Journal of Ultrasound in MedicineEarly View Practice ParameterFree Access The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination First published: 05 April 2023 https://doi.org/10.1002/jum.16228AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination was revised by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with recognition that deviations may occur depending on the clinical situation. Indications Indications for musculoskeletal ultrasound include, but are not limited to: Pain or dysfunction Soft tissue or bone injury Tendon, ligament, or fascial pathology Arthritis, synovitis, or crystal deposition disease Joint effusion and intraarticular bodies Neurovascular entrapment, injury, neuropathy, mass, or subluxation Evaluation of soft tissue masses, swelling, or fluid collections Detection of foreign bodies in the superficial soft tissues Planning and guidance for an invasive procedure Congenital or developmental anomalies Postoperative or postprocedural evaluation Joint laxity, stiffness, decreased range of motion, or misalignment The above is a comprehensive list of general indications for musculoskeletal ultrasound; however, specific and unique indications pertaining to specific joints will be listed in the corresponding sections. Musculoskeletal ultrasound should be performed when there is a valid medical reason. There are no absolute contraindications. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines1 in accordance with AIUM accreditation policies.2 Sonographers performing the ultrasound examination should be appropriately credentialed3 in the specialty area in accordance with the AIUM accreditation policies.2 Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32.4 Physician A physician must be available for consultation with the sonographer on a case-by-case basis. Ideally the physician should be on-site and available to participate actively in the ultrasound examination when required. It is recognized, however, that geographic realities may not permit the presence of an on-site physician in all locations. In this case, a supervising physician should be available for quality assurance and sonographer supervision via a picture archiving and communication system (PACS). Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed healthcare provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local healthcare facility requirements.2 Specification of the Examination The written or electronic request for a musculoskeletal ultrasound examination should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination. General Principles Depending on the clinical request and the patient's symptoms, the ultrasound examination may involve a complete assessment of a joint or an anatomic region, or it may be limited to a specific anatomic structure. Examinations of joints, such as the elbow, hip, knee, and ankle, can be divided into four regions (anterior, medial, lateral, and posterior). A complete examination includes evaluation of the joint and synovium, cortical outline of underlying bones, muscles, tendons and tendon sheaths, ligaments and fascia, capsule, and any additional abnormalities visible in the region. Color and power Doppler may be useful in detecting hyperemia or neovascularity within the tendon and/or tendon sheath, joint, or surrounding structures. Doppler flow is considered a key imaging finding for some pathologic conditions in musculoskeletal ultrasound. The equipment must be optimized for relevant Doppler sensitivity. Images should always be obtained with the ultrasound beam perpendicular to the region of interest to minimize artifact. When applicable, relevant structures should be interrogated in more than 1 plane, at least 2 orthogonal planes. Patient positioning for specific examinations may vary depending on the structure being examined, the patient's clinical condition, and the operator's preference to obtain required short-axis and long-axis images. Dynamic evaluation is an important aspect of all musculoskeletal exam protocols to test for mobility, subluxation/dislocation, or impingement. Transducer movements and manipulation are critical to provide accurate ultrasound images in musculoskeletal ultrasound. Heel-toe and tilting maneuvers help in avoiding anisotropy artifact by changing the angle of insonation while maintaining contact with the skin surface. Sometimes compression with the transducer may be performed to evaluate for solid versus cystic/fluid-filled structures and/or to elicit symptoms (sonopalpation). Specifications of the Shoulder Examination A shoulder examination is requested to evaluate for rotator cuff pathology such as a partial- or full-thickness tear, calcific tendinitis, or tendinosis in adults, and joint-centered pathology in children. Other indications include evaluation of biceps tendon pathology, including tendon instability, subacromial-subdeltoid hypertrophy/bursitis, acromioclavicular arthritis, paralabral cyst, and nerve compression. The long head of the biceps tendon is examined in a transverse plane (short axis) within the bicipital groove and to the musculotendinous junction distally. The insertions of the pectoralis major tendon on the humerus can be evaluated at the same time, when indicated. Longitudinal views (long axis) should also be obtained. Tendon position within the bicipital groove should be commented upon. Dynamic evaluation may be performed in the short axis to evaluate for tendon subluxation or dislocation. The subscapularis is imaged from the musculotendinous junction to the insertion on the lesser tuberosity of the humerus in long-axis and short-axis planes. Dynamic evaluation in the long-axis plane is helpful to evaluate possible subcoracoid impingement. When scanning the supraspinatus and infraspinatus tendons along their long axes, it is important to orient the transducer in an oblique plane. Short-axis views of the tendons should also be obtained by rotating the transducer 90° to the long axis. Correct short-axis positioning may be confirmed by visualizing the coracohumeral ligament in long axis medially, then moving laterally along the shoulder. Additionally, a short-axis view of the long head biceps in the rotator interval can serve as a landmark for appropriate orientation to the supraspinatus and infraspinatus tendons in short axis. When necessary, the more posterior aspect of the infraspinatus and teres minor tendons can be examined by placing the transducer posteriorly at the level of the glenohumeral joint. During the examination of the rotator cuff, the cuff should be frequently compressed with the transducer to detect nonretracted tears. Dynamic evaluation of the rotator cuff during shoulder abduction is useful to evaluate the rotator cuff for subacromial or subligamentous impingement. Tear length (partial-thickness tear) or the degree of retraction of the cuff (full-thickness tear) should be measured on longitudinal views, and tear width should be measured on short-axis views. Tear depth should also be assessed. A partial-thickness tear should be described as originating from the bursal or articular side, or intrasubstance, and its thickness should be assessed. It is also useful to measure the distance between the intra-articular portion of the biceps tendon and the anterior edge of the tear on short-axis views; most degenerative tears begin ~15 mm from the intra-articular portion of the biceps tendon.5 In patients with a rotator cuff tear, the supraspinatus, infraspinatus, and teres minor muscles should be examined for fatty infiltration and atrophy, because these findings may influence the postoperative outcomes. Comparison with the contralateral rotator cuff muscles is often helpful to confirm muscle atrophy and fatty infiltration except when muscle atrophy is the result of a diffuse systemic process. Rotator cuff thickness and echogenicity should also be evaluated; a thick, hypoechoic cuff indicates tendinosis. The postoperative (rotator cuff after repair) rotator cuff may be hypoechoic and/or heterogenous in the early healing period, but that appearance may resolve over a period of time.6 The subacromial–subdeltoid bursa should be examined for the presence of synovial hypertrophy or effusion. Power or color Doppler should also be used to detect hyperemia. Bursal bunching and snapping in the setting of subcoracoid, subacromial, and subligamentous impingement can be assessed with dynamic examination. Glenohumeral joint effusion is best assessed via a posterior approach. Glenohumeral effusion typically lacks Doppler flow and can be displaceable, whereas synovial thickening can contain Doppler flow and is not or only minimally compressible. Posterior labral abnormalities should also be evaluated using this approach. If symptoms warrant, the suprascapular notch and spinoglenoid notch may also be evaluated for a paralabral cyst. The acromioclavicular joint should be evaluated for arthritis, infection, or trauma by placing the transducer at the apex of the shoulder, over the acromion and distal clavicle.7-10 Ultrasound is very useful as the first line of screening of infants and young toddlers with clinically suspected glenohumeral dysplasia. It serves as an alternative to MRI, which provides a more global assessment, providing complementary information without the need for patient sedation. These infants are typically examined in the seated position on the caregiver's lap, facing away from the sonographer. Alternatively, the children can also be scanned in a decubitus position. Each shoulder, both symptomatic and normal sides, is scanned via a posterior approach to evaluate the morphology and alignment between the humeral head and glenoid. Both static and dynamic images are obtained with the shoulder in neutral position and full internal and external rotation. Posterior subluxation is evaluated qualitatively and quantitatively, with the latter involving the use of the α angle and humeral head translation. The α angle is formed between a line drawn along the posterior margin of the scapula and a line drawn tangentially to the posterior cortex of humeral head and posterior edge of the glenoid. An α angle of 30° or less is considered normal. Humeral head translation measures the percentage of the humeral head that is displaced posterior to the axis of the scapula. The normal value for humeral head translation is 50% or less. Muscle atrophy is characterized by asymmetric decreased thickness and bulk when compared with the contralateral normal side. In infants with equivocal radiographs, the clavicle and proximal humerus can be evaluated for displaced fractures secondary to birth trauma11 or nonaccidental trauma. In the latter scenario, the proximal humerus can be assessed for Salter–Harris fractures. However, it is worth noting that nondisplaced fractures and incomplete fractures involving the cortex that are inaccessible by ultrasound can be subtle and missed, respectively. These can be assessed using follow-up radiographs. In infants with Erb's palsy and history of shoulder dystocia, ultrasound is useful for mapping out injuries to the brachial plexus, associated muscle denervation injuries, and glenohumeral subluxation.12 Ultrasound can be helpful intraoperatively to confirm glenohumeral reduction. Specification of an Elbow Examination Examination of the elbow is divided into four regions: anterior, medial, lateral, and posterior. Anterior The anterior joint space and other recesses of the elbow are assessed for joint or bursal effusion, synovial hypertrophy, and intra-articular bodies. Longitudinal and transverse scanning of the anterior humeroradial joint, the humeroulnar joint, and both the coronoid and radial fossae is performed to assess the articular cartilage and cortical bone. The annular recess of the neck of the radius is scanned dynamically with forearm pronation and supination. The same dynamic assessment can be made for the biceps brachii tendon and its attachment to the radial bicipital tuberosity. When evaluating the distal biceps tendon from an anterior approach, the arm should be maximally supinated and extended. The distal biceps tendon can also be evaluated from a medial approach with the elbow flexed and the forearm supinated13 or via a lateral approach14 using the brachioradialis as an acoustic window. The insertion can also be imaged during dynamic scan with a posterior approach. Evaluation of the brachialis muscle, the adjacent radial and brachial vessels, and the median and radial nerves can also be performed as clinically warranted. Lateral Lateral elbow evaluation allows assessment of the lateral epicondyle, the attachments of the common extensor tendon, and the proximal attachments of the extensor carpi radialis longus and brachioradialis. Scanning the posterolateral aspect of the elbow allows evaluation of the lateral collateral ligament complex. The radial nerve, including its deep branch entering the supinator muscles (posterior interosseous nerve), is also evaluated. Medial Medial elbow scanning includes evaluation of the medial epicondyle, common flexor tendon, and ulnar collateral ligament.15, 16 The ulnar nerve is visualized in the cubital tunnel region between the olecranon process and medial epicondyle. Dynamic subluxation and dislocation of the ulnar nerve and adjacent medial head of the triceps muscle are assessed by imaging with flexion and extension of the elbow. Dynamic examination with valgus stress is performed to assess integrity of the ulnar collateral ligament. During valgus stress testing, the elbow may have to be flexed at variable angles to disengage the olecranon from the olecranon fossa. Posterior To evaluate the posterior elbow, the elbow is flexed to 90°. The posterior joint space, triceps brachii tendon, olecranon process, and olecranon bursa are assessed.17-19 In infants, who have not yet developed any elbow ossification centers, radiographic distinction between elbow dislocation and transphyseal fracture-displacement is challenging. Ultrasound can be helpful in this situation, made even more useful by comparison imaging of the contralateral, normal side. Placing the transducer in the longitudinal plane anteriorly or anterolaterally on the elbow can confirm the normal radiocapitellar alignment in the absence of a dislocation. It can assess for disruption at the level of the humeral physis too. Similarly, ultrasound can identify the components of a lateral condyle fracture when the distal humeral epiphysis is not yet ossified and fracture components are radiographically occult. Specifications of the Wrist Examination A wrist examination may be indicated to evaluate a focal abnormality such as a tumor (tenosynovial giant cell tumor of the tendon sheath, peripheral nerve sheath tumor, or lipoma), ganglion, epidermal inclusion cyst, foreign body, or tendon injury. Tenosynovitis, nerve entrapment syndromes, and peripheral nerve disorders such as carpal tunnel syndrome can also be evaluated. In the patient with suspected inflammatory arthritis, the hands and wrists should be evaluated for synovial hypertrophy, joint effusion, bony erosions, tenosynovitis, crystal deposition, and tendon rupture. The examination may include a complete assessment of one or more of the four anatomic regions described below or may be limited to a specific anatomic structure, depending on the clinical presentation. Volar Transverse and longitudinal images should be obtained from the volar wrist crease to the thenar muscles. The transducer will require angulation changes to compensate for the normal contour of the wrist and to minimize anisotropy. The flexor retinaculum, flexor digitorum profundus, superficialis tendons, and the adjacent flexor pollicis longus tendon should be identified within the carpal tunnel. Dynamic imaging with flexion and extension of the fingers will demonstrate the normal motion of these tendons. The median nerve normally lies superficial to these tendons and deep to the flexor retinaculum. The distal portion of the median nerve tapers and divides into multiple branches for the hand. The palmaris longus tendon lies superficial to the retinaculum, if present. Radial On the radial side of the wrist, the flexor carpi radialis longus tendon lies within its own canal. It is important to evaluate the region of the flexor carpi radialis and the radial artery for occult ganglion cysts, which can originate from the radiocarpal joint capsule, scapho-trapezial joint, or flexor carpi radialis tendon sheath itself. All of the tendons can be followed to their sites of insertion if clinically indicated. Ulnar Placing the transducer transversely on the ulnar styloid and moving distally will allow visualization of the triangular fibrocartilage complex (TFCC) in its long axis. Dynamic imaging with radial deviation may be helpful in assessing the integrity of the TFCC. The transducer is then rotated 90° to view the short axis of the TFCC. The ulnomeniscal homologue may be seen just deep to the extensor carpi ulnaris tendon. The extensor carpi ulnaris tendon should be viewed in supination and pronation to assess for In the setting of inflammatory arthritis, the extensor carpi ulnaris should be evaluated for and rupture. On the ulnar side, branches of the ulnar nerve and artery within the ulnar tunnel. The flexor carpi ulnaris tendon and bone the ulnar aspect of the tunnel. the structures are very a even using a is to the examination and compression of when using color or power The extensor divides the aspect of the wrist into which tendons. These tendons are examined in their short and then in their long and the latter being performed with flexion and extension of the The tendons can be followed to their sites of insertion when clinically indicated. the transversely transducer distal to the aspect of the ligament, a of symptomatic ligament tears and ganglion that may be evaluated with and without stress The ligaments are not assessed. Specifications of Ultrasound In patients with suspected inflammatory arthritis, the distal if the joints are evaluated from the volar and in both the longitudinal and transverse for effusion, synovial hypertrophy, synovial and bony This of the examination can be as clinically to evaluate the tendons and their for injuries and/or In the of ultrasound can be used to detect fractures that may be associated with tendon to the the ulnar collateral ligament may be evaluated with and without stress Specifications of a Examination Depending on the patient's a transducer may be required to scan the However, the should use the possible that provides The examination is divided into four regions: anterior, medial, lateral, and posterior. Anterior In the a oblique plane to the long axis of the neck is used for evaluating the head and neck and for detecting joint effusion or The should be rotated The and are used to the anterior the tendon and the vessels, and the and tendon When an of anterior is dynamic scanning is performed over the region of interest using the same that the patient as the by flexion and external rotation. This as the tendon over the that the of the muscle and the tendon is more the of a than the tendon snapping over the underlying Lateral In the lateral decubitus position with the symptomatic side transverse and longitudinal of the and should be of the can be performed when assessing for An or muscle that over the can be assessed in this position using dynamic flexion extension of the Medial The is in external with flexion The distal tendon, because of its oblique may be seen in this position. The muscles and their from the are imaged in their long with the in a oblique Short-axis images are obtained perpendicular to this plane. In the bone and the distal and should be evaluated for musculotendinous or Posterior The patient is with the extended. Transverse and longitudinal views of the tendons, and nerve are obtained. The are imaged from their to the and and The nerve is scanned in its short axis at its at the deep to the It can be followed between the tuberosity and the superficial to the The tendons can be assessed in transverse and long axis for the presence of tears and tendinosis. The bursa is not typically seen an effusion or thickening is in the setting of on the examination of the for the Practice Parameter for the Performance of an Ultrasound Examination for Detection and of of the Specifications of a Examination The is assessed for joint fluid or soft tissue and/or local tissue Ultrasound guidance may be requested to evaluate for fluid in the clinical of a possible joint The region of the and is evaluated for fluid collections or tendon such as tendinosis or tear of the or To assess for the anterior, medial, lateral, and posterior structures should be evaluated for joint and fluid collections and soft tissue In patients with symptoms, ultrasound can provide guidance for to assess for possible tendon impingement. Specifications of a Examination The examination of the is divided into four The examination may involve an assessment of one or more of the four regions of the described below or may be limited to a specific anatomic structure, depending on the clinical presentation. Anterior The patient is with the flexed to Longitudinal and transverse of the and tendons, and recess are obtained. A portion of the distal cartilage can be assessed with the transducer in the space in the transverse plane with the in The and deep are also evaluated using to compression of the by the recess may be evaluated for of joint effusion. Medial During the ultrasound examination, the patient with flexion of the and and with external of the The medial collateral ligament, the tendons and and the medial are scanned in both planes. The anterior and of the medial may be identified in this with valgus If pathology is suspected clinically or by imaging with is Alternatively, if there are to MRI, can be Lateral The patient with the The tendon, biceps tendon, collateral ligament, and are The lateral can also be assessed in this position. The joint line is scanned for lateral pathology, with stress as The common nerve can be in the or identified posterior to the biceps tendon and followed as it the Posterior The patient lies with the extended. The muscle, medial and lateral muscles, tendons, and are assessed. To confirm the diagnosis of a cyst, the of the bursa should be visualized between the medial head of the and tendon. In the posterior of both may be evaluated. The insertion of the posterior ligament may be in a oblique plane in this Specifications of an Examination Ultrasound examination of the is divided into four regions (anterior, medial, lateral, and posterior). The examination may involve an assessment of one or more of the four regions described below or be limited to a specific anatomic structure, depending on the clinical presentation. Anterior The anterior extensor tendons are assessed in long-axis and short-axis from their musculotendinous to their distal medial to lateral, this tendon includes the anterior, extensor extensor digitorum and tendons latter being in some The anterior joint recess is scanned for effusion, intra-articular synovial hypertrophy, and The anterior joint is to the anterior margin and the neck of the The cartilage of the as a hypoechoic line bone. Medial The flexor digitorum and flexor longus tendons in this from anterior to are
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