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MUSCULOSKELETAL ULTRASOUND

FIGURE 4: THE VALUE OF EXTENDED FIELD AND COMPARATIVE SCANNING

Image 4a shows the value of extended field of view scan- ning. Here the MCL is followed superiorly across the knee joint (KJ) and clearly seen to have suffered a severe sprain and an associated avulsion fracture at its attachment to the femur. In the inset (lower right) in image 4b, the right medial meniscus (RMM) looked suspicious with the MCL overlying a prominent bulge and areas of low echo (yellow framed inset). Comparative scanning of both right and left MCL’s (at the same point) helped confirm the abnormality. The patient subsequently underwent arthroscopic surgery to the medial meniscal tear. Generally though, clear views of meniscal

MCL FC KJ 4a

the knee joint and small avulsion fractures. Medial and collateral ligament injury, hamstring tendon injury and bursitis, and other bursa around knee. More peripheral to knee rectus femoris and other muscle tears can be imaged, and this is best done acutely or where there is a persistent large tear. In general, MSKUS of leg muscle lesions (other than tumours or masses) is more difficult due to mixed anisotropy and harder ‘global views’ (of all the deep and superficial structure) that is better done with MRI. However, MSKUS for muscle is useful for disease monitoring and interven- tions such as aspiration of haematoma.

The main internal structures of the knee joint are, as noted above, generally better visualised by MRI. That said, some interesting research has been done on employing MSKUS to help diagnose anterior cruciate ligament tear and meniscal tears. There is also evidence, mainly from Germany, for the use of MSKUS in acute knee injury and haemarthrosis specifically looking for signs of cru- ciate ligament injury with reported sensitivities of 87-91% and a positive predictive value of 100% possible provide real food for thought (11). The posterior cruciate ligament can be seen with

FIGURE 5: EXAMPLES OF ANKLE AND FOOT ULTRASOUND RMM LMM 4b RMM 5a

The medial aspect of the knee is an excellent example of how MSKUS can advance the diagnostic process, sometimes helping to avoid the cost of further investigations. I have diagnosed several Stiedi-Pellegrini lesions of the MCL with ultrasound in cases referred with non-specified refractory medial knee pain (Figure 4). And whilst MRI scanning may be subsequently required to exclude other knee joint pathology, MSKUS can often help speed up the diagnosis of peripheral meniscal lesions, though this is usually through indirect findings such as swelling, extrusion or meniscal cyst - clear US images of actual meniscal tears is elusive, though the advent of 3-D sonoCT may overcome this in future (9), especially where the history and examination may be rather equivocal. Comparative scanning (something not generally practical with MRI) can add significantly to the sensitivity of the examination. Muscle hernias (such as tibialis anterior) also be seen with MSKUS.

In chronic exertional compartment syndrome (CECS) it is reported that with careful and consistent application of the probe both before and immediately after exertion, delays in the normal rate of shrinkage of the anterior compartment correlate with patho- logical CECS and can aid clinical decision making on the question of referral for fasciotomy surgery (4). A new contrast-enhanced MSKUS technique called elastography may in future also be a use- ful investigation for CECS (10). The other most common knee structures or conditions accessible to MSKUS include the patella tendon tendinopathy (and Sinding-Larsen-Johansen Syndrome), Osgood-Shatters syndrome, quadriceps tendon disease, effusion in

24 PB LATMA 5b 5c ATFL F T 5d

Four examples of foot and ankle scans. Figure 5a: Morton’s neuroma (low echo) protruding through the 3rd and 4th metatarsal heads (green). Figure 5b: The classic appearance of a peroneus brevis (PB) tear – the peroneus longus (PL) has impinged through the brevis (PB), just behind the lateral malleolus. The PB appears curved (green dotted), and there is fluid (F) under the retinaculum (orange line). Figure 5c: This shows a normal ATFL with a clear linear demarca- tion (yellow dotted) between the relatively low/anisotropic ATFL and the more echogenic soft tissues above. Figure 5d: Here the ATFL is clearly abnor- mal – the ligament is

intact but swollen, with a curved outline and small hypere- choic avulsion fracture off the fibula (Av).

sportEX medicine 2007;34(Oct):20-26

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