During your appointment you will receive:
- Physiotherapy consultation including clinical examination of your injury
- Diagnostic ultrasound scan (POCUS).
- Scan report
- Exercise program (we use exercise software called P-REHAB Guys)
- Scan with Marek Czeladzki – Chartered Physiotherapist and Sonographer.
Based on both clinical examination and the ultrasound scan findings you will receive either the diagnosis of your injury, or further investigations may be recommended (i.e MRI).
Ultrasound in musculoskeletal pathology
Ultrasound gives me a chance to enhance clinical examination, confirm the diagnosis and rule out other possible causes of pain. It helps me manage patient’s care better, and provide reassurance to patients that their condition is treatable. Ultrasound scan is fast, safe and relatively inexpensive. It changed the way I look at human anatomy and physiotherapy.
I will be regularly updating and adding more content to the following article. Hope you find it helpful. Marek
Table of Contents
Table of Contents
Ultrasound is a quick, cost-effective and accurate scan of musculoskeletal structures. In some respects, due to its high resolution, it may be better than MRI ( i.e when scanning tendons).
MSK (musculoskeletal) ultrasound uses sound waves to produce pictures of muscles, cartilage, tendons, ligaments, nerves, and joints throughout the body. There are no side effects and no radiation that patients are exposed to.
Medical ultrasound (US) can be a powerful tool in the hands of clinician. It can help answer one key question; what type of injury are we dealing with? US is used in various fields of medicine, and in physiotherapy we use it often to assess musculoskeletal injuries.
It is particularly useful when we suspect an injury outside the joint (extra-articular injuries). For that reason, it may be used to assess such injuries like:
- Tennis elbow
- Shoulder injuries – impingement syndrome, rotator cuff tears, bursitis
- Knee injuries – ligamentous injuries, bursitis, tendinopathy, pes anserine, ITB syndrome and many other problems
- Plantar fasciitis
- A wide array of sport injuries
Ultrasound is not good at assessing spinal injuries or telling us what is happening within the joint (MRI would be a much better option).
Ultrasound is however much cheaper, and more accessible to patients than MRI. It simply takes minutes to produce images that may help with selecting the best treatment pathway.
The plantar fascia resembles tendon and is the most common cause of pain in the sole of the foot. A sudden change in training regime ( for example in runners), doing a lot of walking at work, using uncomfortable shoes, flat feet are all the factors that may cause plantar fasciitis.
There are three cords comprising the plantar fasicia with the central cord most commonly affected by a pathological process. The lateral cord sometimes may be a cause of pain in the lateral foot as it inserts to the base of the fifth metatarsal.
On ultrasound we see thickening of the fascia, especially of its central cord. However, sometimes ( ok, it is very rare) you may find calcium deposits in the plantar fascia which may lead to further investigations especially if clinically this is justified.
Shoulder Joint Scan
Your shoulder ultrasound scan will include an assessment of:
- long head of the biceps tendon and its grove in the anterior (front part) shoulder
- condition and integrity of the entire rotator cuff ( read about the rotator cuff and its function here)
- posterior gleno-humeral joint
- ACJ joint – there is a strong link between the ACJ and the shoulder joint pathology, especially rotator cuff pathology. What happens is that due to the rotator cuff pathology the shoulder joint becomes less stable and the head of the humerus moves upwards causing disruption to the ACJ joint capsule. The fluid from the shoulder joint then migrates to the ACJ distending the capsule which we can observe on ultrasound
- sub-acromial and sub-coracoid impingements ( if required and clinically appropriate)
The vast majority of injuries affect the rotator cuff – 4 tendons stabilizing the joint- the supraspinatus ( most frequently affected), infraspinatus, subscapularis and teres minor.
Ultrasound can be very helpful in assessing the extent of the injury and its localizations; it can also provide information that physiotherapist then can use in planning your therapy.
Rotator Cuff Injury
Injury of the rotator cuff can be very painful and occur as a result of the degenerative process and wear and tear in the shoulder. It can also be a consequence of a sport injury or a fall.
This is why sonographer is likely to ask you a series of questions before your scan and use the scan to confirm or rule out a pathology. Other pathologies that are commonly found in the shoulder are:
- Bursitis/bursal thickness – this often relate to the injury of the rotator cuff so when we see a thickened bursa/swollen bursa there is a high risk of the full thickness tear in the rotator cuff tendon.
- Cuff Arthropathy – chronic condition affecting older population
- Calcific tendinopathy – deposits of calcium are found in the rotator cuff and may lead to pain in the shoulder. Hydroxyapatite (HA) crystal deposition disease (HADD) is well recognized; the rotator cuff is the most common site of calcium crystals to aggregate. Since this is a systemic disease, calcium may be present elsewhere, for example, in the Achilles tendon.
- Tendon tears and rupture – commonly seen – especially in the supraspinatus tendon
- Tendinopathy – degenerative changes of the rotator cuff – may explain weakness and pain in your shoulder
Rotator Cuff Atrophy
In the rotator cuff we can examine muscle bellies of the long and short head of the biceps brachi, supraspinatus, infraspinatus and teres minor. The subscapularis muscle is the only one we can’t assess ( as it is hidden between the shoulder blade and the chest wall). Healthy muscle is black, bulky and large on ultrasound. However with muscle atrophy and fat infiltration the image is brighter – more hyper-echoic; the muscle also get smaller, and in most skeletal muscles, this happens usually in a symmetrical way.
The supraspinatus muscle is an exemption as we see reduction of its superior portion first. It is important to know the sonographic anatomy and also be aware of the fat tissue/ pad between the (upper) trapezius and the supraspinatus as the lower-laying superior part of the supraspinatus gradually disappears as atrophy sets in. This pattern helps us evaluate the muscle and its overall health. Atrophy is caused by tendon tear, neurological issues, or simply because the muscle has not been used.
Examples of Shoulder Pathology
Shoulder Labrum Injury
Ultrasound can only assess the labrum in the posterior joint. Pathology within the joint (inside the joint) are best assessed with an MRI. For example, patient presenting with clicking or popping within the joint after a fall or sport injury might be better-assessed with the MRI; this can allow to better visualize the labrum within the joint and any potential injuries like a SLAP lesion or Hill-Sachs lesion
Knee Joint Scan
Knee ultrasound can reveal several pathologies. If you decide to have a scan, it is likely that the following structures will be examined:
Anterior Knee – the front part of the knee including the quad tendon, fat pad, suprapatellar recess, patellar tendon, Hoffa fat pad.
Medial and Lateral Knee – for signs of any meniscal pathology ( especially in the peripheral meniscus), ligamentous damage, biceps femoris injury, pes anserine bursitis
Posterior Knee – Posterior horns of medial and lateral menisci, Baker cyst, tendon insertions.
The whole knee will be assessed for any signs of degeneration, osteoarthritis, effusion, the presence of cystic changes (i.e. para-meniscal cyst)
The medial collateral ligament is a wide band of connective tissue stretching between the medial epicondyle of the femur and running over the medial meniscus ( its deeper portion is actually attached to the meniscus). The MCL is essential to the stability of the knee along with other three ligaments.
It inserts to the tibia, but more anteriorly than you would expect. In most cases an injury will occur in the proximal part of the ligament. Ultrasound is a great way of assessing the meniscus and helps to provide a more accurate grading of an injury.This may help and inform subsequent treatment.
Ultrasound is a valuable tool in detecting pathology of the hip joint. All the structures outside the joint can be assessed with great accuracy if a quality ultrasound system is employed. The procedure is often broken down into three parts to assess: anterior (front) part of the hip, lateral and posterior (back of the hip).
Ultrasound can detect fluid in the joint, pathological changes to the tendons of the iliopsoas muscle, gluteus muscles around the greater trochanter, signs of bursitis. We can also detect cortical changes around the hip joint which may indicate such pathology as osteoarthritis or CAM lesion (labrum injury).
There are three type of bursitis of the hip region:
Iliopsoas bursitis – pain will affect the front of the hip and the groin; this is the most common bursitis in this region.
Trochanteric bursitis – pain will affect the side of the upper leg, it is less common and in most cases pain results from tendinopathy of gluteal tendons rather than bursitis
Ischio-gluteal bursitis – the least common type of bursitis; pain will affect the area of the ischial tuberosity and it is said to be caused by sitting with crossed legs.
Oftentimes in sport such as football, rugby or athletics. The calf injury is the third most common injury after hamstrings and quads. The most common site is the myo-tendineous junction (between the muscle and tendon) of the medial head of the gastrocnemous muscle (inside of your calf); it is so called ‘tennis leg’. Also, injuries often occur in the gastroc aponeourosis (GA) between the gastroc and the soleous. Read this article to find out more.
Ultrasound is very sensitive in detecting gastroc injuries. However, it may struggle with soleus ( another main calf muscle) injuries – for those MRI seems to be a better option. Read the article by Balius, R. et al.
The strongest of all tendons in the body, the Achilles tendon is also prone to injuries. And those do not want to heal fast due to very poor blood supply to the tendon.
Physiotherapy and rehabilitation sometimes take months…and no, rest will not help you recover faster. Oftentimes, those in intensive training overload this tendon, especially if training is not planned sensibly. It is not rare to see patients with bilateral Achilles pain in clinic.
Achilles Tendon Pathology
Ultrasound is great for visualising even subtle changes within the tendon, some claim it is better than MRI. What can we see on ultrasound? What pathology can we detect? The list is long and includes also other pathologies of the posterior ankle.
- Achilles tendinosis – swelling of the tendon, loss of the fibrillar pattern, Achilles is becoming tender, and if there is no modification to a training plan, the pain will surely gets worse.
- Achilles tendinitis – this term is quite controversial and recently has been replaced by broader ‘tendinopathy’. Tendinitis means that along degenerative changes there is also inflammation to the tendon. The problem was that specialists used this term frequently although there was no convincing evidence for inflammation. For example, there would not be any PD (PowerDopler) signal within the tendon.
- Achilles paratenonitis – A protective layer of connective tissue surrounds the tendon and helps it to glide. Sometimes though this part of the tendon gets very painful and we see fluid (black halo); below clearly visible in short and long axis .
- Achilles tears
- Achilles calcific tendinopathy
- Haglund’s deformity
- Enthesopathy of the Achilles tendon
It is a benign, bony growth at the insertaion of the Achilles tendon. If irritated ( for example by shoewear) it may cause pain. The bone spurs and Haglund’s deformity are very common and occur as a reult of the tendon (or plantar fascia in case of the bone spurs) pulling on the bone tissue which over time leads to bone growth. Whar re-occur with Haglund’s deformity is so called bursitis – we have two on the back of the heel. One, between the heel bone and the Achilles tendon, the other, between the tendon and the skin. Ultrasound allows us to assess bony growth and bursae and provide best therapy based on findings.
Ankle injuries can be very well assessed with ultrasound. It is advisable to leave the scan till a bit later rather than scanning straight after the injury. Scanning is usually more focused on the area of injury/pain; not like in the case of the shoulder joint where we scan the whole joint and rotator cuff.
Most common injury is the ankle inversion injury where the foot rolls outside. There are a few ligaments that stabilise the ankle on the lateral side and we often assess: ATFL, AITFL and CFL. Ultrasound gives us also a chance to dynamically test the ankle and these ligaments to check if they are intact.
On the lateral side of the ankle we can also assess peroneus tendons (longus and brevis) which sometimes, due to tendinopathy, may swell up and be causing pain on walking.
An inversion ankle injury may also cause damage to the structures of the medial ankle. There are also other injuries that may result in pain such as: tarsal tunnel syndrom where the posterior tibial nerve is compressed (i.e. by ganglion, tendon, osteophyte). In the medial compartment there are three main tendons that may be a source of pain; tibialis posterior, flexor digitorum longus, flexor hallucis longus.
Ultrasound is an excellent diagnostic tool for diagnosing musculoskeletal issues within the foot. Plantar fasciitis, capsulitis, ganglions, Freiberg’s disease, bursitis (adventitious), Morton neuroma ( or bursa – neuroma complex) are among frequently identified problems. Morton neuroma leads to pain in the front of the foot and on ultrasound we can see an enlargement of the nerve.
There are many small bones and joints within the wrist. There are also many tendons and ligaments that can be a source of pain.
In clinic we see three groups of patients; those presenting with more localised pain(i.e.tendinopathy), those with more generalised pain affecting the whole wrist ( i.e. in gout, OA), and patients with a nerve entrapment, i.e. carpal tunnel syndrome.
It is rare for gout to affect only the wrist. The most common site is the big toe and the 1st metatarso-phalangeal (MTP) joint.
Wrist – ultrasound assessment
On ultrasound we can assess these structures probably even better than with MRI. Distal radio-ulnar joint, radio-carpal recess, scaphoid-lunate ligament SST joint, FCR, extensor compartments, radio-triquatrium ligament , carpal tunnel, are some of the structures that can be well-visualized and assessed for presence of such conditions as – nerve compression (i.e. in carpal tunnel syndrome), tendinopathy, intersection syndrom (distal and proximal), joint effusion, rheumatological conditions (i.e. osteoarthritis, gout).
Ultrasound allows for an accurate assessment of the wrist after an injury i.e. after a fall or sport injury. There are numerous ligaments that may be torn or strained following a fall. You may have an avulsion injury where part of the wrist bone is displaced.
Tennis or golfer elbow are the most common pathologies we detect on musculoskeletal ultrasound. These overuse injuries can be very painful and oftentimes require prolonged therapy. On ultrasound we can see a change in fibrillar pattern, cortical changes including avulsion injuries, change in echogenicity ( tendon becomes darker in places on ultrasound).
There are obviously other, less common, pathologies detectable by ultrasound including – joint synovitis, ligaments injury ( f.e AL, RCL, LUCL or MCL injuries). Sport injuries also can be visualised and assessed with ultrasound; biceps tendon inserting to the radial tuberosity may have a partial – thickness tear or rupture completely.
Injuries to the brachialis tendon ( main elbow flexor) are rare. It is important to scanin the contect of clinical examination as this gives the best idea as to what injury we are dealing with.
Tendon tears – ultrasound is a great tool to detect small and large tears within tendons.
Tendinopathy – this is really an umbrella term describing tendon pathology. Tendinosis means there are degenerative changes (wear and tear) within the tendon and sometimes it is difficult to tell apart tendinosis from a tear on ultrasound. Tendinitis is inflammation of the tendon.
Enthesitis – tendons and ligaments insert into the bone and those attachments (enthesis) can sometimes get inflamed. Power Doppler gives us an additional info about neovascularization (new blood vessels) which may suggest an ongoing inflammatory process.
Peripherial nerve pathology
Carpal Tunnel Syndrome
The median nerve is responsible for symptomps of the carpal tunnel syndrome. Its enlargement is an important indicator of the condition. The nerve often gets squashed underneath the palmar aponeurosis. The good practice is to assess the nerve while it is entering and exiting the carpal tunnel and also during more proximal scanning towards the shoulder. Normal cross-section of the nerve is between 7.0-10.2 mm2.
Schwannomas are benign, slow-growing and often pain-less tumors arising from the nerve sheath. They can occur anywhere in the body, at any age. Patient usually notice a lump on the skin.
Ultrasound is very useful in detecting rheumatological conditions including gout, pseudo-gout or rheumatoid arthritis. The eroded cartilage surface, crystals deposited within joints and tendons, positive power doppler signal are typical ultrasound findings. Find out more about gout, the most common inflammatory arthritis from the article below.
Where is your clinic?
Clinic’s address: Unit 3c at 3 Hursley Road, Chander’s Ford, Eastleigh, SO53 2FW
Are there any side effects?
No, ultrasound is very safe in musculoskeletal medicine. Due to the safety ALARA principle, we only scan as long as it is only necessary to take meaninful images.
How much is the ultrasound scan?
Ultrasound scan, physio consultation and therapy at Physio-Soton cost £129.00.
How can I book ultrasound scan with you?
You can book online or by calling our clinic in Chandlers Ford on 02382182416
Can my GP and I receive a scan report?
Yes, we will send the report to your email address.
- Stephen Bird Ultrasound
- SMUG – Sports Medicine Ultrasound Group
- AECC Bournemouth – Ultrasound Clinic
- Ultrasonographic Findings of the Shoulder in Patients with Rheumatoid Arthritis and Comparison with Physical Examination
- Rotator Cuff Tear Arthropathy
- Application of Ultrasound in Sports Injury – ScienceDirect
- Calf Injury – Tennis Leg and Pedrets Classification
- Are Soleus injuries easily detected by ultrasound?
- Ultrasound diagnosis of quadriceps tendon tear in an uncooperative patient – PMC (nih.gov)
- Understand the difference between US and MRI and which investigation might be better for you
- Ultrasound musculoskeletal scan
I am a Chartered Physiotherapist (MSc), Musciloskeletal Sonographer(PGCert) and Master Myofascial Therapist practicing in Chandler’s Ford, Eastleigh. I was working in the NHS between 2008 and 2021. I specialize in treating musculoskeletal conditions and injuries.