Knee Pain – Ultrasound Imaging

We see lots of patients with knee pain. When the cause is due to soft tissue damage or problems, tissue changes can often be seen clearly with ultrasound scanning. However, nothing ever replaces the standard, detailed physical examination- we only use the scan to confirm our assessment findings, but it’s often fascinating to be able to ‘see’ the tissues involved.
Healing and resolution can also be monitored using follow up scans.
The images below show marked thickening and increased darkness (hypo-echoic signal) in a kneecap tendon – Patella Tendinopathy.
Whilst the patient reported improvement in his symptoms of pain and reduced function with a course of treatment (stretching, and muscle re-strengthening), repeated scans later showed very little change in the size of the tendon. He was intrigued by the early scan result, but very reassured to see the tendon was intact.

Patellar tendon scan

David is not a qualified sonographer. However like many physiotherapists in musculo-skeletal practice, he has received basic training in the use of ultrasound imaging equipment and uses it to confirm his assessment findings and measure progress in recovery from certain injuries.

Tennis Elbow – Ultrasound imaging

Tennis Elbow is the term often used for pain on the outside of the elbow; technically, it is for inflammation of the local tendons (Common Extensor Tendons). However, there can be several different causes for the pain, and careful assessment is needed to make a correct diagnosis, prior to treatment. Following the usual physiotherapy assessment, David may use the dynamic ultrasound scanner to image the local tissues, gaining more information about the local condition.
On the scan below, you can clearly see in the right hand frame very significant thickening and darkening of the Common Extensor Tendons which cross over the Radial Head and elbow joint, compared with the opposite elbow, which is pain free in the left hand frame. We’ve added an anatomy drawing to help you identify the tissues involved. (David says this is the biggest one he’s seen- they aren’t all like this! We referred this patient on for a formal scan)

Tennis Elbow Ultrasound scan

David is not a qualified sonographer. However like many physiotherapists in musculo-skeletal practice, he has received basic training in the use of ultrasound imaging equipment and uses it to confirm his assessment findings and measure progress in recovery from certain injuries.

Achilles Tendon – Ultrasound Imaging

Achilles tendonois or Tendinitis?
There’s a huge amount of information in the ‘net about Achilles Tendonitis but you need to know for sure whether you have got inflamation (which is “-itis”) or the longer lasting, harder to treat “tendnosis”; these two conditions feel pretty similar but they’re managed very differently. You need an expert!!

When patients present with any Achilles tendon complaint, David usually completes his usual physiotherapy assessment with a dynamic ultrasound scan, comparing the affected tendon with the ‘normal’ one.
In tendonosis the tendon feels thickened and tender to palpation, and loses some of it’s pliability; an ultrasound scan shows this thickening very clearly, especially when compared with the unaffected side. The condition is one of tendon overgrowth
(In ladies, the Achilles tendon is usually 3mm to 4mm thick; in males its usually 4mm to 5mm. This can double in tendonosis.)

This longitudinal scan shows a significantly enlarged achilles tendon in the right frame, with a more normal sized tendon on the left

This transverse scan shows a significantly enlarged achilles tendon in the right frame, with a more normal sized tendon on the left

However, when tendonitis is present, much less enlargement occurs because the condition is one of inflammation; the edges of the tendon can appear darker (hypo-echoic)

(Occasionally, we may see irregularities in the tendon structure, in which case we refer back to the GP for formal scanning and reporting. If there is no tear, we can proceed with vigorous remedial exercise protocols.)

Repeat scans:
We will often repeat a scan during a course of treatment, in order to compare record any changes. Since our clinical records are digital, we can embed a detailed image of each scan into the patients notes.

As tendonitis settles, responding to rest, ice, stretching and a gradual return to exercise, the ‘darkness’ (hypo-echoicity) reduces.
In tendonosis, the patients respond well to a graded exercise scheme called “eccentric exercises”; they begin to report less pain & stiffness early in the mornings and less discomfort on exercise. However, on rescanning, we often find that the tendon size has not reduced- occasionally, it has enlarged further.
This is thought to be because the condition is not an inflammatory one, but one of overgrowth. Patients can be disappointed when the tendon still seems to be thick and lumpy but we can reassure them that it is a normal part of the condition.
What is really great is that 80% of patients with this chronic problem respond very well to our treatment protocol, returning to normal daily activity and sport (even when they’ve had problems for many months).

David is not a qualified sonographer. However like many physiotherapists in musculo-skeletal practice, he has received basic training in the use of ultrasound imaging equipment and uses it to confirm his assessment findings and measure progress in recovery from certain injuries.

Calf Muscle Tear – Ultrasound imaging case study

Ultrasound scanning will immediately show us whether you have a tear or a simple strain. Tears show up very clearly, as do collections of blood in the muscle.

At first assessment 5 weeks post injury

The scan above (fig 1) shows a large tear of the Gastrocnemius muscle. Amazingly, this was some 5 weeks AFTER the trauma. The left hand frame shows a dark area (called a hypo echoic signal) between two parts of the muscle that should be attached; it is 12mm deep; in the right hand frame the gap is closed down to 6.5mm by firm pressure via the scanner head. It was clear that the gap was filled with blood / fluid. Under live scanning, we could see the fluid & debris moving within the defect
We were able to surface mark the entire extent of the haematoma in this gentleman’s calf muscle using ultrasound scanning.
The patient was treated with regular sessions of local ultrasound therapy, gentle remedial exercises and massage, with firm compression support 24 hours a day.

2 weeks after treatment has begun

The second scan (fig 2) was taken 2 weeks later, and shows the gap closing satisfactorily with treatment.

4 weeks after beginning treatment

The third scan (fig 3) was taken 2weeks later, and continues to show good progress.

Healing continues....

The fourth scan shows no hypo echoic signal, and you can clearly see the two parts of the muscle are now joined together by scar tissues. The scar is thicker (3.42mm) than the normal tissues that would be there (intermuscular septum) but they are, at least, now attached. He was able to increase his weight bearing exercsie steadily throughout the healing period, safe in the knowledge that the tissues were healing.

Final scan

A further scan was taken two months later, following increasingly dynamic muscle work and re-education. It shows that the scar has been stretched open a little, and now measures 5.11mm. however, it is functionally strong, and he has returned to Martial Arts sports.

David is not a qualified sonographer. However like many physiotherapists in musculo-skeletal practice, he has received basic training in the use of ultrasound imaging equipment and uses it to confirm his assessment findings and measure progress in recovery from certain injuries.

Interesting Ultrasound Scan

We’ve added another, unusual scan, just for your interest.
A young lady slipped on a wet floor and fell onto broken glass- she cut the front of her knee badly, but was stitched up by a local doctor, and seemed to make a good recovery. Back in the UK several months later, the kneecap tendon was still lumpy and sore and came to see David. The image below shows the damage in then left hand frame, which had gone quite deep- the normal patella tendon is shown in the right hand frame.
Again we recommended further investigation. However, she made a very good functional recovery without any surgical intervention.

Interesting patellar tendon ultrasound scan