(Ultrasound Review) This retrospective study, published recently in the Journal of Ultrasound in Medicine, evaluates the use of ultrasound in musculoskeletal examinations incorporating interventional procedures.
One hundred and sixty-five patients underwent 195 procedures over an 18-month period at the Radiology and Nuclear Medicine Department, Hospital for Special Surgery, New York City. Fluoroscopy and CT have more commonly been used for musculoskeletal interventional procedures, but with resolution improvements, mobility, and its real-time nature, the use of ultrasound is increasing. Other advantages of ultrasound include its nonionizing nature, making it appropriate for children and pregnant women.
Direct, real-time visualization of the needle enables more accurate placement of medication into the tendon sheath rather than into the tendon itself. Injection into the tendon may lead to tendon degeneration and rupture. Limitations for CT include a lack of real-time imaging and interference by needle artifact that might obscure small regions of interest such as the tendon sheath.
"Ultrasonographically guided interventions included therapeutic injections into tendon sheaths, Morton’s neuromas, plantar fascia, wrist ganglia, and tarsal tunnel cysts; peritendinous hamstring injections; and synovial cyst and muscle biopsies," the authors said.
Procedures were performed using either a 5-13-MHz linear-array probe or a 5-7-MHz curved-array transducer, depending on the depth of the target and the surface anatomy. The authors advocate the use of a free-hand technique and encourage insertion of the needle perpendicular to the ultrasound beam to create a specular reflector that results in strong needle echogenicity and improved visibility.
The authors found power Doppler to be useful in identifying increased blood flow that was suggestive of inflammation or infection, and this finding influenced their decision about how, when, or whether to intervene.
They concluded, "Excluding large-joint aspirations and injections, we found that 180 of the procedures were more readily performed using ultrasonography than any other imaging modality. The ability to document exact needle placement in real time confirms accurate placement of therapeutic injections, fluid aspiration, and soft-tissue biopsies."
"Use of ultrasonographic guidance in interventional musculoskeletal procedures: a review from a single institution"
Carolyn M Sofka et al
Dept of Radiology and Nuclear Medicine, the Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021-4828, USA
J Ultrasound Med (January) 2001; 20:21–26
By Ultrasound Review
April 13, 2001
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Copyright © 2001 AuntMinnie.com
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
