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The Top 10 Reasons Musculoskeletal Sonography Is an Important Complementary or Alternative Technique to MRI

¹ Department of Radiology, Thomas Jefferson University Hospital, Rm. 763E Main Bldg., 132 S 10th St., Philadelphia, PA 19107-5244.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —21-year-old woman, a Division 1 college tennis player with shoulder pain for 1 year. MR arthrogram revealed SLAP (superior labrum anterior to posterior) lesion that was not confirmed at arthroscopy. Capsulorrhaphy was performed with no relief in symptoms. Repeat shoulder MRI was negative. Short-axis sonogram of supraspinatus tendon reveals linear hypoechoic focus at bursal surface of tendon (arrow). H = humeral head.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —21-year-old woman, a Division 1 college tennis player with shoulder pain for 1 year. MR arthrogram revealed SLAP (superior labrum anterior to posterior) lesion that was not confirmed at arthroscopy. Capsulorrhaphy was performed with no relief in symptoms. Repeat shoulder MRI was negative. Short-axis sonogram of supraspinatus tendon after 5 mL of 0.5% bupivacaine was instilled percutaneously under sonographic guidance into subdeltoid space shows fluid entering bursal-sided supraspinatus tear (asterisk).

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —39-year-old man who had been bothered by knee pain for more than 1 year, especially while riding his bicycle competitively. Knee radiography and MRI were normal. Longitudinal sonogram at level of lateral femoral condyle reveals unsuspected calcification of hyaline cartilage (arrowheads). This area was focally tender to probe pressure, confirming chondrocalcinosis as underlying cause of pain.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —40-year-old woman who had persistent pain for 2 months after removing rose thorn from her finger after gardening. MRI showed flexor tenosynovitis, for which she was treated with nonsteroidal antiinflammatory medications, with little improvement. Longitudinal sonogram at level of proximal interphalangeal joint of right index finger reveals linear foreign body (between arrows) consistent with rose thorn and proven at surgery. Tendon sheath is distended with fluid and debris.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —40-year-old woman who had persistent pain for 2 months after removing rose thorn from her finger after gardening. MRI showed flexor tenosynovitis, for which she was treated with nonsteroidal antiinflammatory medications, with little improvement. Power Doppler sonogram shows marked hyperemia around foreign body, corresponding to tenosynovitis detected on MRI. MRI, however, failed to detect foreign body as underlying problem.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —44-year-old man with painful mass that popped out over his lateral knee with flexion and disappeared with extension. MRI of knee, obtained with knee in extension, failed to find cause of his symptoms. Longitudinal sonogram obtained at lateral aspect of distal femur with knee in extension reveals small amount of fluid (asterisk) in lateral recess of joint but no soft-tissue mass.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —44-year-old man with painful mass that popped out over his lateral knee with flexion and disappeared with extension. MRI of knee, obtained with knee in extension, failed to find cause of his symptoms. Longitudinal sonogram obtained at lateral aspect of distal femur with knee in flexion reveals approximately 1.5-cm soft-tissue mass (M) consistent with fat that abruptly popped into lateral recess of joint, accompanied by pain. At surgery, this mass was shown to be intraarticular fat that was tethered by a plica (arrow).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —24-year-old man, competitive javelin thrower, who had a history of ulnar collateral ligament reconstruction 5 years earlier and recently felt a pop and recurrent pain while throwing. Longitudinal sonogram obtained at medial elbow shows heterogeneous, thickened ulnar collateral ligament (arrows). At rest, joint space (asterisks) between trochlea of humerus (H) and coronoid process of ulna (U) measures 2.8 mm, which is within normal limits.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —24-year-old man, competitive javelin thrower, who had a history of ulnar collateral ligament reconstruction 5 years earlier and recently felt a pop and recurrent pain while throwing. Longitudinal sonogram obtained at medial elbow with elbow in valgus stress shows marked widening of joint space (asterisks) between humerus (H) and ulna (U), now measuring 11.8 mm. Retraction of ligament (arrows) is also accentuated. Findings indicate complete incompetence of reconstructed ulnar collateral ligament. Patient had to undergo repeat ligamentous reconstruction.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —68-year-old man, runner in Senior Olympics, has been experiencing ankle pain. Sonography was ordered to "rule out Achilles tendon tear." Longitudinal sonogram of Achilles tendon (arrowheads) shows thickened tendon with hypoechoic focus (asterisk) and calcaneal enthesophyte (E), consistent with Achilles tendinosis. However, during examination, patient asked, "Doc, why are you scanning there? That's not where it hurts."

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —68-year-old man, runner in Senior Olympics, has been experiencing ankle pain. Sonography was ordered to "rule out Achilles tendon tear." Axial sonogram obtained at area of pain identified by patient reveals thickened, tendinotic peroneus longus (PL) and split tear of peroneus brevis (PB, arrow) at level of distal fibula (F). Knowing where patient hurt enabled radiologist to produce a more clinically relevant report. Sonography also directed therapy to appropriate tendons.

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —46-year-old woman with 2 years of severe, progressively increasing right "hip" pain. During that time she had undergone two hip MRI examinations and one lumbosacral spine MRI examination, all of which failed to detect cause of pain. In retrospect, none of the MRI examinations included actual source of pain in their field of view. Axial sonogram was obtained over area of most severe tenderness—right iliac crest—with image of left iliac crest included for comparison. Thickened hypoechoic structure (arrows) was identified on right that was not present on left.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —46-year-old woman with 2 years of severe, progressively increasing right "hip" pain. During that time she had undergone two hip MRI examinations and one lumbosacral spine MRI examination, all of which failed to detect cause of pain. In retrospect, none of the MRI examinations included actual source of pain in their field of view. Longitudinal extended-field-of-view sonogram at right iliac crest shows right external oblique muscle (M) and tendon (T). Hypoechoic structure seen in A is a thickened and calcified external oblique tendon. This tendinosis likely resulted from repeatedly twisting her torso during her 18 years as a professional blackjack dealer.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —46-year-old woman with 2 years of severe, progressively increasing right "hip" pain. During that time she had undergone two hip MRI examinations and one lumbosacral spine MRI examination, all of which failed to detect cause of pain. In retrospect, none of the MRI examinations included actual source of pain in their field of view. Under local anesthetic and sonographic guidance, 18-gauge spinal needle (arrows) was inserted to fenestrate tendon and break up calcifications. Within 8 weeks after procedure, pain had completely resolved.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —29-year-old woman with severe, unrelenting stabbing pain in right hip. Her pain became significantly worse after osteotomy surgery 2 years previously for hip dysplasia. Numerous imaging studies, including MRI, were unrevealing. Musculoskeletal sonography was not available in her region, so she flew from Portland, OR, to Philadelphia, PA, to be examined. Her orthopedic surgeon provided a prescription for sonography but told me, "You won't find anything; that patient is crazy." Axial sonogram at level of iliopsoas muscle (M) shows surgical screw (arrowheads) that has pierced iliac bone and lies deep in relation to iliopsoas tendon (T). Dynamic images (not shown) showed that whenever patient flexed her hip, tendon rubbed against the screw, reproducing her excruciating pain. Screw was surgically removed (by a different orthopedic surgeon), and her stabbing pain immediately resolved.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —40-year-old woman with thumb pain. MRI was nondiagnostic. Longitudinal sonogram of nail bed of shows subtle hypoechoic mass (M).

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —40-year-old woman with thumb pain. MRI was nondiagnostic. Power Doppler sonogram of mass shows internal flow.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —40-year-old woman with thumb pain. MRI was nondiagnostic. Spectral Doppler waveforms confirm presence of arterial flow. Glomus tumor was diagnosed and confirmed at surgery.

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —64-year-old woman with rheumatoid arthritis and posterior knee pain. MRI showed Baker cyst, and patient was referred for sonographically guided aspiration. Axial sonogram obtained at medial popliteal fossa shows that Baker cyst (arrows) is completely filled with solid material. This finding was not apparent on MRI because Baker cyst was homogeneously hyperintense on T2-weighted images. Note characteristic location between medial head of gastrocnemius (G) and semimembranosus (S) tendons.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —64-year-old woman with rheumatoid arthritis and posterior knee pain. MRI showed Baker cyst, and patient was referred for sonographically guided aspiration. Power Doppler sonogram shows some internal vascularity in Baker cyst, consistent with rheumatoid pannus. Under sonographic guidance, pannus was injected with corticosteroid for symptomatic relief.

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