EQUINE PRACTICE Ultrasonography is becoming

an essential part of the

diagnostic work-up in horses
with musculoskeletal disease

Diagnostic ultrasound of the

limb joints, muscle and bone
in horses MATTHEW SMITH AND ROGER SMITH

DIAGNOSTIC ultrasonography for the musculoskeletal system in the horse was first used in the early
1980s. Initial applications were directed towards the diagnosis of flexor tendon and ligament injuries
in the distal limb, but this modality is now commonly indicated for the assessment of the stifle, hock,
fetlock, carpus, pastern and coffin joints. This article describes the use of diagnostic ultrasound in
horses to examine these joints, as well as muscle and bone, outlining normal versus pathological
findings in each case. While this imaging technique may also be employed to examine the shoulder,
hip, cervical facet and temporomandibular joints, the indications are less frequent and, hence, are
Matthew Smith
graduated from the not discussed in this article. In all cases, knowledge of the normal anatomy is essential in obtaining
Royal Veterinary diagnostically useful images and aiding interpretation.
College (RVC) in
2001. He is a hospital
surgeon at Reynolds
House Referrals in JOINTS to their insertion. The probe must be positioned per-
Newmarket. He holds pendicular (transverse) or parallel (longitudinal) to the
the RCVS certificate
in equine surgery Soft tissue injuries of joints are common, occurring either ligament’s long axis. The collateral ligaments are sub-
(orthopaedics) together with osseous pathology or alone. While arthro- synovial and merge with the uniformly echogenic fibrous
and the European
College of Veterinary scopic examination of joints is routine in the horse and is joint capsule. The synovial membrane is a thin echogenic
Surgeons (ECVS) the gold standard for diagnosing intra-articular pathology, structure, which, in some areas, has synovial villi pro-
diploma in large
animal surgery. He is
ultrasound in conjunction with radiography maximises jecting into the joint as floating echogenic strands in the
an ECVS recognised the diagnostic information that can be obtained non- synovial fluid. Chronic synovitis may result in thicken-
specialist in large
invasively. Arthroscopy can help the clinician to deter- ing of the synovial membrane and joint capsule. A small
animal surgery.
mine therapeutic options, but preoperative diagnostic amount of anechoic joint fluid is normal, but not always
ultrasound may indicate the need to modify the surgical visible. Synovial inflammation will result in an increased
approach, identify animals with a poor prognosis or be volume of fluid, which may contain echogenic debris
able to assess areas that are not visible arthroscopically. (fibrin/adhesions).
The articular cartilage can be readily examined over-
GENERAL APPROACH lying the smooth surface of the subchondral bone, and
The general approach to ultrasonography of all joints should be anechoic.
Roger Smith is similar, regardless of the specific joint to be exam-
graduated from ined. Clipping, degreasing of the skin and application of STIFLE
Cambridge in 1987.
He is professor of coupling gel is routine, and usually necessary to obtain Normal
equine orthopaedics a diagnostic image. Most joints in the equine limb are The cranial aspect of the stifle is best examined with a
at the RVC. He
holds the RCVS superficial, making them amenable to ultrasonographic 5 to 10 MHz linear probe, but a lower frequency (3 MHz)
diploma in equine evaluation. A high frequency (eg, 7·5 to 10 MHz) linear sector or curvilinear probe is required for the caudal
orthopaedics, and
is both a diplomate
array probe is normally suitable to provide high quality aspect. In the weightbearing horse, the patellar ligaments,
of the ECVS and an sonograms, although deeper areas, such as the caudal collateral ligaments, menisci, and femoropatellar and
RCVS specialist in aspect of the stifle, may require the use of lower frequen- femorotibial joints can all be imaged to varying degrees.
equine surgery. He
currently divides cy transducers. Curved array or microconvex transducers The cruciate ligaments are only visible with the stifle
his time between can be useful for imaging structures that are oblique to the flexed (Cauvin and others 1996), and obtaining diagnos-
running a specialist
orthopaedic service skin or to broaden the field of view in large areas. tic images and image interpretation is not easy.
within the RVC and Significant traumatic injury to a joint may result in The medial, middle and lateral patellar ligaments
continuing to direct
research into equine
disruption of the collateral ligaments, and these should can be imaged subcutaneously from their origin on the
tendon disease. be examined medially and laterally from their origin patella and parapatellar fibrocartilage (medial patellar

In Practice (2008) 152 In Practice ● MARCH 20 08

30, 152-159
 (left) Positioning of the ultrasound probe for imaging
of the middle patellar ligament. Transverse (above) and
longitudinal (below) images showing the normal middle
patellar ligament. ITG Intertrochlear groove, FP Fat pad,
P Patella

ligament) to their insertions on the tibial tuberosity. They

are uniformly echogenic structures with a parallel fibre
pattern visible on sagittal images. A large heterogene-
ously echogenic fat pad separates the patellar ligaments
proximally from the femoropatellar joint, but as they
course distally they become subsynovial. The middle
patellar ligament has the largest cross-section, whereas
the medial and lateral ligaments are of similar size. The
articular surfaces of the medial and lateral femoral tro-
chleae (and the intertrochlear groove) can be visualised
between the middle and medial, and middle and lateral,
patellar ligaments, respectively. The medial trochlea is
wider than the lateral on a transverse image. The articu- lar structures with their apex axially. They can be visu-
lar cartilage is visible as an anechoic band between the alised deep to, and cranial and caudal to, the collateral
synovial membrane cranially, and the subchondral bone ligaments. The cranial horns and cranial ligaments are
caudally. The latter is seen as a smooth, regular hyper- visible with the stifle flexed and the probe positioned
echoic line, with acoustic shadowing deeper. The carti- between the middle and medial, and middle and lateral,
lage of the lateral trochlea is normally thicker than that patellar ligaments, respectively, although this is diffi-
of the medial. cult. The articular surfaces of the femoral condyles can
The menisci are most easily imaged in the longitudi- be imaged proximal to the menisci, in both the cranial
nal plane and seen as homogeneously echogenic triangu- and caudal aspects of the stifle. The articular cartilage

Transverse image of the medial (left) and lateral (right) femoral trochleae. The medial trochlear ridge (MTR) is wider than
the lateral trochlear ridge (LTR), but the cartilage (C) of the latter is thicker. FP Fat pad

In Practice ● MARCH 20 08 153


(above) Positioning of the ultrasound probe for imaging of
the lateral meniscus. (right) Schematic diagram showing the
planes for imaging the medial collateral ligament (i) and
the medial meniscus (MM) (ii). (below) Longitudinal image
of the normal medial meniscus just cranial to the medial
collateral ligament. MPL Medial patellar ligament,
MFC Medial femoral condyle, MTC Medial tibial condyle
is a smooth, thin, anechoic band immediately superficial
to the hyperechoic subchondral bone.
The femorotibial collateral ligaments are readily
imaged from their respective origins on the medial and
lateral femoral epicondyles to their insertions on the
medial condyle of the tibia (medial collateral ligament)
and the head of the fibula (lateral collateral ligament).
The structures are uniformly echogenic, and have a par-
allel fibre pattern when the probe is orientated longitudi-
nally. A small amount of anechoic fluid is usually visible
in the medial femorotibial joint over the medial aspect of
the medial condyle when the probe is positioned between
the medial collateral and medial patellar ligaments. The
Longitudinal image showing
a large tear (T) in the medial
meniscus represented
ultrasonographically as a
hypoechoic split. MFC Medial
femoral condyle, MTC Medial
tibial condyle
154
MPL
ii
MM
lateral femorotibial joint can be imaged in a similar loca-
tion laterally, although little or no fluid is seen in a non-
distended joint. The origin of the popliteus muscle can
be identified deep to the lateral collateral ligament, and
the combined origin of the long digital extensor muscle
and peroneus tertius is cranial to it.
Stifle pathology
Soft tissue injuries to the stifle are relatively common,
including, in decreasing frequency of occurrence, the
menisci and their cranial ligaments (medial more often
than lateral), the cruciate ligaments (the cranial ligament
is most frequently affected) and the collateral ligaments
(medial usually).
Longitudinal image of the lateral femoral trochlea (LTR)
in a horse with osteochondrosis. There is a break in the
normal smooth surface of the subchondral bone due to
a discrete osteochondral fragment (OC). C Cartilage
In Practice ● MARCH 20 08
 Despite advances in the knowledge of the ultrasono-
graphic anatomy of the stifle, arthroscopy remains the
gold standard technique for the diagnosis of intra-articu-
lar lesions (Barr and others 2005). Ultrasound is most
useful for diagnosing meniscal injuries, but lesions are
not always identifiable, particularly when limited to their
cranial ligament(s). Neither ultrasonographic nor arthro-
scopic examination enable comprehensive evaluation of
the entire menisci, and the portions that lie between the
tibial and femoral condyles cannot be examined by either
technique. The medial and lateral portions deep to the
collateral ligaments are visible ultrasonographically but
not arthroscopically. However, arthroscopy is more sen-
sitive and may detect lesions not seen using ultrasonog-
raphy, particularly other common (concurrent) pathology
of the articular cartilage and cruciate ligaments.
Ultrasound has also been used to diagnose popliteal
tendonitis, and is valuable in assessing the degree of
patellar ligament involvement in tibial tuberosity frac-
tures. Osteochondrosis is an important cause of stifle
lameness in young horses, and although usually diag-
nosed radiographically, ultrasound can identify some
cases of radiographically silent disease.
HOCK
Normal
The hock is best examined with a high frequency (eg,
10 MHz) linear array probe with a stand-off pad. The
collateral ligaments present medially and laterally are
composed of both long and short components at each
aspect. The long collateral ligaments arise from the
medial and lateral malleoli of the tibia, traverse the
tarsocrural joint distally in a straight direction, and
insert on the tarsus and proximal metatarsus. The short
collateral ligaments are situated deeper than the long
ones, and originate further cranially on their respective
malleoli. They are directed plantarodistally, and each
consists of three fasciculi inserting on the calcaneus and
talus. Due to their differing orientations, each collateral
ligament requires imaging in a separate plane.
Enthesiophyte formation often occurs with desmitis and
can be detected both radiographically and ultrasono-
graphically as roughening to the bony surface. Avulsion
fractures are sometimes recognised at the origin or inser-
tion of the ligaments, and ultrasonography confirms their
association.
The progress of tarsal bone ossification in foals with
incompletely ossified cuboidal bones can be moni-
tored ultrasonographically. As ossification progresses,
the bony surfaces of the small tarsal bones gradually
become visible surrounded by cartilage. Although more
equipment is required, radiography is more useful, and
can identify cuboid bone collapse.
FETLOCK
Normal
The fetlock joint should also be examined with a high
frequency (eg, 10 MHz) linear array probe using a stand-
off pad. From the dorsal aspect of the joint, the joint
capsule and synovial membrane, dorsal synovial pad,
cartilage and subchondral bone of the third metacarpus/
metatarsus can be imaged. The common/long digital
extensor tendon is visible overlying the joint. The outline
of the subchondral bone should be smooth, and the dor-
i
ii
iii

Hock pathology
Acute collateral desmitis is characterised by enlarge-
ment of the affected ligament(s), a generalised decrease
in echogenicity and disruption to the normal long-fibre
pattern. Core lesions are also seen occasionally and
periligamentar swelling is common. In cases of chronic
desmitis, there may be a heterogeneous increase in echo-
genicity of the affected ligaments. Tarsocrural distension Schematic diagram showing the planes for imaging the
long and short medial collateral ligaments of the tarsus.
may accompany desmitis, and either an intra-articular Long (i) and short (ii) talien fasciculus, short calcanean
component or tarsal instability should be considered. fasciculus (iii)

Longitudinal images of the lateral collateral ligaments of the tarsus. (left) Long collateral ligament (LCL). (middle) Short collateral ligament (SCL).
(right) The SCL is enlarged with a loss of parallel fibre pattern, and there is disruption of the surface of the talus. T Tibia

In Practice ● MARCH 20 08 155


(above) Longitudinal image of the dorsal aspect of the
normal metacarpophalangeal joint. (below) There is
an increase in anechoic fluid in the joint. MC3 Third
metacarpal bone, P1 Proximal phalanx, C Joint capsule,
S Dorsal synovial pad
sal synovial pad should be less than 5 mm thick. Medial
and lateral examination allows visualisation of the collat-
eral ligaments from their origins on the third metacarpal/
metatarsal bone to their insertions on the proximal
phalanx and the abaxial surface of the proximal sesam-
oid bones. These ligaments consist of a long superficial
layer and a short deeper layer. The latter runs obliquely
palmarodistally and therefore should be examined in a
separate plane from the superficial layer to obtain an on-
incidence image. Both layers are uniformly echogenic,
with a parallel fibre pattern. The palmar/plantar pouches
can be imaged at this aspect of the joint, where a small
amount of anechoic fluid is normally visible containing
free-floating echogenic strands, which represent the vil-
lous synovium in this location. The branches of the sus-
pensory ligament are subsynovial medially and laterally,
and proximal to the proximal sesamoid bones at this
aspect of the joint.
Longitudinal image of the carpus showing (left) the dorsal carpus. (middle) Transverse image of the normal dorsal intercarpal ligament between the
second (C2) and third (C3) carpal bones. (right) Transverse image showing disruption of the dorsal intercarpal ligament following a carpal destabilising
injury. ECR Extensor carpi radialis tendon, FP Fat pad, R Radius
156
Fetlock pathology
Proliferation of the synovial pad may be recognised dor-
sally as a hypoechogenic or echogenic layer measuring
more than 5 mm (Steyn and others 1989). Capsular thick-
ening, due to a capsulitis, and synovial fluid distension
may also be seen. Changes in the outline of the subchon-
dral bone due to osteophyte formation or osteochondral
fragmentation (traumatic or developmental) may also be
recognised, but radiography is a more useful technique
in most cases. Collateral desmitis is characterised by an
enlargement of the affected ligaments, with decreased
echogenicity and a loss of normal fibre pattern.
CARPUS
Normal
The dorsal aspect of the carpus is traversed by the exten-
sor tendons, namely, the extensor carpi radialis, the com-
mon digital extensor and the extensor carpi obliquus.
The lateral digital extensor is located further laterally
and passes distally in a canal within the lateral collat-
eral ligament. As they traverse the carpus, they are all
invested in synovial sheaths. The dorsal synovial out-
pouchings of the radiocarpal and middle carpal joints
are visible between, and deeper than, the extensor carpi
radialis and common digital extensor tendons, as are the
dorsal surfaces of the carpal bones. A fat pad is present
in the joint capsule of the radiocarpal joint; in longitu-
dinal images, this appears as a triangular-shaped, rela-
tively hypoechogenic structure when compared with the
adjacent tendons. Medially and laterally, the collateral
ligaments of the carpus can be imaged from their ori-
gins on the medial and lateral (ulnar) styloid processes
to their respective insertions on the second and third,
and third and fourth, metacarpal bones. Each ligament
has deep, short fasciculi that attach to the carpal bones.
The collateral ligaments are homogeneously echogenic
structures with a parallel long-fibre pattern. As with the
tarsus and fetlock, the deep and superficial components
require imaging in separate planes.
The palmar intercarpal ligaments can be visualised
between the carpal bones; imaging of these structures
requires the carpus to be flexed. The ultrasonographic
appearance of the medial palmar intercarpal ligament
has been described (Driver and others 2004). This liga-
ment is viewed deep to the extensor carpi radialis tendon,
between the second and third carpal bones in transverse
images, and between the third and radial carpal bones in
longitudinal images. The ligament appears homogene-
ously echogenic, with a granular texture, and has clearly
defined margins.
In Practice ● MARCH 20 08

Transverse image of the normal medial palmar
intercarpal ligament. C2 Second carpal bone,
C3 Third carpal bone
Carpus pathology
Collateral desmitis results in enlargement of the affected
ligament(s), with associated disruption of the long-fibre
pattern and a corresponding reduction in echogenic-
ity. When severe and associated with carpal instability,
disruption to the dorsal carpal ligaments may also be
seen ultrasonographically. Chronic desmitis often results
in enthesious new bone formation, which appears ultra-
sonographically as roughening of the normally smooth
outline of the bony attachment.
Lateral aspect of a dissected foot. The lateral collateral
ligament is delineated by needles placed at its dorsal
and palmar borders
(left) Transverse image of the normal lateral collateral ligament (CL) of the distal interphalangeal joint. (right) Enlarged
and heterogeneous medial collateral ligament of the distal interphalangeal joint. P2 Middle phalanx
In Practice ● MARCH 20 08
Injury to the medial palmar intercarpal ligament
occurs most frequently in racing thoroughbreds and can
be recognised as enlargement of the affected ligament
relative to the contralateral limb, with disruption to the
normal smoothly defined margins (A. J. Driver, personal
communication). However, injury to this structure is bet-
ter defined arthroscopically, where its full extent can be
determined by probing of the ligament.
PASTERN JOINT
The collateral ligaments of the proximal interphalan-
geal joint can be imaged as homogeneously echogenic
structures with a parallel long-fibre pattern, from their
origins on the medial and lateral epicondyles of the dis-
tal proximal phalanx to their insertions on the proximal
middle phalanx. Injury to these ligaments can be seen as
an increase in ligament size, a reduction in echogenicity
and a disruption of the long-fibre pattern. Occasionally,
collateral ligament avulsion fractures may be seen. The
palmar ligaments of the proximal interphalangeal joint
can also be identified, and clinical injury to these has
been demonstrated ultrasonographically.
COFFIN JOINT
Only the proximal third of the collateral ligaments of
the distal interphalangeal joint can be imaged ultrasono-
graphically because the distal two-thirds lie beneath the
hoof capsule. The ligaments are best imaged with a high
frequency (eg, 10 MHz) linear array transducer, and can
be examined in both transverse and longitudinal planes.
They are homogeneously echogenic structures lying with-
Positioning of the ultrasound probe to image the
collateral ligament
157
 (left) Transverse image of
the normal ulnaris lateralis
muscle (M) and its tendon
of insertion (T). (right) The
ulnaris lateralis has avulsed
from its origin and the muscle
is enlarged with a generalised
increase in echogenicity due
to muscle oedema and/or
haemorrhage

in the dorsomedial and dorsolateral depressions in the mal muscle striations and an overall increase in muscle
distal surface of the middle phalanx. Images should be echogenicity.
interpreted with care, as central hypoechoic artefacts are Although uncommon, neoplasia has been reported
relatively easy to create by moving slightly off incidence. and should be considered in cases with focal progressive
Enlargement of the ligament is invariably associ- swelling, and is seen ultrasonographically as a disrup-
ated with injury in its proximal third, and this is readily tion of the normal striated appearance.
demonstrable by comparing it with the contralateral lig-
ament. Injury also results in a heterogeneous echogenic-
ity with disruption to the parallel fibre pattern. Desmitis BONE
is frequently confined to within the hoof capsule
(Dyson and others 2004) and is therefore undetectable Normal cortical bone produces a characteristic strong
ultrasonographically. reflection of the ultrasound beam, and has a smooth out-
line that is occasionally disrupted by normal bony pro-
tuberances. The normality of such discontinuities can
MUSCLE be differentiated from fractures by scanning the contra-
lateral limb.
NORMAL Ultrasound is extremely useful in diagnosing fractures
Normal muscle has a striated appearance, in which in areas of the equine skeleton not amenable to radiograph-
primary hypoechoic muscle fibres are interspersed with
more echogenic fascia, connective tissue and fat. Each
muscle has a characteristic appearance based on the
amount of connective tissue present within the muscle
belly. When the horse does not bear weight on the limb
being examined, the muscle appears more echogenic
due to closer packing of muscle fasciculi. Therefore,
muscular ultrasonography should be performed with
the limb bearing weight. Examination of the contralat-
eral limb is recommended to provide a normal reference
image.

MUSCLE PATHOLOGY
The majority of muscular pathology (eg, myositis, neuro-
genic atrophy) is not associated with ultrasonographic
changes. However, muscular strain results in fibre dis-
ruption and an associated accumulation of loculated
anechoic areas of fluid or haemorrhage. Identification
of the affected muscle is achieved by following it from
its origin to its insertion. Muscle strains are frequently
associated with localised clinical signs, but ultrasound
may be of particular use to detect partial tears in deeper
muscles where clinical signs are less obvious. In chronic
injuries, fibrosis will be seen as areas of heterogeneous
or increased echogenicity.
Muscle oedema may occur following traumatic injury
or in association with postanaesthetic myopathy. This Appearance of a haematoma (H) in the gluteal muscle
can be seen ultrasonographically as a loss of the nor- following a tear

158 In Practice ● MARCH 20 08


(left) Positioning of the ultrasound probe for imaging the iliac wing. (right) Schematic diagram showing the planes for
imaging the iliac wing (i to iii) and the shaft of the pelvis (iv)
Ultrasonographic images of (left) the normal iliac wing (I) and (right) a fractured iliac wing, which shows a break in the
continuity of the surface of the bone (arrow). The overlying gluteal musculature (G) is hypoechoic where haemorrhage
has occurred
ic examination in the standing patient, such as the pelvis,
ribs and scapula. A displaced fracture is recognised as a
break in the normal continuity of the bone. Non-displaced
chronic fractures may be identified by the formation of a
periosteal callus associated with the fracture site.
PELVIS
Ultrasound is used in conjunction with nuclear scin-
tigraphy to diagnose pelvic fractures in the horse. The
wing of the ilium is the most frequent site of fracture
(Hendrickson 2002) and often occurs in racing thor-
oughbreds as a stress fracture. The shaft of the ilium is
also a commonly affected site.
The pelvis is best examined with a 5 MHz convex or
microconvex array transducer. The normal iliac wing
is imaged in the transverse plane as a smooth concave
hyperechoic line from the sacral tuber extending to the
ipsilateral tuber coxae, and appears bilaterally symmet-
rical. Rotating the probe by 90° into the sagittal plane
allows examination of the iliac shaft. Again, the surface
of the bone is smooth and can be traced from the iliac
wing to the acetabulum. Numerous blood vessels are
present in the overlying musculature and these can pro-
duce acoustic shadowing and refraction artefact, which
must not be confused with a fracture.
Acute iliac wing fractures may have a clear fracture
gap present ultrasonographically. Due to their aetiology
(stress remodelling), a callus is frequently associated
with the fracture. The overlying musculature may have
an area of decreased echogenicity representing haemor-
rhage at this site.
In Practice ● MARCH 20 08
i
ii
iii
iv
SUMMARY
The past 25 years has seen a vast improvement in the
quality of images attainable ultrasonographically, and
many portable machines available in practice can pro-
duce diagnostic images. This, together with published
literature documenting normal and abnormal ultra-
sonographic findings, has led to this imaging modal-
ity becoming an important part of the work-up in many
horses with musculoskeletal disease. Experience using
the technology, and knowledge of the normal anatomy
and common artefacts are, however, essential to obtain-
ing diagnostically useful images and their interpretation.
References
BARR, E. D., PINCHBECK, G. L., CLEGG, P. D. & SINGER, E. R. (2005) Comparison of diagnostic
techniques used in investigation of stifle lameness in horses – 40 cases. In Proceedings of the 14th
Annual Scientific Meeting of the European College of Veterinary Surgeons. Lyon, France. July 7 to 9.
pp 41-43
CAUVIN, E. R. J., MUNROE, G. A., BOYD, J. S. & PATERSON, C. (1996) Ultrasonographic examination of
the femorotibial articulation in horses: imaging of the cranial and caudal aspects. Equine Veterinary
Journal 28, 285-296
DRIVER, A. J., BARR, F. J., FULLER, C. J. & BARR, A. R. S. (2004) Ultrasonography of the medial palmar
intercarpal ligament in the thoroughbred: technique and normal appearance. Equine Veterinary
Journal 36, 402-408
DYSON, S. D., MURRAY, R., SCHRAMME, M. & BRANCH, M. (2004) Collateral desmitis of the distal
interphalangeal joint in 18 horses (2001-2002). Equine Veterinary Journal 36, 160-166
HENDRICKSON, D. (2002) The pelvis. In Adams’ Lameness in Horses, 5th edn. Ed T. S. Stashak.
Philadelphia, Lippincott Williams & Wilkins. pp 1044-1053
STEYN, P. F., SCHMITZ, D., WATKINS, J. & HOFFMAN, J. (1989) The sonographic diagnosis of chronic
proliferative synovitis in the metacarpophalangeal joint of a horse. Veterinary Radiology 30, 125-127
Further reading
DENOIX, J. M. (2003) Ultrasonographic examination of joints. In Diagnosis and Management of
Lameness in the Horse. Eds M. W. Ross and S. J. Dyson. Philadelphia, W. B. Saunders. pp 189-139
REEF, V. B. (Ed) (1998) Musculoskeletal ultrasonography. In Equine Diagnostic Ultrasound.
Philadelphia, W. B. Saunders. pp 39-186
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