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Ligaments
3
of tendons can be affected by anisotropy arti-
facts. When the US beam is not orthogonal to
the course of tendon fibers, both a decrease of
reflected and an increase of the diffracted
echoes occur, thus resulting in a significant or
partial reduction of tendon echotexture.
1.2 Ligaments
Ligaments have a structure that is very sim-
ilar to tendons. However, they are thinner
and contain a higher amount of elastin. This
is a necessary component to supply liga-
ments with higher degrees of elasticity that
is needed to provide high degrees of joint
stability, without compromising the range
of motion. Ligaments can be differentiated
into intrinsic and extrinsic ligaments. The
former are rather capsular thickening than
true ligaments and are designed to provide
capsular strengthening; the latter are inde-
pendent from the fibrous capsule and can
be further classified as extracapsular and
intracapsular ligaments.
Ligaments are generally thinner and shorter
than tendons. Also, their inner structure can be less
homogeneous than tendons. US examination of
ligaments, unlike ten dons, is mainly performed
on a long axis view, while transverse views (short
axis) have poor diagnostic value. With US, liga-
ments appear as homogeneous bands, 2–3 mm
thick, lying close to the bone (Fig. 1.4). They usu-
ally appear hyperechoic, although echogenicity
may vary according to ligament course.
Fig. 1.3 Short axis sonogram showing the characteristic
hyperechoic pattern of tendons, with scattered spotty
echoes. M, metacarpal head; white arrowheads, fle
xor
digitorum superficialis tendon; void arrowheads, flexor
digitorum profundus tendon
Fig. 1.4 Long axis US scan sonogram of the lateral collateral ligament of the knee showing the fibrillar pattern of lig-
aments, with linear, homogeneous, hyperintense bands. Arrowheads, lateral collateral ligament; F, lateral condyle of
femur; Fi, fibular head; Ti, tibia
1 Basic Principles of Musculosketal Ultrasound
4
1.3 Peripheral Nerves
Peripheral nerves are characterized by a
complex internal structure made of nervous
fibers (containing axons, myelin sheaths,
and Schwann cells) grouped in fascicles, and
loose connective tissue (containing elastic
fibers and vessels) (Fig. 1.5). A closer look
at nerve sheaths demonstrates an external
sheath, the outer epineurium, which sur-
rounds the nerve fascicles. Each fascicle is
invested in turn with a proper connective
sheath, the perineurium, which encloses a
variable number of nerve fibers separated by
the endoneurium. The connective tissue
interspersed between the outer nerve sheath
and the fascicles is commonly referred to as
the inter-fascicular epineurium and houses
the nerve vasculature.
With the current generation of high-frequency
superficial transducers and compound technol ogy,
US has become a well-accepted and widespread
imaging modality for the evaluation of peripheral
nerves. US provides low-cost, quick, and non-in-
vasive imaging. US provides higher spatial reso-
lution over MR imaging and the ability to explore
long segments of nerve trunks in a single study, al-
so allowing the examination of nerves in both
static and dynamic conditions.
On long axis scans, nerves typically
assume an elongated appearance with multiple
hypo/hyperechoic parallel lines, which corre-
spond to the neuronal fascicles running longi-
tudinally (Fig. 1.6).
On short axis planes, high-resolution US
depicts nerves as honeycomb-like structures
composed of hypoechoic rounded areas (the fas-
cicles) embedded in a hyperechoic background
(interfascicular epineurium) (Fig. 1.7).
Fig. 1.5 Peripheral nerves. Schematic
drawing illustrating the inner structure
of a peripheral nerve. NF, nerve fascicle;
E, epineurium; P, perineurium;
e, endoneurium; IE, interfascicular
epineurium
Fig. 1.6 Peripheral nerves. Lon gitudinal 5–12 MHz US image obtained over the median nerve (white arrows) at the
middle third of the forearm. The nerve is made of parallel linear hypoechoic areas, the fascicles, separated by hyper-
echoic bands, the interfascicular epineurium
Cartilage and Bone
5
The number of fascicles in a nerve may
vary depending on the occurrence of nerve
branching. In nerve bifurcations, the nerve
trunk divides into two or more secondary
nerve bundles, whereas each fascicle enters
only one of the divisional branches without
splitting. The outer boundaries of nerves are
usually undefined due to the similar hypere-
choic appearance of both the superficial
epineurium and the surrounding fat.
Careful scanning technique of nerves based
on the precise knowledge of their position and
analysis of their anatomical relationships with
surrounding structures is essential. Systematic
scanning on short axis planes is preferred to
follow the nerves contiguously throughout the
limbs. Once detected, the nerve is kept in the
center of the US image in its short axis and
then followed proximally and distally shifting
the transducer up or down according to its
course. With this technique, called the “lift
technique”, the examiner is able to explore
long segments of a nerve in a few seconds
throughout the limbs and extremities.
1.4 Cartilage and Bone
Cartilage is a greatly specialized type of con-
nective tissue, mainly composed of water
(70–80% by wet weight). It is avascular and
aneural. The solid component of cartilage is
formed of cells (chondrocytes) that are scat-
tered in a firm gel-like substance (extracellu-
lar matrix) consisting of collagen and proteo-
glycans. Collagen forms a network of fibrils,
which resists the swelling pressure generated
by the proteoglycans. In the musculoskeletal
system, cartilage is classified as either hyaline
or fibrous. Compared to hyaline, fibrocarti-
lage contains more collagen and is more
resistant to tensile strength. Fibrocartilage is
found in intervertebral disks, symphyses, gle-
noid labra, menisci, the round ligament of
the femur, and at sites connecting tendons
or ligaments to bones. Hyaline cartilage is
the most common variety of cartilage. It is
found in costal cartilage, epiphyseal plates,
and covering bones in joints (articular carti-
lage). The free surfaces of most hyaline car-
tilage (but not articular cartilage) are cov-
ered by a layer of fibrous connective tissue
(perichondrium). Hyaline cartilage is strat-
ified and divided into four zones: superfi-
cial, middle, deep, and calcified, hardly
detectably by US (Fig. 1.8).
The orientation of collagen fibers varies
through the four zones of articular cartilage
in order to give better tensile strength. The
fibrillar framework seems to have an
arcade-like arrangement
Hyaline cartilage is easily detectable by
US as a homogeneously hypoanechoic layer
delimited by thin, sharp and hyperechoic mar-
gins.
Fig. 1.7 Nerve echotexture. Transverse US image of the
ulnar nerve at the forearm. The nerve (white arrowhead)
is characterized by a honeycombing appearance made
of round hypoechoic areas in a homogeneous hypere-
choic background
Normal articular cartilage appears as a
well-defined layer with the following distin-
guishing fea tures:
1. high degree of homogeneous transparency
due to its high water content;
2. sharp and continuous synovial space-carti-
lage interface (superficial margin);
3. sharp hyperechoic profile of the bone-car-
tilage interface (deep margin).
The synovial space-cartilage interface is
slight ly thinner than the bone-cartilage inter-
face. Both margins are best visualized when
the direction of the US beam is perpendicular
to the cartilage surface.
The marked difference in chemical struc-
ture between articular cartilage and subchon-
dral bone allows easy detection of the deep
margin, whilst the superficial margin requires
careful exam ination techniques for clear iden-
tification.
Optimization of the visualization of the
cartilage margins is essential for measuring its
thickness.
Cartilage thickness ranges from 0.1 mm on
the articular surface of the head of the proxi-
mal pha lanx to 2.6 mm on the lateral femoral
condyle of the knee joint.
Sharp margins and homogeneous echotex-
ture are hallmarks of normal cartilage (Fig. 1.8)
1.5 Muscles
Muscle is made of bundles of contractile
elementary units, the striated muscle fibers,
with their major axis lying along the con-
traction direction.
Muscular fibers are arranged parallel
one to another and they are supported by a
structure of connective tissue. Muscle is
externally surrounded by a thick connective
sheath called the epimysium; from the
internal aspect of this sheath several septa
depart to constitute the perimysium, which
surrounds several bundles of muscular
fibers, named fascicles. Blood vessels and
nerves run within the perimysium, which
also contains the neuromuscular spindles.
Very light and thin septa arising from the
perymysium spread into the fascicles to sur-
round every single muscular fiber and thus
form the endomysium (Fig. 1.9).
The extremity of a muscle may continue
as a tendon or insert onto the periosteum,
aponeurosis, or the dermis. Wherever a
muscle attaches, the insertion is highly
resistant, as tensile forces turn into tangen-
tial forces that are more easily born.
The macroscopic shape of muscles
varies according to their function. Each
1 Basic Principles of Musculosketal Ultrasound
6
Fig. 1.8 Suprapatellar longitudinal scan of the articular cartilage of the lateral femoral condyle obtained with an 8–16
MHz broadband linear transducer. The transverse suprapatellar scan of the knee demonstrates that, in healthy subjects,
the femoral cartilage (arrowheads) typically appears as a clear-cut, wavy hypoanechoic layer, with upper concavity,
which is thicker at the level of the intercondyloid fossa. TF, trochlea femoris
Muscles
7
muscle presents at least one muscular belly
and two tendons, one at the origin and the
other at the insertion. Muscles with fibers
parallel to the longitudinal axis (muscles of
the abdomen, head and neck) are made for
bearing reasonable weights for long dis-
tance activities. Conversely, the uni-, bi-,
and circum-pennate structures (muscles of
the limbs) can bear greater weights for a
shorter period of time.
The internal structure of muscles can be eas-
ily assessed by US. The epimysium appears as a
hyperechoic external band 2–3 mm thick, contin-
uing without interruption along the correspon-
ding tendon profile on longitudi nal US scans.
The perimysium can be appreciated as hyper-
echoic lines separating the contiguous hypoe-
choic muscular fascicles from one another.
The typical pennate structure of muscles can
be easily assessed in longitudinal axis views
where the hyperechoic fibro-adipose septa con-
verge, with a mainly parallel course, on a cen-
tral aponeurosis, appearing as a thin, highly
reflec tive band (Fig. 1.9).
US evaluation of muscle fiber direction rep-
resents an important parameter to measure the
pennation angle. This angle is measured
between the muscular fibers’ direction and the
central aponeurosis axis (usually corresponding
to the longitudinal muscular axis). The value of
the angle varies depending on the func tion of
the muscle and, within the same muscle, on the
functional state (contraction/ relaxation).
In transverse views, the muscle is sectioned
according to a plane that is orthogonal to the
muscular lon gitudinal axis, with a typical US
structure appear ance. The 1
st
and 2
nd
order fasci-
cles present an irregular polygonal shape,
defined by thin, elongated, hyperechoic septa,
corresponding to the perimysial fibro-adipose
septa (Fig. 1.10).
When studying both muscles and tendons,
the US beam should be as perpendicular as pos-
sible, in order to avoid the appearance of hypoe-
choic artifactual zones that can be misinterpret-
ed by inexperienced oper ators.
US examination can also take advantage of a
comparison with the contralateral mus cle and
with active and passive dynamic maneuvers,
both during contraction and at rest, thus allow-
ing for a functional evaluation of the muscle.
Fig. 1.9 Longitudinal US scan of a pennate muscle. The
characteristic pennate appearance is given by the conver-
gence of perimysial septa (void arrowheads). White
arrowheads, muscular aponeurosis
Fig. 1.10 Transverse US scan shows the polygonal
arrangement of the muscular fascicles and hyperechoic
perimysial septa
The protocol includes anterior, lateral, and
posterior scans.
2.1 Long Head of Biceps Brachii
Tendon (LHBBT)
The biceps brachii muscle consists of two
heads, a long and a short one, which merge
distally into a single muscle belly. The long
head arises from the supraglenoid tuberosity
of the scapula and from the glenoid labrum
as a long and cylindrical tendon, which runs
into the joint cavity of the shoulder, between
the humeral head and the joint capsule. Then
it runs in the bicipital groove, surrounded by
an extension of the synovial capsule. The
tendon joins the short head (that arises from
the coracoid) at the median third of the arm.
The distal tendon of the biceps brachii,
divided in two branches, is inserted on the
bicipital tuberosity of radius (Fig. 2.1).
The patient is sitting opposite to the exam-
iner, the forearm is flexed 90° with the arm
resting on the thigh, slightly internally rotat-
ed, palm facing up (Fig. 2.2).
Shoulder
2
Content s
2.1 Long Head of Biceps Brachii Tendon
2.2 Subscapularis Tendon
2.3 Supraspinatus Tendon and Subacromial-Subdeltoid Bursa
2.4 Coracoacromial Ligament
2.5 Infraspinatus and Teres Minor Tendons
2.6 Acromion-Clavicular Joint
9
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 2.1 Anatomical scheme of the intra- and extra-artic-
ular sections of the long head of biceps tendon (*). H,
humerus; G, scapular glenoid; A, acromion; C, coracoid
Holding the transducer in a horizontal
position (Fig. 2.3a), localize the bicipital
groove (between small and large tuberosity of
the humerus). This structure shall be used as a
landmark to assess the long head of biceps
brachii tendon on an axial scan (Fig. 2.3b).
To avoid any anisotropy artifacts, the
transducer must be kept as perpendicular as
possible to tendon surface (Fig. 2.4a-f).
10
Fig. 2.2 Upper limb position to assess the long head of
biceps tendons
Fig. 2.3a Probe position to evaluate the bicipital groove
Fig. 2.3b Axial scan of LHBBT (arrowheads). GT, greater
tuberosity; LT, lesser tuberosity; D, deltoid muscle
2 Shoulder
Long Head of Biceps Brachii Tendon (LHBBT)
11
Fig. 2.4 Anisotropy artifacts affecting the long head of biceps tendon due to wrong probe positioning. In the wrong po-
sitions (a and c) the “empty bicipital groo
ve” sign can be seen in the corresponding ultrasounds (d and f). This appear-
ance is due to the prevalence of dif
fracted echos over reflected ones. When the US beam is perfectly perpendicular to
the tendon, there is a prevalence of reflected echoes and the LHBBT tendon can be correctly evaluated (b and e).
a
c
d
b
e
f
The probe must then slide caudally to evalu-
ate the vertical part of the LHBBT up to the
myotendinous junction, located under the humer-
al insertion of the pectoralis major tendon (Figs.
2.5a, b). In case of complete rupture of LHBBT,
this area is where the retracted tendon stump can
usually be seen.
Then the probe must be rotated 90° clockwise
to evaluate the LHBBT along its long axis (Figs.
2.6a, b). Note that the LHBBT has an oblique
course, from up to down and from anterior to pos-
terior. For such reason, optimal visualization of the
tendon can be obtained by slightly pressing the dis-
tal edge of the probe on the skin (Fig. 2.6c).
2 Shoulder
12
Fig. 2.5a Probe position on the humeral insertion of
pectoralis major muscle
Fig. 2.5b The axial scan shows
the humeral insertion aponeuro-
sis of the pectoralis major mus-
cle (arrowheads). H, humerus;
B, biceps brachii
Long Head of Biceps Brachii Tendon (LHBBT)
13
Fig. 2.6a Probe position to evaluate the LHBBT
according to its longitudinal axis
Fig. 2.6b Longitudinal scan of
LHBBT (arrowheads) in bicipital
groo
ve
Fig. 2.6c Anisotropy artifact
affecting the LHBBT on longitudinal
scan, due to the wrong orientation
of the US beam