Ultrasound of the Knee

Indications
Musculoskeletal ultrasound (MSUS) of the extremities is considered a first line examination and is performed in conjunction with conventional radiography. The three most common applications for MSUS of the knee are: sport injuries, rheumatologic disorders and periarticular masses.

Sports Injuries
They may be acute or chronic. Clinical symptoms include: Pain Swelling of the joint Joint derangement, with or without locking of the joint MSUS is performed to detect: Joint effusion Ligament, muscle or tendon tear Plica lesions Loose bodies Bursitis

Quadriceps tendon Prefemoral fat pad Suprapatellar recess Suprapatellar fat pad Patella Prepatellar bursa Femoral cartilage Patellar tendon Infrapatellar fat pad Deep intrapatellar bursa Pretibial bursa Skin Fibrous capsule Posterior cruciate ligament Lateral collateral ligament Lateral patellar retinaculum Lateral femoral condyle Popliteal tendon Patella Medial patellar retinaculum Anterior cruciate ligament Medial femoral condyle Medial collateral ligament

Joint space of medial compartment of knee Semimembranosus tendon Pes anserinus (muscle and tendon) Semimembranosus gastrocnemius bursa Medial head of gastrocnemius (muscle and tendon) Posterior cruciate ligament

Biceps femoris muscle Joint space of lateral compartment of knee Plantaris muscle Lateral head of gastrocnemius (muscle and tendon) Joint capsule

Anterior cruciate ligament

Sagittal Midline Knee

Transverse Knee

Interpretation of ultrasound (US) findings in traumatic knees must be correlated with the type of sport activity, the mechanism of injury and in the light of conventional radiography. Although other structures of the knee, such as the menisci, articular cartilages and bones, can be partially evaluated by MSUS, they are not accurately demonstrated by MSUS and need further investigation by CT or MRI.

US is indicated in the following conditions : To confirm and delineate a mass suspected by clinical examination To detect intra-articular mass causing internal derangement of the knee To confirm the cystic nature of a mass To demonstrate complications of surgical procedures in the knee such as hematoma, abscess, seroma or septic arthritis To guide aspiration of the joint itself or to tap periarticular fluid collection or cystic mass The role of MSUS in the evaluation of periarticular masses is important since these lesions cannot be detected by arthroscopy.

Rheumatologic Diseases
Conventional radiography remains the key examination in the diagnosis of arthritis. However, x-rays are limited to the bone and joint space abnormalities. They do not allow a direct visualization of the soft tissue components of the joints, such as the capsule, synovium, tendons, bursae or ligaments. The important roles of MSUS in the diagnosis and management of arthritides are: Detection of joint effusion Guidance of joint aspiration or synovial biopsy To distinguish intra-articular fluid and synovial fluid in bursa or tendon sheath Demonstration of tendon tear Assessment of the degree of synovial hypertrophy

Other Indications
US of the knee can be performed to detect complications (hematoma, abscess, seroma, tumor recurrence) of surgical procedures such as arthrocentesis, arthroscopy, arthrotomy, ACL repair, tumor and cyst resection.

Scanning Technique
The scanning technique should integrate the following considerations: Patient position Transducer position Position of the joint Dynamic maneuver: flexion-extension of the knee and graded compression of articular recess Scanning planes Patient positioning anterior approach The patient is in a supine position The knee is flexed at 15 to 20 degrees A pillow is placed under the knee to immobilize the extremity in this position

Periarticular or Intra-articular Masses

Most masses are found by the patients themselves and are a common reason for consultation. Others are detected during US examination performed for other clinical conditions. Clinical symptoms related to intra - articular masses are: Knee pain Knee effusion Locking or internal derangement of the knee Because clinical examination cannot always detect the presence of a mass, and often fails to confirm the cystic nature of the mass, MSUS is the key examination and helps in deciding on the next type of investigation when needed.

In this position, the following structures are evaluated: Patellar and quadriceps tendons Suprapatellar recess Patellar retinacula Patient positioning posterior approach The patient is in a prone position The knee is extended with both feet hanging over the table In this position, the following structures are evaluated: Popliteal fossa Popliteal vessels and nerves Semimembranosus medial gastrocnemius bursa Patient positioning lateral approach The patient lies in lateral decubitus position, opposite to the knee to be scanned. A pillow should be placed between the knees to stabilize the knee and for patient comfort In this position, the following structures are evaluated: Popliteal and conjoint tendons (biceps femoris tendon and fibular collateral ligament) Iliotibial band Fibular collateral ligament (lateral collateral ligament) Patient positioning medial approach The patient is in supine position and partially tilted towards the affected side The extremity to be scanned should be held in external rotation The hip and knee are in slight external rotation The lateral border of the foot touches the table In this position, the following structures are evaluated: Medial collateral ligament Pes anserina tendons and bursa

Probe placement suprapatellar recess Sagittal scanning of the anterior aspect of the knee The transducer is placed parallel to the long axis of the quadriceps tendon Care must be taken not to excessively compress the recess. Probe placement quadriceps tendon The transducer is placed parallel to the long axis of the thigh over the suprapatellar region and rotated 90 degrees to obtain transverse scans Probe placement patellar tendon The probe is placed in the mid-sagittal plane of the anterior aspect of the knee, between the patella and the tibial tubercle Probe placement medial collateral ligament The probe is placed at the medial aspect of the joint Probe placement lateral collateral ligament/ popliteal tendon The probe is placed on the lateral aspect of the knee joint, bridging the femoral condyle and the fibular head Probe placement iliotibial band The probe is placed at the lateral aspect of the knee The entire band can be demonstrated by real-time examination It can be followed from its iliac origin to the distal insertion on Gerdy's tubercle of the tibia

Sonographic Anatomy
Suprapatellar recess The suprapatellar recess is a thin hypoechoic flat sac. It lies between the suprapatellar and prefemoral fat pads, in the suprapatellar region. Quadriceps tendon The quadriceps muscles are made of four muscles: vastus intermedius vastus medialis vastus lateralis rectus femoris

The tendinous extension of the four muscles merge to form the quadriceps. The quadriceps tendon is a fascicular and hyperechoic band, running deep to the subcutaneous tissues and inserting on the upper pole of the patella. Patellar tendon The patellar tendon is a fascicular hyperechoic band, bridging the patella and the tibial tubercle. The tendon has slightly larger diameters at the patellar insertion. It appears as an ovoid hyperechoic structure on transverse. Medial collateral ligament It originates at the medial femoral condyle and inserts on the medial aspect of the proximal tibia. It is made of two layers. Both layers are hyperechoic flat bands. They are separated by a thin hypoechoic band, representing either a fatty tissue or bursa. Lateral collateral ligament/popliteal tendon The lateral collateral ligament originates at the femoral condyle and inserts distally on the head of the fibula. Before its distal insertion, it merges with the biceps femoris tendon to form the conjoint tendon. The popliteal tendon courses through the posterior horn of the lateral meniscus and inserts in a notch of the lateral femoral condyle, deep to the proximal portion of the lateral collateral ligament. Iliotibial band This band represents the aponeurosis of the tensor fascia lata which arises from the iliac crest and the anterior superior spine of the ilium, and inserts distally on the anterior lateral aspect of the proximal tibia at Gerdys tubercle. It lies immediately under the subcutaneous tissue, and is therefore easy to detect, appearing as a thin fascicular hyperechoic band. Lateral patella retinaculum The patellar retinaculum appears as a hyperechoic band originating from the iliotibial band and the vastus lateralis muscle. It runs obliquely and transversely and inserts on the patella and the patellar tendon, and is composed of two layers.

Medial patella retinaculum Also composed of two layers, it originates from the sartorius and vastus medialis muscles and runs obliquely and transversely, and inserts on the medial aspect of the patella. Posterior cruciate ligament (PCL) Normal PCL appears as a hypoechoic beak-like structure. The low echogenicity is most likely related to anisotropic artifact. The distal portion of the PCL and its bony insertion can be easily demonstrated placing the transducer at midline of the popliteal fossa along the axis of the tibia and then rotating the transducer. Anterior cruciate ligament (ACL) A normal ACL appears as a hyperechoic band. The anterior approach, with the knee flexed more than 90 degrees is used. The transducer is placed at the medial infra-patellar area along the axis of the tibia. The transducer is then rotated 30 degrees counterclockwise for the right knee and 30 degrees clockwise for the left knee. Bursae Medial semimembranosus/gastrocnemius bursa: Its neck lies between these two tendons, at the medial aspect of the popliteal fossa. Suprapatellar bursa or recess: It lies deep to the quadriceps tendon and extends about 6 cm above the patella. It represents the upper extent of the articular cavity. Prepatellar bursa: It is located in the subcutaneous tissue, superficial to the anterior aspect of the patella. Superficial infrapatellar bursa: It is located between the tibial tubercle and the skin. Deep infrapatellar bursa: It is located between the distal patellar tendon and the tibial tubercle. Pes anserina bursa: It is located underneath the semitendinosus, gracilis, and sartorious tendons, which together form the pes anserina tendon. It inserts at the anteromedial aspect of the proximal tibia. Iliotibial bursa: It is located between the distal iliotibial band and the lateral femoral condyle. Fibular collateral ligament/biceps femoris bursa: It is located between the anterior arm of the long head of the biceps femoris and the fibular collateral ligament.

This longitudinal image demonstrates the normal appearance of the proximal patellar tendon.

Transverse scan of the medial retinaculum originating from the patella and extending medially.

On this longitudinal image, the suprapatellar bursa is seen between the two fat pads. Also the quadriceps tendon is seen inserting on the superior border of the patella.

Transverse view of the medial popliteal fossa demonstrating the semimembranosus/gastrocnemius bursa (B). MG: medial gastrocnemius muscle, SM: semimembranosus tendon.

This longitudinal image shows the medial collateral ligament (MCL) at the level of the medial meniscus.

Transverse view of the medial popliteal fossa demonstrates a large bakers cyst which is an abnormal dilation of the semimembranosus/gastrocnemius bursa.

This longitudinal image displays the lateral collateral ligament (LCL) at the level of the lateral meniscus.

This longitudinal scan shows the insertion of the iliotibial band to Gerdys tubercle of the tibia.

This longitudinal image shows acute fusiform patellar tendinitis.

Acutely swollen medial collateral ligament (MCL) is seen above the level of the medial meniscus.

REFERENCES 1. van Holsbeeck M, Introcaso JH. Musculoskeletal Ultrasound. Mosby-Year Book, St. Louis, 1991. 2. Chhem R K, Cardinal E. Musculoskeletal Ultrasound. Guidelines and Gamuts, New York, J Wiley & Sons Publishers, 1999. 3. Starok M, Lenchik L, Trudell D, Resnick D: Normal Patellar Retinaculum. MR and Sonographic Imaging with Cadaveric Correlation. AJR 168 (6): 1493-1499, 1997. 4. Richardson ML, Selby B, Montana MA, Mack LA. Ultrasonography of the Knee. Radiologic Clinics of North America 26 (1): 63-75, 1988. 5. Suzuki S, Kasahara K, Futami T et al. Ultrasound diagnosis of pathology of the anterior and posterior cruciate ligaments of the knee joints. Archives Orthopedic & Trauma Surgery 110 (4): 200 -203, 1997. CLINICAL SOURCES Rethy K Chhem, MD, PhD Toronto, Ontario, Canada Jag Dhanju, RT (R) RDMS Toronto, Ontario, Canada

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