DIAGNOSIS

the knee extended. Also osteophytes and synovitis in rheumatic joint disease (in the knee and elsewhere) can also be seen on MKUS, and which is also more sensitive than plain radiographs at picking up small joint erosions (12).

ANKLE AND FOOT As with the knee, any suspicious injury to the ankle joint (such as an osteochondral lesion) or to other deep structures will invari- ably mean that MRI is indicated, though with the foot in full plan- tar flexion, the anterior articular surface of the talar dome can be well visualised. Many other ankle and foot conditions/injuries involve superficial structures and most of these can be assessed very capably by MSKUS. Invariably the history and the patient’s ability to point to the painful area help guide the structures to be scanned, using the same principles found in Box 2. The following in not exhaustive, but lists the more common conditions where MSKUS is used in the foot and ankle: ■ plantar fasciitis (and fibromas) ■ lateral ankle ligament lesions ■ Achilles tendinopathy ■ local bursal inflammation/swelling in the ankle and foot ■ neuroma (especially Morton’s) ■ all the ankle tendons (for tendinopathy, tears and tenosynovitis) ■ sesamoiditis ■ some stress fractures ■ avulsion fractures ■ joint effusion/synovitis ■ osteophytes (impingement) ■ retinacular lesions (instability and tarsal tunnel syndrome).

Some examples are shown in figure 9. Dynamic scanning is espe- cially useful to pick up subluxations and linear tendon tears affecting the peroneals. Also, because the ankle in particular is usually very ‘bony’, lots of US jelly (or even a special ultrasound ‘stand-off’ gel pad) is required to maintain good even contact with the skin surface.

ADVANCED MSKUS What constitutes ‘advanced MSKUS’? Opinions on this understand- ably will vary, but in general to confidently and competently use MSKUS to guide intervention, image nerves, hernias, most soft tis- sue masses and probably the groin-hip area would normally require longer mentoring beyond any initial postgraduate qualifi- cation. In practical terms it might only be after 2-3 years or reg- ular scanning and further tuition and reflection that a mentor/tutor would ‘sign off’ on these sub-skills. And even then

It may not be deemed appropriate due to lack of case numbers of equipment that has reached its ceiling of performance.

In the

end, each practitioner engaging with MSKUS (as with any other skill such as acupuncture) will have to use professional judgement and probity to develop their own MSKUS scanning repertoire at their own pace, according to their own individual skills, learning curve and mentor/course feedback (7, 13, 14). But figure 6 illus- trates how useful and rewarding MSKUS can be for the sports injuries clinician, especially where the clinic has access to a gym- nasium or rehabilitation facilities. In this case a young soldier presented with 2 years chronic recurrent lower abdominal pain associated with exertion. A previous ultrasound scan was normal.

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