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Musculoskeletal Sports Ultrasound
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Calan Sowa, MD1,2,3 and Scott Annett, MD1,2,3
Traditionally, musculoskeletal (MSK) injuries in sports med-
icine have been evaluated using magnetic resonance imaging
(MRI). With recent improvements in ultrasound technology, it is
becoming more common for initial evaluation of MSK injury to
be made using clinic or sideline-based ultrasound units. A targeted
examination can be particularly beneficial to help confirm a
suspected diagnosis. Here, we discuss the benefits and utility of
ultrasound imaging in the evaluation of sports-related injury.
Benefits
Compared with MRI, ultrasound units are more portable,
significantly cheaper, and faster when evaluating MSK injury.
With the advent of handheld ultrasound technology, point-of-
care evaluation can take place in clinic, the training room, or
on the sideline. Using high-frequency linear transducers, ultra-
sound produces high-resolution images of superficial soft tis-
sue structures, including muscles, tendons, ligaments, and bursae
(1). Even fractures can be visualized with a disruption of the
echogenic outline of the bone. Ultrasound evaluations pose
no added risk from radiation exposure while having reliable
diagnostic capabilities. They also offer the ability to assess
dynamic injuries, such as peroneal tendon subluxation.
Limitations include difficulty visualizing intra-articular and
deep soft tissue structures, as well as having a limited field of view.
Evaluation of Muscle and Tendon
Because nearly 30% of sports injuries occur in the muscles,
ultrasound is an extremely useful imaging modality (2). Muscular
injuries include contusion and laceration as well as strain/tear.
Both muscle and tendon are susceptible to tearing, with severity
ranging from grades I to III based on proportion of muscle/
tendon involved. Ultrasound provides direct visualization of soft
tissue, allowing the user to easily identify injury or pathology.
The fibrillar pattern of parallel lines allows easy identification
of these structures, while torn tendon or muscle would appear
as hypoechoic with localized bleeding. A disruption of tendon
1
Steadman Hawkins Clinic of the Carolinas, Greenville SC 2University of
South Carolina Greenville, Greenville SC and 3Prisma Health-Upstate,
Simpsonville, SC
Address for correspondence: Calan Sowa, MD, Prisma Health-Upstate, Suite
220, 727 S E Main St, Simpsonville, SC 29681; E-mail: calan.sowa@gmail.com.
Column Editor: Lisa C. Barkley MD, FAAFP, FACSM, FSAHM
E-mail: lisabarkley@cdrewu.edu
1537-890X/2006/277–278
Current Sports Medicine Reports
Copyright © 2021 by the American College of Sports Medicine
www.acsm-csmr.org
Copyright © 2021 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
or muscle fibers would suggest a tear, and a soft-tissue stump
consistent with a retracted tear may be visualized. Hematoma
or contusion (including Morel-Lavallee lesion) would appear as
a hypoechoic area secondary to a localized pocket of blood,
while myositis ossificans would appear hyperechoic secondary
to the increased calcification in the soft tissue. Finally, Doppler
evaluation of soft tissue, particularly tendon, can help identify
chronic injury, such as tendinopathy, which results in increased
vascularity of the associated tendon (3).
Evaluation of Ligament
Reliability of evaluation of ligamentous injury depends on
the location of the involved ligament(s). Naturally, superficial
ligaments (i.e., medial collateral ligament, ulnar collateral lig-
ament, anterior talofibular ligament) are more easily visualized
and, thus, more likely to have diagnosable injuries via ultra-
sound. Integrity of the ligament, including direct visualization
of proximal and distal insertion sites as well as the mid-
substance can be evaluated with ultrasound. However, it is
important to remember that high-grade ligamentous injuries
are frequently associated with intra-articular injuries and there-
fore advanced imaging, such as MRI, is usually warranted (4).
Evaluation of Bursae
Bursitis, or inflammation of bursal tissue, is easily evaluated
with ultrasound. Bursae, or small synovial-membrane lined
sacs, serve to reduce friction between bone, tendon, muscle,
and skin and are commonly inflamed in athletes. On ultra-
sound, bursitis presents with pain upon ultrasound probe
pressure, and imaging reveals a thickened and inflamed bursa
with increased, and occasionally, anechoic synovial fluid.
Common sites of bursitis include the olecranon, prepatella
and greater trochanter regions, which are superficial and,
therefore, very conducive to ultrasound evaluation.
Image-Guided Procedures
In the clinic, one of the most useful applications of ultra-
sound is for direct visualization of injection and aspiration
sites. While landmark-guided procedures are possible at sites,
such as the knee or subacromial bursa, deeper structures, such
as the glenohumeral and femoroacetabular joints, have typi-
cally required image guidance with modalities, such as fluo-
roscopy. With ultrasound guidance, these procedures can be
performed in the clinic without the associated risk of radiation
exposure to the patient and the sports medicine physician.
Likewise, performance of procedures under image guidance
increases success rates and improves patient outcomes (5).
Current Sports Medicine Reports 277
 Ultrasound evaluation of MSK injury is cheaper, more conve-
nient, and generally faster when compared with MRI. It is best
used as a focused examination for a specific condition, and the
skill of the sonographer is vitally important in view of the steep
learning curve. Likewise, ultrasound guidance of procedures re-
sults in comparable efficacy rates and less exposure to radia-
tion when compared with fluoroscopic guidance. Emergence
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of portable ultrasound technology brings this ease of use
and utility to the sideline, providing the team physician with
another powerful tool for real-time evaluation of MSK injury.
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278 Volume 20  Number 6  June 2021
Copyright © 2021 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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