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iagnostic and Interventional Musculoskeletalltrasound: Part 2. Clinical Applications

ay Smith, MD, Jonathan T. Finnoff, DO

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usculoskeletal ultrasound involves the use of high-frequency sound waves to image softissues and bony structures in the body for the purposes of diagnosing pathology or guidingeal-time interventional procedures. Recently, an increasing number of physicians haventegrated musculoskeletal ultrasound into their practices to facilitate patient care. Techno-ogical advancements, improved portability, and reduced costs continue to drive theroliferation of ultrasound in clinical medicine. This increased interest creates a need forducation pertaining to all aspects of musculoskeletal ultrasound. The primary purpose ofhis article is to review diagnostic ultrasound technology and its potential clinical applica-ions in the evaluation and treatment of patients with neurological and musculoskeletalisorders. After reviewing this article, physicians should be able to (1) list the advantagesnd disadvantages of ultrasound compared to other available imaging modalities; (2)escribe how ultrasound machines produce images using sound waves; (3) discuss the stepsecessary to acquire and optimize an ultrasound image; (4) understand the differenceltrasound appearances of tendons, nerves, muscles, ligaments, blood vessels, and bones;nd (5) identify multiple applications for diagnostic and interventional musculoskeletalltrasound. Part 2 of this 2-part article will focus on the clinical applications of musculo-keletal ultrasound in clinical practice, including the ultrasonographic appearance oformal and abnormal tissues as well as specific diagnostic and interventional applications inajor body regions.

ORMAL AND ABNORMAL TISSUES

he primary clinical utility of musculoskeletal ultrasound is to examine soft tissues in theody for the purpose of diagnosing pathological changes or performing interventionalrocedures. After obtaining the necessary equipment, knowledge, and skills to perform thexamination, physicians must familiarize themselves with the normal and abnormal appear-nces of tissues. Seamless integration of musculoskeletal ultrasound into clinical practiceequires skill, time, and patience.

Ultrasound can be used to readily identify and differentiate tendons, muscles, ligaments,erves, and vessels at a resolution of �1 mm. These tissues generally are described by theirchogenicity (isoechoic, hypoechoic, anechoic, hyperechoic), echotexture (internal echoattern), degree of anisotropy (i.e., occurs when an otherwise-normal but smooth structureppears “dark” on ultrasonographic imaging as a result of the fact that the ultrasound beamid not encounter the structure perpendicular to the plane of that structure), compressibil-

ty, and the presence or absence of blood flow on Doppler examination. These features areummarized in Table 1 and Figure 1.

Tissue echogenicity is characterized as hyperechoic, hypoechoic, anechoic, or isoechoic.yperechoic structures are brighter (or whiter) than normal or in relation to surrounding

tructures, whereas hypoechoic structures are darker (or blacker) than normal or in relationo surrounding structures. Anechoic structures are devoid of echoes and appear black.soechogenic structures are similar in brightness to surrounding structures. These terms cane used in an absolute sense (ie, tendons are generally hyperechoic, or bright) or in a relativeense (a tendon affected by tendinopathy often appears darker than expected or relative tourrounding tendons and therefore is hypoechoic).

Echotexture refers to the internal pattern of echoes, which can vary depending on

hether the structure is imaged transversely or longitudinally. Tendons exhibit a fibrillar

Sa

PM&R © 2009 by the American Academy of P1934-1482/09/$36.00

Printed in U.S.A.62

.S. Department of Physical Medicine andehabilitation, College of Medicine, Mayolinic, 200 First St SW, Rochester, MN5905. Address correspondence to: J.S.;-mail: Smith.jay@mayo.eduisclosure: nothing to disclose

.T.F. Department of Physical Medicine andehabilitation, College of Medicine, Mayolinic, Rochester, MNisclosure: nothing to disclose

isclosure Key can be found on the Table ofontents and at www.pmrjournal.org

ubmitted for publication July 10, 2008;ccepted September 30.

hysical Medicine and RehabilitationVol. 1, 162-177, February 2009

DOI: 10.1016/j.pmrj.2008.09.002

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attern when imaged longitudinally and a “broom-end” pat-ern when imaged transversely [1-3]. These patterns resultrom the compact arrangement of hyperechoic collagen bun-les within the tendon, separated by the hypoechoic inter-ening ground substance [1-3]. The synovial sheaths oraratenons of tendons frequently can be visualized with aigh-frequency (�10 MHz) transducer and appear as a thin,yperechoic tissue layer surrounding the tendon bulk.

endons

ecause of the tightly packed arrangement of collagen bun-les within a tendon, tendons demonstrate significant anisot-opy. As solid structures, they are noncompressible and doot normally exhibit blood flow. Tendons can be examinedynamically through passive, active, or resisted joint mo-ions, sonopalpation, or transducer compression [1-4]. Mostursa adjacent to tendons are not visualized unless dis-ended; exceptions include the subacromial-subdeltoid, ret-ocalcaneal, and deep infrapatellar bursae.

erves

he fascicular longitudinal and honeycomb transversechotexture patterns of nerves are caused by the hypo-choic nerve fascicles surrounding by hyperechoic con-ective tissue (external and interfascicular epineurium)3,5,6]. Nerves are best examined transversely, duringhich long segments of nerves can be traced (eg, ulnarerve from brachial plexus to the hand). Nerves are differ-ntiated from tendons by their echotexture, relative lack ofnisotropy, location, and proximity to vessels. Provocativeesting during ultrasound evaluation of nerves may in-olve a sonographic Tinel’s sign to localize a regeneratingerve stump or neuroma, range of motion to induce nerveubluxation or dislocation, or muscle or joint motion toemonstrate dynamic stenosis within a musculotendinousr osseofibrous structure, respectively [4,5,7].

igaments

igaments appear similar to tendon but are less compact and

able 1. Normal ultrasonographic characteristics of soft tissue

Tissue Echogenicity

Echotexture Appearan

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ble to the relative multidirectional nature of their incurredtresses. Ligaments appear fibrillar during longitudinal scan-ing. Their echotexture is often not distinguishable duringransverse scanning because of their thin size, but whenransverse imaging is possible, they have a “broom-end”ppearance. Ligaments can easily be distinguished from ten-ons by tracing the ligament to the bony structures to which

t attaches. For example, the medial collateral ligament isasily differentiated from the pes anserine tendons by itsnatomic course (adductor tubercle to proximal medialibia), ligamentous echotexture (Table 1), and deep locationelative to the overlying pes anserine tendons. Dynamic liga-ent testing can be performed under ultrasound to facilitateifferentiation of a high-grade partial versus complete liga-ent tear or to document joint instability [4,8,9].

uscles

ascia and joint capsules have a similar ultrasound appear-nce to ligaments and are easily identified based upon loca-ion. The mixed hypo- and hyperechogenicity of musclerises from the regular pattern of hypoechoic muscle fasciclesithin the hyperechoic peri- and epimysium [6,10]. Longi-

udinally, muscle demonstrates a “feather” or “veins on a leaf”attern, whereas transversely they appear as a “starry night.”ynamically, compression or muscle contraction can revealartial thickness strain injuries [6,10].

essels

eins and arteries appear as hypo- or anechoic tubulartructures that are easily compressible and exhibit bloodow on Doppler examination. Because veins and arteriesre the only tissues that should normally exhibit bloodow, they are easily distinguished from tendons, nerves,nd ligaments. In addition, although both veins and arter-es are generally easily compressible, arteries will remainulsatile during compression, whereas veins will not.dentification of veins and arteries during diagnostic scan-ing will facilitate locating nerves as these 2 structures

Susceptibilityto Anisotropy Compressibility

DopplerFlow

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164 Smith and Finnoff MUSCULOSKELETAL ULTRASOUND: PART 2

onehe ultrasound appearance of bone is distinctive, manifest-

ng as a well-defined, linear, smooth, hyperechoic borderrefer to Figure 3, Part 1 of this review) [11-13]. The hyper-chogenicity of bone is caused by the high reflectivity of thecoustic interface. In fact, virtually the entire sound beam is

igure 1. (a) Transverse view of carpal tunnel, demonstratingontrast to the hyperechoic, fibrillar appearance of the surrou

adialis traversing superficial to the scaphoid bone in the wrist.ll tendons. (c) Longitudinal view of dorsal wrist, producingppearing as a tightly packed, hyperechoic, fibrillar struct

ongitudinal view of the dorsal scapholunate ligament (arongitudinally rather than transversely and can be located bynd scaphoid). (e) Longitudinal view of median nerve in the fopineurium are shown. The fascicular pattern of nerves can bef) Transverse view of the calf musculature. Note the “starryross-section (Figure 1 continues).

eflected and therefore ultrasound is unable to “see” beyond i

one or other highly calcified structures, rendering the imageeyond the interface nearly black. This phenomenon is re-erred to as posterior acoustic shadowing. Consequently,ltrasound can only provide information about the superfi-ial portion of visualized bones. With respect to joints, high-requency (�10 MHz) scanners typically can be used to

d echogenicity honeycomb pattern of median nerve (N), infinger flexor tendons (T). (b) Longitudinal view of flexor carpi

he hyperechoic, fibrillar echotexture, which is characteristic ofsverse view of the dorsal scapholunate ligament (circled),) Correlative transverse view of dorsal wrist, producing aTypical of all ligaments, the ligament is better visualized

g the transducer across the adjacent bony landmarks (lunate(arrows). Hypoechoic fascicles alternating with hyperechoic

ared with the tightly packed fibrillar pattern of tendon (see b).” appearance of the gastrocnemius and soleus muscles in

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hin hyperechoic joint capsule, and a small amount of easilyisplaceable anechoic intra-articular fluid [12-15]. Normalynovium is not able to be visualized with ultrasound.

endon Injuries

ost tissues in the musculoskeletal system demonstrate aimilar spectrum of pathological ultrasound changeshroughout the body. Tendinosis manifests as tendon en-argement, hypoechogenicity, and an increase in the interfi-rillar distance (Figure 2) [1-3]. These changes are the resultf intratendinous edema and an increase in interfibrillarround substance. These changes may be regional or diffuse,nd it is important to note that the fibrillar tendon echotex-ure is maintained [2,3]. Partial-thickness tearing demon-trates the additional finding of focal regions of anechogenic-ty accompanied by loss of the normal fibrillar pattern,onfirmed on both longitudinal and transverse images [2,3].owever, tendon continuity is maintained.High-grade partial-thickness tearing may demonstrate

endon thinning rather than thickening as the result of to aoss of tendon substance. Full-thickness tearing manifests astendon gap occurring in a background of tendinosis-related

igure 1. (Continued) (g) Correlative longitudinal view, deypoechoic muscle fibers separated by hyperechoic fibroadccompanying veins in the wrist. The vessels appear anech

tructures. (j) Correlative longitudinal view with Doppler (Philip

hanges. Differentiation of nonretracted full-thickness tears e

rom high-grade partial-thickness tears may be facilitated byuscle activation, passive stretch, or manual compressionith the transducer, all of which may reveal the gapping of a

ull thickness tear [3,4].Tenosynovitis may appear as simple, anechoic, easily dis-

laceable fluid surrounding the tendon, or as complex fluidith mixed echogenicity. Synovial hypertrophy may also beresent and is frequently associated with hyperemia onoppler examination [2,3]. The ultrasonographic appear-nce of complex fluid within the tendon sheath is nonspe-ific, and diagnostic aspiration should be completed if infec-ion is suspected. Intratendinous calcifications appear asinear or ovoid hyperechoic structures with variable amountsf posterior acoustic shadowing, depending on their densityFigure 3) [3,16]. Similar to bone, when calcifications areense, ultrasonographic evaluation of structures deep to thealcification is problematic.

igament Injuries

he manifestations of ligament injury are similar to thoseescribed for tendons. Low-grade injuries manifest as en-

arged, hypoechoic ligaments with an otherwise-normal

rating the typical pennate (“feather-like”) arrangement ofconnective tissue. (h) Transverse view of radial artery and

) Doppler examination confirms the vascular nature of thePhilips Medical Systems, Bothell, WA).

monstiposeoic. (i

chotexture, whereas partial- and full-thickness tears dem-

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nstrate fiber disruption. Comparison with unaffected liga-ents in other areas facilitates detection of more subtle

bnormalities. Stress testing may be used to differentiateartial versus complete tears and assess joint stability [4].

erve Injuries

eripheral nerves also can be evaluated for signs of entrap-ent or inflammation. Similar to tendons and ligaments,

ffected nerves exhibit regional swelling and diffuse hypo-chogenicity, often accompanied by a loss in their normalascicular pattern [3,5,6,17]. Entrapment sites may be local-zed by evaluating for swelling proximal to the entrapmentite and a focal narrowing at that site, that is, a “notch sign”3,5,6]. Dynamic testing can evaluate for subluxation orislocation [18].

igure 2. (a) Longitudinal view of normal Achilles tendon, exxtended field of view ultrasound image of patient with mypoechogenicity with maintenance of the fibrillar echotextureop screen � superficial, bottom screen � deep (Philips iU22, P

igure 3. Longitudinal view of supraspinatus tendon in a pa-ient with a large intratendinous calcification (arrows) andymptomatic rotator cuff calcific tendinopathy. Note appear-nce of calcium deposit, similar to bone in Figure 3. Posteriorcoustic shadowing obscures evaluation of structures deep to

he calcification. Left screen � lateral, right screen � medial,op screen � superficial, bottom screen � deep (Philips iU22,

ihilips Medical Systems, Bothell, WA).

uscle Injuries

ow-grade muscle strains exhibit subtle regions of hypo-chogenicity accompanied by obscuration of the normal pen-ate echotexture; the affected area looks “washed out” [6,10].igher grade injuries and contusions demonstrate variableegrees of frank fiber disruption and heterogenous fluidypical of a hematoma.

one and Joint Disorders

rregularities in the otherwise superficial, smooth surface ofone may be indicative of periostitis or stress fracture [12].urther evaluation of any suspicious bone disorder is neces-ary because of the inherent limitations of ultrasound. Ultra-ound is very sensitive for detecting joint effusions through-ut the body [19,20].

Simple effusions are anechoic, compressible, and devoidf Doppler flow. Complex, heterogeneous appearing fluid isnonspecific finding and may be indicative of infection [20].spiration is recommended as clinically indicated. Synovitisppears as noncompressible, echogenic tissue within a jointor tendon sheath), possibly exhibiting hyperemia on Dopp-er examination. Periarticular erosions, crystal disease-re-ated deposits, and gouty tophi can all be observed duringoint evaluation; however, one should recognize that poten-ially clinically important findings may not be accessible toltrasound examination deep within a joint [12]. Enlargedursae typically contain simple anechoic fluid, but complexuid may be present, similar to joint effusions. Periarticularnd peritendinous ganglia appear as multilobulated, ane-hoic, noncompressible structures devoid of blood flow21,22].

LINICAL APPLICATIONS

uring the past 10 years, the clinical applications of diagnos-ic and interventional musculoskeletal ultrasound have ex-anded rapidly. Technological advancements and an increas-

g a typical hyperechoic, fibrillar echotexture. (b) Correlativestance Achilles tendinopathy. Note the focal swelling andscreen � inferior (CALC � calcaneus), right screen � superior,Medical Systems, Bothell, WA).

hibitinid-sub. Left

ng diversity of users have established ultrasound as a clinical

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roblem-solving tool in musculoskeletal medicine. The pre-equisites for successful scanning as well as basic scanningrinciples have been reviewed in Part 1 of this 2-part article11]. When approaching a regional musculoskeletal disor-er, the physician is reminded to follow a standard examina-ion protocol to answer a predefined clinical question, eval-ating target structures both transversely and longitudinally.

houlder

he high prevalence of rotator cuff disorders coupled withltrasound’s ability to evaluate tendons with high resolutionave established ultrasound as a front-line diagnostic tool inany patients presenting with shoulder pain [23,24]. The

arliest consistent application of musculoskeletal ultrasoundas the evaluation of rotator cuff and associated soft tissueathologies [25,26]. Since that time, clinical applications inhe shoulder have increased dramatically.

The shoulder region can typically be examined with high-requency (�10 MHz) linear array transducers, although inarger patients mid-range frequency (6-10 MHz) transducers

ay be required [23,24,27,28]. Specific guidelines for ultra-onographic evaluation of the shoulder have been establishedsee Table 3, Part 1 of this 2-part article [11]). Examinershould be aware that the curved geometry of the rotator cuffendons creates anisotropy during most examinations, par-icularly at the musculotendinous junction [23,28,29].ransducer repositioning, as previously described, should besed to differentiate anisotropy from true pathology23,28,29].

Ultrasound can be used to detect and characterize tendonisorders affecting the biceps and rotator cuff, includingiceps tenosynovitis, tendinosis, and partial- or full-thick-ess tearing [23,24,30-33]. In addition, sonography is betterolerated and preferred by patients compared with a mag-etic resonance imaging (MRI) scan [34].

Physicians must recognize that fluid around the bicepsendon may represent tenosynovitis or an extension of alenohumeral joint effusion, because the bicipital sheathirectly communicates with the joint [23,28,31]. In fact,

oose bodies arising from the glenohumeral joint may bedentified within the biceps sheath. Bicipital tenosynovitis isuggested by the presence of concomitant bicipital tendi-opathy or tearing, echogenic synovial hypertrophy, painuring sonopalpation, and hyperemia on Doppler examina-ion [23,31]. A dynamic evaluation can reveal bicipital insta-ility during external rotation [32].

In experienced hands, ultrasound can identify the pres-nce and extent of partial-thickness and full-thickness rotatoruff tears with accuracy similar to MRI (see Figure 6b, Part 1f this 2-part article) [11,24,27,30,33,35-39].

In addition, ultrasound can be used to identify fluid in theubacromial-subdeltoid bursa, bursal hypertrophy, and im-ingement of hypertrophied rotator cuff tendons or bursal tis-ue against the lateral acromion during arm elevation (ultra-onographic impingement sign) [33,40,41]. Consequently,

hen clinically relevant information is desired regarding the

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tatus of the rotator cuff or biceps tendon, ultrasound may beonsidered as an initial diagnostic test after obtaining appropri-te radiographs [24,27,33,35,38,39].

For example, with respect to a patient presenting with anppropriate history, shoulder pain, stiffness, passive motionoss, and a normal radiograph, an unremarkable ultrasoundould support the diagnosis of adhesive capsulitis, facilitat-

ng implementation of appropriate treatment [42,43]. Ultra-ound enables follow-up of partial-thickness or small full-hickness rotator cuff tears for signs of structural progression.ltrasound-guided injections into the bicipital tendon sheathnd subacromial-subdeltoid bursa may be performed foriagnostic or therapeutic purposes [44-48]. In a subset ofatients presenting with symptomatic calcific rotator cuffendinopathy, the use of ultrasound can delineate the pres-nce and extent of the calcification, excluded concomitantotator cuff tears (atypical in this group), and facilitate treat-ent via ultrasound-guided percutaneous lavage and aspira-

ion (Figure 4) [16,49-53]. Examiners are reminded thatltrasound cannot completely investigate the glenohumeral

abrum or intra-articular regions of the glenohumeral, acro-ioclavicular, or sternoclavicular joints [24-28]. Conse-

uently, physicians must rely on alternative diagnostic imag-ng such as radiographs, computed tomography (CT), or MRIo definitively confirm the presence or absence of pathologiesffecting these areas.

Ultrasound can be used to detect loose bodies in theosterior glenohumeral joint recess and fragmentation ofony margins consistent with erosive arthritis and synovitis.hen necessary, ultrasound can facilitate accurate diagnostic

spiration or therapeutic injection into these joints [44,45].ltrasound also may be used to identify relevant periarticularathologies, such as spinoglenoid notch cysts associated withosterior labral tears, or acromioclavicular joint cysts associ-ted with massive rotator cuff tears [23,54]. Ultrasound

igure 4. Longitudinal view of supraspinatus tendon. A 22-auge needle (arrows) has been guided into a symptomatic,yperechoic, intratendinous calcification. With the use of a

avage technique, the hydroxyapatite crystals are aspirated,esulting in an eggshell appearance. Left screen � lateral, rightcreen � medial, top screen � superficial, bottom screen �

eep (Philips iU22, Philips Medical Systems, Bothell, WA).

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168 Smith and Finnoff MUSCULOSKELETAL ULTRASOUND: PART 2

uidance can facilitate cyst aspiration for temporary symp-om control as clinically indicated [54].

Ultrasound provides significant advantages over MRI andT scans to evaluate the postoperative shoulder [55]. Diag-ostic evaluation is most commonly performed to excludeotator cuff tear after rotator cuff repair or total shoulderrthroplasty [55]. Examination of the postoperative shoulders one of the most challenging diagnostic musculoskeletalxaminations and should only be performed by experiencedractitioners [54].

lbow

he superficially located structures about the elbow are ame-able to ultrasound examination with high-frequency (�10Hz) transducers. With respect to the lateral elbow, ultra-

ound provides excellent imaging of the common extensorendon. Although not typically required for initial diagnosis,ltrasound can assist in management of refractory cases

ateral epicondylosis (also called tennis elbow) by character-zing the extent of tendon tearing and identifying the pres-nce of concomitant radial collateral ligament injury (Figure) [56,57]. As clinically indicated, the radial nerve may beraced as it passes through the supinator to identify focalwelling and stenosis suggestive of radial tunnel syndrome7]. Nerve examination may be supplemented by visualiza-ion during pronation-supination. The radiocapitellar artic-lation may be examined for osteoarthritic changes or a plica,nd effusion or loose bodies may be seen in the annular recessdjacent to the radial neck [19,20]. A comprehensive articu-ar assessment would require radiographs, CT, or MRI.

Ultrasound guidance may be used to aspirate effusions,iagnostically block the radial nerve at the supinator, oruide corticosteroid injection into the common extensorendon region [20,58,59]. Because of the inconsistent andften marginal long-term results of corticosteroid injectionso treat common extensor tendinopathy/lateral epicondylo-is, in recently described procedures, researchers have at-empted to more directly stimulate a healing response58,59]. Ultrasound-guided percutaneous tenotomy, plate-et-rich plasma injection, sclerosing therapy, and autologouslood injections have all produced promising short-term

mprovements in refractory cases, although prospective ran-omized studies and longer-term follow-up are currently

acking [60-64].Ultrasound has similar applications on the medial elbow,

articularly with respect to the management of flexor-prona-or tendinopathy or medial epicondylosis (also called Golfer’slbow) [65,66]. In addition, ultrasound can readily trace thelnar nerve from the mid-humerus to mid-forearm, provid-

ng anatomic localization of ulnar nerve compression abouthe elbow [67,68]. Thus, ultrasound can supplement elect-odiagnostic testing by demonstrating the location of struc-ural nerve changes, as well as potentially identifying under-ying causes such as loose bodies, synovitis, osteophytes,umors, subluxation or dislocation, or a snapping triceps

endon [3,18,67,68]. f

Identification of ulnar nerve subluxation may influencehe approach to therapeutic injection in this region, as well ashe distance measurements used to calculate nerve conduc-ion velocity across the elbow [69]. The medial collateraligament (also known as ulnar collateral ligament) can bevaluated to reveal partial or complete tears [9,70]. Valgustress testing during ultrasound visualization can revealsymmetric increases in ulnohumeral joint laxity as an indi-ator of instability, thus assisting in diagnosis and triage9,71]. Finally, the median nerve can be identified in theid-arm and traced distally as it traverses through the pro-ator teres, identifying potential entrapment sites in patientsresenting with proximal median neuropathies [3].

For most physicians, applications in the anterior elbowre limited. Imaging the distal bicep tendon is technicallyhallenging, and MRI remains the test of choice in most cases.oose bodies may be identified in the anterior recesses, butT scan is much more sensitive when the primary indication

or diagnostic testing is a search for loose bodies throughouthe elbow [20]. In comparison, the triceps tendon is easilyxamined using ultrasound, revealing tendinopathy, partialearing and, in rare cases, full-thickness tearing. Elbow effu-ions are best visualized posteriorly when the elbow is flexed,ithin the olecranon fossa [19,20]. Loose bodies may also beetected in this location (Figure 6). Ultrasound can be usedor diagnostic elbow joint aspiration and injection via aosterior approach when clinically indicated [20].

rist-Hand

ltrasound can provide exquisitely detailed images of ten-ons, nerves, vessels, joint capsules, retinacula/pulleys, andome ligaments in the wrist-hand [72-74]. The superficialocation of these structures allows interrogation with high-

igure 5. Longitudinal view of the lateral elbow and commonxtensor tendon in a patient presenting with refractory “lateralpicondylitis.” Arrows denote a focal region of hypoechoge-icity accompanied by obscuration of the normal fibrillarchotexture of the tendon. These changes are consistent withigh-grade tendinopathy with focal intra-substance partialhickness tearing. RH � radial head, CAP � capitellum. Leftcreen � distal, right screen � proximal, top screen � superfi-ial, bottom screen � deep (Philips iU22, Philips Medical Sys-

ems, Bothell, WA).

requency linear transducers (12-17 MHz), providing resolu-

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ion of less than a millimeter. If available, small footprintinear array transducers allow greater maneuverability and

ay be particularly useful during ultrasound-guided proce-ures. Clinically, ultrasound is a powerful tool to differenti-te among multiple potential pain generators in patientsresenting with regional wrist-hand complaints and can fa-ilitate therapeutic aspiration or injection.

On the dorsal wrist, the tendons within all 6 wrist exten-or compartments may be traced from their musculotendi-ous junctions to their distal insertions [72]. Ultrasound cane used to identify the presence of tendinopathy, partial-hickness tearing, or full-thickness tearing, thus assisting inriage and management [75]. Associated tenosynovitis orntrasynovial pannus can be accurately identified, particu-arly with the use of power Doppler [75,76]. Dynamic exam-nation may reveal symptomatic snapping of tendons as theyross other tendons, joint, bony prominences/osteophytes,r synovial pannus [4].

Provocative supination-pronation testing during ultra-onographic visualization can objectively document extensorarpi ulnaris subluxation in patients presenting with dorso-lnar wrist pain and snapping [4,77]. All dorsal wrist tendonheaths are accessible to ultrasound-guided aspiration/injec-ion. Within the first dorsal extensor compartment, ultra-ound can readily identify fibrous or fibroosseous septaeetween the abductor pollicis longus and extensor pollicisrevis tendons, the presence of which have been implicated

n suboptimal injection responses to injections in cases ofeQuervain’s tenosynovitis [72,78-80]. In these cases, ultra-

ound guidance can ensure injectate distribution into bothubcompartments.

The dorsal radiocarpal and distal radioulnar joint recessesan be assessed for effusion or synovitis [72]. Ultrasound-uided aspiration/injection can proceed as clinically indi-ated. In most patients the dorsal scapholunate ligament maye identified as a fibrillar, hyperechoic structure spanning the

igure 6. Longitudinal view of the posterior elbow, demon-trating a calcified loose body in the olecranon fossa (arrows)n a patient with elbow pain, stiffness, and normal radiographs.eft screen � proximal, right screen � distal, top screen �uperficial, bottom screen � deep (Philips iU22, Philips Medicalystems, Bothell, WA).

orsal osseous margins of the scaphoid and lunate (Fig-i

re 1d) [72]. The ligament is located by scanning in annatomic transverse plane just distal to Lister’s tubercle onhe dorsal radius. This is a common location for periarticularanglion cysts, which are readily identified by ultrasound asell-defined, noncompressible, anechoic structures devoidf internal blood flow [21]. Ultrasound-guided aspiration,ith or without corticosteroid injection, may provide short-r intermediate term relief (Figure 7) [22]. The superficialadial nerve can be imaged as it emerges from beneath therachioradialis tendon and courses distally and dorsally overhe first extensor compartment tendons, facilitating identifi-ation of focal neuropathy or post-traumatic neuroma.

Similar to the dorsal wrist, all volar wrist tendons may beraced proximal to distal, allowing the physician to identifyhe presence and extent of tendinopathy and associated teno-ynovitis [72,75]. The volar radiocarpal joint recesses may benvestigated for effusion and synovitis [72]. The volar-radialrist is the second most common location for periarticularanglia, usually arising from the scaphotrapeziotrapezoidalrticulation [21]. These ganglia typically are located betweenhe flexor carpi radialis ulnarly and the radial artery radially.ltrasound guidance may be used to aspirate/inject any of

hese areas as clinically indicated, although the operatorhould exercise appropriate caution because of the proximityf neurovascular structures [21,22].

The role of ultrasound in the evaluation of carpal tunnelyndrome continues to evolve [80,81]. When abnormal, theedian nerve will appear enlarged and hypoechoic, and willemonstrate some obscuration of its internal fascicular struc-ure when imaged transversely (Figure 8) [82]. The severityf ultrasonographically documented anatomic changes cor-elates closely with electrophysiologic abnormalities [81].

igure 7. Transverse view of dorsal wrist in an athlete present-ng with a symptomatic, complex, dorsal wrist ganglion asso-iated with the scapholunate ligament. Using ultrasound guid-nce, a 19-gauge needle (arrows) is safely advancedetween tendons into the cyst for therapeutic aspiration and

njection. Left screen � radial, right screen � ulnar, top screensuperficial, bottom screen � deep (Philips iU22, Philips Med-

cal Systems, Bothell, WA).

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he most useful indicator of median neuropathy at the carpalunnel is an increased in the cross-sectional area at the carpalunnel entrance, delineated by the pisiform ulnarly and thecaphoid tubercle radially. A cross-sectional area of �15m2 is clearly abnormal, whereas 10-15 mm2 is equivocal

nd �10 mm2 is normal [83]. The carpal tunnel ultrasoundxamination may provide useful information when electro-iagnostic studies are equivocal, or secondary causes of car-al tunnel syndrome are suspected (eg, ganglia, flexor tendonenosynovitis) [84]. Anatomic variants such as a bifid medianerve and and/or persistent median artery are readily identi-ed [72,85]. Ultrasound guidance can be used to safely directarpal tunnel injections as well as facilitate percutaneousreatment of underlying pathologies, such as periarticularanglion cysts or synovial pannus (Figure 8) [22,86]. Inatients presenting with symptoms referable to Guyon’s ca-al, ultrasound examination may reveal ulnar nerve struc-ural changes indicative of neuropathy, as well as secondaryauses of ulnar nerve compression such as pisotriquetralanglia, ulnar artery aneurysms, or anomalous muscles3,72].

Within the hand, ultrasound can image the flexor andxtensor tendons in their entirety, identifying tendinopathy,artial-thickness tearing, or full-thickness tearing [3,75].assive or active motion may facilitate differentiation of high-rade partial-thickness tears from full-thickness tears [4,75].he collateral ligaments may be imaged at the metacarpopha-

angeal and interphalangeal joints and appear as moderatelyhick, hyperechoic, fibrillar structures [72]. Low-gradeprains appear as enlarged, diffusely hypoechoic ligaments,hereas partial or complete fiber disruptions indicate higherrade injuries. Radial or ulnar stress testing during ultra-ound examination will differentiate high-grade partial- from

igure 8. Transverse view of the proximal carpal tunnel duringltrasound guided injection in a patient with refractory carpalunnel syndrome failing to improve after previous non-guidednjection. Needle is depicted by arrows and passes just deepo a swollen, hypoechoic median nerve with obscuration of itsormal fascicular pattern. Left screen � radial, right screen �lnar, top screen � superficial, bottom screen � deep (Philips

U22, Philips Medical Systems, Bothell, WA).

ull-thickness sprains, as well as provide a functional assess- s

ent of joint stability. Ultrasound can image the ulnar col-ateral ligament of the thumb, and identify the presence orbsence of a Stener lesion with acceptable accuracy [8,87].

Very high-frequency linear transducers (�12 MHz) caneadily identify the A1, A2, and A4 pulleys in most patients73]. Disruption of the A2 pulley (Climber’s finger) is mani-ested as pulley discontinuity and can be confirmed ultra-onographically when active finger flexion results in volarubluxation of the flexor tendon as demonstrated ultrasono-raphically [74,75]. Patients with stenosing tenosynovitistrigger finger) usually demonstrate thickening of the A1ulley and dyskinetic tendon movement during active orassive finger flexion-extension [75]. Most cases are clinicallybvious and do not require confirmatory imaging. However,hen nonguided injections fail to alleviate symptoms, ultra-

ound guidance will ensure injectate placement and mayeveal additional underlying pathologies of clinical impor-ance [88].

The ability of ultrasound to image the collateral ligaments,exor and extensor tendons, and volar plate allow ultrasoundo provide potentially useful diagnostic information in theetting of finger dislocations. Ultrasound can be used tolearly identify the involved structures, facilitate stabilityssessment, and identify radiographically occult fractures. Inatients presenting with atraumatic finger joint complaints,ltrasound can be used to detect occult effusion and synovitisith better sensitivity than clinical examination, potentially

evealing an underlying inflammatory arthropathy [14].arly detection is relevant because of the emerging emphasisn early aggressive treatment with disease modifying agents14]. The role of ultrasound guidance to aspirate/inject fingeroints has been well established in the literature [13,89].

Although ultrasound is a powerful clinical tool whenppropriately applied in the wrist-hand region, it is notithout limitations. Currently, ultrasound cannot ade-uately evaluate the triangular fibrocartilage complex or in-ercarpal joints and ligaments with sufficient diagnostic ac-uracy for clinical use. In addition, like other body regions, aariety of tumors, most commonly giant cell tumors, mayanifest in the wrist-hand regions [90]. Although ultrasound

an assist in localizing, characterizing, and biopsying softissue tumors, it is frequently not the optimal imaging mo-ality for soft tissue mass evaluation. Physicians performingltrasound should be aware of these limitations to avoidisdiagnosis.

ip Region

ltrasound examination of the hip region is relatively chal-enging because of the deep location of the target structures,omplex anatomy, and extensive investigation area. Largeootprint medium-high frequency (7-10 MHz) linear trans-ucers or low-medium frequency (2-6 MHz) curvilinearransducers are required, providing increased imaging deptht the expense of resolution.

The hip joint can be readily examined for effusion or

ynovitis, and techniques for ultrasound-guided hip aspira-

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ion and/or injection are well described (Figure 9) [91-94].lthough acetabular labral tears may be observed during thexamination, ultrasound is not capable of completely evalu-ting the labrum or the intra-articular space. Within thenterior hip region, ultrasound may also help to identifyliopsoas tendinopathy, iliopsoas bursitis, and adductor ten-inopathy or tears.

Dynamic ultrasonographic examination during provoca-ive maneuvers is the diagnostic test of choice for symptom-tic snapping iliopsoas tendons at the level of the pelvic brimr femoral head [95,96]. Ultrasound-guided iliopsoas peri-endinous injection may confirm the diagnosis of symptom-tic snapping iliopsoas tendons, or iliopsoas tendinopathy inative or post-arthroplasty hips [96-98]. Although the diag-ostic role of ultrasound with respect to the lateral femoralutaneous nerve remains undefined, most high-resolutioncanners can readily identify the nerve at the level of thenterior superior iliac spine, facilitating diagnostic or thera-eutic ultrasound-guided blockade in patients presentingith burning anterolateral thigh pain consistent with meral-ia paresthetica [99].

In the lateral hip, ultrasound may be used to differentiatereater trochanteric bursitis from gluteal tendinopathy andan identify gluteal tears in native or postarthroplasty hips100]. The greater trochanteric (ie, subgluteus maximus)ursa is not visualized during ultrasonography unless abnor-al. When clinically indicated, ultrasound can precisely

uide diagnostic/therapeutic injections into hip bursae orluteal peritendinous regions. The diagnostic role of ultra-ound in the posterior hip region is limited. Ultrasound mayelp to identify moderate-to-severe hamstring tendinopathy

igure 9. Ultrasound-guided intra-articular hip injection. Nee-le (arrows) has penetrated the anterior hip capsule at the

emoral head (FH)-neck junction, entering the anterior jointecess. From this position, the hip joint can be injected. Notehe curved image geometry created by the 5-2 MHz curvilin-ar array transducer used for the procedure. A � acetabulum,

eft screen � distal, right screen � proximal, top screen �uperficial, bottom screen � deep (Philips iU22, Philips Medicalystems, Bothell, WA).

nd tears but is not likely as sensitive as MRI scan. However, t

ltrasound guidance may be used to accurately guide ischialursa aspiration/injection or proximal hamstring peritendi-ous injections [101]. Ultrasound-guided techniques foririformis sheath and sacroiliac joint injections have beenescribed and may be useful alternatives to fluoroscopicallyuided procedures, particularly when radiation is contrain-icated (eg, pregnancy) [102,103].

Although the diagnostic role of ultrasound continues tovolve with respect to the hip, physicians should exerciseaution when considering using ultrasound as a primarymaging modality for regional hip pain. The technical limita-ions of ultrasound favor CT or MRI for diagnostic purposesn most cases. Ultrasound may be considered when specificnformation is desired about superficial structures (eg, ad-uctor tendons, iliopsoas tendons, lateral femoral cutaneouserve), with the understanding that the small field of viewrovided by the ultrasound exam limits the ability to excludeignificant findings beyond the examined region. On theontrary, once pathology is identified, ultrasound may beffectively used to guide needles to virtually any target loca-ion within the hip region.

nee Region

iagnostic examination of the knee can typically be per-ormed with high-frequency (�10 MHz) linear transducersecause of the superficial location of most target structures.he primary indications for ultrasound in the anterior kneere to evaluate the extensor mechanism and to identify andspirate knee effusions. The echogenic, fibrillar trilaminartructure of the distal quadriceps tendon is readily revealedith the use of high-frequency transducers, facilitating as-

essment of tears in native or postarthroplasty knees104,105]. Although patellar tendinopathy is typically atraightforward clinical diagnosis, structural changes areore likely to be observed on ultrasound than MRI in symp-

omatic patients [106]. Tendon neovascularization as de-ected by power Doppler examination appears to correlateith clinical symptoms, although the relationship is not

bsolute (Figure 10) [106,107].Initial experience with ultrasound-guided sclerosis of

eovessels and dry needling coupled with autologous bloodnjections has produced favorable results [108,109]. Furtherrospective investigation of these promising therapeutic in-erventions is warranted. Ultrasound examination may assistn triage and rehabilitation progression by differentiatingendinosis from high-grade partial thickness tearing, as wells determining the presence of associated superficial or deepnfrapatellar bursopathy. Identification of these latter condi-ions as pain generators with the use of sonopalpation mayead to therapeutic ultrasound-guided injection. Knee effu-ions are best detected in the suprapatellar pouch by usingagittal views and appear as anechoic fluid collections15,110,111]. Doppler examination may reveal hyperemiaonsistent with synovitis. When clinically indicated, ultra-ound guidance may be used to aspirate effusions and inject

herapeutic agents [110,111].

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Patients presenting with lateral knee pain or swelling maye evaluated for the presence of distal iliotibial band syn-rome, lateral perimeniscal ganglion cysts, biceps femorisendinopathy, or common fibular (peroneal) nerve disorders110,112-114]. The complex anatomy of this region limitshe diagnostic utility of ultrasound, but when clinically indi-ated, ultrasound can be used to guide therapeutic cystspiration and injection, peritendinous injection, or distalliotibial band injection [112].

In the posterior knee, ultrasound is most commonly usedo diagnose and treat popliteal cysts (Baker cysts; see Figure, Part 1 of this 2-part article) [11,115]. The use of ultra-ound can readily detect Baker cysts, can identify cyst leakager rupture, and can guide therapeutic aspiration and injec-ion [115]. Ultrasonographically, Baker cysts appear as ane-hoic or hypoechoic fluid collections located between theedial gastrocnemius and semimembranosus tendons that

learly communicate with the posterior tibiofemoral joint15,115]. If the appearance is atypical or a communicativetalk cannot be identified with certainty, clinicians shouldearch for other conditions that may produce posterior kneeain, including popliteal artery aneurysm, semimembrano-us tendinopathy, or tumors. An MRI scan should be ob-ained as necessary.

Although ultrasound may clearly identify the medial col-ateral ligament, ultrasonographic examination does not typ-cally provide additional clinically useful information. Ultra-ound may be used to document pes anserine bursitis anduide therapeutic injection of the saphenous nerve in pa-ients presenting with medial knee pain syndromes. Ultra-ound is not predictably useful for excluding the presence ofntra-articular knee disorders such as cruciate ligament dis-uption, (osteo-)chondral injury, or meniscal tear [110,116].

nkle-Foot

irtually all tendons and nerves about the ankle and foot

igure 10. (a) Longitudinal view of the proximal patellarendinopathy. Note marked tendon thickening, diffuse hypoeb) Extended field of view (ie, panoramic) imaging of the samllows a better appreciation of the extent of tendon thickenin

creen � proximal, top screen � superficial, bottom screen �

egion are amenable to diagnostic ultrasound examination.B

igh-frequency (�10 MHz) linear array and small footprintinear array transducers are typically used.

In patients presenting with posterior ankle pain, ultra-ound can be used to identify Achilles tendinopathy andifferentiate between tendinosis and partial-thickness tearingFigures 2 and 11) [117]. Doppler examination may revealendon neovascularization, which is typically present in moreevere and symptomatic cases [118]. Associated paratenoni-is, retrocalcaneal bursitis, and retro-Achilles (superficialchilles) bursitis may be identified as primary or contribut-

ng conditions [117,119]. Ultrasound-guided bursa andaratenon injections may assist in diagnosis and manage-ent of these latter conditions, although caution must be

xercised with respect to the use of corticosteroids in theicinity of the Achilles or other ankle-foot tendons [119-22].

n in an athlete with chronic, refractory proximal patellarnicity, extensive neovascularization on Doppler examination.ient, providing a more global view of the tendon. This imagetive to normal (denoted by arrows). Left screen � distal, right(Philips iU22, Philips Medical Systems, Bothell, WA).

igure 11. Longitudinal view of Achilles tendon in formerunner with chronic heel pain. The tendon exhibits structuralhanges of chronic tendinopathy, including moderate thick-ning, diffuse hypoechogenicity, and neovascularization onoppler examination. In addition, there is an irregular ane-hoic region on the undersurface of the tendon, adjacent to

he calcaneus, consistent with partial thickness tearing. Leftcreen � cranial, right screen � distal, top screen � superficial,ottom screen � deep (Philips iU22, Philips Medical Systems,

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Recent uncontrolled case series have reported symptom-tic improvement in patients with chronic Achilles tendi-opathy treated with ultrasound-guided sclerosis of neoves-els or intratendinous injection of dextrose (prolotherapy)123,124]. Further research is warranted in this regard. Ul-rasound can be used to readily identify Achilles tendonupture and assist in triage. In selected patients, tendonpposition during ankle plantar flexion has been associatedith a favorable outcome after nonoperative management

125].Deep posterior ankle pain may be caused by flexor hallu-

is longus tendinopathy or tenosynovitis, posterior ankleoint effusion/synovitis or loose bodies, or os trigonum syn-rome, all of which may be evaluated ultrasonographicallyn more sophisticated machines [117]. Therapeutic tendonheath injection or diagnostic/therapeutic os trigonum injec-ion can be completed ultrasonographically as clinically in-icated [122].

In the posteromedial ankle, ultrasound can be used toeadily depict the structures within the tarsal tunnel anddjacent region [126]. Ultrasound can detect and character-ze posterior tibial tendon disorders as accurately as MRI forlinical decision making [117,127]. Although uncommonlyerformed, ultrasound guidance can be used to inject theosterior tibial tendon sheath for diagnostic or therapeuticurposes [119,122]. The tibial nerve, medial and laterallantar branches, and medial calcaneal branch can all be

nvestigated using high-frequency transducers, facilitatingdentification of compression, inflammation, or neuroma.ltrasound-guided nerve block can be performed as indi-ated. Periarticular ganglion cysts arising from the medialibiotalar or subtalar joints may produce ankle pain or truearsal tunnel syndrome [126]. They appear as anechoic,ultilobulated structures and can be therapeutically aspi-

ated using ultrasound guidance, although improvement isften temporary [117,122]. It is important to recognize thatltrasound cannot adequately evaluate the joint structuresrom which such a cyst may arise, and MRI would be recom-

ended in such cases.The peroneal tendons account for the majority of pain

yndromes in the posterolateral ankle. The use of ultrasoundccurately identifies and characterizes peroneal tendon dis-rders and is the test of choice for demonstrating tendonubluxation or dislocation (Figure 12) [117,128,129]. Moreecently, symptomatic peroneal tendon snapping within theetrofibular groove has been identified as a source of postero-ateral ankle pain as demonstrated by ultrasound117,128,129]. Therapeutic and diagnostic peroneus longusr brevis tendon sheath injections may be performed aslinically indicated [122]. Although uncommon, sural nerveisorders can manifest as posterolateral ankle pain. The nervean be easily identified just anterior to the Achilles tendonnd adjacent to the lesser saphenous vein. From this point, itan be traced distally in a transverse view to the level of itsifurcation at the base of the fifth metatarsal in most cases.

Tendon disorders are uncommon in the anterior ankle,

lthough ultrasound can readily confirm a clinically sus- d

ected anterior tibialis tendon rupture [117]. Ankle jointffusions are best visualized anteriorly in an anatomical sag-ttal plane with the ankle in slight plantarflexion [117].ffusions are usually simple but may be complex and containvariable amount of synovitis or loose bodies [117]. Ultra-

ound-guided aspiration and injection can be performed; onehould take care to avoid the dorsalis pedis artery and deepbular (peroneal) nerve [20,122]. In the appropriate clinicaletting, hyperechoic debris in the anterolateral gutter wouldupport a clinical diagnosis of anterolateral impingementyndrome [130]. Ultrasound-guided injection may be help-ul to accurately place the injectate into the meniscoid tissue.xamination of the anterior talofibular, calcaneofibular, andosterior talofibular ligaments can be performed but is gen-rally of no clinical utility because the ultrasonographic find-ngs do not alter management [131].

Within the foot, ultrasound is most commonly used toonfirm a clinical diagnosis of plantar fasciitis and character-ze the structural severity [119,132]. Similar to lateral epi-ondylosis in the elbow, soft-tissue imaging is not indicatedn most cases. In refractory or atypical cases, thickening�4-5 mm), hypoechogenicity, and heterogeneity of thelantar fascia would support a clinical diagnosis of plantarasciitis [132-134]. The absence of structural findings war-ants a search for other causes.

Ultrasound-guided plantar fascia injections have been re-orted to provide greater therapeutic efficacy compared withonguided injections in a single investigation, although firmonclusions in this regard await further study [119,133-35]. Ultrasound can evaluate all the midfoot joints via a

igure 12. Transverse view of the peroneus brevis (PB) andongus (PL) tendons just distal to the fibular tip in a middle agedunner with lateral ankle pain. Both tendons are surrounded bynechoic fluid, which is consistent with tenosynovitis. The per-neus longus is markedly thickened, diffusely hypoechoic, andxhibits multiple areas of fissuring (arrows), consistent with highrade tendinopathy with longitudinal split tears. Left screen �ranial, right screen � caudal, top screen � superficial (lat-ral), bottom screen � deep (medial) (Philips iU22, Philipsedical Systems, Bothell, WA).

orsal approach, identifying arthritis, synovitis, and periar-

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174 Smith and Finnoff MUSCULOSKELETAL ULTRASOUND: PART 2

icular ganglia [136]. Dorsal osteophytic lipping resulting ineuritis or tendinopathy can be depicted with static ultra-ound and confirmed with dynamic testing. Diagnostic orherapeutic ultrasound-guided joint aspirations and injec-ions may be performed for these conditions as clinicallyndicated [122,136].

Investigation of the plantar aspect of the midfoot remainshallenging because of the complex anatomy and similarchogenicity of multiple layers of crossing tendons. Therimary indication for ultrasound in this region is to confirmclinically suspected plantar fibroma, appearing as a focal,ypoechoic fusiform swelling located within the plantar fas-ia along its medial border [137]. A mass lesion presentingith any other appearance warrants further evaluation withT or MRI. Within the forefoot, ultrasound can detect effu-

ions and/or synovitis in the metatarsophalangeal and inter-halangeal joints, plantar plate disruptions, and Morton neu-omas in addition to intermetatarsal bursitis, facilitatingdentification of potential pain generators in patients present-ng with forefoot pain or metatarsalgia [138,139].

Morton neuroma appears as a well defined, noncompress-ble, hypoechoic mass lesion within the plantar aspect of thentermetatarsal space at the level of the metatarsal heads, asisualized from a plantar approach [138,139]. Continuityith the interdigital nerve confirms the diagnosis but is

nconsistently visualized even when sophisticated machinesre used [18]. Morton neuroma is often accompanied byntermetatarsal bursitis, appearing as an anechoic, compress-ble fluid collection dorsal to the Morton neuroma as visual-zed from a plantar approach [138,139]. Therapeutic jointspiration and injection, as well as Morton neuroma andntermetatarsal bursa injection, can be performed with these of ultrasound guidance [122,140].

Despite the broad range of clinical applications in thenkle and foot, ultrasound cannot adequately evaluate thentra-articular structures of the hindfoot or midfoot jointsnd has limited capability to image many deeply locatedtructures in the plantar midfoot region. Radiographs areecommended to supplement any ultrasound examinationnd, when clinically indicated, advanced diagnostic imaginghould be pursued in the form of MRI, CT, or bone scan.

HE FUTURE OF MUSCULOSKELETALLTRASOUND IN PHYSIATRY

he integration of diagnostic and interventional musculo-keletal ultrasound into clinical practice represents a signifi-ant development in the field of physiatry. Having success-ully prescribed therapeutic ultrasound for more than 50ears, physiatrists now have the opportunity to use muscu-oskeletal ultrasound as a clinical decision-making tool forhe benefit of their patients. With this opportunity comes thehallenge of creating the future of musculoskeletal ultra-ound in physiatry. To meet this challenge, physiatrists must1) develop an infrastructure to provide musculoskeletalltrasound education, (2) implement practice guidelines to

nsure the appropriate application of ultrasound technology,

3) establish a method of documenting competency amonghysiatrists who choose to integrate musculoskeletal ultra-ound in their practices, and (4) continue to explore andocument cost-effective clinical applications of musculoskel-tal ultrasound in physiatric practice. These actions are nec-ssary to establish physiatrists as credible users of musculo-keletal ultrasound as viewed by our patients, our colleaguesn other medical specialties, and third-party payers. To ourdvantage, we have walked down this path before, as oureld successfully managed the evolution of electrodiagnosticnd spinal injection techniques during the 20th century. The1st century now presents a similar challenge with the pro-

iferation of diagnostic and interventional musculoskeletalltrasound.

Physiatrists share a long and rich history with ultrasoundechnology and are uniquely positioned to be leaders in theeld of musculoskeletal ultrasound. The information pre-ented in this 2-part article is relevant to all physiatrists as weitness the rapid infiltration of diagnostic and interventionalltrasound into musculoskeletal medicine. More impor-antly, the authors hope that this review will inspire inter-sted and motivated physiatrists to integrate musculoskeletalltrasound into their practices and participate in the activitieshat will solidify the position of this powerful technology inhe future.

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