This document provides definitions and ultrasound imaging appearances of common musculoskeletal abnormalities including: 1. Joint effusion seen as anechoic intraarticular fluid. 2. Synovial hypertrophy seen as non-displaceable hypoechoic tissue that may exhibit Doppler signals, indicating inflammation. 3. Tendon lesions like tenosynovitis seen as hypoechoic synovial sheath widening and tendinitis seen as hypoechoic and thickened tendons. 4. Enthesopathy seen as hypoechoic tendon attachments to bone that may have Doppler signals and bony changes. 5. Bursitis seen as abnormally distended anechoic or hypoechoic

1. Basic musculoskeletal ultrasound abnormalities:
definitions and appearance
Dr. Kai-Len Tsai M.D
Attending Physician, Taipei Medical University Hospital

2. Learning Objective
• To detect, assess and score synovial, tenosynovial
and entheseal inflammatory activity
• To detect, assess and score structural joint
damage(i.e. bone, tendons, cartilage

3. outline
1. Joint effusion
2. Synovial hypertrophy,
3. Tenosynovitis,
4. Enthesopathy, enthesitis,
5. Bursitis,
6. Bone abnormalities,
7. Cartilage lesions

4. 1. Joint effusion 關節積液
• Synovial Fluid
• Abnormal hypoechoic or anechoic (relative to
subdermal fat, but sometimes may be isoechoic or
hyperechoic) intraarticular material that is
displaceable and compressible, but does not exhibit
Doppler signals
Anechoic 無回音
Hypoechoic 低回音
Isoechoic 同回音
Hyperechoic 高回音

5. 髖關節HIP joint
膝關節Knee
Joint effusion
關節積液
肩關節shoulder 肩唇
蹠骨關節MTP joint
腕關節Wrist joint
肘關節Elbow 踝關節Ankle joint

6. dorsal osteophytes of PIP joint
A small quantity of fluid can be
present in the normal
Long-axis view of the 2nd PIP joint flexor aspect. joint (arrow).

7. Grey scale scoring of joint effusion and
synovial hypertrophy
• Semi-quantitative scoring system
• Grade 0: No effusion
• Grade 1: Minimal amount of joint effusion
• Grade 2: Moderate amount of joint effusion[little
distension of the joint capsule]
• Grade 3: Extensive amount of joint effusion[with
high distension of the joint capsule]
J Rheumatol. 2005 Dec;32(12):2485-7.

8. Grade 1
Grade 0
Grade 2
Grade 3
Joint effusion grading

9. 2. Synovial hypertrophy
滑膜增生
• Abnormal hypoechoic (relative to subdermal fat, but
sometimes may be isoechoic or hyperechoic)
intraarticular tissue that is non-displaceable and
poorly compressible and which may exhibit Doppler
signals

10. 腕關節Wrist joint
踝關節Ankle joint
膝關節Knee joint 蹠骨關節MTP joint

11. Synovial hypertrophy &
Doppler ultrasonography
• Doppler ultrasonography:
• Is able to visualize blood flow by the change in frequency
of sound waves reflected by moving objects(termed the
Doppler shift), such as the cells inside blood vessels)
• CDUS technique is affected by the direction of blood flow,
whereas the images obtained by PDUS are not direction-coded(
able to detect a very slow blood flow rate, which is
typical for inflamed joints and tendon areas is patients
with RA

12. Active or inactive
• In the detection of highly vascularized pannus tissue,
which indicates active inflamed joints and tendons,
and furthermore, in the differentiation of active and
inactive RA.

14. Scoring system
• Inflammatory or active synovial
hypertorphy(greyscale scoring)
• Grade 0 :No hypoechoic synovial thickening
• Grade 1 :Minimal hypoechoic synovial thickening(filling
the angle between the periarticular bones, without
bulging over the line linking tops of the bones)
• Grade 2 : Hypoechoic synovial thickening bulging over
the line linking tops of the periarticular bones but
without extension along the bone diaphysis
• Grade 4 : Hypoechoic synovial thickening bulging over
the line linking tops of the periarticular bones and with
extension to at least one of the bone diaphses

15. GSUS semiquantitatively
0 . absence, 1 . mild,
3 . Severe synovitis.
2 . moderate,
Grade 1 describes a small hypoechoic/anechoic line
beneath the joint capsule.
Grade 3 characterizes a strong
distension of the joint capsule
Grade 2, the joint capsule is
elevated parallel to the joint area.

16. 掌指關節MCP joint

17. 腕關節Wrist

18. 掌指關節，腹面

19. OMERACT-EULAR PDUS
composite scoring of synovitis
• Grade 0 (normal) : no synovial hypertrophy, no Doppler
signals
• Grade 1 : minimal synovitis, minimal synovial hypertrophy,
with (or without) no more than grade 1 Doppler signal
• Grade 2: moderate synovitis
• Moderate synovial hypertrophy with or without no more than
grade 2 Doppler signal
• Minimal synovial hypertrophy and grade 2 Doppler signals
• Grade 3: Severe synovitis
• Severe synovial hypertrophy with or without Doppler signal
• Minimal/moderate synovial hypertrophy and grade 3 Doppler
signal

20. 掌指關節MCP joint

22. 請問現在您區分出關節積水和滑膜增
生的區域嗎?
*

23. 請問您對這關節的
power Doppler
signals 評幾分?
Grading?

24. 3. Tendon lesions 肌腱
• Tenosynovitis 肌腱滑膜炎
• hypoechoic or anechoic synovial sheath widening or
thickening(effusion),
• tendon thickness
• peritendinous ± intra-tendinous PD or CD Doppler
signal
• Tendinitis 肌腱炎
• Tendon rupture

25. Normal biceps tendon
Target sign

27. Tenosynovitis (RA patient)

28. Tenosynovitis (Gouty arthritis)

29. Ankle joint lateral view
Peroneal tendon tenosynovitis
A RA patient

30. Trigger finger

31. Tendinitis (Achilles tendon，沒有sheath!
Tenosynovitis

32. Tendinitis
Achilles tendon
Ankylosing spondylitis

34. Calcification tendinitis

36. Tenosynovitis scoring
• Scoring Doppler in tenosynovitis
• Grade 0 : No peri-tendinous signals
• Grade 1 : Focal pen-tendinous signals
• Grade 2 : Multifocal peri-teninous signals
• Grade 3 : Diffuse peri-tendinous signals

38. 4. Enthesopathy, enthesitis
著骨點病變，附骨點病變
• Abnormally hypoechoic (loss of normal fibrillar
architectur) and/or thickened tendon or ligament at
its bony attachment (may occasionally contain
hyperechoic foci consistent with calcification), seen
in 2 perpendicular planes that may exhibit Doppler
signals and /or bony changes, including
enthesophytes, erosion, or irregularity)

39. Achilles tendon

40. These two pictures are both belonging to one AS patient
with left heel pain. Which is left one?

41. Knee deep infrapatellar bursa

42. 5. Bursitis 滑囊炎
Bursitis is the inflammation of one or more
bursae (small sacs) of synovial fluid in the body.
1. Shoulder bursa
• subacromnal-subdeltoid bursa: At ultrasound it appears as a
very thin uniform, 1to 2 mm hypoechoic layer of synovial fluid
surrounded by hyperchoic bursal wall and peribursal fat layers.
• Abnormal distention of the SASD bursa may appear anechoic
or hypoechoic from simple fluid, or it may range from
hypoechoic to hyperechoic as a result of complex fluid or
synovial hypertrophy.

43. Supraspinatus tendon
Subdeltoid bursa

44. Subdeltoid bursitis
normal

45. Gouty arthritis patient
類風濕結節not bursa !
Olecranon bursa

46. hemorrhagic bursitis of great trochanter

47. Patellar bone
Patellar bone
normal
Knee bursa

48. Baker’s cyst

49. Baker’s cyst rupture

50. 6. Bone abnormalities
• Bone erosion
• An intra-articular discontinuity of the bone surface that
is visible in 2 perpendicular phanes
• Osteophytes
• Cortical protrusion seen in two planes

52. Semiquantitative scoring system of bone erosion
• metacarpophalangeal (MCP) joints
• normal: <2 mm;
• small erosion: 2 mm;
• moderate erosion: >2–<4 mm;
• large erosion: ≥4 mm.

53. Scoring
erosion
• 2nd MCP joint dorsal views
• 0: no ersion
• 1: <1mm
• 2: 1~2mm
• 3: 2~4mm
• 4: >4 mm
Rheumatology 2004;43:829–838

54. Bone erosion
normal

55. Osteophyte

56. 7. Cartilage lesions
• Cartilage pathology
• Thining
• Loss of hypo-eccogenisity
• Total disappearance
• Crystal disease
• Double contour sign
• Intracartilage calcification
normal

57. Not double contour sign
double contour sign
Crystal disease
Double contour sign
Intracartilage calcification
Rheumatology (Oxford) July 1, 2007 vol. 46 no. 7 1116-1121

58. 請問你看到什麼?