Musculoskeletal ultrasound (MSK US) involves the use of high-frequency (up to 17 MHz) sound waves to image soft tissues and bony structures in the body for the purposes of diagnosing pathology or guiding real-time interventional procedures.
Epidemiology including risk factors and primary prevention
During the past decade an increasing number of physiatrists have integrated MSK US into their practices to facilitate the management of patients presenting with a wide variety of musculoskeletal and neurological complaints. Ultrasound is currently the fastest growing diagnostic and therapeutic (image assistive) imaging modality among physiatrists and other clinicians managing patients with musculoskeletal disorders (e.g., rheumatologists, sport medicine physicians, podiatrists). Recognizing the utility and value of low-cost, high-resolution, and dynamic musculoskeletal imaging, in conjunction with a comprehensive clinical exam, use of ultrasound as a first line medical diagnostic tool has grown recently in part due to the integration of the imaging modality into training curricula for residency and fellowship programs, as well as expanding treatment options for physicians.1,2,3,4 There are no known risk factors or contraindications to the use of US by a qualified practitioner.
An ultrasound imaging device consists of the transducer, a transmitter to direct electric current to the transducer, a receiver to perceive and amplify signals, a monitor display for real-time video display, and, likely, a digital storage medium for collected images and video5. Each transducer contains many thin crystals that are stimulated by electrical voltage, which by the reverse piezoelectric effect, generates ultrasound waves in complex patterns. These waves travel through the body, where they encounter acoustic interfaces (areas between adjacent tissue layers where tissue density and/or stiffness changes). At each acoustic interface, some sound is reflected back to the transducer, which then serves as an antenna and by the piezoelectric effect, generates the electric signal needed to process the information and generate a two-dimensional black and white image known as B-mode US. The ability to detect subtle acoustic interfaces allows modern MSK US machines to resolve structures with a resolution of less than 1 mm. The combination of submillimeter resolution and real-time imaging has positioned MSK US as a powerful clinical problem-solving tool in physiatric practice.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Current applications include, but are not limited to:
- Diagnosis of tendinosis, partial- and full- thickness tendon tears (g.,rotator cuff, patellar tendon, Achilles tendon).
- Diagnosis of nerve entrapments (g.,carpal tunnel syndrome, ulnar neuropathy at the elbow, tarsal tunnel syndrome).
- Evaluation of ligamentous injury and joint instability syndromes such as valgus instability of the elbow or varus instability of the knee.
- Evaluation of dynamic complaints such as subluxating/dislocating ulnar nerves, snapping popliteus tendons, snapping hip syndrome, and peroneal tendon subluxation/dislocation.
- Diagnosis of acute (g.,contusion or strain) or chronic muscle injury (myopathy or denervation).
- Joint aspiration/injection, peri-tendinous injection, or peri-neural injection, in which US can be used to accurately and efficiently guide the needle to the target region.
- Aspiration and injection of various fluid collections (g.,Baker’s cyst, olecranon bursitis).
- Percutaneous lavage and aspiration of calcific rotator cuff tendinosis.
- Advanced procedures such as percutaneous tenotomy and precise delivery of biologics and regenerative therapies such as platelet-rich plasma and stem cells.
Specific secondary or associated conditions and complications
There are essentially no contraindications to a MSK US examination. MSK US examinations are unaffected by claustrophobia, impart no radiation to the patient or examiner, and unlike magnetic resonance imaging (MRI) and computed tomography (CT) are relatively unaffected by prostheses and other orthopedic hardware. Studies have shown that patients with shoulder complaints prefer US over MRI scan.6-8 Furthermore, US is an excellent tool to investigate tendon disorders and fluid collections associated with orthopedic implants [9-12].
2. ESSENTIALS OF ASSESSMENT
As a dynamic imaging study, MSK US is best utilized in the context of a patient-specific clinical history and physical examination. A typical required MSK history includes:
- Onset of injury
- Pain location, quality, character, aggravating/alleviating factors
- Neurological concerns
Diagnostic US examinations should follow established protocols. During a US examination, many physical examination maneuvers can be performed to assess dynamic aspects of musculoskeletal pathology not visualized on static imaging modalities such as X-rays, CT, or MRI. Consequently, MSK US examinations are most effective when performed in conjunction with a standard physical examination of the affected region, consisting of:
- Range of motion
- Neurological examination
- Special (named) tests
Perhaps the most important advantage of MSK US is the ability to assess MSK structures in a dynamic or functional state. Real-time MSK US imaging is the only imaging modality currently available to dynamically evaluate soft-tissue structures, thus facilitating the investigation of dynamic processes such as nerve instability and snapping tendons or bursae. In addition, through “sonopalpation,” the physiatrist can place the probe directly over the point of pain or other complaint and correlate pathologic findings with reproduction of symptoms. Abnormalities should be measured using short and long axes, perpendicular to the area of interest . Patient positioning for specific examinations may vary depending on the indication, clinical condition, and patient’s age .
Although the many advantages of MSK US render it an attractive, office-based imaging modality for clinical practice, every physiatrist should be aware of three important limitations of MSK US:
- Limited penetration: US beams lose energy as a function of depth. The rate of this energy loss is dependent on frequency. High frequency transducers (> 10 MHz) provide submillimeter resolution, but may penetrate only 2-3 cm into the body. Lower frequency transducers may penetrate 7-10 cm or more, but with reduced resolution. Thus, depending on the desired resolution, the diagnostic capabilities of MSK US may be reduced when evaluating deep body regions such as the hip or in patients of large body habitus. US does not effectively penetrate normal bone. Consequently, US cannot be used to evaluate bone marrow disorders and provides only a limited view of most joint surfaces.
- Equipment cost: In a way similar to electrodiagnostic equipment, physiatrists must generally purchase or rent MSK US machines in order to effectively integrate MSK US services into their practices. Although US machine quality continues to improve, there are significant differences among available models. Cost will generally be determined by resolution and the number of probes purchased. Luckily, there are numerous high-quality machines currently available to meet the needs and budgets of most physiatric practices.
- Operator dependence: The clinician must recognize the abnormality and appropriately interpret it. However, similar to electrodiagnostic examinations, MSK US also requires the physiatrist to physically acquire the information. Acquiring the skill of optimal image acquisition often provides the greatest challenge to most physiatrists who are seeking to integrate MSK US into their practices.
Early predictions of outcomes
US can improve patient outcome by offering more precise diagnostic and treatment locatizations in real time, often without delays or high costs seen with other imaging modalities such as MRI.13-18, 29, 30 Furthermore, ultrasound guidance for interventional procedures confers improved precision and, potentially, greater efficacy when compared to landmark guided injections.19-23 When compared to radiographic imaging, ultrasound can be used to identify early bone changes, such as subclinical synovitis or early bony erosions that the former cannot readily identify.24-28
A key advantage of MSK US is the ability to study structures right in the office setting as a supplement to the history and physical exam.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Many of the conditions identified with MSK ultrasound respond most favorably in the initial treatment phase to supervised active rehabilitation. A role of US in society is to hopefully reduce health care costs by reducing the need for expensive MRI studies in many cases. Also the immediacy of diagnosis reduces anxiety for the patient. Proper training is essential before adding this modality to a musculoskeletal practice.3,13
At different disease stages
The presence or extent of Doppler flow may also reflect the severity or chronicity of a tendon or ligament disorder.32-34 Although not currently FDA-approved specifically for the purposes of a musculoskeletal ultrasound examination, US contrast agents will likely expand the applications of Doppler US, including the possibility of identifying viable tissue and/or monitoring tissue healing via precise assessment of vascularity.35-36
Coordination of care
Physiatrists skilled in musculoskeletal medicine and employing ultrasound guided techniques still must remain grounded in coordinating multidisciplinary treatment approaches to care of the patient designed to maximize functional outcomes.
Patient & family education
Patients and family can be educated on their injury immediately at the time of diagnosis with US, versus waiting days or weeks for other advanced imagining modalities to be completed (example, MRI, CT, etc.) As clinicians continue to search for methods to improve medication adherence and health literacy among patient populations, musculoskeletal ultrasound has shown promise as a valuable visual aid to further expand patients’ understanding of their diagnoses.37
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
The integration of MSK US into residency and fellowship training is steadily evolving. While musculoskeletal ultrasound is not a mandatory requirement for ACGME accredited Sports Fellowship training, it has been incorporated into the education and skill training of the fellow for both diagnostic purposes and in learning MSK related interventional procedures. Residency training programs have begun to incorporate MSK US into curricula with, for example, Physical Medicine and Rehabilitation residency programs requiring trainees to perform at least 10 MSK US over their training period. 38. Other residency training programs, such as Emergency Medicine, have requirements for bedside ultrasound examinations, but not a specific number of MSK US scans.Rheumatology Fellowship training programs, in general, encourage proficiency in MSK ultrasound in order to obtain necessary certifications (for example, Registered in Musculoskeletal Sonography (RMSK) certification) for clinical practice 39-40. Furthermore, weekend courses, one-on-one mentorships, on-line learning,and independent practice are just a few methods that clinicians currently use to obtain training. As a result, there is great diversity among the skill sets of physiatrists currently utilizing MSK US in their practices. Therefore, it is important to adopt peer-reviewed, evidence based practice guidelines that reflect competence and provide practitioners guidance as to what they need to know in order to feel confident and competent in MSK US 41-44.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
The current applications for musculoskeletal ultrasound in clinical practice are broad and will continue to expand as ultrasound technology is rapidly improving.
Improvements in equipment such as matrix array transducers is an example of the type of probes likely to play an increasing role in musculoskeletal ultrasound. The composition of the crystals allow for near, middle and far field focusing at the high frequencies required for MSK application, thus providing superior resolution and tissue differentiation.45
Three dimensional ultrasound (3DUS) provides volumetric assessment of tissues which has already seen application in fetal and cardiac assessment.45 The primary feature of 3DUS is the ability to reconstruct volumetric data in any plane, providing in-depth anatomical detail to better evaluate soft tissue, muscle and tendons, as well as improved guidance for ultrasound procedures.46,47 One limitation is the operator must hold the transducer statically as the data is acquired, rendering it susceptible to errors.48 Furthermore, specialized transducers and software are required, and unfortunately, there is no commercially available software at this time.45,47
Color or power Doppler ultrasound can examine tissue vascularity and inflammatory conditions, but have limited sensitivity in low flowing vessels.47 Contrast-enhanced ultrasound (CEUS), consisting of gas microbubbles injected intravenously, can allow for precise assessment of vascularity by monitoring the flow and spread of the bubbles.47 Several studies has demonstrated that CEUS has a higher sensitivity than power Doppler to monitor patients with rheumatoid arthritis, active synovitis, assess soft tissue masses, as well as the vascularity of repaired rotator cuff tendons.47,49,50 This modality has been used in places across Europe and Asia, and in the near future may possibly be readily available in the United States.47
Fusion of ultrasound imaging with MRI or CT data using special equipment increases diagnostic accuracy, while negating the limitations of each type of imaging.47 This can assist in guiding biopsy needles and has been demonstrated to improve the accuracy of sacroiliac joint injections.51 However, this method can be time consuming and requires significant user skill.45
One emerging modality to visualize the elastic properties of tissue is called elastography. There are several methods of elastography with the primary concept being normal tissue has a different stiffness than pathological tissues.45 Different techniques apply a type of force, such as compression (sonoelastography) or acoustic (shear wave elastography) to the area of interest and the stiffness of the tissue is measured to determine pathology.47 The application in musculoskeletal disorders is to evalute soft tissues, muscles and tendons. Studies have demonstrated that elastography can differentiate between stiffer, healthy tendons and softer, symptomatic patients with tendinopathies with excellent diagnostic accuracy.52,53,54 It can also be employed to monitor treatment and training protocols in athletes with tendinopathies, without the use of expensive MRI scans.45,47At present, the transducer frequencies used are not high enough to study the most superficial structures with clarity, but there is promising results for the future.45
Advancements in technology have given rise to ultrasound guided percutaneous procedures which are minimally invasive and are associated with lower risk of infection, wound dehiscence, decreased pain while having faster healing and return to activities compared to surgical approaches.55 Trigger finger A1 pulley release and carpal tunnel transection are examples of procedures that are showing improved outcomes in comparison to open surgery.47,55,56 Ultrasound guided tendon fenestration or tenotomy, involves passing a needle through a chronic tendinopathy in order to cause an acute reaction that is theoretically more likely to heal.57 When used with ultrasound, it can enhance the accuracy and guidance of the fenestrating needle.47 It is an alternative to surgical procedures and although some preliminary studies have shown improvement in symptoms, more long term research is required.57 Tenex, a handheld instrument for ultrasound guided percutaneous ultrasonic tenotomy was recently approved by the FDA in order to debride and emulsify tendinopathic tissue. In a case series, Tenex was shown to provide lasting symptom relief from lateral epicondylosis3 years post procedure.45,58
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
The role of musculoskeletal ultrasound as a clinical problem-solving tool in physiatric practice is already well established. Multiple studies have documented the utility of diagnostic US when performed by competent individuals.60 For example, a recent a meta-analysis concluded that MSK US is equally accurate to MRI to evaluate the rotator cuff.60 Further research will be necessary in order to define the specific indications for diagnostic musculoskeletal ultrasound. With respect to interventional procedures, there is strong, consistent evidence that using ultrasound guidance improves accuracy of various types of injections, however there is currently limited evidence that they are more efficacious or cost effective than landmark guided injections.61 As concerns are raised pertaining to overutilization, further research and consensus should seek to define specific circumstances in which US guidance adds value in terms of improved patient safety, increased procedural efficiency, improved efficacy, or reduced cost. Lastly, with numerous emerging technologies in the field of musculoskeletal ultrasound, there is a need for quality research to determine the appropriate treatment for specific conditions.61
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Original Version of the Topic
Jay Smith, MD. Ultrasound Imaging of Musculoskeletal Disorders. 01/24/2013.
Andrew Beaufort, MD
Nothing to Disclose
Richard G Chang, MD, MPH
Nothing to Disclose
Kameron Bazmi, MD
Nothing to Disclose