AJR 2004; 182:341-351
© American Roentgen Ray Society
Sonography of Lower Limb Muscle Injury
Justin Charles Lee1 and
Jeremiah Healy
1 Both authors: Department of Radiology, Chelsea and Westminster Healthcare NHS
Trust, 369 Fulham Rd., London SW10 9NH, England.
Received September 23, 2002;
accepted after revision May 29, 2003.
Address correspondence to J. Healy
(j.healy{at}ic.ac.uk).
Introduction
Because of advances in technology, sonography offers significant advantages
over other imaging techniques in assessing muscle trauma. High-frequency
transducers yield images with excellent spatial resolution. The real-time
capability allows dynamic evaluation of muscle and tendon injuries. Sonography
provides clinical correlation with imaging findings, allowing accurate
diagnosis. Furthermore, sonography is quicker, more accessible, and cheaper
than MRI. We present an illustrated review of the use of sonography in muscle
injury.
Equipment and Software
Muscles are usually examined using a linear array high-frequency
transducer. For deep lesions, it may be necessary to use a low-frequency
curvilinear transducer to increase tissue penetration. Current systems allow
imaging from 3 to 15 MHz, visualizing deep and superficial muscle structures.
In addition, new software developments such as imaging with an extended field
of view can be useful in showing pathology in relation to its surrounding
anatomy [1] (Figs.
1A,
1B,
1C,
1D and
2A,
2B). Color-flow and power
Doppler sonography are widely available and may help delineate areas of acute
muscle injury by showing increased blood flow to the affected area.
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Fig. 1A. —28-year-old healthy man. Transverse sonogram of anterior
thigh muscles (A) and diagram (B) show perimysium as dot or
short-line echoes (arrows, A) against hypoechoic background of
muscle fibers.
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Fig. 1B. —28-year-old healthy man. Transverse sonogram of anterior
thigh muscles (A) and diagram (B) show perimysium as dot or
short-line echoes (arrows, A) against hypoechoic background of
muscle fibers.
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Fig. 1C. —28-year-old healthy man. Transverse extended-field-of-view
sonogram (C) of thigh and diagram (D) show that any lesion in
muscle can be related to its surrounding anatomy. This finding helps referring
clinician.
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Fig. 1D. —28-year-old healthy man. Transverse extended-field-of-view
sonogram (C) of thigh and diagram (D) show that any lesion in
muscle can be related to its surrounding anatomy. This finding helps referring
clinician.
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Fig. 2A. —28-year-old healthy man. Longitudinal extended-field-of-view
sonogram (A) and diagram (B) of anterior thigh show perimysium
as oblique parallel echogenic striae against hypoechoic background of muscle
fibers.
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Fig. 2B. —28-year-old healthy man. Longitudinal extended-field-of-view
sonogram (A) and diagram (B) of anterior thigh show perimysium
as oblique parallel echogenic striae against hypoechoic background of muscle
fibers.
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Normal Appearance
Muscle fibers are grouped into fascicles separated by septa of fibroadipose
tissue, the perimysium. The whole muscle is enclosed in a fascial sheath, the
epimysium. In the transverse plane (Fig.
1A,
1B,
1C,
1D), the perimysium is seen as
dot echoes or short lines scattered throughout the hypoechoic background,
representing the bulk of the muscle fibers. Large intramuscular septa may
produce a reticular pattern, and intermuscular septa appear brightly
echogenic. In the longitudinal plane (Fig.
2A,
2B), the perimysium is seen as
oblique parallel echogenic striae against a hypoechoic background.
Intramuscular extensions of tendons are identified as thick, fibrillar, and
echogenic structures. Intermuscular fasciae are brightly echogenic. During
contraction, the muscle alters shape and becomes hypoechoic with increased
angulation of the echogenic septa.
When an ultrasound beam interacts with multiple parallel sound interfaces,
such as muscle or tendon fibers, anisotropy artifact may result in marked
hypoechogenicity, which may mimic a tear
(Fig. 3). Therefore, the
sonographer must keep the transducer perpendicular to the muscle being
examined.
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Fig. 3. —32-year-old healthy man. Dual-image transverse sonogram of
anterior thigh shows anisotropy artifact. Image on left taken with transducer
angled to muscle shows hypoechoic area (arrows) in rectus femoris
muscle (RF), anterior to vastus intermedius muscle (VI), which may be mistaken
for pathology. Image on right shows normal appearance when transducer is
correctly held perpendicular to muscle.
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Muscle Trauma
We describe three types of acute skeletal muscle trauma: strains, tears,
and contusions and hematomas. Chronic lesions after muscle trauma include
fibrous scars, muscle hernias, and heterotopic calcification.
Acute Muscle Injuries
Strains and Tears
Strains may follow overuse or overstretching and present with stiffness and
soreness, particularly in the hamstrings, rectus femoris muscle, hip adductor
and flexor muscles, and medial gastrocnemius muscle
[2]. The musculotendinous
junction is the most common site of injury. Clinical grades I, II, and III are
described.
Clinical grade I strains present with the previously mentioned symptoms,
but there is rapid recovery and no loss of muscle strength after conservative
management. Sonographically, grade I strains may have a normal appearance or
show focal or general areas of increased echogenicity (Fig.
4A,
4B). However, perifascial fluid
may be seen, and up to 50% of grade I strains show generalized
hyperechogenicity [3].
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Fig. 4A. —24-year-old man with grade I rectus femoris muscle strain.
Transverse sonogram (A) and diagram (B) of both thighs show
hyperechoic swollen left rectus femoris muscle (RF, arrows, A)
anterior to vastus intermedius muscle (VI).
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Fig. 4B. —24-year-old man with grade I rectus femoris muscle strain.
Transverse sonogram (A) and diagram (B) of both thighs show
hyperechoic swollen left rectus femoris muscle (RF, arrows, A)
anterior to vastus intermedius muscle (VI).
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Delayed-onset muscle soreness is a condition seen after strenuous activity,
for which findings on sonography may be normal or show geographic
hyperechogenicity similar to that of a grade I muscle strain. The two
conditions are distinguished clinically. In delayed-onset muscle soreness, the
symptoms increase progressively over the first 24–48 hr, peaking at day
3 and resolving by day 7 with conservative management. However, in grade I
strains, symptoms start at the time of injury and resolve over a 2-week
period.
Clinical grade II muscle strains, representing intrasubstance tears,
present with pain and loss of function. Sonographically, there is
discontinuity of muscle fibers in echogenic perimysial striae (Figs.
5A,
5B,
5C,
5D). Hypervascularity around
the disrupted muscle fibers may increase lesion conspicuity if color Doppler
sonography is used (Fig. 5E).
An intramuscular fluid collection may be seen with a surrounding hyperechoic
halo [4]. Dynamic scanning
during contraction may enhance the size and contrast of the lesion (Fig.
6A,
6B,
6C,
6D). Grade II strains include
partial detachment of muscle from the adjacent fascia or aponeurosis, such as
tennis leg, in which the medial gastrocnemius muscle detaches from its common
aponeurosis with the soleus muscle
[5] (Fig.
7A,
7B).
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Fig. 5A. —23-year-old man with grade II biceps femoris muscle strain.
Transverse sonogram (A) and diagram (B) of biceps femoris muscle
show hyperechogenicity with disruption of muscle fibers (open arrows,
A) surrounding relatively hypoechoic tendon (solid arrow,
A).
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Fig. 5B. —23-year-old man with grade II biceps femoris muscle strain.
Transverse sonogram (A) and diagram (B) of biceps femoris muscle
show hyperechogenicity with disruption of muscle fibers (open arrows,
A) surrounding relatively hypoechoic tendon (solid arrow,
A).
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Fig. 5C. —23-year-old man with grade II biceps femoris muscle strain.
Longitudinal sonogram (C), obtained in same location as A, and
diagram (D) confirm muscle fiber disruption (open arrows,
C) around tendon (solid arrow, C). Cursors indicate
length of tear.
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Fig. 5D. —23-year-old man with grade II biceps femoris muscle strain.
Longitudinal sonogram (C), obtained in same location as A, and
diagram (D) confirm muscle fiber disruption (open arrows,
C) around tendon (solid arrow, C). Cursors indicate
length of tear.
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Fig. 6A. —22-year-old man with grade II strain of biceps femoris
muscle. Transverse sonogram (A), obtained at rest, and diagram
(B) of hamstrings show partial disruption of biceps femoris muscle
fibers (straight arrows, A) in close relation to tendon
(curved arrow, A).
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Fig. 6B. —22-year-old man with grade II strain of biceps femoris
muscle. Transverse sonogram (A), obtained at rest, and diagram
(B) of hamstrings show partial disruption of biceps femoris muscle
fibers (straight arrows, A) in close relation to tendon
(curved arrow, A).
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Fig. 6C. —22-year-old man with grade II strain of biceps femoris
muscle. Transverse sonogram (C), obtained in same location as A,
and diagram (D) show how tear can be made more conspicuous during
muscle contraction. In C, straight arrows indicate disrupted biceps
femoris muscle fibers, and curved arrow indicates tendon.
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Fig. 6D. —22-year-old man with grade II strain of biceps femoris
muscle. Transverse sonogram (C), obtained in same location as A,
and diagram (D) show how tear can be made more conspicuous during
muscle contraction. In C, straight arrows indicate disrupted biceps
femoris muscle fibers, and curved arrow indicates tendon.
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Fig. 7A. —21-year-old man with tennis leg. Longitudinal sonogram
(A) and diagram (B) of calf show detachment (arrows,
A) of medial gastrocnemius muscle (MG) from common aponeurosis with
soleus muscle (S).
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Fig. 7B. —21-year-old man with tennis leg. Longitudinal sonogram
(A) and diagram (B) of calf show detachment (arrows,
A) of medial gastrocnemius muscle (MG) from common aponeurosis with
soleus muscle (S).
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Grade III strains include injuries in which complete myotendinous or
tendoosseous avulsion has occurred and are usually caused by violent
contraction against firm resistance. Early surgery may be required to avoid
tear extension or retraction, muscle atrophy, and shortening after scar
formation. Sonography may show the complete discontinuity of the muscle fibers
and associated hematoma (Fig.
8A,
8B,
8C,
8D). The "clapper in
bell" sign refers to the retracted echogenic muscle fragments surrounded
by hypoechoic hematoma (Fig.
9A,
9B,
9C,
9D).
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Fig. 8A. —28-year-old man with grade III rectus femoris muscle strain.
Longitudinal sonogram (A) and diagram (B) of rectus femoris
muscle (RF) in relaxation show discontinuity of muscle fibers with associated
hematoma (H).
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Fig. 8B. —28-year-old man with grade III rectus femoris muscle strain.
Longitudinal sonogram (A) and diagram (B) of rectus femoris
muscle (RF) in relaxation show discontinuity of muscle fibers with associated
hematoma (H).
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Fig. 8C. —28-year-old man with grade III rectus femoris muscle strain.
Longitudinal sonogram (C), in same location as A, and diagram
(D) were obtained during contraction. Dynamic scanning improves lesion
definition and confirms that tear is at musculotendinous junction. RF = rectus
femoris muscle, H = hematoma, T = tendon.
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Fig. 8D. —28-year-old man with grade III rectus femoris muscle strain.
Longitudinal sonogram (C), in same location as A, and diagram
(D) were obtained during contraction. Dynamic scanning improves lesion
definition and confirms that tear is at musculotendinous junction. RF = rectus
femoris muscle, H = hematoma, T = tendon.
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Fig. 9A. —25-year-old man with grade III tear of rectus femoris muscle.
Transverse sonogram (A) and diagram (B) of distal rectus femoris
muscle show "clapper in bell" sign of retracted tendon
(arrow, A) surrounded by hypoechoic hematoma
(arrowheads, A) characteristic of grade III muscle tear.
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Fig. 9B. —25-year-old man with grade III tear of rectus femoris muscle.
Transverse sonogram (A) and diagram (B) of distal rectus femoris
muscle show "clapper in bell" sign of retracted tendon
(arrow, A) surrounded by hypoechoic hematoma
(arrowheads, A) characteristic of grade III muscle tear.
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Fig. 9C. —25-year-old man with grade III tear of rectus femoris muscle.
Longitudinal sonogram (C), obtained in same location as A, and
diagram (D) show rectus femoris muscle (RF) in relation to its tendon
(T), confirming that tear is at musculotendinous junction. Rectus femoris
muscle lies superficial to vastus intermedius muscle (VI).
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Fig. 9D. —25-year-old man with grade III tear of rectus femoris muscle.
Longitudinal sonogram (C), obtained in same location as A, and
diagram (D) show rectus femoris muscle (RF) in relation to its tendon
(T), confirming that tear is at musculotendinous junction. Rectus femoris
muscle lies superficial to vastus intermedius muscle (VI).
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Sonography Versus MRI
Sonographic findings can distinguish grade I from grade II strains, both of
which have similar hyperintensity on T2-weighted MRI. This feature is
clinically useful, aiding in both prognosis and rehabilitation planning. Grade
I strains have a low risk of tear extension and heal within 2 weeks with
conservative management. Grade II strains require up to 4 weeks of
conservative management, with a significant risk of tear extension if the
patient returns to full exercise too soon. Furthermore, objective follow-up
can be performed using sonography, which may show normal appearance 2–3
weeks after a healed grade I strain.
Contusion and Hematoma
Intramuscular contusion occurs after blunt trauma to the muscle and
presents with immediate and prolonged pain at the injury site.
Sonographically, a contusion is seen as an ill-defined area of
hyperechogenicity in the muscle, which may cross fascial boundaries (Fig.
10A,
10B,
10C,
10D). In the acute situation,
the muscle becomes swollen and may be isoechoic with unaffected muscle
[6]. After several days, a
hematoma may form, which appears as a hypoechoic fluid collection and may
contain debris (Fig. 11A,
11B,
11C,
11D). If the fluid is under
tension and painful, sonographically guided aspiration can be performed.
However, when hematomas are acute, they can be difficult to aspirate because
of their gelatinous nature.
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Fig. 10A. —24-year-old man with intramuscular contusion. Longitudinal
sonogram (A) and diagram (B) of anterior thigh show ill-defined
area of hyperechogenicity predominantly in rectus femoris muscle (RF),
extending into vastus lateralis muscle (VL) and vastus intermedius muscle
(VI), consistent with diagnosis of intramuscular contusion.
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Fig. 10B. —24-year-old man with intramuscular contusion. Longitudinal
sonogram (A) and diagram (B) of anterior thigh show ill-defined
area of hyperechogenicity predominantly in rectus femoris muscle (RF),
extending into vastus lateralis muscle (VL) and vastus intermedius muscle
(VI), consistent with diagnosis of intramuscular contusion.
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Fig. 10C. —24-year-old man with intramuscular contusion. Transverse
sonogram (C), obtained in same location as A, and diagram
(D) show that contusion crosses muscle fascial boundaries, a
characteristic feature. RF = rectus femoris muscle, VL = vastus lateralis
muscle, VI = vastus intermedius muscle.
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Fig. 10D. —24-year-old man with intramuscular contusion. Transverse
sonogram (C), obtained in same location as A, and diagram
(D) show that contusion crosses muscle fascial boundaries, a
characteristic feature. RF = rectus femoris muscle, VL = vastus lateralis
muscle, VI = vastus intermedius muscle.
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Fig. 11A. —27-year-old man with intramuscular hematoma. Longitudinal
sonogram (A) and diagram (B) of anterior compartment of leg show
hypoechoic hematoma (H) in tibialis anterior muscle with posterior layering of
congealed blood (arrows, A).
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Fig. 11B. —27-year-old man with intramuscular hematoma. Longitudinal
sonogram (A) and diagram (B) of anterior compartment of leg show
hypoechoic hematoma (H) in tibialis anterior muscle with posterior layering of
congealed blood (arrows, A).
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Fig. 11C. —27-year-old man with intramuscular hematoma. Transverse
sonogram (C) obtained in same location as A and diagram
(D) show hematoma (H) with posterior layering of congealed blood
(arrow, C) in tibialis anterior muscle in relation to muscles
of anterior compartment.
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Fig. 11D. —27-year-old man with intramuscular hematoma. Transverse
sonogram (C) obtained in same location as A and diagram
(D) show hematoma (H) with posterior layering of congealed blood
(arrow, C) in tibialis anterior muscle in relation to muscles
of anterior compartment.
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Chronic Lesions
Fibrous Scar
After acute injury, most minor muscle strains heal completely without
complication. A scar may form, however, if recurrent or severe injury has
occurred. Furthermore, fibrous scars can predispose to recurrent tears.
Sonographically, the scar appears as a hyperechoic or heterogeneous, linear,
or stellate lesion adherent to the epimysium (Fig.
12A,
12B,
12C,
12D). The lesion does not
change with contraction of the muscle belly.
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Fig. 12A. —29-year-old man with biceps femoris intramuscular scar.
Transverse sonogram (A) and diagram (B) of biceps femoris muscle
show hyperechoic scar (long arrow, A) with surrounding
hypoechoic rim (short arrows, A).
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Fig. 12B. —29-year-old man with biceps femoris intramuscular scar.
Transverse sonogram (A) and diagram (B) of biceps femoris muscle
show hyperechoic scar (long arrow, A) with surrounding
hypoechoic rim (short arrows, A).
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Fig. 12C. —29-year-old man with biceps femoris intramuscular scar.
Longitudinal extended-field-of-view sonogram (C), obtained in same
location as A, and diagram (D) show that scar is situated at
musculotendinous junction. In C, long arrow indicates hyperechoic scar,
and short arrows indicate hypoechoic rim.
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Fig. 12D. —29-year-old man with biceps femoris intramuscular scar.
Longitudinal extended-field-of-view sonogram (C), obtained in same
location as A, and diagram (D) show that scar is situated at
musculotendinous junction. In C, long arrow indicates hyperechoic scar,
and short arrows indicate hypoechoic rim.
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Muscle Hernia
Herniation of muscle fibers through a weakened aponeurosis or fascia can
occur after blunt or penetrating trauma. The diagnosis may be confirmed on
sonography during muscle contraction, showing the hernia clearly consisting of
normal muscle fibers (Fig.
13A,
13B,
13C).
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Fig. 13A. —26-year-old man with biceps femoris muscle hernia.
Longitudinal extended-field-of-view sonogram of posterior thigh in relaxation
shows focal defect in aponeurosis (straight arrow) over biceps
femoris muscle (curved arrow) with herniated muscle fibers passing
through it.
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Fig. 13B. —26-year-old man with biceps femoris muscle hernia.
Longitudinal extended-field-of-view sonogram (B) and diagram (C)
of same location as in A show increased conspicuity of herniated muscle
during contraction. In B, straight arrow indicates aponeurosis, and
curved arrow indicates biceps femoris muscle.
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Fig. 13C. —26-year-old man with biceps femoris muscle hernia.
Longitudinal extended-field-of-view sonogram (B) and diagram (C)
of same location as in A show increased conspicuity of herniated muscle
during contraction. In B, straight arrow indicates aponeurosis, and
curved arrow indicates biceps femoris muscle.
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Myositis Ossificans
Heterotopic bone formation in muscle may be seen after trauma, burns, and
immobilization. It presents with swelling and loss of function
disproportionate to the severity of the initial trauma. In the early phase
before calcification is seen on radiographs, a hypoechoic mass with sheets of
echogenic material is seen on sonography (Fig.
14A,
14B). Later, areas of coarse
calcification casting acoustic shadows, often parallel to the adjacent
diaphysis, may be seen [7].
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Fig. 14A. —28-year-old man with biopsy-proven myositis ossificans.
Transverse sector-mode sonogram (A) and diagram (B) of calf show
hypoechoic mass with punctate and lamellar calcifications (arrows,
A).
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Fig. 14B. —28-year-old man with biopsy-proven myositis ossificans.
Transverse sector-mode sonogram (A) and diagram (B) of calf show
hypoechoic mass with punctate and lamellar calcifications (arrows,
A).
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Discussion
Muscle sonography provides a rapid, readily available, high-resolution
technique for assessing both acute and chronic muscle injuries. Its
interactive real-time capability allows accurate correlation with clinical
symptoms and signs, providing an extension of the clinical examination.
Although MRI provides better image contrast resolution, sonography offers
superior spatial resolution, which allows distinction of grade I and grade II
muscle strains. This separation influences both patient management and
prognosis. In addition, sonography may also be used after injury to monitor
lesion resolution or to guide muscle lesion aspiration or biopsy
[8].
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Semin Musculoskelet Radiol1999; 3:115
–134[Medline]
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