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Workbook
Musculoskeletal Ultrasound
September 26, 2013
Shoulder Checklist
Long biceps tendon
Patient position:
 Facing the examiner
 Shoulder in slight medial rotation; elbow in flexion and supination
Plane/ region: Transverse (axial): from a) intraarticular portion to b)
myotendinous junction (at level of the pectoralis major tendon).
What you will see:
 Long head of the biceps tendon
 Supraspinatus tendon
 Transverse humeral ligament
 Subscapularis tendon
 Lesser tuberosity
 Greater tuberosity
 Short head of the biceps
 Long head of the biceps (musculotendinous junction)
 Humeral shaft
 Pectoralis major tendon
Plane/ region: Logitudinal (sagittal):
What you will see:
 Long head of biceps; fibrillar structure
 Lesser tuberosity
 Long head of the biceps tendon
Notes:
Subscapularis muscle and tendon
Patient position:
 Facing the examiner
 Shoulder in lateral rotation; elbow in flexion/ supination
Plane/ region: longitudinal (axial): full vertical width of tendon.
What you will see:
 Subscapularis muscle, tendon, and insertion





Supraspinatus tendon
Coracoid process
Deltoid
Greater tuberosity
Lesser tuberosity
Notes:
 Do passive medial/ lateral rotation while examining
Plane/ region: Transverse (sagittal):
What you will see:
 Lesser tuberosity
 Fascicles of subscapularis tendon
Supraspinatus tendon
Patient position:
 Lateral to examiner
 Shoulder in extension and medial rotation
 Hand on ipsilateral buttock
Plane/ region: Longitudinal (oblique sagittal)
 Identify the intra-articular portion of biceps LH in the transverse plane;
then rotate probe until biceps LH is elongated. Supraspinatus is found by
sliding laterally.
What you will see:
 Acromion
 Myotendinous junction of supraspinatus
 Deltoid
 Greater tuberosity
 Articular cartilage
 Long head of the biceps tendon
 Supraspinatus tendon
 Infraspinatus tendon
 Subacromial subdeltoid bursa
Notes:
Plane/ region: Transverse (oblique axial):
What you will see:
 Deltoid
 Greater tuberosity
 Articular cartilage
 Long head of the biceps tendon
 Supraspinatus tendon
 Infraspinatus tendon
 Subacromial subdeltoid bursa
Infraspinatus and teres minor muscles and tendons
Patient position:
 Anterior/ lateral to examiner
 Shoulder medial rotation
 Hand on opposite thigh
Plane/ region: Transverse (oblique sagittal) – two locations:
 Over muscles; perpendicular to spine of scapula
 Over tendons; just lateral to acromion
What you will see:
 Spine of scapula
 Deltoid
 Infraspinatus muscle and tendon (a more lateral position)
 Teres minor muscle and tendon
 Greater tuberosity
Notes:
Posterior glenohumeral structures
Patient position:
 Anterior/ lateral to examiner
 Shoulder medial rotation
 Hand on opposite thigh
Plane/ region: Longitudinal (axial) – 2 positions; 2nd more lateral
What you will see:
 Spinoglenoid notch
 Bony glenoid
 Humeral head
 Infraspinatus and teres minor tendons (longitudinally)
 Posterior labrum
Elbow Checklist
Anterior Elbow
Patient position:
 Facing the examiner
 Elbow in extension - over table
Plane/ region: Transverse (axial): from 5cm above joint to the joint line
What you will see:
 Biceps (superficial)
 Brachialis (deep; tendon forms laterally within muscle belly)
 Brachial artery (medial to biceps)
 Median nerve (medial to artery)
 Articular cartilage of trochlea and capitellum
 Pronator and brachioradialis muscles bounding the cubital fossa
Notes:
Note the decreasing size of biceps muscle and increasing thickness of the
brachialis tendon as you slide distally.
Distal Biceps and Brachialis Insertions
Patient position:
 Facing the examiner
 Maximal supination
Plane/ region: Longitudinal (sagittal)
What you will see:
 Brachial artery
 Biceps tendon – passing in front supinator on the way to insertion
 Distal brachialis muscle and tendon
 Coronoid fossa
 Fat pads in radial and coronoid fossae
 Brachialis
 Capitellum and trochlea(articular cartilage)
 Radial head + annular ligament
 Supinator
Notes:


Biceps tendon curves distally and posteriorly. Apply pressure and tilt to
get probe parallel to tendon
Brachialis is; only a short tendon
Lateral
Patient position:
 Facing the examiner
 Full extension or 90 degrees flexion
 Palms together
 Thumbs up
Plane/ region: Longitudinal (coronal) – proximal end at lateral epicondyle
What you will see:
 Brachioradialis insertion
 Common extensor tendon (posterior to brachioradialis)
 Lateral synovial fringe
 Lateral epicondyle
 Radial head
Plane/ region: Transverse (axial)
What you will see:
 Common tendon origin
Notes:
Radiocapitellar Joint
Patient position:
 Facing the examiner
 Full extension (transverse) or 90 degrees flexion (longitudinal)
Plane/ region: Longitudinal (coronal) – proximal end at lateral epicondyle
What you will see:
 Common extensor tendon
 Lateral synovial fringe


Lateral epicondyle
Radial head (note cartilage)
Plane/ region: Transverse (axial)
What you will see:
 Annular ligament
 Radial head (note cartilage)
 Radial shaft
 Supinator
Notes:
 Dynamic scanning during passive pronation/ supination
Medial Elbow
Patient position:
 Facing the examiner
 Full extension and supination
 External rotation at shoulder and 90 degrees flexion at elbow (for medial
collateral ligament)
Plane/ region: Longitudinal (coronal) – proximal end at medial epicondyle
What you will see:
 Common flexor tendon (thinner and shorter than extensor tendon)
 Medial epicondyle
 Ulna
 Anterior part of medial collateral ligament
Notes:
 Dynamic scanning with valgus stress for medial collateral ligament
Posterior Elbow – Triceps
Patient position:
 Examiner standing behind patient
 Full (forced) pronation with 90 degrees flexion
Plane/ region: Longitudinal (sagittal) proximal to olecranon and posterior to elbow
and olecranon process
What you will see:






Olecranon
Posterior olecranon recess (fluid more visible at 45 degrees)
Fat pad in olecranon fossa
Triceps muscle
Triceps tendon
Olecranon bursa
Notes:
 Use only light pressure for olecranon bursa
Cubital Tunnel and Ulnar Nerve
Patient position:
 Examiner standing behind patient
 Full pronation with extension 90 degrees flexion at elbow
Plane/ region: Transverse (axial); medial to olecranon and posterior to elbow
What you will see:
 Olecranon process
 Medial epicondyle
 Cubital tunnel retinaculum
 Ulnar nerve (rotate probe to longitudinal once you see the nerve)
Notes:
Wrist/ Hand Checklist
Dorsal Wrist: 1st Extensor Compartment
Patient position:
 Sitting; mid-pronation with thumb up
Plane/ region: Transverse (axial) anterior to radial styloid and 2cm proximal/
distal to it
What you will see:
 Abductor pollicis longus
 Extensor pollicis brevis
 Radial artery
 Cephalic vein
Notes:
 If having difficulties locating compartment, start by finding artery
Dorsal Wrist: 2nd Extensor Compartment
Patient position:
 Sitting; full pronation
Plane/ region: Transverse (axial) over dorsal radius laterally and 2cm proximal to
it
What you will see:
 Extensor carpi radialis longus and brevis tendons; diverging distally
 More cranially, the tendons from the 1st compartment (abductor pollicis
longus and extensor pollicis brevis) crossing ECRL and ECRB
Notes:
 Use Lister’s tubercle as the medial landmark
Dorsal Wrist: 3rd Extensor Compartment
Patient position:
 Sitting; full pronation
Plane/ region: Transverse (axial) over dorsal radius laterally
What you will see:


Extensor pollicis longus crossing the tendons from the 2nd compartment
(more laterally the more distal)
Extensor carpi radialis brevis and longus tendons
Notes:
 Use Lister’s tubercle as a landmark in the middle of the screen
 Use the muscles from the 1st and 2nd compartments for reference
Dorsal Wrist: 4th and 5th Extensor Compartment
Patient position:
 Sitting; full pronation
Plane/ region: Transverse (axial) over dorsal mid and medial radius
What you will see:
 Extensor digitorum communis
 Extensor indicis proprius
 Extensor digiti minimi
 Articular cartilage of ulnar head
 Extensor pollicis longus cross the common extensor tendons a few cm
proximally
Notes:
 4th compartment (extensor communicis) is distinct, hyperechoic
 5th compartment (extensor digiti minimi ) is over the distal radioulnar joint
 Use Lister’s tubercle as a lateral landmark
Scapholunate Ligament
Patient position:
 Sitting; full pronation
 Hand in ulnar deviation
Plane/ region: Oblique transverse (slightly lateral and distal) over dorsal lateral
wrist.
What you will see:
 Extensor digitorum communis
 Extensor digiti minimi
 Extensor carpi radialis brevis
Notes:


4th compartment (extensor dig. communis) is superficial to lunate
Add a longitudinal scan of scaphoid while doing ulnar and radial deviations
Dorsal Wrist: 6th Extensor Compartment
Patient position:
 Sitting; forearm extended back
 Hand in mid-pronation; ulnar side up
Plane/ region: Transverse (axial) over distal/ dorsal ulna
What you will see:
 Extensor carpi ulnaris tendon
 Styloid process of ulna
Notes:
 Extend wrist to see extensor carpi ulnaris tendon lifts extensor retinaculum
Distal Radioulnar Joint
Patient position:
 Sitting; full pronation
Plane/ region: Transverse (axial) over distal/ dorsal radius and ulna
What you will see:
 Distal radioulnar joint line and recess
 4th and 5th compartment tendons
 Ulnar head and neck
Notes:
 Do short range pronations to identify joint relative to the stationary ulna
Dorsal Radiocarpal and Mid-Carpal Joints
Patient position:
 Sitting; full pronation and slight flexion
Plane/ region: Longitudinal (sagittal) over
a) Dorsal/ lateral radius to 1st metacarpal
b) Dorsal/ medial radius to 3rd metacarpal
c) Dorsal ulna to 5th metacarpal
What you will see:
 All carpal bones except pisiform
 Distal radius and ulna
 Tendons of all dorsal compartments
Notes:
 Do short range extension to identify joint lines against stationary radius/
ulna
Proximal Carpal Tunnel
Patient position:
 Sitting; full supination
Plane/ region: Transverse (axial) over proximal row of carpal bones.
What you will see:
 Carpal bones, particularly proximal row
 Flexor digitorum tendons
 Flexor carpi radialis tendon
 Flexor retinaculum
 Flexor pollicis longus tendon
 Ulnar nerve and artery in Guyon tunnel.
 Median nerve
Notes:
 Keep pisiform and tubercle of scaphoid in view as fixed points
 Tilt probe and flex fingers
Distal Carpal Tunnel
Patient position:
 Sitting; full supination
Plane/ region: Transverse (axial) over proximal row of carpal bones.
What you will see:
 Carpal bones, particularly distal row
 Flexor digitorum tendons
 Flexor carpi radialis tendon





Flexor retinaculum
Flexor pollicis longus tendon
Ulnar artery
Ulnar nerve now split into superficial (medial) and deep
Median nerve
Notes:
 Keep ridge of trapezium and hook of hamate in view as fixed points
 Tilt probe and flex fingers
Hip Checklist
Anterior Hip: Joint Recess and Iliopsoas Tendon
Patient position:
 Supine
Plane/ region: Oblique longitudinal (sagittal) over femoral neck and hip joint
 Over femoral neck
 Over joint
What you will see:
 Acetabulum
 Anterosuperior labrum
 Anterior joint recess
 Femoral head
 Femoral neck
 Iliopsoas muscle
 Iliopsoas tendon
 Acetabular labrum
Plane/ region: Transverse (axial) over joint
What you will see:
 Femoral head
 Iliopsoas muscle
 Iliopsoas tendon, in the deep, medial part of the muscle (over iliopectineal
line)
Notes:
Rectus Femoris and Anterior Thigh Muscles
Patient position: Supine
Plane/ region: Longitudinal (sagittal)
What you will see:
 AIIS, directly above the head of femur
 Direct tendon of rectus femoris
 Indirect (reflected) tendon of rectus femoris
Plane/ region: Transverse (axial), from the level AIIS to 10cm distal to AIIS
What you will see:
 AIIS
 Direct tendon of the rectus femoris muscle
 Iliopsoas muscle
 Sartorius muscle
 Tensor fasciae latae
 Vastus intermedius muscle
 Proximal myotendinous junction of rectus femoris
 Rectus femoris muscle
Notes:
Lateral Hip: Gluteus Minimus, Medius, and Fascia Lata
Patient position: Sidelying
Plane/ region: Transverse (axial) above greater trochanter from TFL anteriorly to
gluteus maximus posteriorly
What you will see:
 Gluteus maximus muscle
 Gluteus minimus tendon and muscle
 Gluteus medius tendon and muscle
 Greater trochanter
 Fascia lata
Plane/ region: Longitudinal (coronal plane)
What you will see:
 Ilium
 Gluteus maximus muscle
 Gluteus minimus tendon and muscle
 Gluteus medius tendon and muscle
 Greater trochanter

Fascia lata
Knee Checklist
Quadriceps Tendon
Patient position:
 Supine with knee slightly flexed
Plane/ region: Longitudinal (sagittal) immediately above patella
What you will see:
 Patella
 Quadriceps tendon:
o superficial layer (from rectus femoris)
o intermediate layer (from vastus lateralis and medialis)
o deep layer (from vastus intermedius)
o Identify layers by moving obl/ laterally from vastus medialis muscle
 Femur
Plane/ region: Transverse (axial) 5-10cm above patella
What you will see:
 Vastus lateralis muscle
 Vastus medialis muscle
 Vastus intermedius muscle
 Quadriceps tendon
Notes:
Femoral Trochlea
Patient position:
 Supine with knee fully flexed
Plane/ region: transverse to tendon (axial) immediately above patella
What you will see:



Trochlea of femur
Articular cartilage of trochlea
Quadriceps tendon
Notes:
Patellar Ligament
Patient position:
 Supine with knee slightly flexed
Plane/ region: Longitudinal (sagittal) immediately below patella, down to the
tibial insertion
What you will see:
 Patella
 Patellar ligament
 Superficial infrapatellar bursa
 Deep infrapatellar bursa (between tendon and tibial epiphysis)
 Fat pad of Hoffa
 Tibia
Notes:
Medial Collateral Ligament and Pes Anserinus
Patient position:
 Supine with knee slightly flexed; leg laterally rotated
Plane/ region: Longitudinal (coronal) below the medial epicondyle (more oblique
anteriorly for pes anserinus)
What you will see:
 Medial collateral ligament
o superficial part
o deep part
 Medial meniscus
 Pes anserinus insertion
Notes:
 Scanning ligament while applying valgus stress may aid diagnosis
Iliotibial Band
Patient position:
 Supine with knee slightly flexed; leg medially rotated
Plane/ region: Longitudinal (coronal) from the lateral femoral condyle to Gerdy’s
tubercle
What you will see:
 Iliotibial band; asterisk, Gerdy’s tubercle; LFC,
 Lateral femoral condyle
Plane/ region: Transverse (axial) medial and lateral to patella
What you will see:
 Lateral/ medial parapatellar recesses
 Lateral/ medial patellar retinacula
 Femur
 Patella
Notes:
Lateral Collateral Ligament
Patient position:
 Supine with knee slightly flexed; leg medially rotated
Plane/ region: Longitudinal (oblique coronal – caudal/ posterior) above fibular
head
What you will see:
 Femur
 Popliteal tendon
 Lateral collateral ligament
 Lateral meniscus
 Fibular head
Notes:
Posterolateral Knee - Biceps Femoris
Patient position:
 Prone with knee extended and laterally rotated
Plane/ region: Longitudinal (sagittal) immediately above joint line
What you will see:
 Biceps femoris tendon
 Articular cartilage of lateral femoral condyle
 Biceps femoris muscle
 Lateral meniscus
 Fibular head
 Lateral femoral condyle
 Fabella (in 15-20%)
Notes:
Ankle Checklist
Anterior talofibular ligament
Patient position:
 Seated on table; knee flexed to 45⁰, foot supported and inverted
 Alternatively, sidelying with pillow under the medial malleolus
Plane/ region: Longitudinal (axial oblique; slightly caudal and anterior), at joint
line
What you will see:
 Lateral malleolus
 Talus
 Anterior talofibular ligament
Notes:
 May do sonographic anterior drawer test: Patient prone with the foot over
the edge of table while pulling the foot anteriorly in plantar flexion and
inversion.
Anterior tibiofibular ligament
Patient position:
 Seated on table; knee flexed to 45⁰, foot supported and inverted
 Alternatively, sidelying with pillow under the medial malleolus
Plane/ region: Longitudinal to tibiofibular ligament (axial oblique; slightly caudal
and lateral), at joint line
What you will see:
 Lateral malleolus
 Tibia
 Anterior tibiofibular ligament
Notes:
Peroneal tendons
Patient position:
 Sidelying with support under medial side of foot
Plane/ region: Transverse (axial oblique, across tendons), above joint line to 5 th
metatarsal base
What you will see:
 Superior retinaculum (from fibula to Achilles tendon)
 Inferior peroneal retinaculum (from fibula to calcaneus)
 Peroneus brevis muscle and tendon
 Peroneus longus muscle and tendon
 Lateral malleolus
 Calcaneus - peroneal tubercle
 Cuboid
 5th metatarsal base
 Calcaneofibular ligament?
Notes:
 Maintain probe perpendicular to tendons
 When subluxation is suspected, add resisted dorsiflexion and eversion
Tibialis posterior and flexor digitorum longus tendons
Patient position:
 Sitting or supine with support under lateral side of foot
Plane/ region: Transverse (oblique axial, across tendons), behind medial
malleolus
What you will see:
 Posterior tibial artery (between veins)
 Medial malleolus
 Posterior tibial veins
 Tibialis posterior tendon
 Flexor digitorum longus tendon
 Flexor retinaculum
 Talus
 Naviculum
Notes:
 Check for accessory os trigonum
Deltoid ligament
Patient position:
 Sitting or supine with support under lateral side of the dorsiflexed foot
Plane/ region: Longitudinal (oblique coronal planes posteriorly and anteriorly
tilted), below medial malleolus
What you will see:
 Medial malleolus
 Talus
 Calcaneus
 Tibials posterior tendon
 Tibiotalar ligament
 Tibiocalcaneal ligament
Notes:
Achilles tendon
Patient position:
 Prone with dorsiflexed foot over the edge of the table
Plane/ region: Longitudinal (sagittal plane) from the myotendinous junction down
to the insertion of the tendon into calcaneus
What you will see:
 Tibia
 Calcaneus
 Gastrocnemius
 Soleus
 Achilles tendon
 Kager fat pad
 Flexor hallucic longus muscle
Notes: