Fundamentals of Musculoskeletal

Ultrasound (Fundamentals Radiology)

3rd Edition
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It is my pleasure to present the third edition
of the textbook, Fundamentals of Musculoskeletal
Ultrasound. Since the last edition, there have been
further advances in the clinical applications of
musculoskeletal ultrasound and related research.
Scanning techniques and protocols have also been
refined with improved knowledge of anatomy as
seen with ultrasound. This revision provides an
update of important clinical applications and scan-
ning techniques, based on progress in the field and
relevant peer-reviewed publications. This third
edition includes nearly 400 new images, including
color photographs and color illustrations.
The organization of the textbook is similar to
prior editions. New to this edition is the inclusion
of Chapters 1 and 2 in hard copy form, which
provides an introduction to musculoskeletal ultra-
sound and basic pathology concepts, respectively.
Chapters 3 through 8 review anatomy, scanning
technique, and common pathology of each specific
joint and regional anatomy, including the shoul-
der; elbow; wrist and hand; hip and thigh; knee;
and ankle, foot, and lower leg, respectively. To
illustrate scanning technique, photographs show
transducer placement and corresponding ultra-
sound images show resulting anatomy. Scanning
protocols and sample reports are also included. In
PREFACE
addition to common pathology of tendons, muscle,
and ligaments, other topics include ultrasound
evaluation of masses, peripheral nerves, and
inflammatory arthritis. Chapter 9 provides an
overview of ultrasound-guided musculoskeletal
procedures, which is a very popular application
of musculoskeletal ultrasound. Photographs show
simulated needle and ultrasound transducer place-
ment on a model to illustrate guidance techniques.
A new feature of the third edition are the
updated online videos showing ultrasound cine
clips, which simulate real-time scanning. Each of
the over 200 videos are now individually narrated,
where I describe the pertinent imaging findings
using a pointer, similar to a lecture format.
This enhanced feature will help emphasize the
specific teaching points for each video. In addi-
tion to the videos, a complete electronic version
of the textbook is available online via www.
Expertconsult.com.
It has been exciting to see the popularity and
clinical applications of musculoskeletal ultrasound
continue to increase. With knowledge of anatomy
and pathology as seen with ultrasound and proper
scanning technique, musculoskeletal ultrasound
can play an important role in the evaluation of
the musculoskeletal system.
Jon A. Jacobson, MD
vii
 ACKNOWLEDGMENT

I would like to thank Philips Healthcare for use of their ultrasound equipment.

viii
 CONTENTS

CH A P T E R 1
Introduction, 1

CH A P T E R 2
Basic Pathology Concepts, 16

CH A P T E R 3
Shoulder Ultrasound, 55

CH A P T E R 4
Elbow Ultrasound, 127

CH A P T E R 5
Wrist and Hand Ultrasound, 168

CH A P T E R 6
Hip and Thigh Ultrasound, 223

CH A P T E R 7
Knee Ultrasound, 284

CH A P T E R 8
Ankle, Foot, and Lower Leg Ultrasound, 328

CH A P T E R 9
Interventional Techniques, 407

AP P E N D I X
Sample Diagnostic Ultrasound Reports, 444

VID E O S
Videos are included in the ebook. To access the ebook,
go to expertconsult.inkling.com.

ix
 EXAMINATION CHECKLISTS

TABLE 3.1 Shoulder Ultrasound TABLE 5.1 Wrist and Hand Ultrasound
Examination Checklist Examination Checklist
Step Structures/Pathologic Features of Interest Structures of Interest/Pathologic
Location Features
1 Biceps brachii long head
2 Subscapularis, biceps tendon dislocation Volar (1) Median nerve
3 Supraspinatus, infraspinatus Flexor tendons
4 Acromioclavicular joint, subacromial- Volar joint recesses
subdeltoid bursa, dynamic evaluation Volar (2) Scaphoid
5 Posterior glenohumeral joint, labrum, Flexor carpi radialis
teres minor, infraspinatus, atrophy Radial artery
Volar ganglion cyst
Volar (3) Ulnar nerve and artery
Dorsal (1) Extensor tendons
TABLE 4.1 Elbow Ultrasound Dorsal joint recesses
Examination Checklist Dorsal (2) Scapholunate ligament
Dorsal ganglion cyst
Location Structures of Interest Dorsal (3) Triangular fibrocartilage complex
Anterior Brachialis
Biceps brachii
Median nerve
Anterior joint recess
Medial Ulnar collateral ligament
Common flexor tendon and TABLE 5.2 Finger Ultrasound
pronator teres Examination Checklist
Ulnar nerve
Location Structures of Interest
Lateral Common extensor tendon
Lateral collateral ligament complex Volar Flexor tendons
Radial head and annular recess Pulleys
Capitellum Volar plate
Radial nerve Joint recesses
Posterior Posterior joint recess Dorsal Extensor tendon
Triceps brachii Joint recesses
Olecranon bursa Other Collateral ligaments

x
 Examination Checklists xi

TABLE 6.1 Hip and Thigh Ultrasound TABLE 8.1 Ankle, Calf, and Forefoot
Examination Checklist Ultrasound Examination Checklist
Location Structures of Interest Location Structures of Interest
Hip: anterior Hip joint, iliopsoas, rectus Ankle: anterior Anterior tibiotalar joint recess
femoris, sartorius, pubic Tibialis anterior
symphysis Extensor hallucis longus
Hip: lateral Greater trochanter, gluteal Dorsal pedis artery
tendons, bursae, iliotibial Superficial peroneal nerve
tract, tensor fascia latae Extensor digitorum longus
Hip: posterior Sacroiliac joints, piriformis, Ankle: medial Tibialis posterior
and other external rotators Flexor digitorum longus
of the hip Tibial nerve
Inguinal region Deep inguinal ring, Hesselbach Flexor hallucis longus
triangle, femoral artery Deltoid ligament
region Ankle: lateral Peroneus longus and brevis
Thigh: anterior Rectus femoris, vastus Anterior talofibular ligament
medialis, vastus intermedius, Calcaneofibular ligament
vastus lateralis Anterior tibiofibular ligament
Thigh: medial Femoral artery and nerve, Ankle: posterior Achilles tendon
sartorius, gracilis, adductors Posterior bursae
Plantar fascia
Thigh: posterior Semimembranosus,
semitendinosus, biceps Calf Soleus
femoris, sciatic nerve Medial and lateral heads of
gastrocnemius
Plantaris
Achilles tendon
Forefoot Dorsal joint recesses
Morton neuroma
Tendons and plantar plate
TABLE 7.1 Knee Ultrasound
Examination Checklist
Location of
Interest Structures/Pathologic Features
Anterior Quadriceps tendon
Patella
Patellar tendon
Patellar retinaculum
Suprapatellar recess
Medial and lateral recesses
Anterior knee bursae
Femoral articular cartilage
Medial Medial collateral ligament
Medial meniscus: body and
anterior horn
Pes anserinus
Lateral Iliotibial tract
Lateral collateral ligament
Biceps femoris
Common peroneal nerve
Anterolateral ligament
Popliteus
Lateral meniscus: body and
anterior horn
Posterior Baker cyst
Menisci: posterior horns
Posterior cruciate ligament
Anterior cruciate ligament
Neurovascular structures
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INTRODUCTION
CHAPTER OUTLINE
Equipment Considerations and Image
Formation
Scanning Technique
Image Appearance
Sonographic Appearances of Normal
Structures
Sonographic Artifacts
Miscellaneous Ultrasound Techniques
Color and Power Doppler
Dynamic Imaging
EQUIPMENT CONSIDERATIONS
AND IMAGE FORMATION
One of the primary physical components of an
ultrasound machine is the transducer, which is
connected by a cable to the other components,
including the image screen or monitor and the
computer processing unit. The transducer is placed
on the skin surface and determines the imaging
plane and structures that are imaged. Ultrasound
is a unique imaging method in that sound waves
are used rather than ionizing radiation for image
production. An essential principle of ultrasound
imaging relates to the piezoelectric effect of the
ultrasound transducer crystal, which allows electri-
cal signal to be changed to ultrasonic energy and
vice versa. An ultrasound machine sends the
electrical signal to the transducer, which results
in the production of sound waves. The transducer
is coupled to the soft tissues with acoustic trans-
mission gel, which allows transmission of the
sound waves into the soft tissues. These sound
waves interact with soft tissue interfaces, some
of which reflect back toward the skin surface and
the transducer, where they are converted to an
electrical current used to produce the ultrasound
image. At soft tissue interfaces between tissues
that have significant differences in impedance,
there is sound wave reflection, which produces a
bright echo that is proportional to the impedance
CHAPTER 1
difference. A sound wave that is perpendicular to
the surface of an object being imaged will be
reflected more than if it is not perpendicular. In
addition to reflection, sound waves can be absorbed
and refracted by the soft tissue interfaces. The
absorption of a sound wave is enhanced with
increasing frequency of the transducer and greater
tissue viscosity.1
An important consideration in ultrasound
imaging is the frequency of the transducer because
this determines image quality. A transducer is
designated by the range of sound wave frequencies
it can produce, described in megahertz (MHz).
The higher the frequency, the higher the resolu-
tion of the image; however, this is at the expense
of sound beam penetration as a result of sound
wave absorption.1 In contrast, a low-frequency
transducer optimally assesses deeper structures,
but it has relatively lower resolution. Transducers
may also be designated as linear or curvilinear
(Fig. 1.1). With a linear transducer, the sound
wave is propagated in a linear fashion parallel
to the transducer surface (Video 1.1). This is
optimum in evaluation of the musculoskeletal
system to assess linear structures, such as tendons,
to avoid artifact. A curvilinear transducer may be
used in evaluation of deeper structures because
this increases the field of view (Video 1.2). A small
footprint linear probe is ideal for imaging the
hand, ankle, and foot given the contours of these
body parts that allow only limited contact with
the probe surface (Fig. 1.1C). A small footprint
transducer with an offset is helpful when perform-
ing procedures on the distal extremities.
The physical size, power, resolution, and cost
of ultrasound units vary, and these factors are all
related. For example, an ultrasound machine that
is approximately 3 × 3 × 4 feet high will likely be
very powerful, have many imaging applications,
and be able to support multiple transducers,
including high-frequency transducers that result
in exquisite high-resolution images. Smaller,
portable machines are also available, some of which
are smaller than a notebook computer. Although
these machines cost less than the larger units,
there may be tradeoffs related to image resolution
and applications. Ultrasound units as small as a
handheld electronic device have been introduced,
although transducer options may be limited at
1
2 CHAPTER 1

A B C
FIGURE 1.1 Transducers. Photographs show linear 12-5 MHz (A), curvilinear 9-4 MHz (B), and compact linear
15-7 MHz (C) transducers.

A B
FIGURE 1.2 Transducer Positioning. A and B, Photographs show that the transducer is stabilized with simultaneous
contact of the transducer, the skin surface, and the examiner’s hand.

this time. As technology advances, these differ-
ences have been minimized as the portable
ultrasound machines have become more powerful
and the larger units have become smaller. It is
therefore essential in the selection of a proper
ultrasound unit to consider how an ultrasound
machine will be used, the size of the structures
that need to be imaged, the need for machine
portability, and the capabilities of the ultrasound
machine.
SCANNING TECHNIQUE
To produce an ultrasound image, the transducer
is held on the surface of the skin to image the
underlying structures. Ample acoustic transmission
gel should be used to enable the sound beam to
be transmitted from the transducer to the soft
tissues and to allow the returning echoes to be
converted to the ultrasound image. I prefer a layer
of thick transmission gel over a more cumbersome
gel standoff pad. Gel that is more like liquid
consistency is also less ideal because the gel tends
not to stay localized at the imaging site. The
transducer should be held between the thumb
and fingers of the examiner’s dominant hand, with
the end of the transducer near the ulnar aspect
of the hand (Fig. 1.2A). The transducer should
be stabilized or anchored on the patient with either
the small finger or the heel of the imaging hand
(Fig. 1.2B). This technique is essential to maintain
proper pressure of the transducer on the skin, to
avoid involuntary movement of the transducer,
and to allow fine adjustments in transducer
positioning. Remember that the sound beam

A B
FIGURE 1.3 Transducer Movements. A, Heel-toe maneuver. B, Toggle maneuver. (Modified from an illustration
by Carolyn Nowak, Ann Arbor, Michigan; http://www.carolyncnowak.com/medtech.html.)
emitted from the transducer is focused relative
to the short end of the transducer, and side-to-side
movement of the transducer should only be a
millimeter at a time.
Various terms describe manual movements of
the transducer during scanning. The term heel-toe
is used when the transducer is rocked or angled
along the long axis of the transducer (Fig. 1.3A).
The term toggle is used when the transducer is
angled from side to side (Fig. 1.3B). With both
the heel-toe and toggle maneuvers, the transducer
is not moved from its location, but rather the
transducer is angled. The term translate is used
when the transducer is moved to a new location
while maintaining a perpendicular angle with the
skin surface. The term sweep is used when the
transducer is slid from side to side while maintain-
ing a stable hand position, similar to sweeping a
broom.
With regard to ergonomics, proper ultrasound
scanning technique can help minimize fatigue and
work-related injuries. Anchoring of the transducer
to the patient by making contact between the
scanning hand and the patient as described earlier
decreases muscle fatigue of the examining arm.
In addition, making sure that the scanning hand
is lower than the ipsilateral shoulder with the
elbow close to the body also decreases fatigue of
the shoulder. If the examiner uses a chair, one at
the appropriate height, preferably with wheels
and with some type of back support, will improve
Introduction 3
comfort and maneuverability. Last, the ultrasound
monitor should be near the patient’s area being
scanned so that visualization of both the patient
and the monitor can occur while minimizing
turning of the head or spine.
There are three basic steps when performing
musculoskeletal ultrasound, and these steps are
also similar to obtaining an adequate image with
magnetic resonance imaging (MRI). The first step
is to image the structure of interest in long axis
and short axis (if applicable), which depends on
knowledge of anatomy. Identification of bone
landmarks is helpful for orientation. The second
step is to eliminate artifacts, more specifically
anisotropy (see later discussion in this chapter)
when considering ultrasound. When imaging
a structure over bone, the cortex will appear
hyperechoic and well defined when the sound beam
is perpendicular, which indicates that the tissues
over that segment of bone are free of anisotropy.
The last step is characterization of pathology. Note
the use of bone in two of the previous steps to
understand anatomy and the proper imaging plane
and to indicate that the sound beam is directed
correctly to eliminate anisotropy.
IMAGE APPEARANCE
Once the transducer is placed on the patient’s
skin with intervening gel, a rectangular image
4 CHAPTER 1
P can be adjusted by a knob on the ultrasound
T
FIGURE 1.4 Normal Patellar Tendon. Ultrasound image
of patellar tendon in long axis (arrowheads) shows
hyperechoic fibrillar echotexture. P, Patella; T, tibia.
(when using a linear transducer) appears on the
monitor. The top of the image represents the
superficial soft tissues that are in contact with
the transducer, and the deeper structures appear
toward the lower aspect of the image (Fig. 1.4).
To understand the resulting ultrasound image,
consider the sound beam as a plane or slice that
extends down from the transducer along its long
axis. It is this plane that is portrayed on the image.
The left and right sides of the image can represent
either end of the transducer, and this can usually
be switched by using the left-to-right invert button
on the ultrasound machine or by simply rotating
the transducer 180 degrees. When imaging a
structure in long axis, it is common to have the
proximal aspect on the left side of the image and
the distal aspect on the right.
Image optimization is essential to maximize
resolution and clarity. The first step is to select
the proper transducer and frequency. Higher-
frequency transducers (10 MHz or greater) op-
timally evaluate superficial structures, whereas
lower-frequency transducers are used for deep
structures. Linear transducers are typically used,
unless the area of interest is deep, such as the hip
region, where a curvilinear transducer may be
chosen. After the proper transducer is selected
and placed on the patient, the next step is to
adjust the depth of the sound beam; this is
accomplished by a button or dial on the ultrasound
machine. The depth of the sound beam is adjusted
until the structure of interest is visible and centered
in the image (Fig. 1.5A and B). The next step in
optimization is to adjust the focal zones of the
ultrasound beam, if present on the ultrasound
machine. This feature is typically displayed on
the side of the image as a number of cursors or
other symbols. It is optimum to reduce the number
of focal zones to span the area of interest because
increased focal zones will decrease the frame rate
that produces a windshield-wiper effect. It is also
important to move the depth of the focal zones
to the depth where the structure is to be imaged
to optimize resolution (Fig. 1.5C). Some ultra-
sound machines have a broad focal zone that may
not have to be moved. Finally, the overall gain
machine to increase or decrease the overall bright-
ness of the echoes, which is in part determined
by the ambient light in the examination room
(Fig. 1.5D). The gain should ideally be set where
one can appreciate the ultrasound characteristics
of normal soft tissues (as described later in this
chapter).
The ultrasound image is produced when the
sound beam interacts with the tissues beneath
the transducer and this information returns to
the transducer. At an interface between tissues
where there is a large difference in impedance,
the sound beam is strongly reflected, and this
produces a very bright echo on the image, which
is described as hyperechoic. Examples include
interfaces between bone and soft tissues, where
the area beneath the interface is completely black
from shadowing because no echoes extend beyond
the interface. An area on the image that has no
echo and is black is termed anechoic, whereas an
area with a weak or low echo is termed hypoechoic.
If a structure is of equal echogenicity to the
adjacent soft tissues, it may be described as isoechoic.
SONOGRAPHIC APPEARANCES OF
NORMAL STRUCTURES
Musculoskeletal structures have characteristic
appearances on ultrasound imaging.2 Normal
tendons appear hyperechoic with a fiber-like
or fibrillar echotexture (see Fig. 1.4).3 At close
inspection, the linear fibrillar echoes within a
tendon represent the endotendineum septa, which
contain connective tissue, elastic fibers, nerve
endings, blood, and lymph vessels.3 Continuous
tendon fibers are best appreciated when they are
imaged long axis to the tendon. On such a long
axis image, by convention the proximal aspect is
on the left side of the image, with the distal aspect
on the right. In short axis, normal hyperechoic
tendon fibers appear as bristles of a brush seen on
end (see Fig. 1.9A). Normal muscle tissue appears
relatively hypoechoic (Fig. 1.6). At closer inspec-
tion, the hypoechoic muscle tissue is separated by
fine hyperechoic fibroadipose septa or perimysium,
which surrounds the hypoechoic muscle bundles.
The surface of bone or calcification is typically
very hyperechoic, with posterior acoustic shadow-
ing and possibly posterior reverberation if the
surface of the bone is smooth and flat (Fig. 1.6).
The hyaline cartilage covering the articular surface
of bone is hypoechoic and uniform (Fig. 1.7A
and B), whereas the fibrocartilage, such as the
 Introduction 5

D
FIGURE 1.5 Optimizing the Ultrasound Image. A, Ultrasound image of forearm musculature shows improper
depth, focal zone, and gain. B, Depth is corrected as area of interest is centered in image. C, Focal zone width is
decreased and centered at area of interest (arrows). D, Gain is increased.

labrum of the hip and shoulder, and the knee

H axis perpendicular to the ultrasound beam.
FIGURE 1.6 Muscle. Ultrasound image of brachialis and
biceps brachii muscles in long axis shows hypoechoic
muscle and hyperechoic fibroadipose septa (arrows).
H, Humerus.
menisci are hyperechoic (Fig. 1.7B). Ligaments
have a hyperechoic, striated appearance that
is more compact compared with tendons (Fig.
1.8). In addition, ligaments are also identified in
that they connect two osseous structures. Often
normal ligaments may appear relatively hypoechoic
when surrounded by hyperechoic subcutaneous
fat; however, a compact linear hyperechoic liga-
ment can be appreciated when imaged in long
Normal peripheral nerves have a fascicular
appearance in which the individual nerve fascicles
are hypoechoic, surrounded by hyperechoic con-
nective tissue epineurium (Fig. 1.9).4 Hyperechoic
fat is typically seen around larger peripheral nerves.
6 CHAPTER 1

E/D

G
F

A B
FIGURE 1.7 Cartilage. A, Ultrasound image transverse over the distal anterior femur shows hypoechoic hyaline
cartilage (arrowheads). F, Femur. B, Ultrasound image of infraspinatus in long axis (I) shows a hyperechoic
fibrocartilage glenoid labrum (arrowheads) and hypoechoic hyaline cartilage (curved arrow). Note hyperechoic
epidermis and dermis (E/D), and adjacent deeper hypoechoic hypodermis with hyperechoic septa. G, Glenoid;
H, humerus.

such artifact is anisotropy.6 When a tendon is

m
F
T angled as little as 2 to 3 degrees relative to the long
FIGURE 1.8 Tibial Collateral Ligament. Ultrasound image
of tibial collateral ligament of the knee in long axis
shows compact fibrillar echotexture (arrowheads). F,
Femur; m, meniscus; T, tibia.
In short axis, peripheral nerves display a honeycomb
or speckled appearance, which assists in their identi-
fication. Because peripheral nerves have a relatively
mixed hyperechoic and hypoechoic echotexture,
their appearance changes relative to the adjacent
tissues. For example, the median nerve in the
forearm, when surrounded by hypoechoic muscle,
appears relatively hyperechoic; in contrast, more
distally in the carpal tunnel, when it is surrounded
by hyperechoic tendon, the median nerve appears
relatively hypoechoic (see Fig. 5.4D). The epider-
mis and dermis collectively appear hyperechoic,
whereas the hypodermis shows hypoechoic fat and
hyperechoic fibrous septa (see Fig. 1.7).
SONOGRAPHIC ARTIFACTS
One should be familiar with several artifacts
common to musculoskeletal ultrasound.5 One
imaged perpendicular to the ultrasound beam, the
characteristic hyperechoic fibrillar appearance is
displayed. However, when the ultrasound beam is
axis of such a structure, the normal hyperechoic
appearance is lost; the tendon becomes more
hypoechoic with increased insonation angle (Figs.
1.10 to 1.13). A tissue is anisotropic if its properties
change when measured from different directions.
This variation of ultrasound interaction with fibril-
lar tissues involves tendons and ligaments and, to
a lesser extent, muscle. Because abnormal tendons
and ligaments may also appear hypoechoic, it is
important to focus on that segment of tendon or
ligament that is perpendicular to the ultrasound
beam, to exclude anisotropy. With a curved
structure, such as the distal aspect of the supra-
spinatus tendon, the transducer is continually
repositioned or angled to exclude anisotropy as
the cause of a hypoechoic tendon segment (Fig.
1.11 and Video 1.3). Anisotropy is noted both in
long axis and short axis of ligaments and tendons
(Video 1.4), but it occurs when the sound beam
is angled relative to the long axis of a structure
(Fig. 1.12). Therefore, to correct for anisotropy,
the transducer is angled along the long axis of
the imaged tendon or ligament; when imaging a
tendon in long axis, the transducer is angled as a
heel-toe maneuver (see Fig. 1.3A and Video 1.5),
whereas in short axis, the transducer is toggled
(see Fig. 1.3B and Video 1.6). Anisotropy can
be used to one’s advantage in identification
of a hyperechoic tendon or ligament in close
proximity to hyperechoic soft tissues, such as
 Introduction 7

F
R

C
A B
FIGURE 1.9 Median Nerve. A, Ultrasound image of median nerve in short axis (arrowheads) shows individual
hypoechoic nerve fascicles (arrow) and the adjacent hyperechoic flexor carpi radialis tendon (open arrows). B,
Ultrasound image of median nerve in long axis (arrowheads) shows hypoechoic nerve fascicles (arrow). Note
the adjacent fibrillar flexor digitorum (F) and palmaris longus (P) tendons. C, Capitate; L, lunate; R, radius.

involved interface. Examples of structures that

P display a dirty shadow (resulting from superim-
FIGURE 1.10 Anisotropy. Ultrasound image of flexor
tendons of the finger in long axis shows normal tendon
hyperechogenicity (arrowheads) becoming more hy-
poechoic as the tendon becomes oblique relative to
the sound beam (open arrows). P, Proximal phalanx.
in the ankle and wrist. When imaging a tendon
in short axis, toggling the transducer will cause
the tendon to become hypoechoic, thus allowing
its distinction from the adjacent hyperechoic fat
that does not demonstrate anisotropy (Fig. 1.12).
Once the tendon is identified, anisotropy must
be corrected to exclude pathology. Anisotropy is
also helpful in identification of some ligaments,
such as in the ankle, because they are often adja-
cent to hyperechoic fat (Fig. 1.13). In addition,
hyperechoic tendon calcifications can be made
more conspicuous when they are surrounded by
hypoechoic tendon from anisotropy with angu-
lation of the transducer (see Fig. 3.63). When
performing an interventional procedure, it is
anisotropy that causes the needle to become less
conspicuous when the needle is not perpendicular
to the sound beam (see Fig. 9.8).
Another important artifact is shadowing. This
occurs when the ultrasound beam is reflected,
absorbed, or refracted.7 The resulting image shows
an anechoic area that extends deep from the
produce shadowing include interfaces with bone
or calcification (Fig. 1.14), some foreign bodies
(see Chapter 2), and gas. An object with a small
radius of curvature or a rough surface will display
a clean shadow, whereas an object with a large
radius of curvature and a smooth surface will
posed reverberation echoes).8 Refractile shadowing
may also occur at the edge of some structures,
such as a foreign body or the end of a torn Achilles
or patellar tendon (Fig. 1.15).9
Another type of artifact is posterior acoustic
enhancement or increased through-transmission. This
occurs during imaging of fluid (Figs. 1.16 and
1.17) and some solid soft tissue tumors, such as
peripheral nerve sheath tumors (see Fig. 2.59)
and pigmented villonodular tenosynovitis (giant
cell tumors of tendon sheath) (Fig. 1.18).10 In
these situations, the sound beam is relatively less
attenuated compared with the adjacent tissues;
therefore, the deeper soft tissues will appear
relatively hyperechoic compared with the adjacent
soft tissues.7
Another artifact with musculoskeletal implica-
tions is posterior reverberation. This occurs when
the surface of an object is smooth and flat, such
as a metal object or the surface of bone. In this
situation, the sound beam reflects back and forth
between the smooth surface and the transducer
and produces a series of linear reflective echoes
that extend deep to the structure.7 If the series
of reflective echoes is more continuous deep to
the structure, the term ring-down artifact is used,
as may be seen with metal surfaces (Fig. 1.19).
Ultrasound is ideal in evaluation of structures
immediately overlying metal hardware because
this reverberation artifact occurs deep to the
hardware without obscuring the superficial soft
tissues. Related to posterior reverberation is the
8 CHAPTER 1

S
S

H
H
A B
FIGURE 1.11 Anisotropy. Ultrasound images of distal supraspinatus tendon in long axis (S) shows an area of
hypoechoic anisotropy (curved arrow) (A), where the tendon fibers become oblique to the sound beam, which
is eliminated (B) when the transducer is repositioned so that the tendon fibers are perpendicular to the sound
beam. H, Humerus.

P
F

A B
FIGURE 1.12 Anisotropy. Ultrasound images of tibialis posterior (P) and flexor digitorum longus (F) tendons in
short axis at the ankle show normal tendon hyperechogenicity (A) and hypoechoic anisotropy (open arrows) (B),
when angling or toggling the transducer along the long axis of the tendons, thus aiding in identification of tendons
relative to surrounding hyperechoic fat.

A B
FIGURE 1.13 Anisotropy. Ultrasound images of anterior talofibular ligament in long axis (arrowheads) in the ankle
show normal ligament hyperechogenicity (A) and hypoechoic anisotropy (open arrows) (B), when angling the
transducer along the long axis of the ligament, thus aiding in identification of ligament relative to surrounding
hyperechoic fat. F, Fibula; T, talus.

FIGURE 1.14 Shadowing. Ultrasound image of Achilles
tendon in long axis (arrowheads) shows hyperechoic
ossification (arrows) with posterior acoustic shadowing
(open arrows).
FIGURE 1.15 Refractile Shadowing. Ultrasound image
of Achilles tendon in long axis (arrowheads) shows
shadowing (open arrows) at the site of a full-thickness
tear (curved arrow).
FIGURE 1.16 Increased Through-Transmission. Ultra-
sound image of a ganglion cyst (arrows) in the ankle
shows increased through-transmission (open arrows).
t, Flexor hallucis longus tendon.
Introduction 9
FIGURE 1.17 Increased Through-Transmission. Ultra-
sound image of a soft tissue abscess (arrows) in the
shoulder shows increased through-transmission (open
arrows).
FIGURE 1.18 Increased Through-Transmission. Ultra-
sound image of a pigmented villonodular tenosynovitis
(giant cell tumor of the tendon sheath) (between × and
+ cursors) shows increased through-transmission (open
arrows).
FIGURE 1.19 Ring-Down Artifact. Ultrasound image in
long axis to the femoral component of a total hip
arthroplasty shows the hyperechoic metal surface of
the arthroplasty (arrows) and posterior ring-down artifact
(open arrows). Note the overlying joint fluid (f) and
adjacent native femur (F).
10 CHAPTER 1
comet-tail artifact, such as that seen with soft
tissue gas (Fig. 1.20), which appears as a short
segment of posterior bright echoes that narrows
further from the source of the artifact.
One additional artifact to consider is beam-width
artifact. This is essentially analogous to volume
averaging and occurs if the ultrasound beam is
too wide relative to the object being imaged. An
example is imaging of a small calcification in which
the relatively large beam width may eliminate
shadowing. This effect can be reduced by adjusting
the focal zone to the level of the object of
interest.7
MISCELLANEOUS ULTRASOUND
TECHNIQUES
Several ultrasound techniques or applications
available with some ultrasound machines can
H ultrasound findings (Figs. 1.24 and 1.25).14 An
FIGURE 1.20 Comet-Tail Artifact. Ultrasound over an
infected subacromial-subdeltoid bursa (arrows) shows
hyperechoic foci of gas with comet-tail artifact (arrow-
heads). H, Greater tuberosity of the humerus.
A B
FIGURE 1.21 Spatial Compounding. Ultrasound images of the supraspinatus tendon without (A) and with
(B) spatial compounding show softening of the image in B.
enhance scanning and diagnostic capabilities. One
such method is spatial compound sonography.11
Unlike conventional ultrasound, sound beams
with spatial compound sonography are produced
at several different angles, with information
combined to form a single ultrasound image. This
improves tissue plane definition, but it has a
smoothing effect, and motion blur is more likely
because frames are compounded (Fig. 1.21). The
use of spatial compounding may alter the artifact
produced by a foreign body, which may change
its conspicuity (see Fig. 2.47).
Another ultrasound technique is tissue harmonic
imaging. Unlike conventional ultrasound, which
receives only the fundamental or transmitted
frequency to produce the image, with tissue
harmonic imaging, harmonic frequencies produced
during ultrasound beam propagation through
tissues are used to produce the image. This
technique assists in evaluation of deep structures
and also improves joint and tendon surface visibil-
ity.12,13 The technique may more clearly delineate
the edge of a soft tissue mass (Fig. 1.22) or a
fluid-filled tendon tear (Fig. 1.23). One pitfall is
that hypoechoic tendinosis may appear more
anechoic with tissue harmonic imaging and
simulate a tendon tear.
One helpful technique available on some
ultrasound machines is extended field of view. With
this technique, an ultrasound image is produced
by combining image information obtained during
real-time scanning. This allows imaging of an
entire muscle from origin to insertion; it is helpful
in measuring large abnormalities (e.g., tumor or
tendon tear) and in displaying and communicating
alternative to extended field of view imaging that
is available on some ultrasound equipment is the
split-screen function, which essentially joins two
images on the display screen that doubles the
field of view.
 Introduction 11

A B
FIGURE 1.22 Tissue Harmonic Imaging. Ultrasound images of a recurrent giant cell tumor (arrowheads) without
(A) and with (B) tissue harmonic imaging show increased definition of the mass borders in B. Note posterior
increased through-transmission.

A B
FIGURE 1.23 Tissue Harmonic Imaging. Ultrasound images of full-thickness supraspinatus tendon tear in long
axis (arrows) without (A) and with (B) tissue harmonic imaging show clearer distinction of retracted tendon stump
(left arrow) because intervening fluid is more hypoechoic.

FIGURE 1.24 Extended Field of View. Ultrasound image

of the Achilles tendon in long axis shows hypoechoic
and enlarged tendinosis (open arrows) and retro-Achilles
bursitis (curved arrow). Note the normal Achilles thick-
FIGURE 1.25 Extended Field of View. Ultrasound image
ness proximally (arrowheads). C, Calcaneus.
shows full extent of a lipoma (between arrows).

A number of ultrasound techniques are rela-
tively new, and their practical musculoskeletal
applications are still being defined. One such
technique is three-dimensional ultrasound, which
acquires data as a volume (either mechanically or
freehand) and thus enables reconstruction at any
imaging plane (Fig. 1.26). This technique has been
used to characterize rotator cuff tears and to
quantify a volume of tissue such as tumor or
synovial hypertrophy.15,16 An additional technique
12 CHAPTER 1

FIGURE 1.27 Ultrasound Elastography: Foreign Body

FIGURE 1.26 Three-Dimensional Imaging. Ultrasound
Granuloma. Ultrasound image of common extensor
image reconstructed in the coronal plane shows a
tendon elbow shows suture granuloma (blue mass-like
heterogeneous thigh sarcoma (arrowheads).
area below white arrow). Note that hard tissues are
displayed in blue and soft tissues in red. (Courtesy Y.
Morag, Ann Arbor, Michigan.)
is fusion imaging, in which real-time ultrasound
imaging can be superimposed on computed
tomography (CT) or MRI; this has been used to
assist with needle guidance for sacroiliac joint
injections.17 One last technique is sonoelastography,
which is used to assess the elastic properties of
tissue. The three types of sonoelastography include
compression elastography (using manual compres-
sion), shear wave elastography (using a directional
shear wave), and transient elastography (using a
short pulse).18 With compression elastography,
manual compression of tissue produces strain or
displacement within the tissue. Displacement
is less when tissue is hard; it is displayed as blue
on the ultrasound image, whereas soft tissue is
displayed as red (Fig. 1.27). With regard to
musculoskeletal applications, normal tendons FIGURE 1.28 Color Doppler: Schwannoma. Color Doppler
ultrasound image shows increased blood flow in
appear as blue, whereas areas of tendinopathy, hypoechoic peripheral nerve sheath tumor.
such as of the Achilles tendon or common extensor
tendon of the elbow, appear as red.16,19-22 With
shear wave and transient elastography, the velocity
of the shear wave is measured to determine colored blood flow superimposed on a gray-scale
elasticity and has the advantage of less operator image, in which two colors such as red and blue
dependence and ability to produce qualitative and represent flow toward and away from the trans-
quantitative information.18,23 ducer, respectively (Fig. 1.28).24 Pulsed-wave or
duplex Doppler ultrasound displays an ultrasound
image and waveform (Fig. 1.29). There are
COLOR AND POWER DOPPLER important considerations to optimize the Doppler
ultrasound. Reducing the width of the field of
Most ultrasound machines include color and power view and increasing the frame rate are helpful.
Doppler imaging capabilities, with possible To correct for aliasing (when the Doppler shift
spectral waveform analysis. Ultrasound uses the frequency of blood is greater than the detected
Doppler effect, in which the sound frequency of frequency, which causes an error in frequency
an object changes as the object travels toward or measurement), one can increase the pulse repeti-
away from a point of reference, to obtain informa- tion frequency, lower the ultrasound frequency,
tion about blood flow. Color flow imaging shows or increase the angle between the sound beam
 Introduction 13

B C
FIGURE 1.29 Color Doppler: Radial Artery Thrombosis. A, Color Doppler ultrasound image in long axis to the
radial artery (arrowheads) at the wrist shows hypoechoic thrombus and diminished blood flow. B, Pulsed-wave
Doppler shows the loss of normal arterial flow at the site of thrombus (B) and distal reconstitution from the deep
palmar arch (C).

and the flow direction toward perpendicular. Power
Doppler is another method of color Doppler
ultrasound that is generally considered more
sensitive to blood flow (it shows small vessels and
slow flow rates) compared with conventional color
Doppler, although significant variability exists
depending on the ultrasound machine.25 Unlike
conventional color Doppler, power Doppler
assigns a color to blood flow regardless of direction
(Fig. 1.30) and is extremely sensitive to movement
of the transducer, which produces a flash artifact.
The color gain should be optimally adjusted for
Doppler imaging to avoid artifact if the setting
is too sensitive and for false-negative flow if
sensitivity is too low. To optimize power Doppler
imaging, set the color background (without the
gray-scale displayed) so that the lowest level of
color nearly uniformly is present, with only
minimal presence of the next highest color level.26
Increased blood flow on color or power
Doppler imaging may occur with increased perfu-
sion, inflammation, and neovascularity. In imaging
soft tissues, color and power Doppler imaging
are used to confirm that an anechoic tubular
structure is a blood vessel and to confirm blood
flow. When a mass is identified, increased blood
14 CHAPTER 1
FIGURE 1.30 Power Doppler: Schwannoma. Power
Doppler ultrasound image shows increased blood flow
in hypoechoic peripheral nerve sheath tumor.
FIGURE 1.31 Power Doppler: B-Cell Lymphoma. Power
Doppler ultrasound image shows increased blood flow
in hypoechoic lymphoma (arrowheads). Note posterior
increased through-transmission.
flow may suggest neovascularity, possibly from
malignancy (Fig. 1.31).27 Although the finding is
nonspecific, a tumor without flow is more likely
to be benign, and malignant tumors usually
demonstrate increased flow and irregular vessels.28
With regard to superficial lymph nodes, either
no flow or hilar flow is more common with benign
lymph node enlargement, and spotted, peripheral,
or mixed patterns of flow are more common with
malignant lymph node enlargement (see Chapter
2).29 Color or power Doppler imaging is also
helpful in the differentiation between complex
fluid and a mass or synovitis; the former typically
has no internal flow, and the latter may show
increased flow.30 After treatment for inflammatory
arthritis, color and power Doppler imaging can
show interval decrease in flow, which would
indicate a positive response.31 It is also important
to use color Doppler imaging during a biopsy to
ensure that major vessels are avoided.
DYNAMIC IMAGING
One significant advantage of ultrasound over other
static imaging methods, such as radiography, CT,
and conventional MRI, is the dynamic capability.
On a basic level, ultrasound evaluation can be
directly guided by a patient’s history, symptoms,
and findings at physical examination. In fact,
regardless of the protocol followed for imaging
a joint, it is essential that ultrasound is focused
during one aspect of the examination over any
area of point tenderness or focal symptoms.32 Once
ultrasound examination is begun, the patient can
directly provide feedback with regard to pain or
other symptoms with transducer pressure over
an ultrasound abnormality. When a patient has
a palpable abnormality, direct palpation under
ultrasound visualization will ensure that the
imaged abnormality corresponds to the abnormal-
ity. Graded compression also provides additional
information about soft tissue masses; lipomas are
often soft and pliable (see Video 2.7).
In the setting of a rotator cuff tear, compression
can help demonstrate the volume loss associated
with a full-thickness tear (see Video 3.23). With
regard to peripheral nerves, transducer pressure
over a nerve at the site of entrapment can repro-
duce symptoms and help to guide the examination.
Transducer pressure over a stump neuroma is also
used to determine if a neuroma is causing symp-
toms. If during examination there is question of
a complex fluid collection, variable transducer
pressure can demonstrate swirling of internal
debris and displacement, which indicates a fluid
component (see Videos 6.14 to 6.16). In contrast,
synovial hypertrophy would show only minimal
compression without internal movement of echoes,
with possible additional findings of flow on color
and power Doppler imaging (see Video 8.5).
Dynamic imaging is also important in evalu-
ation of complete full-thickness muscle, tendon,
or ligament tear. When a full-thickness muscle
or tendon tear is suspected, the muscle-tendon
unit may be actively contracted or passively moved
during imaging in long axis (see Videos 7.15 and
8.46). Demonstration of muscle or tendon stumps
that move away from each other during this
dynamic maneuver at the site of the tear indicates
full-thickness extent. With regard to ligament
tear, a joint can be stressed while imaging in long
axis to the ligament to evaluate for ligament

disruption and abnormal joint space widening.
One example of this is applying valgus stress to
the elbow when evaluating for ulnar collateral
ligament tear (see Videos 4.15 to 4.17).
One last application of dynamic imaging is in
evaluation of an abnormality that is present only
when an extremity is moved or positioned in a
particular manner. Examples of this include
evaluation of the long head of biceps brachii
tendon for subluxation or dislocation with shoulder
external rotation (see Video 3.43), the ulnar nerve
(see Video 4.21) and snapping triceps syndrome
with elbow flexion (see Video 4.22), the peroneal
tendon with dorsiflexion and eversion of the ankle
(see Videos 8.30 to 8.33), and snapping hip
syndrome (see Videos 6.18 to 6.21). Muscle
contraction is often required for the diagnosis of
muscle hernia (see Videos 8.40 to 8.42). Dynamic
imaging of a patient during Valsalva maneuver is
an essential component in evaluation for inguinal
region hernia (see Videos 6.26 to 6.31). In addition
to the foregoing examples, if the patient has any
complaints that occur with a specific movement
or position, the ultrasound transducer can be
Introduction 15
placed over the abnormal area, and the patient
can be asked to re-create the symptom.
SELECT REFERENCES
5. Gimber LH, Melville DM, Klauser AS, et al:
Artifacts at musculoskeletal US: resident and fellow
education feature. Radiographics 36(2):479–480,
2016.
12. Anvari A, Forsberg F, Samir AE: A primer on the
physical principles of tissue harmonic imaging.
Radiographics 35(7):1955–1964, 2015.
16. Klauser AS, Peetrons P: Developments in
musculoskeletal ultrasound and clinical applications.
Skeletal Radiol (Sep 3), 2009.
18. Klauser AS, Miyamoto H, Bellmann-Weiler R,
et al: Sonoelastography: musculoskeletal applica-
tions. Radiology 272(3):622–633, 2014.
24. Boote EJ: AAPM/RSNA physics tutorial for resi-
dents: topics in US: Doppler US techniques:
concepts of blood flow detection and flow dynamics.
Radiographics 23(5):1315–1327, 2003.
The complete references for this chapter can be found on
www.expertconsult.com.

REFERENCES
1. Curry TS, Dowdey JE, Murry RC: Christensen’s
physics of diagnostic radiology, ed 4, Philadelphia,
1990, Lea and Febiger.
2. Erickson SJ: High-resolution imaging of the
musculoskeletal system. Radiology 205(3):593–618,
1997.
3. Martinoli C, Derchi LE, Pastorino C, et al: Analysis
of echotexture of tendons with US. Radiology 186(3):
839–843, 1993.
4. Silvestri E, Martinoli C, Derchi LE, et al: Echotex-
ture of peripheral nerves: correlation between US
and histologic findings and criteria to differentiate
tendons. Radiology 197(1):291–296, 1995.
5. Gimber LH, Melville DM, Klauser AS, et al:
Artifacts at musculoskeletal US: resident and fellow
education feature. Radiographics 36(2):479–480,
2016.
6. Crass JR, van de Vegte GL, Harkavy LA: Tendon
echogenicity: ex vivo study. Radiology 167(2):499–
501, 1988.
7. Scanlan KA: Sonographic artifacts and their origins.
AJR Am J Roentgenol 156(6):1267–1272, 1991.
8. Rubin JM, Adler RS, Bude RO, et al: Clean and
dirty shadowing at US: a reappraisal. Radiology
181(1):231–236, 1991.
9. Hartgerink P, Fessell DP, Jacobson JA, et al: Full-
versus partial-thickness Achilles tendon tears:
sonographic accuracy and characterization in 26
cases with surgical correlation. Radiology 220(2):
406–412, 2001.
10. Reynolds DL, Jr, Jacobson JA, Inampudi P, et al:
Sonographic characteristics of peripheral nerve
sheath tumors. AJR Am J Roentgenol 182(3):741–744,
2004.
11. Lin DC, Nazarian LN, O’Kane PL, et al: Advan-
tages of real-time spatial compound sonography
of the musculoskeletal system versus conventional
sonography. AJR Am J Roentgenol 179(6):1629–1631,
2002.
12. Anvari A, Forsberg F, Samir AE: A primer on the
physical principles of tissue harmonic imaging.
Radiographics 35(7):1955–1964, 2015.
13. Strobel K, Zanetti M, Nagy L, et al: Suspected
rotator cuff lesions: tissue harmonic imaging versus
conventional US of the shoulder. Radiology 230(1):
243–249, 2004.
14. Lin EC, Middleton WD, Teefey SA: Extended
field of view sonography in musculoskeletal
imaging. J Ultrasound Med 18(2):147–152, 1999.
15. Kang CH, Kim SS, Kim JH, et al: Supraspinatus
tendon tears: comparison of 3D US and MR
arthrography with surgical correlation. Skeletal
Radiol 38(11):1063–1069, 2009.
16. Klauser AS, Peetrons P: Developments in
musculoskeletal ultrasound and clinical applications.
Skeletal Radiol (Sep 3), 2009.
17. Klauser AS, De Zordo T, Feuchtner GM, et al:
Fusion of real-time US with CT images to guide
sacroiliac joint injection in vitro and in vivo.
Radiology 256(2):547–553, 2010.
Introduction 15.e1
18. Klauser AS, Miyamoto H, Bellmann-Weiler R,
et al: Sonoelastography: musculoskeletal applica-
tions. Radiology 272(3):622–633, 2014.
19. De Zordo T, Chhem R, Smekal V, et al: Real-time
sonoelastography: findings in patients with symp-
tomatic Achilles tendons and comparison to healthy
volunteers. Ultraschall Med 31(4):394–400, 2010.
20. De Zordo T, Fink C, Feuchtner GM, et al: Real-
time sonoelastography findings in healthy Achilles
tendons. AJR Am J Roentgenol 193(2):W134–W138,
2009.
21. De Zordo T, Lill SR, Fink C, et al: Real-time
sonoelastography of lateral epicondylitis: compari-
son of findings between patients and healthy
volunteers. AJR Am J Roentgenol 193(1):180–185,
2009.
22. Klauser AS, Faschingbauer R, Jaschke WR: Is
sonoelastography of value in assessing tendons?
Semin Musculoskelet Radiol 14(3):323–333, 2010.
23. Arda K, Ciledag N, Aktas E, et al: Quantitative
assessment of normal soft-tissue elasticity using
shear-wave ultrasound elastography. AJR Am J
Roentgenol 197(3):532–536, 2011.
24. Boote EJ: AAPM/RSNA physics tutorial for resi-
dents: topics in US: Doppler US techniques:
concepts of blood flow detection and flow dynamics.
Radiographics 23(5):1315–1327, 2003.
25. Torp-Pedersen S, Christensen R, Szkudlarek M,
et al: Power and color Doppler ultrasound settings
for inflammatory flow: impact on scoring of disease
activity in patients with rheumatoid arthritis.
Arthritis Rheumatol 67(2):386–395, 2015.
26. Bude RO, Rubin JM: Power Doppler sonography.
Radiology 200(1):21–23, 1996.
27. Bodner G, Schocke MF, Rachbauer F, et al: Dif-
ferentiation of malignant and benign musculoskel-
etal tumors: combined color and power Doppler
US and spectral wave analysis. Radiology 223(2):
410–416, 2002.
28. Belli P, Costantini M, Mirk P, et al: Role of
color Doppler sonography in the assessment of
musculoskeletal soft tissue masses. J Ultrasound
Med 19(12):823–830, 2000.
29. Wu CH, Shih JC, Chang YL, et al: Two-dimensional
and three-dimensional power Doppler sonographic
classification of vascular patterns in cervical
lymphadenopathies. J Ultrasound Med 17(7):459–
464, 1998.
30. Breidahl WH, Stafford Johnson DB, Newman JS,
et al: Power Doppler sonography in tenosynovitis:
significance of the peritendinous hypoechoic rim.
J Ultrasound Med 17(2):103–107, 1998.
31. Ribbens C, Andre B, Marcelis S, et al: Rheumatoid
hand joint synovitis: gray-scale and power Doppler
US quantifications following anti-tumor necrosis
factor-alpha treatment: pilot study. Radiology 229(2):
562–569, 2003.
32. Jamadar DA, Jacobson JA, Caoili EM, et al:
Musculoskeletal sonography technique: focused
versus comprehensive evaluation. AJR Am J
Roentgenol 190(1):5–9, 2008.
 CHA P T ER 2
BASIC PATHOLOGY CONCEPTS
CHAPTER OUTLINE
Muscle and Tendon Injury
Bone Injury
Infection
Arthritis
Rheumatoid Arthritis
Psoriatic Arthritis
Gout
Osteoarthritis
Myositis and Diabetic Muscle Infarction
Soft Tissue Foreign Bodies
Peripheral Nerve Entrapment
Soft Tissue Masses
Lipoma
Peripheral Nerve Sheath Tumors
Vascular Anomalies
Ganglion Cysts
Lymph Nodes
Malignant Soft Tissue Tumors
Bone Masses
MUSCLE AND TENDON INJURY
Muscle and tendon injuries may be categorized
as acute and chronic. Acute injuries tend to take
the form of direct impact injury, stretch injury
during contraction (strain), or penetrating injury.
Acute muscle injury can be clinically categorized
as grade 1 (no appreciable fiber disruption), grade
2 (partial tear or moderate fiber disruption with
compromised strength), and grade 3 (complete
fiber disruption).1 At sonography, muscle contusion
and hemorrhage acutely appear hyperechoic (Fig.
2.1).2,3 Excessive and intense muscle activity may
produce diffuse muscle hyperechogenicity if
imaged acutely from transient muscle edema,
termed delayed onset muscle soreness (Fig. 2.2).4
Muscle tears will appear as an abnormal hypoechoic
or mixed echogenicity area or muscle defect.5 One
hallmark of full-thickness tear is muscle or tendon
retraction, which is made more obvious with
passive movement or active muscle contraction.
Hemorrhage will later appear more hypoechoic
16
(Fig. 2.3), although a heterogeneous appearance
with mixed echogenicity is common (Fig. 2.4).
As soft tissue hemorrhage resorbs, a hematoma
will become smaller and more echogenic, begin-
ning at the periphery (Fig. 2.5). A residual anechoic
fluid collection or seroma may remain (Fig. 2.6).
Hemorrhage located between the subcutaneous
fat and the adjacent hip musculature can occur
with trauma as a degloving-type injury, called the
Morel-Lavallée lesion (Fig. 2.7).6 Residual scar
formation appears hyperechoic (Fig. 2.8). Het-
erotopic ossification may remain and is hyperechoic
with posterior acoustic shadowing (Fig. 2.9). An
area of damaged muscle may ossify, termed myositis
ossificans (Fig. 2.10), and ultrasound can show early
mineralization before visualization on radiogra-
phy.7 Often, computed tomography (CT) is needed
to demonstrate the characteristic peripheral
rim of mineralization characteristic of myositis
ossificans, given shadowing seen on ultrasound.
Prior trauma to muscle or its nerve supply can
result in muscle atrophy, which causes increased
echogenicity and decreased size of the affected
muscle (Fig. 2.11).
With direct impact injury, the belly of a muscle
is typically involved with hematoma and variable
fiber disruption (Fig. 2.12). In contrast, stretch-
ing of a contracting muscle typically results in
injury at the musculotendinous junction and is
more common with muscles that span two joints,
such as the hamstring muscles (Fig. 2.13) and the
medial head of the gastrocnemius (Fig. 2.14).
The specific type of muscle architecture should
be considered when evaluating for myotendinous
injury. For example, a muscle with a unipennate
architecture (e.g., the medial head of the gastroc-
nemius) shows injury at the myotendinous junction
located at its periphery (Fig. 2.14).8 A muscle with
circumpennate or bipennate architecture (e.g., the
indirect head of the rectus femoris) may show
injury at its distal musculotendinous junction or
within the muscle belly as a central aponeurosis
tear (see Fig. 6.65A).9 Musculotendinous injury
also demonstrates variable echogenicity from
hemorrhage and fluid, depending on the age of the
injury and the degree of fiber disruption. Passive
joint movement or active muscle contraction can
demonstrate retraction at the site of the injury
that indicates full-thickness tear. Particularly in
children, these types of acute tendon injuries may
 Basic Pathology Concepts 17

A B
FIGURE 2.1 Acute Muscle Injury. Ultrasound images of (A) the thenar musculature and (B) the tibialis anterior
muscle show areas of hyperechoic hemorrhage (open arrows). T, Tendon.

A B
FIGURE 2.2 Delayed Onset Muscle Soreness. Ultrasound images of (A) brachioradialis and (B) brachialis muscle
in short axis from two different patients show diffuse hyperechoic muscle edema (arrows) compared with normal
muscle (M).

be associated with bone fragment avulsion at the
tendon attachments, which appear hyperechoic
with possible shadowing.
With penetrating injury or laceration, acute
muscle and tendon injury may occur at any site.
The obvious physical examination findings usually
guide the ultrasound evaluation. Muscle and
tendon injuries are again classified as partial-
thickness or full-thickness tears. Dynamic imaging
is helpful in this distinction because it makes
retraction related to full-thickness tears more
conspicuous. Gas introduced during the penetrat-
ing injury can make evaluation extremely difficult;
air appears hyperechoic with heterogeneous
posterior shadowing. In addition to muscle or
tendon abnormality, penetrating injury may also
produce bone and peripheral nerve injury (see
Fig. 6.93B).
18 CHAPTER 2

A B
FIGURE 2.3 Subacute Muscle Injury. Ultrasound images of (A) the thenar musculature and (B) the tibialis anterior
muscle show heterogeneous areas of hypoechoic hemorrhage (arrows).

A C
FIGURE 2.4 Hemorrhage. Ultrasound images of (A) the pectoralis major, (B) medial head of gastrocnemius, and
(C) soleus show heterogeneous mixed echogenicity hemorrhage (arrows). G, Gastrocnemius.
 Basic Pathology Concepts 19

T
B

A T

C D
FIGURE 2.5 Organizing Hematoma. Ultrasound images (A and B) anterior to the tibia and (C and D) within the
calf show interval decrease in size of hematoma (arrows) (A to B, C to D) with increased echogenicity at the
periphery. T, Tibia.

R R
R
A B
FIGURE 2.6 Seroma. Ultrasound images (A and B) from two different patients show anechoic fluid collection
(arrows) at site of prior hemorrhage. R, Ribs in A.

Chronic muscle and tendon injuries are usually
the result of overuse, with tendon degeneration
and possible tear. It has been shown that such
involved tendons show eosinophilic, fibrillar, and
mucoid degeneration but do not contain acute
inflammatory cells; therefore, the term tendinosis
is used rather than tendinitis.10-12 At sonography,
tendinosis appears as hypoechoic enlargement of
the involved tendon, but without tendon fiber
disruption (see later chapters). Several tendons
may commonly show increased blood flow on
color or power Doppler imaging in the setting
of tendinosis, such as the patellar tendon, Achilles
tendon, and common extensor tendon of the
20 CHAPTER 2

FIGURE 2.7 Morel-Lavallée Lesion. Ultrasound image

over lateral hip shows anechoic fluid (arrows) at the
site of prior hemorrhage between subcutaneous fat
(F) and musculature (M).

FIGURE 2.9 Heterotopic Ossification. Ultrasound image

shows hyperechoic surface of heterotopic ossification
(arrows) with posterior acoustic shadowing (open
arrows).

B
A

C
FIGURE 2.8 Muscle Scar. Ultrasound images of (A) the symptomatic semimembranosus and (B) the contralateral
asymptomatic side show hyperechoic scar formation (arrows) and decreased size of affected muscle. Ultrasound
image of (C) rectus femoris in long axis shows focal increased echogenicity (arrows).
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN