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Normal Ultrasound Anatomy
of the Musculoskeletal System
Enzo Silvestri • Alessandro Muda •
Luca Maria Sconfienza
Editors
Normal Ultrasound
Anatomy of the
Musculoskeletal
System
A pratical guide
Presentazione di
Lisa Licitra, Patrizia Olmi
123
Editors
Enzo Silvestri
Ospedale Evangelico Internazionale
Unit of Radiology
Genoa, Italy
Alessandro Muda
University Hospital “San Martino”
Unit of Radiology
Genoa, Italy
Contributors
Emanuele Fabbro, MD
Giulio Ferrero, MD
Chiara Martini, MD
Davide Orlandi, MD
Post Graduate School of Radiodiagnostic
University of Genoa
Genoa, Italy
Luca Maria Sconfienza
IRCCS Policlinico San Donato
Unit of Radiology
San Donato Milanese (MI), Italy
DOI 10.1007/978-88-470-2457-1
Springer Milan Dordrecht Heidelberg London New York
Library of Congress Control Number: 2011941514
© Springer-Verlag Italia 2012
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in the absence of a specific statement, that such names are exempt from the relevant protective laws and regula-
tions and therefore free for general use.
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contained in this book. In every individual case the user must check such information by consulting the relevant
literature.
9 8 7 6 5 4 3 2 1 2012 2013 2014
Cover design: Ikona S.r.l., Milan, Italy
Typesetting: Graphostudio, Milan, Italy
Printing and binding: Printer Trento S.r.l., Trento, Italy
Printed in Italy
Springer-Verlag Italia S.r.l. – Via Decembrio 28 – I-20137 Milan
Springer is a part of Springer Science+Business Media (www.springer.com)
ISBN 978-88-470-2456-4 ISBN 978-88-470-2457-1 (eBook)
The use of Ultrasound has become widely accepted as an imaging modal-
ity in assessment of the musculoskeletal system, as it is quick, cheap, and
readily available. Also, recent technological improvements in this field have
demonstrated that this imaging modality can provide extremely useful infor-
mation to diagnose and treat musculoskeletal diseases.
When first approaching musculoskeletal ultrasound, many obstacles may
be encountered: for example, it may be difficult at first to position the probe
correctly, or the ultrasound images may not be correctly interpreted. Also,
the high number of artifacts and pitfalls that can be encountered in clinical
practice may further complicate the approach to this imaging modality. Fi-
nally, most medical professionals find it difficult to remember the normal
anatomy of the musculoskeletal system.
For these reasons, we decided to prepare this handbook, which aims to
be a quick and practical reference in daily routine. It is based on a distance-
learning project, prepared in 2010 for Italian radiologists, orthopedists, and
rheumatologists. We wanted to keep the text as concise as possible, to allow
plenty of space for anatomical schemes, pictures of anatomical landmarks
for a better understanding of the correct placement of the probe, and ultra-
sound images, highlighting the most relevant anatomical structures of the
main joints: shoulder, elbow, hand and wrist, hip, knee, ankle and foot. In
addition, an initial chapter dealing with basic principles of musculoskeletal
ultrasound is included.
Finally, we acknowledge the hard work of our colleagues Emanuele Fab-
bro, Giulio Ferrero, Chiara Martini, and Davide Orlandi, whose help with
drawing most anatomical schemes and acting as models for anatomical pic-
tures made an invaluable contribution to this book.
Genoa, November 2011 Enzo Silvestri
Alessandro Muda
Luca Maria Sconfienza
Preface
v
vii
01 Basic Principles of Musculosketal Ultrasound . . . . . . . . . . 1
1.1 Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Peripheral nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Cartilage and bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
02 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1 Long Head of Biceps Brachii Tendon (LHBBT) . . . . . . 9
2.2
Subscapularis Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Supraspinatus Tendon and Subacromial-Subdeltoid
Bursa (SASD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Coracoacromial Ligament . . . . . . . . . . . . . . . . . . . . . . . 20
2.5 Infraspinatus and Teres Minor Tendons . . . . . . . . . . . . . 21
2.6 Acromion-Clavicular Joint . . . . . . . . . . . . . . . . . . . . . . 21
03Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1.1 Distal Tendon of Biceps Brachii
. . . . . . . . . . . . . . 27
3.1.2. Anterior Joint Recess . . . . . . . . . . . . . . . . . . . . . . 30
3.1.3 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.1.4 Radial and Posterior Interosseous Nerves . . . . . . 30
3.2 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.1 Common Extensor Tendon . . . . . . . . . . . . . . . . . . 35
3.2.2 Humeral-Radial Joint . . . . . . . . . . . . . . . . . . . . . . 35
3.3 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.3.1 Common Flexor Tendon . . . . . . . . . . . . . . . . . . . . 38
3.3.2 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 38
3.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.4.1 Triceps Brachii Muscle and Tendon . . . . . . . . . . . 41
3.4.2 Olecranon Fossa and Posterior Olecranon Recess 41
3.4.3 Cubital Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 41
04 Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 Palmar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1.1 Carpal T
unnel and Median nerve . . . . . . . . . . . . . 45
Contents
4.1.2 Guyon Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 50
4.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.2.1 Extensor Tendon Compartments . . . . . . . . . . . . . . 51
4.2.1.1 First Compartment . . . . . . . . . . . . . . . . . . . . . 51
4.2.1.2 Second Compartment . . . . . . . . . . . . . . . . . . . 54
4.2.1.3 Third Compartment . . . . . . . . . . . . . . . . . . . . . 56
4.2.1.4 Fourth and Fifth Compartment . . . . . . . . . . . . 58
4.2.1.5 Sixth Compartment . . . . . . . . . . . . . . . . . . . . . 60
4.2.2 Distal Radio-Ulnar Joint . . . . . . . . . . . . . . . . . . . . 60
05 Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1 Ventral Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.1 P
almar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.2 Flexor Digitorum Tendons . . . . . . . . . . . . . . . . . . 64
5.1.3 Metacarpophalangeal and Interphalangeal Joints . 68
5.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.2.1 Extensor Digitorum Tendons . . . . . . . . . . . . . . . . 71
06 Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Anterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.1 Sartorius and Tensor F
asciae Latae . . . . . . . . . . . . 76
6.1.2 Rectus Femoris . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.1.3 Iliopsoas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.1.4 Femoral Neurovascular Bundle . . . . . . . . . . . . . . 82
6.1.5 Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.2 Medial Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.2.1 Adductor Tendons and Muscles . . . . . . . . . . . . . . 85
6.3 Lateral Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.3.1 Gluteus Tendons and Muscles . . . . . . . . . . . . . . . 86
6.4 Posterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.4.1 Ischiocrural Tendons (Hamstrings) . . . . . . . . . . . . 89
6.4.2 Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
07Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.1 Quadriceps Tendon
. . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.2 Suprapatellar and Paracondylar Recesses . . . . . . . 96
7.1.3 Femoral Trochlea . . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.4 Patellar Retinacula . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.5 Patellar Tendon or Ligament . . . . . . . . . . . . . . . . . 100
7.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.2.1 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 102
7.2.2 Goose’s Foot Tendons . . . . . . . . . . . . . . . . . . . . . . 102
7.3 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.1 Iliotibial Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.2 Lateral Collateral Ligament . . . . . . . . . . . . . . . . . 105
7.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 108
Contentsviii
7.4.1 Medial Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.4.2 Semimembranosus Bursa . . . . . . . . . . . . . . . . . . . 108
7.4.3 Popliteal Neurovascular Bundle . . . . . . . . . . . . . . 110
7.4.4 Posterolateral Corner and Biceps Femoris Tendon 111
7.4.5 Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
0
08 Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1.1 Anterior Talo-Fib
ular Ligament . . . . . . . . . . . . . . 116
8.1.2 Anterior Tibio-Fibular Ligament . . . . . . . . . . . . . 118
8.1.3 Calcaneo-Fibular Ligament . . . . . . . . . . . . . . . . . 119
8.1.4 Peroneal Tendons . . . . . . . . . . . . . . . . . . . . . . . . . 119
8.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.1 Deltoid Ligament . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.2 Tarsal Tunnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.3 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.1 Achilles Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.2 Posterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 129
8.4 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 130
8.4.1 Anterior Tendons and Deep Peroneal Nerve . . . . 130
8.4.2 Anterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 132
09 Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1 Hindfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1.1 Plantar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . .
133
9.2 Forefoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.1 Plantar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Contents ix
1.1 Tendons
Tendons are critical biomechanical units in
the musculoskeletal system, the function of
which is to transmit muscular strength to
mobile skeletal segments. Tendons are
extremely resistant to traction, almost like
bone, being able to bear up to 1000 kg per 10
mm
2
transverse section. Conversely, tendons
are not very elastic, being only able to toler-
ate a maximum elongation of 6% before
being damaged. Tendons have very slow
metabolism, even during action, and it can
only be significantly increased by inflamma-
tory conditions and traumas. Tendons macro-
scopically appear as ribbon-like structures,
with extremely variable shape and dimen-
sions, characterized by the presence of dense
fibrous tissue arranged in parallel bundles.
Primary bundles are assembled to form sec-
ondary bundles (representing the tendon’s
functional unit), which are in turn clustered in
tertiary bundles. The endotenon is a thin con-
nective strip surrounding the primary, sec-
ondary and tertiary bundles, and also sepa-
rates them. Small vessels and nerves run
within the endotenon thickness. The epitenon
is a thin band of stronger connective tissue
that envelops the whole tendon (Fig. 1.1).
From a functional and anatomical point of
view, tendons can be divided into two types:
supporting (or anchor) and sliding tendons.
Anchor tendons (such as the Achilles and the
patellar tendon) are typically bigger and
stronger than sliding tendons, they are not
provided with a synovial sheath, but they are
surrounded by a connective lamina external
to the epitenon, called the peritenon. Sliding
tendons are wrapped in a covering sheath
(teno-synovial sheath) whose function is to
guarantee better sliding and protection to the
tendons when they run adjacent to irregular
osseous surfaces, sites of potential friction.
The sites of union between tendon and mus-
cle or tendon and bone are named myotendi-
nous or osteotendinous junctions, respec-
tively. This latter is also called enthesis. The
myotendinous junction is usually well-
defined: at this level the tendon fibers are
interspersed with the endomysial fibers.
Conversely, the enthesis has a more compli-
cated structure, as it can be either fibrous or
fibrocartilaginous according to the tendon
mobility, the angle formed between the ten-
don fibers and the bone, and the presence of
an underlying retinaculum.
Basic Principles of Musculosketal
Ultrasound
1
Content s
1.1 Tendons
1.2 Ligaments
1.3 Peripheral Nerves
1.4 Cartilage and Bone
1.5 Muscles
1
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
1 Basic Principles of Musculosketal Ultrasound
2
Ultrasonography (US) represents the gold
standard technique for tendon assessment.
With the advent of high resolution transducers
and specific image processing software, eval-
uation of the inner structure of tendons was
made easier. Also, US is the only imaging
modality that allows for a dynamic evaluation
of tendons and joints. When imaged on a lon-
gitudinal view (long axis), the tendon appears
as a hyperechoic ribbon-like structure. The
tendon has an inner fibrillar echotexture that
can be appreciated as a succession of thin
hyperechoic fibrillar bands, slight ly wavy,
which tend to grow apart from one anoth er
when the tendon is released and to move clos -
er when the tendon is tense. This fibrillar
echotexture is caused by the specular reflec-
tions within the tendon, determined by the
existing acoustic interface between the
endotenon septa. The tendon is surrounded by
hyperechoic bands that correspond to the
paratenon (Fig. 1.2).
In a transverse view (short axis), the ten-
dons appear as round- or oval-shaped struc-
tures, characterized by several homogeneously-
scattered spotty echoes (Fig. 1.3).
Transverse scans are optimal to measure
tendon thickness, as it can be overestimated
when measured on longitudinal scans.
In clinical practice, ultrasound evaluation
Fig. 1.1 Anatomical drawing of a tendon. I, primary
bundle; II, secondary bundle; III, tertiary b
undle; E,
epitenon; e, endotenon
Fig. 1.2 The fibrillar echotexture of a nor mal
tendon is created by the interfaces between
collagen fibers and endotenon septa (long axis
scan). Arrowheads, tendon