Diagnostic Ultrasound in Knee Disorders

There is a limited role for ultrasound in the assessment of acute knee pain. The benefits of ultrasound are that it is relatively non-invasive, freely available, well accepted by patients, cheap, and that it has technical benefits including dynamic evaluation 1,2. Its limitations include reliability, which is largely operator dependent, its small field, and its inability to evaluate bone and other structures.

The utility of ultrasound has not been studied to the extent of other modalities, particularly MRI. In one study ultrasound was compared to MRI for the detection of ACL ruptures 3 and found to be as specific and 91% as sensitive. In that study, there was sensitivity of 91% and specificity of 100% for the detection of a ruptured ACL in 37 patients. Ultrasound also has a reported role in the detection of acute collateral ligament injuries 4.

Ultrasound has a role in the assessment of tendon lesions, particularly partial and complete quadriceps rupture 5. It can be useful for differentiating between cellulitis, soft tissue abscess and septic arthritis in a patient presenting with a confusing clinical picture 6. It can also be invaluable in assessing cysts and other soft tissue lesions around the knee, including differentiating between popliteal cyst and other local swellings including aneurysm, nerve sheath tumour and ganglia 6. Joint effusions are readily detected by ultrasound. Other fluid collections such as bursitis can also be detected, and if necessary ultrasound guided needling can be used. 7

Mourad et al 8 found ultrasound to be more accurate than CT scan for chronic patellar tendinitis in nine patients in which the results were compared to histological examination.

References

1. Richardson ML, Selby B, Montana MA, Mack LA. Ultrasonography of the knee. Radiol Clin North Am 1988; 26:63-74.2. Van Holsbeeck M, Intracaso JH. Musculoskeletal ultrasonography. Radiol Clin North Am 1992; 30:907-925.

3. Ptasnik R, Feller J, Bartlett J, Fitt G, Mitchell A, Hennessy O. The value of sonography in the diagnosis of traumatic rupture of the anterior cruciate ligament of the knee. AJR 1995; 164:1461-1463.

4. Strome GM, Bouffard JA, van Holsbeeck M. Knee. In: Musculoskeletal Ultrasound.Ed Fornage BD. Churchill Livingstone, NY, 1995, 201-219.

5. Bianchi S, Abdelwahab IF, Zwass A et al. Diagnosis of tears of the quadriceps tendon of the knee: value of sonography. Am J Roentgenol 1994; 162:1137.

6. Jacobson JA, van Holsbeeck MT. Musculoskeletal ultrasonography. Orthop Clin N Amer 1998; 29:135-167.

Ultrasound of the knee allows high-resolution imaging of superficial knee anatomy while simultaneously allowing dynamic evaluation of some of the tendons and ligaments. Knee ultrasound is somewhat limited compared with ultrasound examinations of other joints because the cruciate ligaments and the entirety of the meniscus are usually difficult to visualize.

Anterior knee

The knee is flexed 20-30° (flexion of the knee tightens the extensor tendons, decreasing the chance of anisotropy occurring in a lax tendon):

transverse and longitudinal images of the quadriceps tendon from its myotendinous junctions to its attachment on the superior patella (rectus femoris myotendinous junction is more cranial than the vastus junctions)

evaluate the suprapatellar and parapatellar joint recessessuprapatellar fat pad

prefemoral fat pad

small amounts of synovial fluid may preferentially locate to the parapatellar joint recess

evaluate the femoral trochleabest examined in full knee flexion

useful for examination of the trochlear cartilage

evaluate the patellar retinacula

evaluate the medial patellar articular facet (lateral facet not visible on ultrasound)

evaluate the patellar tendon and patellar bursaprepatellar bursa normally not visible

infrapatellar bursasmall amount of fluid in the deep infrapatellar bursa is normal

normally no fluid in the superficial infrapatellar bursa

Lateral knee

The knee is flexed 20-30°:

evaluate the distal iliotibial band in long axis (located between the anterior and middle third of the lateral knee)

evaluate the lateral collateral ligament in long axismay detect para-articular ganglia

may see lateral meniscal pathology (e.g. meniscal cyst)extreme knee flexion may bring out a meniscal abnormality

Medial knee

The knee is flexed 20-30°, with external rotation:

evaluate medial collateral ligament and pes anserinus tendons in long axisvalgus stress may be useful to examine the ligament

Posterior knee

Often examined with the patient prone and the knee extended, thereby gaining access to the dynamic fat-filled popliteal fossa:

evaluate the medial tendons in short axis (medial to lateral)sartorius

gracilis

semitendinosus

moving even more medially, evaluate the semimembranosus-gastrocnemius bursa in short axisa popliteal cyst (Baker's cyst) arises between these tendons

evaluate the popliteal neurovascular bundle and intercondylar fossa in short axis

evaluate the posterolateral corner and biceps femoris in short and long axis

evaluate the peroneal nervestart with the common peroneal nerve branching off the sciatic nerve above the knee

follow it around the fibular head

Pathology

A number of knee abnormalities can be identified on ultrasound, including:

patellar tendinosis/patellar tendon tear

quadriceps tendon tear

prepatellar bursitis

infrapatellar bursitis

popliteal cyst (Baker cyst)

techniques

image knee ultrasound

Occasionally a periferal menisceal cyst can be emptied through a large bore needle

with good vacuum and make the patient asymptomatic at once !

knee sonogram

sonogram of patellar tendon

hello, with ultrasound can study the entire pathology quadriceps patellar tendon patellar tendons distal hamstring collateral ligaments the hyaline cartilage of the femoral trochlea in partial form, recognize parameniscal cysts, periarticular ganglions and in any adjacent structure such as muscles, tendons, nerves such as perineural, adventitial of popliteal vessels, aneurysms of popliteal vessels. we can also evaluate with Doppler power technique the degree of vascularization or vascular flow of the evaluated structures and define if we are seeing an acute or chronic process. we easily recognize calcifications of soft tissues and their precise location.

we have limitations to osseous edema and all intraarticular lesions such as cruciate ligament injuries, chondromalacia osteochondral lesions, intraarticular free bodies, meniscal lesions, intraosseous ganglions, ganglions related to the cruciate ligaments, etc

I hope you can use the information

Thanx Rafael Barousse for your input

Ultrasonography for knee is fast and emergency diagnsotic method for acut trauma, specially to see the haemarthros and swelling. We this diagnostic method we can see all pery articular soft structure of the knee, and we can measure size of rupture and patelofemoral angle. We can see and measure PCL, and compare with healthy knee. We can see changes of chondral tissue, and degenerative change of bones. we can see arteria and vena poplitea.

We can evaluate condition of the knee with measure of some structures or changes before and after treatment. we can measure the size of muscle before and after training.

https://www.ultrasoundpaedia.com/normal-knee/

Muscles around the knee joint (to exclude tears, atrophy), medial, lateral collateral ligaments, quadriceps tendon, ligamentum patellae can be assessed with knee ultrasound. Additionally periphery of the menisci, thickness of the meniscus, joint effusions, Baker's cysts can be assessed reliably.

Thanx Iroshani Kodikara for adding information.

ACL and PCL TEARS , MEDIAL AND LATERAL COLLATERAL LIGAMENTS

BAKERS CYSTS

thank you Nassor musa salim for your input

Dear college Syed Amir Gilani, I think I have met you on ISMUS congres in Ohrid 2004,

I start to learn MUS, by your lectures, presented on congress.

After that I start to explore patients with US in reha process because I am doctor specialist for PM&Reha.

I am in same opinion with Nassor Sallim for examination of knee:

ACL and PCL TEARS , MEDIAL AND LATERAL COLLATERAL LIGAMENTS

BAKERS CYSTS, plus added patelofemoral angle and its chondral structure.

College Gilani. if you are person what I think best regards from Macedonia.