drainage procedures. All procedures
uefied purulent material in cases of isoechoic or must be performed under aseptic conditions,
hyperechoic abscesses. US plays a major role which include sterile draping of the transducer.
in the detection and management of superficial Patient must be prepared for the drainage proce-
abscesses, being deeper fluid collections, par- dure, which includes being informed about the
ticularly in the lumbar and pelvic regions, more nature of the procedure and the possible related
easily managed by the guidance of magnetic res- discomfort in compliance with medicolegal
onance imaging or computed tomography (diag- legislation. A diagnostic puncture must be per-
nosis, determination of location and extent, and formed in all patients introducing a spinal needle
percutaneous management). MR imaging and CT (16–18 G) into the fluid collection under con-
also provide detailed information regarding osse- tinuous US guidance and fluid from the cavity is
aspirated with a syringe. When pus is aspirated,
either the needle drainage or the catheter drain-
age protocol may be implemented, with the lat-
ter being an extension of the diagnostic puncture
introducing a guidewire and a self-­retaining pig-
tail catheter over the guidewire into the cavity.

32.3 Hematoma

Ultrasound-guided hematoma evacuation is a

well-tolerated procedure. However, the propor-
tion of unsuccessful evacuations and hematoma
recurrence is substantial (13%). Such a rate of
Fig. 32.1 Longitudinal US scan of an anechoic collec-
tion with multiple internal echoes (asterisk). The margins
unsuccessful evacuation is because of excessive
are well circumscribed and septa are present with color density and/or viscosity of the content. Ideally,
Doppler imaging demonstrating hyperemia at the level of hematoma evacuation must be performed before
the septum and absence of flow in the center. The abscess 3–5 days since the beginning of the muscular
is lying on the cortical bony surface of the tibia
32 Fluid Collection Evacuation 295

a b c d

Fig. 32.2 Reactivated chronic osteomyelitis. (a–c) MRI tal sequence and longitudinal sonogram of the distal thigh
T1w and STIR coronal sequences and GRE T2*w sagittal demonstrate a large hypoechoic heterogeneous abscess that
sequence of left tibia show signs of chronic osteomyelitis with communicates with the bone marrow cavity through a cortical
widening of the diaphysis, cortical thickening, and irregular break. During US study, compression with the transducer
periosteal reaction. Multiple central medullary lesions consis- demonstrated in-­and-­
out motion of debris from the bone
tent with sequestrum are also visible. (c, d) GRE T2*w sagit- through the opening in the cortex

bleed, especially in the case of large hematomas Further Readings

in the liquid phase.
Between 10% and 23% of bleeding episodes Baoge L, et al. Treatment of skeletal injury: a review.
in the musculoskeletal system of hemophilia ISRN Orthopaed. 2012;2102:7.
patients occur in the muscles. When a muscle Cardinal E, et al. Role of ultrasound in musculoskel-
etal infections. Imag Musculosk Spinal Infect.
bleed is suspected, confirmation must be achieved 2001;39(2):191–201.
by means of imaging tests (ultrasound, MRI, CT). De la Corte-Rodriguez H, et al. Treatment of muscle hae-
Then, immediate (early) enhanced on-­ demand matomas in haemophiliacs with special emphasis on
hematological treatment must be started until the percutaneous drainage. Blood Coagul Fibrinolysis.
2014;25(8):787–94.
full disappearance of the hematoma. If untreated, Lorentzen T, et al. Ultrasound-guided drainage of deep
muscle bleeds can cause complications such as pelvic abscesses: experience with 33 cases. Ultrasound
nerve injury, compartment syndrome, myosi- Med Biol. 2011;37(5):723–8.
tis ossificans, pseudotumor, and even infection Querol F, Rodriguez-Merchan EC. The role of ultrasonog-
raphy in the diagnosis of the musculo-skeletal prob-
(abscess). Currently, the literature for muscle lems of haemophilia. Haemophilia. 2012;18:e215–26.
hematomas in the nonhemophilic population Stainsby BE, et al. Management approaches to acute mus-
suggests that ultrasound-guided percutaneous cular strain and hematoma in national level soccer
drainage, or surgical drainage performed as open players: a report of two cases. J Can Chiropr Assoc.
2012;56:262–8.
surgery if percutaneous drainage fails, could be
beneficial in terms of achieving better and faster
symptom relief.
 Index

A C
Abscesses, 294 Calcaneo-fibular ligament (CFL), 190
Achilles tendon, 230 Calcific myonecrosis, 222, 223
Acromioclavicular joint (ACJ) stability, 188 Calcific periarthritis, 108
Acute traumatic bursitis, 18 Calcific stage, 130
Acute traumatic injuries, 64–65 Calcific tendinitis, shoulder, 129, 130
Adhesive capsulitis, 13, 137 complications, 132, 134, 135
Adipose-derived mesenchymal stem cells (ASCs), 271 hydroxyapatite, 129
Angiomas, 68 imaging, 130–132
Ankle interosseous ligaments, 188–190 radiography, 130
Annular pulleys, 32 Calcifications, 131
Anterior interosseous nerve (AIN), 200 Carpal tunnel syndrome (CTS), 63, 201, 202
Anterior tarsal tunnel syndrome, 205, 206 Cartilage, 3
Anterior thigh surgeries, 283 damage, 76
Arnold–Hilgartner score, 150 thinning, 85, 87
Arthrocentesis, 251 Caudo-cranial approach with the articular joint space,
Articular capsule, 12, 13 260
Articular cartilage, 6, 7 Chemical bursitis, 19
Artrosynovitis, 260 Chronic stenosing tenosynovitis, 37
Axillary block, 281, 282 Classification of psoriatic arthritis (CASPAR), 92
Color and power Doppler analysis, 69
Color and/or power Doppler ultrasound techniques, 239,
B 240
Baker’s cyst, 20 Common peroneal nerve (CPN), 203, 204
Basic calcium phosphate crystal deposition disease, 108, Communicating synovial bursae, 19
109 Compact bone, 7
Baxter neuropathy, 207 Compression neuropathy, 203
Bicipital pulley disruption, 188 Connective tissue disorders
Biopsy, 251 ILD, 116, 117
Bone erosion, 84, 85 Sjögren’s syndrome, 114–116
Bone fracture, 9 systemic lupus erythematosus (SLE), 113, 114
Bone tissue, 7 systemic sclerosis, 114
Bone trauma Contrast enhanced ultrasound (CEUS), 217, 234
fractures, 158–160 applications of quantitative analysis, 242–244
peripheral soft-tissue modifications, 157 in assessment of inflammatory arthritis, 241, 244
stress fractures, 160, 161 clinical application of CEUS in therapeutic
ultrasound (US), 158 monitoring in inflammatory arthritis, 244
Bone vascularity, 217 limitations, 244
Bursae, 18 quantitative analysis, 242
Bursitis, 18–21, 257 Contusion, 169

© Springer Nature Switzerland AG 2022 297

F. Martino et al. (eds.), Musculoskeletal Ultrasound in Orthopedic and Rheumatic disease in Adults,
https://doi.org/10.1007/978-3-030-91202-4
298 Index

Coraco-clavicular ligaments, 188 SPN, 204, 205

Coraco-humeral ligament, 188 tibial nerve, 206, 207
Cranial-caudal approach, 260 of upper limb
Crystal-related arthropathies axillary nerve, 196
basic calcium phosphate crystal deposition disease, MCN, 196
108, 109 median nerve, 200–202
crystal types, 101 radial nerve, 196–198
diagnosis, 102 SSN, 194–196
gout, 102 ulnar nerve, 198–200
clinical features, 102 Epiphyseal plate, 7
conventional radiography (CR), 102 Epiphysis, 7
diagnosis, 102 European League Against Rheumatism (EULAR)
disease monitoring, 105 conventional radiography, 92
scanning protocol, 105 Examined joints, 237–239
US findings at joint level, 102–104 Extra-articular distal radial fractures, 160
US findings at tendon, bursa and subcutaneous Extrinsic ligaments, 31
level, 104, 105
pyrophosphate arthropathy, 105–108
US appearance, 101, 102 F
Cubital tunnel syndrome, 199, 200 Femoral nerve block, 283, 285
Fibrocartilage, 3
Fibrocartilaginous calcifications, 106
D Flat bones, 7
Dactylitis, 92, 95 Fluid collection evacuation, 293–295
Deep gluteal syndrome, 203 Fracture repair
Deep peroneal nerve (DPN), 205, 206 components, 215
Degenerative and inflammatory enthesopathy, 40–42 imaging, 216, 217
Dermis and hypodermis Fractures, 158–160
pathological findings, 67–69 Frozen shoulder (FS), 137–139
skin and subcutaneous tissue, 67
Diaphysis, 7
Distal biceps brachii tendon (DBBT), 227 G
Doppler quantitative assessment of synovial blood flow, Gottron’s papule, 67
241 Guyon's canal syndrome, 200
Doppler technique, 33
Drugs injections, 251
Dry-needling, 269 H
Dupuytren’s contracture, 69 Haemophilia early arthropathy detection with ultrasound
Dynamic evaluation of the soft-tissue area by palpation/ (HEAD-US), 153
gentle compression, 294 Haglund-Sever’s disease, 42
Dynamic ultrasound examination, 221 Hemarthrosis, 15
Dynamic ultrasound imaging, 185 Hematoma, 168, 220, 221
Hemophiliac arthropathy, 149, 150, 152, 153
Hemorrhagic bursitis, 19
E Heterotopic ossification, 227
Edema, 168 High volume injection, 268
Emergency condition, 159 Higher frequency probes, 6
Endotenon, 28 Hill-Sachs lesion, 158
Entheseal tear, 42 Hyaline cartilage, 3–6
Enthesitis, 92 Hyaline cartilage calcifications, 106
Enthesopathy/insertional tendinopathy, 40, 178, 179 Hydroxyapatite, 108
Entrapment neuropathy Hypertrophic or hyperplasic synovial thickening, 16
features, 194
of lower limb
CPN, 203, 204 I
DPN, 205, 206 Iliopsoas bursitis, 260
interdigital nerves, 207, 208 Inferior calcaneal nerve (ICN), 207
LFCN, 202 Infraclavicular block, 280, 281
medial proper plantar digital nerve, 208 Injury
sciatic nerve, 203 examination, 160
Index 299

mechanism of, 160 Metabolic diseases, 119

muscle (see Muscle injury) Morel-Lavallée lesions, 225, 226
periosteal color Doppler flow, 161 Morton neuroma, 207, 208
In-plane US imaging, 256 Multiloculated abscesses, 294
Insertional tendinopathy, 40 Munich consensus classification, 164
Interdigital nerves (IN), 207, 208 Muscle bundles, 52
Intermuscular fluid collection, 174 Muscle healing process, complications, 222, 224, 226
Interscalene block, 280 Muscle hernias, 224, 225
Interstitial lung disease (ILD), 116, 117 Muscle injury
Intra- and peri-articular injection, 253 classification, 164
Intra-articular injection at the level of the hip, 260 direct trauma, 169
Intra-articular steroid injection, 253 indirect trauma, 170–173
Intratendineous partial tear, 180 mechanism of injury, 164
Intrinsic capsular ligaments, 31 complications, 173, 175
Isokinetic group, 164 magnetic resonance imaging, 164
ultrasound
advantages, 165
J color Doppler, 166
Jogger’s foot, 206, 207 disadvantages, 165
Joint and bursal infiltration, 253, 255–257 follow up, 167
Joint cavity widening, 83 non-structural injury, 167
Juxta-articular osteoporosis, 82 power Doppler, 166
structural injury, 168
tissue distortion, 167
K Muscle strain, 58
Kellgren-Lawrence score, 73 Muscles
Kiloh-Nevin syndrome, 201 contralateral muscle, 54
Knee menisci, 6 inflammatory and degenerative diseases, 55–57
Kocher criteria, 144 muscle morphology, 52
muscle thickness, 53
muscular fibers, 49
L pennate-type muscles, 50
Lacerations, 169 skeletal muscle architecture, 51
Lateral (in-plane) approach, 260 traumatic injury, 57–60
Lateral femoral cutaneous nerve (LFCN) block, 202, 287 ultrasound, 55
Ledderhose disease, 69 Muscular fibers, 49
Leukocyte-and platelet-rich plasma (L-PRP), 270 Muscular ruptures, 58
Ligament tears, 45–46 Musculocutaneous nerve (MCN), 196
Ligaments, 31 Musculoskeletal system, 251
Lipohemarthrosis, 16 Musculoskeletal ultrasound scoring methods, 234, 236,
Lipomas, 68 238–241
Liposclerosis, 67 Myofibrils, 50
Long bones, 7 Myositis ossificas (MO), 223, 224
Long head of biceps brachii (LHBB), 182
Lower limb ultrasound guided blocks, 282, 283, 285,
287, 289 N
Neoangiogenesisis, 17
Neovascularization, 217
M Nerve compressive syndromes, 63
Maffulli-Chan classification, 164 Nerve stretching syndromes, 64
Medial hallucal digital nerve, 208 Non-communicating bursitis, 18–19
Medial plantar nerve (MPN), 206, 207 Nonsteroidal anti-inflammatory drugs (NSAIDs), 274,
Medial proper plantar digital nerve, 208 276
Median, radial and ulnar nerves, 282 Non-structural muscle injuries, 171, 172
Medullary cavity (endosteum), 7 Notta-Nelaton’s disease, 37
Meniscal cyst, 23
Meniscal extrusion, 22
Meniscal lesions, 22–24 O
Menisci, 14 Obturator nerve block, 285, 287
Meniscocapsular separation, 24 Osgood-Schlatter’s disease, 42
300 Index

Osseous and cartilagineous surface Power Doppler module, 260

bone fracture, 9 Power Doppler ultrasound (PDU), 216
bone tissue, 7 Precalcific stage, 130
cartilage, 3–6 Progressive myositis ossificans (PMO), 56
osteo-chondral degenerative changes, 8–9 Progressive ossificans fibrodysplasia of munchmeyer, 56
osteo-chondral erosive lesion, 9 Pronator syndrome, 201
Osteoarthritis (OA) Pseudo-thrombophlebitic syndrome, 20
cartilage damage, 76 Psoriatic arthritis, 92, 93
diagnosis and follow-up, 73, 74 characteristic features, 92
Kellgren-Lawrence score, 73 clinical examination, 93
musculoskeletal ultrasound (US), 74 clinical patterns, 92
osteophytes, 78 dactylitis, 92, 95
prevalence, 73 definition, 92
subclinical inflammatory features, 74 enthesitis, 92, 95, 96
synovial fluid, 75, 76 EULAR recommendations, 92
synovitis, 74, 75 juxta-articular osteoporosis, 93
therapeutic interventions, 73 tenosynovitis, 96, 98
Osteoarthritis Research Society International (OARSI) US assessment, 93
guidelines, 254 Pure platelet-rich fibrin (P-PRF), 270
Osteophytes, 78 Pure PRP (P-PRP), 270
Out of plane needle US visualization, 256 Pyarthrosis, 15
Outcome measures in rheumatology (OMERACT), 74 Pyrophosphate arthropathy, 105–108

P Q
Panniculitis, 68 Quadrilateral space syndrome (QSS), 196
Paratenonitis, 35–38 Quantitative analysis of CEUS, 242
Pennate-type muscles, 50
Periosteum, 7
Peripheral calcifications, 224 R
Peripheral entrapment neuropathies, see Entrapment Radial tunnel syndrome, 197, 198
neuropathy Recurrent hemarthrosis, 150
Peripheral nerve blocks, 251, 279, 280, 282, 283, 285, Reichel syndrome, 121
287, 289 Retinacula, 32, 182
Peripheral nerves Retinaculum, 29
acute traumatic injuries, 64–65 Rheumatic nodules, 67
Carpal tunnel syndrome, 63 Rheumatoid arthritis (RA)
electrodiagnostic testing, 61 annual incidence, 81
elevator technique, 62 anti-cyclic citrullinated peptide (ACPA) antibodies,
honeycomb, 62 82
interfascicular epineurium, 61 bone erosion, 84, 85
motor and motor-sensory nerves, 63 cartilage thinning, 85, 87
nerve compressive syndromes, 63 color Doppler and power Doppler modalities, 82
ultrasound measurement, 63 conventional radiography (CR), 82
Peritendinitis, 37–38 definition, 81
Peri-tendinous intra-synovial injection therapy with epidemiologic studies, 81
steroid, 256 EULAR, 82
Peroneal tendon groove refashioning, 229 inflammatory changes, 83
Peroneal tendons (PT), 228 initial evaluation, 82
Physiological cross-sectional area (PCSA), 52, 54 juxta-articular osteoporosis, 82
Pigmented villonodular synovitis (PVNS), 16, 125–127 joint pain and swelling, 82
Plantar fibromatosis, 69 laboratory tests, 82
Platelet-rich plasma (PRP), 270 MRI, 82
Pneumohydrarthrosis, 16 OMERACT/EULAR ultrasound, 83
Polymyositis, 56 prevalence, 81
Postcalcific stage, 130 rheumatoid factor (RF), 82
Posterior interosseous nerve (PIN) syndrome, 197, 198 symptoms, 82
Posterior tibial nerve (PTN), 206 synovitis, 83, 84
Post-traumatic re-rupture, 230 tendon damage, 88, 89
Power Doppler imaging, 221 tenosynovitis, 87, 88
Index 301

2010 ACR/EULAR criteria, 82 Supraclavicular block, 280

US evaluation, 82, 83 Supracondylar process syndrome, 200
Rheumatology, 55 Suprapatellar scanning, 6
generalities in ultrasound-guided procedures, 253, Suprascapular nerve (SSN), 194–196
255–258 Susceptibilityweighted imaging (SWI), 132
Rodnan skin score, 114 Syndesmosis, 188
Rotator cuff, 226 Synovial calcification, 21
Synovial cavities, 11, 12
Synovial fluid aspiration, 253
S Synovial fluid calcifications, 106
Scapho-lunate joint, 21 Synovial ganglia, 21
Scapholunate ligament disruption, 186–188 Synovial hyperplasia, 151
Scar tissue, 220, 221 Synovial membrane, 12
Sciatic nerve blocks, 203, 287–291 Synovial osteochondromatosis
Septic arthritis, 143, 144, 146 diagnostic imaging, 122, 123
Septic bursitis, 19 Reichel syndrome, 121
Serohemorrhagic cyst, 175 secondary synovial chondromatosis, 121
Seronegative spondyloarthritis stage 1, 121
bacterial infections, 92 stage 2, 121
classification, 91 stage 3, 121
HLA-B27 antigen, 91 symptoms, 122
joint involvement, 93 Synovial spaces
musculoskeletal manifestations, 91 bursitis, 18–21
prevalence, 91 endo-articular loose bodies, 24–25
psoriatic arthritis, 92, 93 joint effusion, 15–16
Serous myositis, 55 meniscal lesions, 22–24
Seven-joint US composite scoring system, 239 proliferation, 16–18
Shear wave elastography, 34 sonographic and Doppler normal anatomy, 11–15
Short bones, 7 synovial calcification, 21
Shoulder calcific tendinitis, 130 synovial inflammation, 16–18
Shoulder calcifications Synovitis, 74, 75, 83, 84
clinical outcome, 276 Systemic lupus erythematosus (SLE), 113, 114
complications, 277 Systemic sclerosis, 114
pre-procedural phase, 274–276
ultrasonography, 273
x-ray, 273 T
Sinding-Larsen-Johansson’s disease, 42 Tarsal tunnel syndrome, 206
Sjögren’s syndrome, 114–116 Tendinopathy, 267
Skeletal muscle architecture, 51 Tendinosis, 39, 40, 177, 178
Skeletal muscle healing, 220 Tendon and muscle rupture repair, 219–221, 223–228,
Sliding tendons, 28 230
Sonoelastography (SEL), 33 Tendon cysts, 45
Spinoglenoid (inferior) notch, 195 Tendon damage, 88, 89
Spiral groove syndrome, 197 Tendon dislocations, 42–45, 182, 183
Spontaneous bleeding, 150 Tendon infiltrative treatments
Stener lesion, 186 high volume injection, 268
Steroi/hyaluronic acid injection, 253 synovial sheath injection, 268
Strain elastography, 34 Tendon regenerative treatments
Stress fractures, 160, 161 adipose-derived mesenchymal stem cells, 271
Structural muscle injuries, 172, 173 dry-needling, 270
Subperiosteal hematoma, 188 platelet-rich plasma, 270
Superficial abscesses, 293 Tendon rupture, 42, 180, 182
Superficial interosseous ligaments Tendon sheath effusion, 87
ankle interosseous ligaments, 188–190 Tendon sheath widening, 87
coraco-clavicular ligaments, 188 Tendon trauma
coraco-humeral ligament, 188 dislocations, 182, 183
scapholunate ligament disruption, 186–188 enthesopathy/insertional tendinopathy, 178, 179
Stener lesion, 186 etiological factors, 177
Superficial peroneal nerve (SPN), 204, 205 tendinosis, 177, 178
Supinator syndrome, 197, 198 tendon rupture, 180, 182
302 Index

Tendons and ligaments Tibial nerve (TN), 206, 207

degenerative and inflammatory enthesopathy, 40–42 Traumatic injury, 57–60
entheseal tear, 42 Triangular fibrocartilage complex (TFCC), 6
ligament tears, 45–46 Triangular fibrocartilage proper (TFC), 14
myotendinous junction, 28
osteotendinous junction, 28
paratenonitis, 35–38 U
SEL, 34 Ultrasonography, 273
shear wave elastography, 34 Ultrasound after tendon surgery repair, 226–230
shock absorber, 28 Ultrasound grading system for joint effusion, 234
sliding and anchor tendons, 31 Ultrasound guided treatment, 251
slow metabolism, 27 Ultrasound-guided drainage of soft tissues abscesses, 294
strain elastography, 34 Ultrasound-guided haematoma evacuation, 294, 295
structure of ligaments, 32 Ultrasound guided hyaluronic acid injection, 261
tendinosis, 39, 40 Ultrasound-guided percutaneous irrigation of calcific
tendon cysts, 45 tendinopathy (US-PICT), 274
tendon dislocation, 42–45 Ultrasound-guided upper limb nerve blocks, 279–282
tendon rupture, 42 US scanning approach, 6
tendons controlling multiplanar movement, 28 Ultrasound scoring systems, 234–237
thickness, 31
Tenosynovial sheath, 28
Tenosynovitis, 36, 37, 87, 88, 96, 98, 268 V
Therapeutic options Viscosupplementation, technique and indications,
arthroscopy, 274 258–261
extracorporeal shockwaves, 274
percutaneus irrigation, 274
subacromial steroid injections, 274 W
Therapy efficacy evaluation in synovitis, 233, 234, 236, White cartilage, 3
237, 239–242, 244