1. Jenelle Beadle, RDMS Inland Imaging November 4 th, 2014

2. Muscles, tendons, ligaments & bursae Histologic anatomy and ultrasound appearance correlation Common abnormalities visualized using ultrasound Muskuloskeletal Sonography

3. …650 skeletal muscles. …4000 tendons. …900 ligaments. … 160 bursae. In the human body, there are…

4. Muscles Isoechoic/hypoechoic (compared to fat) Linear hypoechoic bundles (fascicles) surrounded by echogenic perimysium

5. Epimysium & Fascia: single, hyperechoic line at the muscle boundary (arrows) Perimysium: innumerable hyperechoic lines (arrowheads) Fascicles: hypoechoic bundles of muscle fibers in between

6. Muscles are typically evaluated with ultrasound for pain and/or a palpable abnormality. Often times with a history of traumatic injury Most common abnormal findings include strains/tears and tumors. Adductor Magnus Muscle Gastrocnemius RuptureNormal Intramuscular Sarcoma Intramuscular Myxoma

7. Muscle strains/tears most commonly occur in the lower extremity typically near the musculotendinous junction severity of muscle strain injuries are graded I, II or III Strain (Grade I): pain; resolves in about 2 weeks normal thickened and hyperechoic

8. Muscle strains/tears most commonly occur in the lower extremity typically near the musculotendinous junction severity of muscle strain injuries are graded I, II or III Strain (Grade I): pain; resolves in about 2 weeks normal thickened and hyperechoic With a contusion, echogenicity may cross fascial boundaries.

9. Tear (Grade II): pain with loss of function; resolves in about 4 weeks intrasubstance tears; detachment from fascia or aponeurosis disruption of striated pattern intramuscular fluid collection with hyperechoic halo (hypervascular) “Tennis Leg” Trans Long

10. Avulsion (Grade III): pain with loss of function, usually caused by strong contraction against firm resistance myotendinous (muscle to tendon) or tendoosseous (tendon to bone) complete discontinuity of muscle fibers; hematoma Musculotendinous junction tear

11. Tendons (muscle-to-bone) Echogenic (compared to muscle) Linear fibril bundles of collagen in a supporting matrix Short axis: “finely punctate pattern” multiple echogenic dots Long axis: “fibrillar architecture” multiple, closely spaced parallel lines Long Patellar Tendon Trans Long

12. Anisotropy artifact Trans Achilles Tendon Anisotropy

13. Tendinopathy Sonographic evaluation: size/thickness, contour and echotexture Dynamic scanning can also be helpful Tendinosis thickened, hypoechoic, hypervascular; may have some loss of fibrillar pattern occurs with or without tendon tears Acute: strained by traumatic injury Chronic: general wear-and-tear (age-related changes, inflammatory disorders) may have calcifications present (calcific tendinosis); round or linear in shape Chronic tendinosis predisposes a tendon to further injury As a result, tendons that typically affected by overuse or degeneration are also the tendons most commonly strained or torn. Supraspinatus, achilles, patellar, quadriceps and common extensor (elbow) tendons

14. Achilles Tendinosis

15. Common Extensor Tendinosis (lateral epicondylitis) “Tennis Elbow” (although 95% are not in tennis players) usually results from repetitive motion injuries (chronic) Normal Common Extensor Tendon Our personal favorite form of chronic tendonosis…

16. Supraspinatus TendonisisQuadriceps/Patellar Tendinosis

17. Tendon Tears/Ruptures Acute or Chronic most tendon tears are a result of chronic overuse rather than acute trauma Associated with adjacent tendinosis makes identifying small partial tears difficult Ultrasound Findings (often more easily appreciated with dynamic scanning) partial/complete nonvisualization distinct focal hypoechoic/anechoic defect apparent disruption of linear fibrillar architecture contour abnormality Most commonly torn tendons are supraspinatus and achilles Tears are categorized partial full thickness (complete rupture)

18. Partial Tear a portion of the tendon remains intact includes “intratendinous” tears Long Common Extensor Tendon Long Distal Biceps Tendon Long Achilles Tendon Trans Peroneal Longus/Brevis Tendons

19. Partial Tear with a large partial tear, some retraction of the torn tendon may be identified Long Quadriceps Tendon Trans Achilles Tendon

20. Full Thickness Tear rupture that extends across the entire width and depth of the tendon proximal muscular retraction of the entire tendon non-functional tendon distal at insertion Long Achilles Tendon ProxDist Long Patellar Tendon

21. Complete achilles rupture with intact plantaris tendon absent 7-20% Trans Achilles Rupture Long Achilles Rupture

22. Ligaments (bone-to-bone) Isoechoic/hypoechoic (compared to tendons) Similar composition as tendons, but fibers are less organized structure; more of an interlaced, woven pattern. Fibrillar pattern, but slightly changing the orientation of the tranducer will bring other fibers into view. This less regular structure is what makes ligaments slightly less echogenic than tendons. Injury is often associated with joint derangement (acute). Sprain: stretching or tearing of a ligament (“strain”- tendon) Range from invisible “micro-tears” to complete rupture Most commonly injured ligaments are in the knee and ankle

23. Ankle Ligaments Anterior Talofibular Ligament (most commonly injured) anterior lateral malleolus to anterior talus best seen in w/ tendon stressed (plantar flexion) injured with supination (lateral rotation of the ankle) iIsolated, or associated with Calcaneofibular Ligament (up to 70%) peroneal tendons

24. Ligament Sprain/Rupture Thickened & hypoechoic with surrounding fluid Evidence of tear may be seen (hypoechoic area that interrupts fibers) “a”: anterior talofibular ligament “b”: calcaneofibular ligament Curved lines: peroneal tendons Ruptured Anterior Talofibular Ligament Normal

25. Knee ACL: Anterior Cruciate Ligament (can’t be seen well enough with ultrasound) PCL: Posterior Cruciate Ligament (not commonly injured) Lateral Collateral Ligament (not commonly injured) Medial Collateral Ligament Medial Meniscus (purple) & Medial Collateral Ligament (green)

26. Bursae Thin layer of anechoic fluid (synovial) surrounded by hyperechoic walls. Not typically visualized unless abnormal. Synovial-lined sac overlying bony surfaces at areas of tendon friction. Some communicate with the joint space (ex: semimembranosus bursa) Baker’s Cyst (Popliteal Cyst) typically communicates with the joint capsule via the semimembranosus bursa.

27. Bursitis: Repetitive motion and overuse Inflammatory disorders (rheumatoid arthritis, gout, etc.) Shoulder, elbow, hip & knee Most common site: Subacromial Bursa (shoulder) Does not normal communicate with the joint space, but can if there is a full thickness tear. Subacromial Bursitis

28. Other common sites of bursitis… Prepatellar Bursa (“housemaid’s knee”) Infrapatellar Bursa (“clergyman’s knee”) Prepatellar Bursitis Deep Infrapatellar Bursitis Infrapetellar Bursitis

29. Other common sites of bursitis… Trochanteric (lateral hip) Trochanteric Bursitis (Deep) Between the greater trochanter and the gluteus medius muscle insertion. Trochanteric Bursitis Gluteus Medius Insertion

30. Other common sites of bursitis… Iliopsoas Bursa Long Iliopsoas Bursitis Trans Iliopsoas Bursitis

31. Other common sites of bursitis… Olecranon Bursa (“student’s elbow”) Triceps Tendon Long Olecranon Bursitis Trans Olecranon Bursitis

32. “Skeletal Muscle Ultrasound” European Journal Translational Myology 2010; 1 (4): 145- 155 “Ultrasonographic Findings of Musculoskeletal Tissues” J Korean Orthop Assoc. 2013 Oct;48(5):334-341 “Sonography of Common Tendon Injuries” American Journal of Roentgenology. 2009;193: 607-618 “Tendon and Ligament Imaging” Br J Radiol. Aug 2012; 85(1016): 1157–1172 “Imaging of the Bursae” J Clin Imaging Sci 2011; 1:22 “Ultrasonography of tendon abnormalities” OA Musculoskeletal Medicine 2013 Jun 01;1(2):12 “Sonography of Lower Limb Muscle Injury” American Journal of Roentgenology. 2004;182: 341-351 “Full Thickness and Partial Thickness Supraspinatus Tendon Tears” Radiology 2004; 230:234–242 “Long Head of Biceps Brachii Tendon Evaluation...” AJR 2011; 197:942–948 “Ultrasound of the Shoulder” JBR–BTR, 2007, 90: 325-337 Gaitini D. “Shoulder Ultrasonography: Performance and Common Findings” J Clin Imaging Sci 2012; 2: 38-38 Read J, Perko M. “Ultrasound Diagnosis of Subacromial Impingement for Lesions of the Rotator Cuff” AJUM May 2010; 13 (2): 11-15 References

33. http://www.sonoguide.com/soft_tissue.html http://www.dynamicultrasound.org/dugphysics.html http://www.ultrasoundcases.info/Slide-View.aspx?cat=405&case=1858 http://www.ultrasoundcases.info/Slide-View.aspx?cat=405&case=1858 http://www.shoulderdoc.co.uk/article.asp?section=904 http://www.radiologyassistant.nl/en/p50cf8392cbd97/us-guided- injection-of-joints.html http://www.radiologyassistant.nl/en/p50cf8392cbd97/us-guided- injection-of-joints.html http://radiopaedia.org/articles/posterosuperior-impingement-of-th- shoulder http://radiopaedia.org/articles/posterosuperior-impingement-of-th- shoulder References (continued…)