Thursday , 23 November 2017
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MSK Ultrasound case studies

Tibialis anterior rupture – Robert Mast, Extended Scope Physiotherapist/MSK Sonographer (RMastPhysio)

Tibialis anterior ultrasound

This patient in their 60's presented to me in clinic with an approximate 3 month history of a sudden onset of dorsal foot pain. The patient was limping but had not taken much notice of this. In the past month the dorsal foot pain had subsided and instead they had noticed a cramping sensation in the peroneal muscle region. Examination showed that the foot was kept in a position of eversion. (Figure 1). This was also seen during gait where it appeared hard to clear the floor with the medial foot. Clinical observation demonstrated a significant compensatory gait pattern with …

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Anisotropy, friend or foe? -Dave Baker, Extended Scope Physiotherapist and MSK Sonographer (@davebakerphysio)

Images from Sonosite M-Turbo system with linear transducer 6-13MHz In order for the ultrasound machine to create an image the systems software must make a number of assumptions. The assumptions that the machine makes are:- There are a number of reasons why deviations from these assumptions occur and the variations around these assumptions give rise to many of the known artefacts associated with ultrasound image creation (Hoskins et al 2003). One of the most common artefacts we come across in clinical practice, is that of anisoptropy. Anisoptropy as a sonographic artefact is described as an ‘angle dependent appearance of tissues'. …

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Anterior elbow pain: A case of partial tear of the distal biceps tendon -Stuart Wildman (@swildmanphysio) Extended Scope Physio and MSK Sonographer

Differential diagnosis: Complete rupture of the biceps tendon Partial thickness tear of the biceps tendon Discussion Distal biceps tears tend to occur in middle aged men and are usually related to trauma. Tears of the distal insertion of the biceps are less common than the proximal tears of the long head of biceps (Lobo et al, 2013). Clinically, complete ruptures of the distal biceps insertion are easily diagnosed, with significant loss of power, palpable defect in the antecubital fossa  and noticeable functional difficulties. Partial thickness tears are more challenging to highlight clinically (Miller & Adler, 2000), with a varied presentation …

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Quadriceps tendon rupture – Jon Sharpe, Consultant MSK Radiologist (@jonsharpe360)

This patient had suffered a fall and developed sudden anterior knee pain and inability to straight leg raise. Interesting just how much you can see on the plain films below and how closely it correlates to the US findings.         Dr Jon Sharpe works at Yorkshire Radiology, who can be found on twitter @YorkshireRad   Further articles of interest Sonography of Partial-Thickness Quadriceps Tendon Tears With Surgical Correlation (2003) Journal of Ultrasound in Medicine, 22:1323–1329 Please do rate and share via the links below and visit the other case studies on this website. If you would like to …

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Two cases of De Quervain’s Tenosynovitis. TSV or not TSV – that is the question? – Allister Taggart (@allistertaggart) Consultant Rheumatologist

For those sonographers, like myself, who deal with a lot of inflammatory disease, Doppler has become an important part of the sonographic assessment of any patient. Take the tenosynovium as an example. Tenosynovitis (TSV) is best assessed using a transverse probe position so that one gets a view of the whole tendon and its surrounding sheath. Tenosynovitis is often seen as a “ring of fire” around the tendon and this represents increased vascularity of the tenosynovium. Figure 1 shows the transverse scan of the first dorsal compartment of the wrist in a 33 year old nursing mother who developed classical …

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Sonographic appearance of Chondrocalcinosis – Dr Peter Browne, Consultant Rheumatologist (@peterbrowne42 )

A gentleman in his 80' scame to the clinic with a background of haemachromatosis which was diagnosed in his 70s, rotator cuff disease bilaterally and he had been diagnosed with rheumatoid arthritis several years earlier and treated with methotrexate with good benefit in terms of symptoms. He tolerated methotrexate well and was wondering if he could come off it at this stage. He reported no early morning stiffness and interestingly had never had early morning stiffness.. Ultrasound demonstrates chondrocalcinosis in the 2nd and 3rd MCPs bilaterally. There were no erosions. His wrists were unremarkable. Normal inflammatory markers are noted and …

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Myositis Ossificans – Carles Pedret (carlespedret), Sports Medicine and Sports Orthopedics

This male football (soccer) player. Suffered a muscle contusion during a match in the lateral side of the thigh. The initial diagnosis was a vastus medialis muscle rupture with a hematoma. After 3 weeks he came to our medical services with a painful, tender, enlarging mass, located in the lateral side of the thigh (where the first injury was). In the ultrasound examination we found a heterotopic calcification inside the vastus medialis muscle which was a myositis ossificans. We also made a CT scan to complete the diagnosis. CT images are similar to those of plain radiography, demonstrating mineralisation proceeding …

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Finger flexor tenosynovitis? -Suresh Sudula (@SURESHSUDULA), MSK Sonographer and MSK Consultant

This 55 year old lady had been referred to the radiology department by a hand surgeon, for an ultrasound of the finger with suspicion of flexor tenosynovitis. Initial images ultrasound images show thickening of common flexor tendon of the finger associated with hyperaemia on power Doppler suggestive of tenosynovitis (Figure 1). I was concluding the scan, and the patient suddenly recalled that she did some work in her garden a few weeks earlier and  since then she had  noticed symptoms. She also reported the sensation that something was inside. Following a further careful examination under ultrasound there was indeed a focal …

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Adductor longus rupture – Carles Pedret (@carlespedret), Sports Medicine and Sports Orthopedics

This man in his 30's was a basketball player, who recalled making a sudden lunge and an eccentric contraction with his adductor muscles during a game. He felt an acute pain and he had to retire from the match. Approximately 24 hours later we performed the ultrasound examination where we saw a complete adductor longus rupture from the pubic symphysis. It can be observed in the images below that the rupture involved both muscle and tendon fibres. There is also a video below to demonstrate the tear. The patient was treated with physiotherapy treatment and without surgery. The first 2 -3 …

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Ultrasound Guided Injection of the hip joint: Technique Tutorial – Dr Daniel Fascia (@danfascia) , Consultant MSK and Sports Radiologist, Yorkshire Radiology

Why use ultrasound? Whilst it still remains more popular to inject joints using fluoroscopy across the world, one cannot deny the attractions of ultrasound being cheap, small in form and readily accessible in the clinic / office environment. Advances in ultrasound equipment have improved needle guiding, tissue detail and penetration. Technologies such as virtual convex on linear probes and beam steering make accurately aiming of an obliquely travelling needle into deep tissue ever more straightforward. In the hands of a skilled operator, ultrasound is actually safer than fluoroscopy. There is no radiation (for the patient and operator) and needle guidance …

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Large partial thickness tear of the Achilles tendon – Rob Mast (@RMastPhysio), Extended Scope Physiotherapist and MSK Sonographer

Figure 2

A gentleman in his mid-40s was referred to our clinic by his GP. He acutely injured himself with pain being felt at the posterior ankle four months ago when running for a bus. At the time he experienced acute and severe pain and was unable to bear weight. He went to A&E where he had an x-ray which was reported as normal. He was then re-assured that it was only a sprain and that things would improve of its own accord with time. He again re-injured the same site a month later or so when rushing around in the street. …

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Scapholunate ligament tear – Rob Mast, Extended Scope Physiotherapist

This is a case of a patient in their 30's. They reported their wrist was forced into a position of extreme flexion and feeling something "go" in the wrist. Ever since then they had noticed an unstable feeling at the wrist. At times when extending from a flexed position the wrist locked.  They also reported difficulty picking up a kettle and generally felt less confident when using the wrist.   On clinical examination it was clear that there was dorsal subluxation of a carpal bone, most noticeable when returning from palmar flexion into extension. Palpation of the Lunate bone was …

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Avulsion injury of the distal phalanx – Sophie Cochran – MSK Sonographer / Stuart Wildman – Extended Scope Physiotherapist

This post will outline two cases of the sonographic presentation of an avulsion injury to the distal phalanx. For the first time we have had two cases presented,with thanks to Sophie Cochran for sending her case into The Ultrasound Site to contribute! Case 1 This patient in their early 30's, presented with a left 3rd metacarpal injury.  She recalled falling over and feeling pain and discomfort in the distal interphalangeal joint. She also noticed an inability to extend her finger fully. On examination, she presented with a mallet finger, and no activation of DIP extension. On ultrasound in clinic, there …

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Patella tendinopathy and non-union of the ossification centres – Dr Matthieu Sailly (@MedecinsDuSport) Sports Medicine Physician, Switzerland

Following on from the recent case I posted on patellar tendinopathy and the role of diagostic MSK Ultrasound, Dr Matthieu Sailly, Sports Medicine Physician at Centre Synergie Medical, Lausanne in Switzerland got in touch and has contributed the following clinical thoughts on patellar tendinopathy and non-union of ossification centres. With a focus on the potential sequel of complaints that may arise  following  non union of the ossification centre. Tibial tuberosity Osgood Schlatter disease (OSD) may lead to chronic symptoms in 5 to 12% of the cases depending the literature (1). Distal patellar tendinopathy is not so frequent. This condition is …

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Patellar tendinopathy and diagnostic ultrasound – Stuart Wildman, Extended Scope Physiotherapist

This is a case study/overview of patellar tendinopathy and diagnostic ultrasound, focussing on summarising the role of ultrasound in the diagnosis. It aims to provide a source of evidence based information for clinicians. The treatment of tendinopathy and the current thoughts on the mechanisms behind it are outside the scope of the aim of this article.Please feel free to comment at the end of the post to discuss this somewhat debateable area of MSK medicine and musculoskeletal ultrasound. This patient in his late 20's presented with an eight month history of right anterior knee pain. This had started insidiously, and …

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Pretibial ganglion following ACL reconstruction – Stuart Wildman (@SWildmanPhysio), Extended Scope Physiotherapist

This interesting case was referred for assessment after the patient had experienced 6 months of anterior knee pain, with a background history of an Anterior Cruciate Ligament repair. The patient was in their 20's and presented with soreness in the region of the tibial tuberosity. They could not recall any recent trauma, and had no initial complications following the surgery. They reported no episodes of locking , giving way or instability. They did recall an occasional smaller area of swelling appearing on the anterior shin over recent months. On examination, there was nothing of note on observation with no wasting, …

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Intramuscular lipoma – Suresh Sudula (@SureshSudula) , MSK Consultant Physiotherapist

This 54 year old lady presented with a one year history of a soft tissue lump over the ulna aspect of the right hand. She reported that the lump had been getting slightly bigger over the last few weeks and it was not painful. A diagnostic MSK ultrasound scan of her right hand in the clinic today showed an ill-defined mixed echogenic inhomogeneous soft tissue mass noted over the hypo thenar eminence of the right hand extending to the ulna border.  The soft tissue mass measured 3.2 x 1.5cm in diameter. There is no vascularity noted on power doppler.  Appearances …

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Trigger Finger..or was it? -Stuart Wildman (@SWildmanPhysio) Extended Scope Physiotherapist

Giant Cell Tumour on MSK ultrasound

This patient was in their late teens and was referred for a 'trigger finger, please inject', I thought it made an interesting case so have written it up here for discussion. Initial thoughts were that this would be a fairly straight forward referral as trigger finger is often a pleasing condition to treat with good response rates to a local steroid injection. I then saw the patients age being in the late teens, and immediately you become fairly sure that it isn't a trigger finger, or at least an unusual presentation in someone of that age. The patient reported a …

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Insertional enthesitis of the triceps – Rob Mast (@RMastPhysio) MSK Sonographer and Extended Scope Physiotherapist

MSK ultrasound of the triceps insertion

This patient in his 30's had chronic unilateral posterior elbow pain of varied severity over the past few years . He could not recall and history of trauma, and had no occupational risks that would predispose him to issues in this region. In the past he had been diagnosed with olecranon bursitis and apparently at that time he said there had been noticeable swelling. The more persistent recent pain was a low level ache that was constantly present. There were no other joint complaints, history of back pain or systemic inflammatory signs. Machine used: Sonosite M-Turbo The patient was subsequently refered for …

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Achilles tendinopathy – Peter Gettings, MSK Physiotherapist (@Peter_Gettings)

This male patient in their early 60's was referred to our ultrasound clinic for evaluation of his bilateral Achilles pain. He had been assessed by a colleague and diagnosed clinically as Achilles tendinopathy. The main reason for referral was to rule out other pathology and check the quality of his tissue prior to commencing treatment. It is well documented that musculoskeletal ultrasound is an important imaging modality when considering Achilles' tendon pathology. This very useful article by Klauser et al (2012) used a Delphi-based consensus to come up with clinical indications for musculoskeletal ultrasound. Using the criteria below they concluded …

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Angioleiomyoma – Bev Roos, Ultrasonographer, South Africa

This gentleman in his 40's, who is right hand dominant presented with a mass on the ulnar aspect of his right palm in the region of the pisiform. It does not feel like a ganglion. Machine used:  Philips IU22  Musculoskeletal Ultrasound report: There is a well circumscribed, oval hypoechoic 9.4 x 5.1 x 10.5 mm mass (Figure 1), overlying the pisiform and ulnar nerve, but not overlying the ulnar artery, within the deep dermis and subcutaneous layer. Low level echoes within the mass are consistent with solid tissue, although there does appear to be a small cystic component, demonstrated by the …

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Schwannoma of the median nerve – Bev Roos , Ultrasonographer–Special Interest MSK, South Africa

This patient was a gentleman in his 40's, right hand dominant, who presented with a right radial volar wrist “ganglion” for a few months. Clinically there was a large multilobulated soft mass between Flexor Carpi Radialis (FCR) and Palmaris Longus (PL). It did not feel like a ganglion and there was positive Tinnel's over the mass. The patient was referred for an ultrasound to examine the region further. The report for the ultrasound is outlined below and the images displayed in the gallery above. Please click on the individual images to view them. 'There is a well circumscribed, lobulated, hypoechoic 28 …

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Exertional tibialis anterior muscle hernia – Suresh Sudula, MSK Consultant

This interesting case demonstrates the benefit of linking  musculoskeletal ultrasound with a clinical examination. This football player had been referred to the ultrasound department with a three year history of a lump which appeared intermittently over the lateral aspect of her leg. She had been seen by an Orthopaedic physician and had an ultrasound scan without conclusive findings or diagnosis.  She was also referred to an Orthopaedic surgeon who requested an MRI scan which was reported as normal. The MRI Images can be seen here... When I saw the patient in clinic I asked her what provokes the lump in …

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Ulnar collateral ligament injury of the thumb – Stuart Wildman, Extended Scope Physiotherapist

Ulnar collateral ligament on MSK ultrasound

This patient presented six months after having a fall onto an outstretched hand. She felt a sharp pain in her left thumb at the time, and reported difficulties with gripping and using it since. On examination there was some visible enlargement and localised swelling of the ulnar aspect of the metacarpophalangeal joint (MCPJ) of the left thumb. There was also localised tenderness to palpation on the joint line. Joint range was reduced to approximately 1/2 the normal range of flexion and extension,limited by pain. Radial deviation was particularly painful with valgus stress testing (See Figure 1 and 2), but there …

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Lump compressing median nerve – Suresh Sudula, MSK Consultant Physiotherapist

This gentleman, in his late 50's, presented with a lump over the volar wrist which had been there for a couple of years. He reported that the lump was not getting any bigger in size or painful, however he noticed the development of paraesthesia in the hand over the last 6/12. He had been referred to hand surgeon who asked for an ultrasound scan of the lump. Specifically the nature and anatomical relation to the median nerve. The report for the ultrasound images in the gallery above was  'There is a subcutaneous soft tissue mass which measures 1.5 x 0.5cm in …

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Ganglion on the dorsum of the wrist – Stuart Wildman, Extended Scope Physiotherapist

This patient in their 30s presented with an insidious, 3 year history of wrist pain. She had particularly noticed difficulty with pushing off her wrist, and extending her wrist fully. Previous Physiotherapy had not been helpful, hence her referral to the Extended Scope Physiotherapy clinic. On observation, her pain was primarily located to the dorsum of the wrist, and quite specifically towards the radial aspect (see demonstration above). There was no swelling, redness or deformity. The wrist essentially had a normal appearance. She did not report any paraesthesia. There was no other significant past medical history.The patient was not taking …

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Morel-Lavallée lesion- Suresh Sudula, MSK Consultant Physiotherapist

Figure 4: Longitudinal view of Morell Lavallee lesion

This gentleman in his early 30's, had been referred with a nine week history of swelling over the lateral aspect of the left thigh.  He recalled being hit with a metal bar, and the swelling developing since. The patient reported the swelling had gone down  slightly but there was still a visible swelling present over the lateral aspect. He did not report any paraesthesia. On examination, there was a visible swelling over lateral aspect of the left thigh. There was no evidence of bruising. There was full range of movement of the knee and hip. There was no tenderness on …

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Achilles rupture – Rob Mast , Extended Scope Physiotherapist

I reviewed this lady in her 40's in my ultrasound clinic 6 months post injury. She informed me that when landing from a jump, during an exercise session she heard a loud snapping sound and felt an immediate severe pain in her right Achilles area. She was unable to walk and was brought to an A&E department. She had an x-ray done which was negative. She was told that she had suffered an “Achilles Sprain” for which nothing could be done except wait for it to heal. She subsequently carried on with her normal ADLs as best she could. She had …

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Acute patella tendon impact injury – Niek Vink, Physiotherapist & Ultrasonographer (Dutch National Training Centre for Ultrasound)

Figure 1: Long view of patella tendon 5 weeks following direct impact trauma

Thanks to Niek Vink,Physiotherapist and Ultrasonographer, for contributing this case from his clinic at the Dutch National Training Centre for Ultrasound. It provides an insight into the appearance of tissues with acute trauma. This interesting case gives insight into the sonographic appearance of an acute patella tendon impact injury and the visible changes still present 4 1/2 months after the injury. This patient was in his early 30's and sustained direct trauma from a hockeyball impacting against the distal patella tendon. The patient presented with direct tenderness over the patella tendon. Ultrasound images at five weeks (Figure 1 and 2)  post trauma show …

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Fat rupture mimicking a muscle tear – Suresh Sudula, Consultant MSK Physiotherapist

Transverse view of fat rupture of thigh

This case provides some food for thought when assessing patients who have palpable steps in their soft tissues following direct trauma. This patient in his late 20's had fallen off his bike six weeks earlier, but had continued to complain of a swelling over the lateral aspect of his thigh. The area which impacted the ground when he fell. Although he did report that this had improved steadily over the past six weeks. He was subsequently referred to the Radiology department for an ultrasound of the area. As this patient was seen within Radiology, there was not time for a full …

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