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EULAR on-line course on Ultrasound

B-mode MSUS and Doppler MSUS


physics; indications and limits of
MSUS; normal findings and basic
abnormalities; artefacts; image
documentations; how to write a
report on MSUS findings

Marcin Szukdlarek, Lene Terslev

LEARNING OBJECTIVES
The following module is dealing with the basic physics of both grey-scale and Doppler ultrasound
including the most important pitfalls.
Upon completion of the first module the participant should be able to:

Identify normal structures in musculoskeletal ultrasound


Identify basic pathologies in musculoskeletal ultrasound
Know of basic physics for grey-scale and Doppler
Know of most frequent occurring pitfalls important for the correct interpretation of the US images
Be able to optimize image settings for grey-scale and Doppler
Be able to write a report of an US examination
Be aware of image documentation options
Know of limitations and indications for performing US examinations
B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings Module 1

1. Physics of ultrasound waves.

Ultrasound is an imaging modality that creates images by emitting ultrasound waves. These waves are
reflected by the tissue they penetrate and information about the reflected waves is shown in black and white.
How is this possible?

A sound wave is characterized primarily by its frequency (f, in Hz-Herz) and amplitude (A, in meter). Other
sound wave parameters are the velocity (c, in m/sec) and the wavelength (d, in meter); the latter is calculated
from the frequency and the velocity (d =c/f). In the range of the ultrasonic frequencies, the velocity of sound is
nearly constant in any human tissue. Medical ultrasound devices base their measurements on an average
velocity of sound (1540 m/sec) through soft tissue. Human hearing, depending on age, ranges from 20-20,000
Hz. Ultrasound for medical diagnostic purposes lies within the frequency range of 2-20 MHz (1
MHz=1,000,000Hz), while frequencies up to 60 MHz are under investigation.

From a practical point of view there are three subsets of acoustic vibration defined according to frequency:

a) below the level detectable by the humane ear (infrasone; e.g. vibration of heavy buildings) <20 Hz

b) detectable by the human ear (audio) = 20- 20.000 Hz

c) above the detectable sound level by the human ear (ultrasone; e.g. medical ultrasound, bats navigational
tone, dogs whistle) > 20 kHz

- Transducers, reflection and scattering.

In sonographic transducers an electric signal is converted into short ultrasonic sound pulses ( 2 msec) that are
transmitted into tissues. These pulses are reflected by the tissue, and these reflected pulses are converted into
an electric signal again. This ability of crystals to convert an electric signal into sound and vice versa is called
the piezo-electric effect of crystals; another application of this effect is the record player. When a sound
wave passes through a medium (a) and hits the smooth surface of another medium (b) perpendicularly, part of
the sound wave will return (reflection) into the original medium (a) and part of the energy will enter medium
(b), going in same direction as the original sound wave (Figure 1). The perpendicular reflection with an
amplitude smaller than the emitted wave is received by the transducer and displayed. When a sound wave hits
an irregular but smooth or a rough target, the reflections will go in different directions; this is called scattering.

As a result of scattering most of the sound waves will not reach the transducer, so the surface of the target will
be visualized by a weak signal.

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To produce an echo, a reflecting interface must be present. Sound passing through a totally homogeneous
medium encounters no interfaces and the image is anechoic. The junction of tissues consisting of materials
with different physical properties is a so-called acoustic interface.

In the example above the border zone of mediums a and b forms an acoustic interface.

Acoustic impedance (Z) is determined by the density of the tissue (p) and the velocity of sound (c ) in that
tissue (Z = p x c) (Fig 1). The amount of reflection is determined by the difference in acoustic impedance
between the two materials forming the interface.

Some examples of acoustic impedance of various tissues are fat (Z:1.4), muscles (Z:1.7), bone (Z: 7.8) and air
(Z:0.0004), respectively.

When a sound beam strikes an interface that is perpendicular to the beam, the percentage of energy reflected
is given by: R = [ ( Z2 - Z1) / (Z2 + Z1]2 x 100, whereby R = percentage of beam reflected; Z1 = acoustic
impedance of medium 1; Z2 = acoustic impedance of medium 2. At the interface between two tissues with a
small difference in acoustic impedance, such as muscles and fat, only a small part of the sound wave (about
1%) will be reflected, permitting most of the sound wave to continue on. Air (Z: 0.0004) and bone (Z: 7.8) have
very different acoustic impedances compared to most soft tissues (Z: 1.4-1.8) in the human body.

Figure 1. Reflection. Sound wave in medium a hits the interface between medium a and b. Part of the sound
wave is reflected (grey arrow in medium a) while a smaller part (black arrow in medium b) of the original
sound wave (black arrow in medium a) enters medium b and so on.

A soft tissue-bone interface reflects a large portion (about 44%) of the emitted sound beam.

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A soft tissue-air interface reflects almost the entire beam, giving an intense echo but leaving no energy for
further imaging. Because of this, transducers must be in direct contact with the patients skin without an air
gap, which is accomplished by using gel, oil or alcohol (with the same Z-value as most soft tissues) for contact
scanning.

- Echogenicity of images on the monitor

This phenomenon depends on the percentage of beam reflected and can be divided into:

a) hyperechoic, meaning a high percentage reflection, e.g. tendon, bone and air (bright/white).

b) hypoechoic, meaning a low percentage of reflection, e.g. synovial proliferation (dark grey).

c) anechoic, meaning (almost) no reflection, e.g. cysts or intra-articular fluid (black).

- Attenuation

When sound passes through tissue it loses energy; the amplitude of the sound waves decreases as they travel
further from their source. Factors that contribute to the attenuation of ultrasound waves are the transfer of
sounds into heat in tissue as it passes through (absorption) and loss of sound by reflection and scattering of
the ultrasound beam. Attenuation also depends on the frequency of the ultrasound wave. High frequencies
attenuate faster than lower frequencies.

- Resolution

Resolution is divided into 1) spatial resolution and 2) contrast resolution.

1. Spatial resolution is the ability to differentiate two closely situated objects as distinct structures. This in turn
can be separated into:

a) axial resolution or the ability to distinguish two objects lying in tandem along the axis of the beam (at
different depths) and

b) lateral resolution or the ability to distinguish two adjacent objects at the same depth.

2. Contrast resolution is the ability to display small differences in echogenicity as different grey tones on the
monitor.

High frequencies (> 12 MHz) can give high axial resolution but on the expense of tissue penetration, while low
frequencies (<10 MHz) result in better penetration into deeper tissues at the cost of axial resolution.

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2. Sonographic characteristics of normal tissues and features of basic pathological


conditions (from superficial to deeper structures).

The soft tissue structures have different reflecting capabilities that determine their appearance on the US
image. Each structure has its own characteristics.

- Skin

For imaging of the skin with sonography high frequency transducers (>13 MHz) are necessary.

For patients with scleroderma investigators have suggested that high frequency

(20 MHz) sonography is a feasible method for measuring skin thickness and stiffness (elastography) and they
advise sonography for diagnosis, long-term follow-up, and assessment of therapeutic studies. Further
investigations should clarify the value of sonography of the skin (Figure 2).

- Fat

Fat is hypoechoic with thin horizontal hyperechoic striae inside being connective tissue fibres (Figure 2).
Lipomas are often hyperechoic compared to the surrounding hypoechoic fat (Figure 3).

Figure 2. Transverse image upper leg shows skin (hyperechoic) on top and fat (hypoechoic) underneath Fat
underneath the skin Text: different structures are seen: skin, fat, muscles (rectus femoris and vastus
intermedius of quadriceps) over the femoral bone half way the upper leg.

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Figure 3. Lipoma. Note the horizontal lines inside and the rim around it on the outside

- Tendons

Longitudinal imaging of tendons shows a typical network of linear hyperechoic fibrillar patterns on US when
the insonation angle is 90 degrees (Figure 4).

The echogenic fibrils are the sonographic reflection of the endotendineal and peritendineal septa.

Tenosynovitis with fluid on US appears as an anechoic rim of fluid around the tendon (Figure 5a and 5b) when
synovial proliferation is present it is seen as hypoechoic tissue surrounding the tendon (Figure 5b). In US the
term tendinosis (tendon degeneration) is preferred over tendinitis since various studies have shown that only
a few acute inflammatory cells are present in pathologic specimens. Tendinosis is used to describe an enlarged
tendon with increased hypoechogenicity. However, in clinical practice the term tendinitis is far more
common than tendinosis.

Figure 4. Patella tendon in longitudinal image over Hoffas fad pad

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Figure 5. A. blue arrow indicates fluid of a tenosynovitis in longitudinal image; B. blue arrow indicates fluid in
transverse image; yellow arrow indicates synovial proliferation.

Loss of normal fibrillar echotexture visualized by irregular hypoechoic of anechoic areas in the tendon might
be due to partial full thickness tears (Figure 6) or anisotropy. Anisotropy may occur when the insonation angle
is not 90 degrees and is an artifact that makes the tendon look hypoechoic (dark) in parts (Figure 7).

Tendon tears may vary from partial to small full-thickness and large-massive full-thickness tears (Figure 8).
Tendon calcifications (Figure 9) may appear as a result of tendinitis.

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Figure 6. Transverse image of a partial rotator cuff tear on the joint side of the cuff. Note the white line (blue
arrow) above the humeral head (H) expressing fluid over the cartilage (c) and is called the cartilage interface
sign

Figure 7. Steered beam and anisotropy. Only when the sound beam hits part of a tendon perpendicularly will
that part of the tendon be visualized (between the two asterisks). If the sound beam is not directed
perpendicularly to part of the tendon, this part cannot be seen (a=anisotropy), because reflections will not
return to the transducer. By turning the sound beam (steered beam) to the left or to the right, anisotropic
parts of the tendon can be imaged, because these previously anisotropic parts are now hit perpendicularly.
MCP=metacarpophalangeal joint

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Figure 8. No rotator cuff is seen any more because of a massive rotator cuff tear. The Deltoid muscle (D) lays
over the naked humeral head (H).

Figure 9. Acoustic shadow. Within the supraspinatus tendon (ssp) a calcification is visualized (between the
two asterisks). Acoustic shadow behind the calcification causes an apparent interruption of the humeral (h)
cortex (between the two X signs).

- Muscle

Muscles appear on a longitudinal image hypoechoic with parallel and oblique echoic fibres, corresponding to
the endomysium, perimysium and epimysium (Figure 10). On a transverse image muscle is hypoechoic with
multiple echoic dots, corresponding to the cross-sections of the endomysium, perimysium and epimysium.

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Figure 10. Muscle. A. Longitudinal: feathery structure; B. Transverse: speckled aspect of muscle

In case of myositis or trauma this normal architecture might be lost (Figure 11). In both conditions comparison
with the healthy other extremity might help. In the event of trauma often hematomas are present. In case of
myositis oedema is present seen as more than normal hypoechogenicity on US.

Figure 11. Hematoma A. Hematoma is hyper-echoic in the first hours. B. Later on it may become hypo-echoic.

- Ligaments

Ligaments are hyperechoic, with a compact fibrillar pattern (Figure 12).

Ligaments, like tendons, will appear swollen and hypoechoic when damaged after trauma. Rupture of
ligaments may also be visualized by sonography.

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Figure 12. Ligaments. Long axis of the anterior talo-fibular ligament is hyperechoic

- Nerves

Peripheral nerves appear hyperechoic. On longitudinal scans the internal structure of nerves is characterized
by linear hypoechoic areas corresponding with the fascicles, separated by hyperechoic bands corresponding
with the endoneurium and perineurium. Outside the nerve parallel hyperechoic bands are found which
correspond with the epineurium. When peripheral nerves are compressed, e.g. by other tissues, they appear
swollen and less hyperechoic.

- Blood vessels

Blood vessels are visualized as anechoic longitudinal tubular structures in the longitudinal plane and a round
structure in the transverse plane that may be compressed. (Figure 13).

In case of temporal arteritis a dark halo might be detected within the vessel wall (Figure 14).

Figure 13. Normal artery with colour Doppler

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Figure 14. Temporal arteritis: halo around the artery

- Periosteum
Normally periosteum is not visible, but can be seen as a white line over an hypoechoic or anechoic mass when
it is lifted up from the underlying bone, e.g. by an haematoma or subperiosteal abscess as part of
osteomyelitis.

- Bone
A very bright echo is produced at the interface of soft tissue and bone cortex as bone is a very good reflector
of ultrasound waves (Figure 15). Bright echoes are also observed in the case of soft tissue calcification (Figure
9) and ossification. Cortical erosions (Figure 15) in RA can be seen as a cortical defect in two planes earlier than
with x-ray.

Figure 15. Erosion. Level of the erosion bottom is at a lower level than the cortex of normal bone. An erosion
should be seen on longitudinal and transverse image.

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- Bursae

Bursae are anechoic sacs and can only be visualized better when they become inflamed (Figure 16) except for
the Achilles bursa and the bursa at the distal insertion of the patella ligamentum that may be visualized even
without inflammation.

In traumatic bursitis there is usually only fluid (anechoic) or blood (anechoic often with internal echoes), while
in inflammatory processes effusion, synovial proliferation or both can be present. A snowflake-like echoic
pattern in a bursa may be caused by gout, but may also be seen after intra-articular administration of
corticosteroids.

Figure 16. Bursitis. Longitudinal image over Achilles tendon. 1. Normal size of Achilles tendon; 2. Swollen
Achilles tendon; arrow: bursitis; C = Calcaneal bone

- Cartilage

-Hyaline articular cartilage appears as a sharp anechoic layer over the hyperechoic bony cortex (Figure 17). The
US image of articular cartilage depends on the amount of water in the cartilage. In children and young adults
this hypo- or anechogenicity is higher than in elderly people, thus echogenicity tends to increase with age. The
weight-bearing cartilage of femur can be investigated under full flexion of the knee.

Loss of the normal sharpness of the synovial space-cartilage interface and loss of cartilage transparency is
among the earliest signs of osteoarthritis. A later sign is marked thinning of the cartilage layer.

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The value of sonography in the evaluation of articular cartilage remains to be determined. Urate crystal
deposits may be seen on the surface of the hyaline cartilage as a thin line or dots on the cartilage (Figure 18).
-Fibro-cartilage, such as a meniscus of the knee (Figure 19) or wrist and the labrum of the shoulder or hip,
appears hyperechoic on US. Fibrocartilage is prone to chondrocalcinosis.

Figure 17. Hyaline cartilage longitudinal image. In the normal situation this cartilage is an-echoic.

Figure 18. Double contour (blue arrow) which means on the outside of the cartilage is a line of gout crystals
seen. This line moves with the bone during dynamic examination.

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Figure 19. Fibro-cartilage. Longitudinal image over the knee joint on the medial/lateral side. The meniscus is
shown as a hyperechoic structure (arrow) and the fibro-cartilage as the anechoic line over the bone.

- Fluid

Fluid is compressible and displaceable when applying transducer pressure.

Clear fluid in a bursa or in a ganglion cyst (Figure 20) or effusion in the case of arthritis, appears anechoic on
the image. The effusion may change into a hypoechoic or even hyperechoic appearance in case of infection,
debris in the event of long-standing chronic arthritis or long-standing hematoma in the case of
haemophilia/trauma.

Figure 20. Tendon ganglion. Notice the posterior acoustic enhancement (blue arrow head) below the fluid
above it (yellow arrow).

- Synovium

Synovial proliferation is hypoechoic and is non-displaceable and poorly compressible when applying
transducer pressure.

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Normally the synovial lining cannot be seen on the image, however, in the case of arthritis (Figure 21) or
tenosynovitis (Figure 22), synovial proliferation and/or synovial fluid can be seen. Changes in synovial
hypertrophy can be seen after therapy.

Figure 21. Synovial proliferation. Arthritis with mainly synovial proliferation (see arrow) in MTP1.

Figure 22. Synovial proliferation in a tenosynovitis. (arrows)

- Gas

Gas (e.g. air) can be seen on a sonogram as bright hyperechoic echoes (Figure 23) sometimes with posterior
reverberation artifacts.

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Figure 23. Air injected in chicken meat; experimental setting for educational purposes. Note the strong
reflections of the air

3. Doppler physics

Though grey-scale US provides information about the anatomy and morphological changes in the examined
area Doppler US is able to provide information about flow in the investigated structures. How is this possible?

The reason that flow can be seen is because of the Doppler shift which is basically a change in the transmitted
frequency when reflected by an object in motion (the erythrocytes) (Figure 24). The difference between the
emitted frequency and the received frequency is then translated into colour information which is then
superimposed on the grey scale image showing the flow in the region. The transducer is both a stationary
source but also a receiver. The change in frequency is known as the Doppler shift, named after the Austrian
physicist and mathematician Chr. Andreas Doppler, who first described the phenomenon in 1843 for light.

It is assumed that the mainly the erythrocytes are responsible for the scattering of US by blood. The
erythrocyte is smaller in size than the wavelength of US and thereby acts as a point scatter (Rayleigh-Tyndall
scattering).

The Doppler shift is however, related to more than just the change in frequency. When the US pulse is being
scattered or reflected from moving blood cells, two successive Doppler shifts are involved. First, the sound
from the stationary transmitting transducer is received by the moving erythrocytes. Second, the cells act as
moving sources as they re-eradiate the US back toward the transducer, which is also the stationary receiver.

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Figure 24. Doppler shift

These two Doppler shifts account for the factor 2 in the Doppler equation:

fD = ft fr = (2x ft x v x cos )/c

where: fD is the Doppler shift, ft is the transmitted frequency, fr is the received frequency, v is the blood
velocity, is the insonation angle (the angle between the ultrasound beam and the blood flow), and c is the
speed of sound. The Doppler shift is thus directly proportional to the velocity of the flow, v, the insonation
angle, , and the transmitted frequency of the US, ft.

Motion toward the transducer gives a higher frequency or positive Doppler shift and motion away from the
transducer gives a lower frequency or negative Doppler shift. The faster the blood flows toward or away from
the transducer the greater the Doppler shift will be.

If the insonation angle is 900 to the flow (running parallel to the probe) the cosine to the angle is zero, which
means no Doppler shift is detectable and no flow will be displayed (Figure 25).

To change the Doppler shift the operator may alter the insonation angle and the frequency.

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Figure 25. MCP joint. The direction of the blood is shown with red going towards and blue away from the
probe. When the insonation angle is 90 degrees there is no flow information (arrow)

- Angle

The Doppler angle or insonation angle is the angle between the Doppler beam and the direction of flow in the
vessel and is of importance in the determination of the Doppler shift and the velocity. Generally, the
insonation angle is of importance because the erythrocytes are rarely moving directly towards or away from
the transducer but will be moving in a direction at some given angle to the Doppler beam.

Most instruments incorporate the operating frequency and the sound speed into the Doppler equation for a
determination of flow speed in e.g. centimetres (cm) per second. In this equation the Doppler angle is
assumed to be zero though this is seldom true.

When examining small vessels not visible to the eye as in the synovium it is not possible to identify the
insonation angle and thereby perform angle correction when dealing with vessels of such a small size as in the
synovium. Angle correction is of importance when examining larger vessels (e.g. in vasculitis). If angle
correction is not done, the unit on the velocity scale on the y-axis will correspond to an insonation angle of 00
thereby resulting in erroneous velocities.

- Doppler modalities

To display the flow colour or power Doppler may be used. The analysis is performed in the Doppler box, which
is divided into cells. Each cell behaves like an independent Doppler gate with its own Doppler analysis. Here an
analysis of the return frequencies is carried out. The frequencies have different velocities because the
erythrocytes travel with different velocities and every velocity has an energy.

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Colour Doppler
Colour Doppler (CD) displays the mean velocity of the erythrocytes and it is displayed as a colour. The colours
that arise relates to the mean velocity and direction of the moving erythrocytes and CD is an image of the
blood velocity

Power Doppler
Power Doppler (PD) on the other hand summarizes the energies from the velocity. The hue relates to the
number of moving erythrocytes and is an image of the detected blood pool. PD does not measure velocity or
direction.

4. Doppler artefacts

When working with Doppler in musculoskeletal US artefacts are a natural part of the examination and it is
important to know of the most frequently occurring artefacts as they may disturb the interpretation of the
image. Knowledge of these artefacts will help to ensure a correct interpretation of the Doppler information by
distinguishing between true and false flow.

- Random noise:

Random noise is a common artefact. Random noise is produced in all electrical circuits. When the gain is set
too high, this noise becomes detectable in both the colour and power Doppler circuitry. It is seen as colour foci
appearing randomly in the image and is easily identified as an artefact because the colours never reappear in
the same location as true flow does (Figure 26). Random noise makes it difficult to interpret the image
correctly and to avoid random noise the gain most be adjusted correctly. This is done by increasing the gain
until random noise is seen in the image then gradually lowering the gain until only a very few noise pixels are
seen in the image. However, if the gain is lowered too much flow information is lost.

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Figure 26. Random noise is seen as colour foci appearing randomly in the image and is easily identified as an
artefact because the colours never reappear in the same location as true flow does. Random noise is gain
dependent.

- Aliasing:

Aliasing for Doppler ultrasound when used in a rheumatological context is seldom of relevance but is described
as it is always falsely mentioned as a drawback to CD compared to PD though it is really not.

This is one of the most well-known artefacts in CD examinations and arises when the Doppler shift of the
moving blood is higher than half of the pulse repetition frequency (PRF) called the Nyquist limit. When this
happens the signal folds over showing false velocity of the flow displayed (showing pixels with an opposite
direction than the surrounding flow) Figure 27. In true reverse flow there is a detectable black line between
the opposite directions of flow because between the areas with opposite directions there must be an area
with no velocity - no Doppler shift and therefore no signal (Figure 25). To avoid aliasing the PRF may be
increased, however by increasing the PFR the sensitivity to low velocity flow is reduced. Another option when
working with larger vessels like in giant cell arteritis is to alter the insonation angle.

This artefact is only important when velocity and/or direction are important to the examination and so far this
has never been proven important when working with slow flow as seen in rheumatology. It is the presence or
absence of flow (colours) that are relevant and not the direction or the velocity of the detected flow.
Therefore the PRF should be kept low so not to lose slow flow information. Aliasing is therefore not important
and should be an accepted artefact. There is one exception for this rule and that is the application of colour
Doppler in vasculitis.

Aliasing does not occur in PD.

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Figure 27. In true reverse flow there is a detectable black line between the opposite directions of flow (a)
because between the areas with opposite directions there must be an area with no velocity - no Doppler shift
and therefore no signal (white arrow)

Aliasing is when the signal folds over showing false velocity of the flow displayed (showing pixels with an
opposite direction than the surrounding flow) (b)

- Motion:

Motion artefacts are also known as flash or clutter artefacts.


The Doppler detects motion between the transducer and the tissue. If both the transducer and the patient are
immobile, the only thing moving is the blood that generates the colours in the Doppler image. However,
movement of the patient, transducer, or movement of the tissue or vessel wall caused by arterial pulsation
during Doppler imaging give motion relative to the transducer and produce a Doppler shift (Figure 28). The
movements are slower than the flowing blood and therefore produce lower frequency Doppler shifts. These
are seen as randomly occurring short flashes of large confluent areas of colour. Motion artefacts may easily be
separated from true flow signals as they are not pulsating and seldom re-occur in the same place.
Motion artefacts from tissue movements (e.g. vessel wall) may be avoided by adjusting the wall filters. They
are high pass filters which means that a Doppler shift must be above a certain threshold to be displayed. Such
filters, however, also remove information from slow moving blood. Therefore the wall filters should be kept as
low as possible.

Motion artefacts from the movement of transducer or from the patient may be avoided by keeping the
transducer and patient immobile during examination will eliminate some motion artefacts.

When the Doppler is at its highest sensitivity just at or below the noise level, intermittent motion artefacts
must be accepted.

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Figure 28. Motion artefacts are seen as randomly occurring short flashes of large confluent areas of colour
(arrows) due to motion relative to the transducer.

- Blooming:

The blooming artefact describes the phenomenon that the colour bleeds over the vessel wall making them
look larger than they really are (Figure 29). It depends on the gain and by lowering the Doppler gain blooming
artefact will be minimized on expense of losing slow flow information. The Doppler gain should be adjusted as
mentioned in the random noise section and not by looking at blooming artefacts. It is therefore an artefact
that must be accepted as a systematic error in image evaluation. The excess colour in the image is not really
false since it is generated by flow.

- Mirror:

Any highly reflecting smooth surface (almost always the bone) may act as an acoustic mirror. The mirror
artefact is easily identified when the true image (vessel) as well as the mirror (bone) and mirror image all are in
the image (Figure 30). The mirror image is more difficult when only the mirror and mirror image are present. If
the artefact is investigated with spectral Doppler it will show true flow because it is a mirror image of true
flow. It is however important to remember that true flow (Doppler activity) are never seen inside the bone if
the bone surface is intact.

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Figure 29. The blooming artefact describes the phenomenon that the colour bleeds over the vessel wall (a)
making them look larger than they really are. Can be removed by lowering the gain but then slow flow will be
lost (b)

Figure 30. The bone act as a highly reflective surface. The mirror artefact is here seen with the true vessel (*)
as well as the mirror of the vessel (arrow) on the other side of the reflecting surface (bone)

- Reverberation:
The Doppler pulse behaves just as the grey-scale pulse with respect to reverberation. A superficial vessel may
be repeated lower in the image (simple reverberation) or display a showering of colour behind the vessel
(complex reverberation) (Figure 31). Deeper in the image the false colour foci may be seen inside synovium
and if investigated with spectral Doppler they will show true flow (because they are reverberations of true

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flow). One way to ensure that the necessary information is present in the image to be able to evaluate
possible reverberation artefacts is to make sure that the colour box always goes to the top of the image to
display any vessels located outside the joint that may be the source for reverberation artefacts.

Figure 31. A superficial vessel may be repeated lower in the image (simple reverberation) or display a
showering of colour behind the vessel (complex reverberation). The image is showing the latter including the
impact of the Doppler information in the synovium below (ulnar part of the wrist).

It is not possible to adjust your way out of a reverberation artefact and this artefact may therefore cause
severe problems in areas with synovial hypertrophy that needs to be examined with Doppler ultrasound, if
there is an overlying vessel in that area. The only solution is to find another area in the joint to evaluate where
no reverberation artefact disturbs the image.

5. Indications and limits of MSUS

The ultrasound evaluation is quick and dynamic, enables assessment of more than one joint region in one
session, is repeatable and easily accessible and may serve as an educational tool for explaining and visualizing
the disease process to the patient. There are no contraindications, risks and side-effects which makes US
unique imaging modality.

Ultrasound examination allows both static and dynamic anatomical assessment of the visualized structures,
and with Doppler information of perfusion may be obtained in the imaged areas.

The musculoskeletal ultrasound (MSUS) examination enables assessment of:

- joint and bursal effusion;

- synovial thickening;

- ganglion cysts;

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- presence of bone erosions;

- presence of tendon pathology (tendinopathy, enthesopathy and tears);

- ligament pathology;

- nerve entrapments;

- detection and evacuation of foreign bodies;

- guidance of punctures, aspirations, biopsies and injections.

Although for most rheumatic diseases it remains to be proven, musculoskeletal ultrasound potentially enables
physicians to diagnose and monitor the disease process over time.

The MSUS examination has also its limitations. Ultrasound cannot penetrate bone and air, and especially the
former makes the assessment of the large joints incomplete. Fat decreases quality of images. For some
structures the method has a long learning curve. The available ultrasound units have varying quality, which is
particularly true for the Doppler modalities.

It should also not be forgotten that the competency of the rheumatologist performing the ultrasound
examination is rarely equal to the competency of the musculoskeletal radiologist. Therefore, assessment of
injuries and soft tissue masses, suspected of neoplastic processes, should be left in the hands of those, who
are used to diagnose those pathologies. And the indications for musculoskeletal examination performed by
the rheumatologist should reflect the level of competency of the local rheumatologist.

6. Image documentation

In the opinion of the authors the image documentation must contain the most representative images of the
pathology found, visualized in two planes, optimally using the standard positions for the imaged structure,
both B-mode and Doppler (though the latter only if relevant).

The aim of the image saving is fourfold:

- documentation of the present examination supporting its description;

- basis for comparison with future examinations;

- correlation with other imaging modalities;

- potential audit.

The images should be stored on the ultrasound unit with a possibility of external back-up. The latter may be
effected by means of PACS, external hard disk, CD-ROMs and the like.

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The stored images should be identifiable by characteristic bony landmarks, and if not apparent from the image
itself from additional information in the image itself, i.e. left side, examined joint and so on. They should also
be clearly labelled with the patients name and ID number, as well as the date and place of the examination.

The image documentation must be accompanied by a report of the examining physician.

7. How to write a report on MSUS findings

The MSUS report should be an answer to the question asked by the referring physician.

In the report the examining physician should concentrate on the description of the findings, based on
ultrasound terminology, without interpreting the findings in relation to the clinical situation, unless the
question asked and the available clinical data allow such an interpretation.

The report should be concise.

In the authors opinion a report on MSUS must contain the following elements:

1. Date and place (name of the department) of the examination

2. Surname, family name and ID number of the patient

3. Number of the examination, if the log book/registry of US examinations is held

4. Name and title of the examiner

5. Name, title and the department of the referring physician

6. The clinical question which has led to the MSUS examination and a short summary of the case story

7. Name of the region/regions examined

8. Description of all the elements of the examined region, even if they presented no pathological
changes, including the remark on, if only the B-mode or also Doppler/contrast examination were performed

9. Answer to the clinical question/conclusion

10. Recommendation for future treatment or diagnostics, if relevant

Appendix A shows an example of an ultrasound report

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MSUS REPORT

Hospital / Department / Unit

Date

Patients Surname and Family Name: xxxxx xxxxx

Patients ID no.: xxxxxx-xxxx

Examination no.: XXXX

Examiner: xxxxx xxxxx

Referred from: xxxxx xxxxx

Short summary of the case story and the clinical question:

59 years old earlier healthy man, who in the last three months spontaneously

developed pain and restricted mobility in the right shoulder. Clinically, restricted abduction and external
rotation in the shoulder joint. No swelling, some tenderness of the joint on palpation laterally. No earlier
traumas.

Rotator-cuff tendinitis? Bursitis? Synovitis? Joint effusion?

If relevant, steroid injection after the concluded assessment may be considered, there exist no
contraindications for the treatment. The patient is informed of the possibility and agrees.

Joint region examined: Both shoulders

Examinations description:

Examination performed on both shoulders, with the left shoulder as the healthy comparator.

All rotator-cuff tendons normal, with preserved structure and normal thickness. The available entheses
without signs of pathology. Right subdeltoid bursa widened up to 1,5 mm with anechogenic contents, no
synovial villi or deposits inside. Normal acromioclavicular and available parts of the glenohumeral joints.
Normal anterior and posterior recesses.

Doppler examination of the subdeltoid bursa without flow signals.

Conclusion:

Right subdeltoid bursitis.

With the patients consent, under sterile conditions and ultrasound-guidance the puncture of the right
subdeltoid bursa was performed from the posterior lateral position with evacuation of 5 ml of yellow,
transparent fluid and administration of 1 ml methylprednisolone with 4 ml 1% lidocaine in the bursa
without complications. The patient is informed of possible flair-up, flushing and infection risk. The injection
site shall remain dry in 24 hours.

Suggested clinical control within two weeks.

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SUMMARY POINTS

The normal structures in musculoskeletal ultrasound have different appearance that makes it
possible to differentiate between them

Basic pathologies appear with their characteristics in musculoskeletal ultrasound

There is a trade-off between penetration and resolution

Reverberation, mirror, noise, motion, blooming and aliasing are the most frequently occurring
artefacts that may influence the image interpretation

Gain, focus and frequency are important settings for optimizing the image for grey-scale and
Doppler. For Doppler also PRF and colour priority adjustments will have major impact on the
sensitivity to detect flow

In a report the indication, ultrasound findings and treatment plan must be noted

Images may be saved as PACS, on external hard disk, CD-ROMs or USB-sticks

Soft tissue structures are easily visualized by US but it cannot penetrate bone why only the bone
cortex can be evaluated in accessible areas.

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3. Jacobson JA, Holsbeeck MT van. Musculoskeletal ultrasonography. Orthop Clin North Am 1998;29:135-
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Additional material

1. Ultrasound acoustics: (www.explorescience.com)

2. Schmidt WA, Schmidt H, Schicke B, Gromnica-Ihle E. Standard reference values for musculoskeletal
ultrasonography. Ann Rheum Dis. 2004;63(8):988-94.

3. Fornage BD, Rifkin MD. Ultrasound examination of tendons. Radiol Clin North Am 1988;26:87-107

4. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal system 2007. ISBN 978-3-540-42267-9,


Springer. Page: 1-137.

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