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Sonoanatomic Fundamentals of Musculoskeletal Ultrasound

Article in Journal of Indian Rheumatology Association · August 2018

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Review Article

Sonoanatomic Fundamentals of Musculoskeletal Ultrasound

Ingrid Möller1,2, M Isabel Miguel-Perez2, David Bong1,3, Albert Perez4, Carlo Martinoli5
1
Instituto Poal de Reumatologia, 2Departament de Patologia i Terapèutica Experimental, Unitat d'Anatomia i Embriologia Humana, 3Departament de
cliniques (Enfermeria), Facultat de Medicina i Ciències de la Salut, Campus de Bellvitge, Universidad de Barcelona, 4Department of Basic Sciences,
Universitat Internacional de Catalunya, Barcelona, Spain, 5Department of Health Science, University of Genoa, Ospedale Policlinico San Martino, Genova,
Italy

Received: May, 2018

Accepted: June, 2018
Abstract
Published: August, 2018 Over the years, anatomists have discerned basic anatomic principles that are applicable to the
understanding of the structure and function of the superficial “soft tissues” of the human body
including fascia, tendon, muscle, enthesis and nerve. Musculoskeletal ultrasound affords an
inexpensive, high-resolution, dynamic, real-time, safe and well-tolerated imaging modality to
visualize these tissues. The purpose of this article is to apply these anatomic principles to the
Address for correspondence:
Dr. Ingrid Möller,
ultrasound image of these structures and enhance the fundamental anatomic understanding
Castanyer 15, Barcelona 08022, of practitioners of musculoskeletal ultrasound.
Spain.
E‑mail: ingridmoller@gmail.com Key Words: Fascia, musculoskeletal, nerves, Sonoanatomy, ultrasound

Introduction Since MSKUS has a resolution that exceeds other imaging

modalities and is dynamic and performed in real time,
In evaluating the so‑called “soft tissues” of the human
mastering the anatomy of the musculoskeletal system
body, a thorough knowledge of anatomy is fundamental to
involves understanding the functions, biomechanics, and
performing an accurate physical examination and developing
interrelationships between the different components that
a tenable differential diagnosis and for the evaluation of
occupy the space between the subcutaneous tissue and the
imaging of these soft tissues especially in the locomotor
bone. The anatomic and functional organization of skeletal
system. Imaging utilizing high‑resolution musculoskeletal
muscle, for example, is governed by general principles,
ultrasound (MSKUS) is increasingly becoming a routine
among which the following stand out: the disposition
part of rheumatologic care. Sonoanatomy refers to the
of the different structures must obtain maximum
knowledge of anatomy necessary to interpret the complex
performance with the minimum energy consumption while
two‑dimensional gray‑scale anatomic image obtained of
at the same time protecting essential elements. This article
three‑dimensional musculoskeletal tissues. Studies have
is intended to consider the importance of the elemental
shown that limited knowledge of musculoskeletal anatomy
aspects of the musculoskeletal system related to the
on the part of the rheumatologist presents a significant
ultrasound image as follows: fascia including retinacula,
challenge in assimilating MSKUS and being able to apply
muscle and tendon, and finally, the enthesis. It has been
it to the problem‑solving required in daily practice.[1]
organized from superficial structures to deep and begins
Recently, MSKUS and the sonoanatomic images have been
with the fasciae owing to their ubiquitous multifunctional
employed as a tool in the teaching , the basic principles
nature and overall importance in their biomechanical
of musculoskeletal anatomy to health‑care professionals
contribution to the musculoskeletal system.
at the medical school.[2] All of this have generated the
need for continued enhancement of the anatomic Fascia
knowledge base to stay abreast of scientific advances in
the understanding of rheumatic and soft‑tissue disorders Fasciae are soft connective tissue that Benjamin, in his
along with improvements in instrumentation.[3] Yet, it goes review,[4] described “as a body‑wide mechanosensitive
beyond simple memorization of more anatomic details. signaling system with an integrating function analogous
to that of the nervous system.” According to its location

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DOI:
How to cite this article: Möller I, Miguel-Perez MI, Bong D, Perez A,
Martinoli C. Sonoanatomic fundamentals of musculoskeletal ultrasound.
10.4103/0973-3698.238194
Indian J Rheumatol 2018;13:S4-8.

© 2018 Indian Journal of Rheumatology | Published by Wolters Kluwer - Medknow S4

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Möller, et al.: Sonoanatomy fundamentals

and function, the fascia can be divided into superficial and

deep, although this distinction can be difficult in some
locations of the locomotor system.
The superficial fascia is the adipose tissue [Figure 1]
or areolar connective tissue beneath the skin, which
transports blood vessels from nerves to the skin while
facilitating or restricting movement between it and the
underlying tissues. It gives the skin ability to slip and then
recover to its initial position as noted on the dorsum of the
hand or foot. In other locations, it is firmly fixed to deep
planes (palm of the hand or sole of the foot) restricting
the movement in favor of a gripping function; in places
such as the interphalangeal folds, it attaches directly to the
flexor tendon sheaths with the consequent risk of tendon
sheath infection when there are puncture wounds at that
Figure 1: Superficial fascia: the superficial fascia (a) is just under the skin (b)
level [Figure 2]. The collagen fibers maintain a certain in a dissection of the arm
direction in the dermis that gives rise to some skin marks
called Langer lines whereas the Kraissl lines show the
maximum tension of the skin when the muscles contract.
However, superficial and deep fasciae can be combined
and be affected jointly in fibromatosis such as Dupuytren’’s
disease or Ledderhose’s disease. The deep fascia is the
best organized and “bundles” muscles and tendons of the
locomotor system.
The deep fascia surrounds the muscles under the superficial
fascia and divides extremities into the different anatomic
and functional muscular compartments [Figure 3]. A classic
example of clinical interest is the fascia of the psoas
muscle that originates on T12 to L5 vertebrae. A localized
infection in one of these vertebral bodies can spread
distally to the inguinal region transmitted through this
Figure 2: The transversal cut of a finger shows the close relations of the
fascia. Fasciae vary according to their location and adapting adipose tissue (black arrow) with the flexor tendon sheath (*)
to the function they perform. These modifications may
be of interest when interpreting ultrasound or magnetic
resonance imaging of the locomotor system. In certain
retinacula, which are adaptations of the deep fasciae
or in the plantar fascia subjected to significant load, the
fibroblasts have a chondrocytic phenotype producing
fibrocartilage in response to mechanical stress. This also
happens in tendons subjected to the friction stress, such
as the posterior tibialis, in its trajectory around the medial
malleolus. In the sole of the foot or the palm of the hand,
the characteristic tissue of the superficial fascia will be
fibroadipose to adapt to the pressures encountered in
these areas. Modifications of the fibroadipose tissue of
the sole of the foot should be taken into account in the
differential diagnosis of biomechanical foot pain.
Retinacula Figure 3: This transversal cut of the leg shows the deep fascia how makes
the different compartments for the anterior, lateral, and posterior muscles.
The retinacula are specializations of the deep fascia In the posterior compartment also, there is a different compartment for the
destined to create tunnels that facilitate the sliding and superficial and deep muscles

direction of the tendons maintaining them in their correct

position.[5] It is interesting to know that the tendons pathologies related to entrapment. The classic example
located under the retinacula will always have synovial is the flexor retinaculum of the wrist through which
sheaths. When creating closed spaces, they can cause passes not only flexor tendons of the fingers but also the

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Möller, et al.: Sonoanatomy fundamentals
median nerve. Under the retinaculum, the median nerve
can be compressed producing carpal tunnel syndrome.
“Functional” retinacula are exemplified by the sagittal
bands that prevent the subluxation of the extensor tendons
of the fingers at the metacarpophalangeal joints [Figure 4]
or by the pulleys that on the palmar aspect of the fingers
prevent bowstringing of the flexor tendons of the fingers.
The retinacula of the wrist, the ankle or the flexor pulleys
of the fingers are composed of three different layers of
tissue adapted to their function with a sliding internal
surface composed of cells that secrete hyaluronic, a
thicker intermediate layer with support function made up
of collagen fibers, fibroblasts, and elastin, and an outer
layer of loose connective tissue which contains vascular
channels. Variations in both composition and thickness
either of the retinaculum or its content can generate
pathologic alterations such as trigger finger or stenosing
tenosynovitis.
Muscle and Tendon
Skeletal muscles in the human body provide mobility,
stability, and posture. They can be classified according to
their shape, size, direction, and function (fast and slow
contraction). According to the function they perform,
the muscles distribute their fibers in different ways.
Those muscles in which the alignment of the sarcomeres
is oblique with respect to the longitudinal axis of the
muscle/tendon are called penniform [Figure 5]. The
angle of penance is a variable influenced by factors such
as genetics, age, and muscular training. In general, it
can be said that the greater the angle of penance, the
lower the force load generated toward the corresponding
tendon. A muscle maintains its complex relationship with
the neurovascular system from embryonic development.
Perimysium and endomysium, the connective tissue that
surrounds and packages muscle fibers contribute to the
maintenance and transmission of muscle‑tendon‑bone
tension.
Figure 4: In the dorsum of the hand, it is possible to visualize the sagittal
bands that keep the extensors tendon (black arrows)
Indian Journal of Rheumatology ¦ Supplement 1 2018
The tendons, being of fibroelastic composition, transmit
mechanical forces from the muscle to the bone to
generate movement while controlling the speed at which is
performed. Wood Jones highlighted the importance of the
union between muscle and surrounding fascia (“myofascial
unions”) as a form of force transmission to surrounding
tissues and compares it with the exoskeleton that
nonvertebrate animals possess. In the human being,
these “myofascial unions” are important in creating a
stable column in the lower extremities that maintain
the erect position.[6,7] For each muscle, there will be at
least two tendons, proximal and distal, a myotendinous
junction and an enthesis. The tendon is continuous with
the periosteal tissue of the bone. Many tendons reinforce
the joint capsules forming part of the capsule and thus
contributing to capsular function. An example of this is the
extensor digitorum complex that forms the dorsal capsule
of the proximal phalangeal joint. The extensor digitorum
complex also exemplifies the functional collaboration that
may exist between various muscles and tendons. In this
case, the interossei and lumbricals that join the extensors
of the fingers in addition to reinforcing the capsule of
the phalangeal metacarpal joint are also contributing to
its delicate function. Further morphologic and functional
adaptations of tendons include widening and shortening
if force generation is required, as opposed to lengthening
and thinning if it performs delicate movements as in the
fingers. In general, the tendons of muscles of greater
volume in the extremities give origin to their tendon
before reaching the hand/wrist or foot/ankle to avoid
dysfunction by attempting to slide the muscle mass into
the confined space created by the retinaculum. Internal
tendon architecture facilitates movement between the
different fascicles of the tendon in different planes. The
endotendon is a thin sheath of connective tissue that
surrounds each fiber and connects it with neighboring
fibers and facilitates interfascicular displacement while
directing the vasculonervous bundle. This intratendinous
ability of different fibers and fascicles (bundles of fibers)
to slide independently is an important property of the
tendon from a functional point of view and can be
altered in various tendon pathologies. Tendons may be
surrounded by a synovial sheath. Tendons, such as the
Figure 5: This muscle show a penniform of this fiber that inserts in a
central tendon
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Möller, et al.: Sonoanatomy fundamentals
peroneus longus, only have synovial sheaths intermittently
at points they encounter the most friction. Some tendons
lack a synovial sheath, such as the Achilles tendon, and
are surrounded by a paratenon, a loose areolar connective
tissue that functions as an elastic cover that enhances
free movement of the tendon about the surrounding
tissues. Finally, sac‑like synovial structures, i.e., bursae may
be interposed between tendons and points of frictions
such as in the area where the distal biceps tendon runs
between the proximal radius and ulnar during supination
and pronation of the forearm. In the aging process or
secondary to trauma or recurrent microtrauma, the tendon
may become smaller as the size of the tendon collagen
fibers decreases.[8]
The tendon is less vascularized than its corresponding
muscle and occurs mainly at the level of the myotendinous
junction. The vessels, after penetrating the tendon, run
parallel to the tendinous fibers and are scarce in the areas
where the tendon changes direction such as in the tibialis
posterior tendon as it curves around the medial malleolus
of the ankle or the flexor tendons of the fingers as they
run through a pulley. In places where the tendon is more
ischemic, there is a greater predisposition to degenerative
processes and/or ruptures.
The fat pads associated with the tendons have several
functions as follows: they distribute the synovial fluid in
intratendinous bursae, they protect the blood vessels as
they enter the tendon, and they act as an immune organ
containing lymphocytes, granulocytes, and macrophages
with their interleukins, cytokines, growth, and adipokines.[9]
Enthesis
The area where tendon, ligament, and joint capsule or
retinaculum attached to the bone is called an enthesis.
To dissipate the significant forces in these regions and
enhance the strength of the junctions on the bone, the
enthesis may have fascial expansions that link them to
different neighboring structures, for example, the bicipital
aponeurosis which in addition to contributing to the
supinator function of the biceps brachii, stabilizes it by
inserting it into the deep fascia of the forearm in the dorsal
ulna. Similar to the posterior tibialis which inserts into all
of the tarsal bones of the medial and plantar midfoot, the
semimembranosus muscle has multiple insertions located
throughout the knee region such as in the posterior
capsule of the knee, in the proximal/middle third of the
tibia, in the patella, and in the medial femoral condyle.
These multiple insertions improve the medial stabilization
of the knee joint. The proximal and distal insertions of
the tendons of the rectus femoris muscle, the only part of
the quadriceps that crosses two joints, allows the rectus
femoris to be not only extensor of the knee but also a
flexor of the hip. These functions are facilitated by having
entheses in different directions that align with the force
vectors of each movement. Thus, in the clinical evaluation
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and the imaging of these entheses, one must bear in mind
their potential anatomical complexity.
The so‑called “enthesis organ” consists of connection of
tendon, ligament, and joint capsule or retinaculum to the
bone (the enthesis itself) along with the fibrocartilage
contained within the tendon, ligament, joint capsule
or retinaculum, plus the adjacent trabecular bone, and
associated bursa and fat pad. At times, the deep fascia
can also integrate with this “organ.” Entheses are normally
avascular in their fibrocartilaginous component but may
undergo vascularization in response to pathological stimuli.
Thus, the enthesis organ and its interdependent
components can manifest two very different pathologic
expressions as follows: microtrauma/degeneration and
inflammation, with distinct lesions identified by imaging
techniques such as MSKUS.
Nerves
Nerves are round or flattened cords, with a complex
internal structure made of myelinated and unmyelinated
nerve fibers, containing axons and Schwann cells grouped
in fascicles.[10] The architecture of peripheral nerves is made
up of an external sheath – the outer epineurium – which
surrounds the nerve fascicles. Each fascicle is invested by
an individual connective sheath – the perineurium – which
contains a variable number of nerve fibers and is
responsible for the “blood–nerve” barrier. Each nerve fiber
is then invested by the endoneurium. Along the course of
the nerve, fibers can traverse from one fascicle to another
fascicle, and fascicles can split and merge. The stromal
tissue intervening between the outer nerve sheath and
the fascicles is commonly referred to as the interfascicular
epineurium (internal epineurium), as opposed to the outer
epineurium which envelopes the nerve trunk as a whole.
The amount of connective tissue of the epineurium is more
abundant in large multifascicular nerves and in regions
in which the nerve is mobile across joints.[11] It provides
cushioning for the nerve, and therefore, more resistance
to compression injury.[11] Externally, the outer (external)
epineurium is in continuity with the loose areolar tissue of
perineural tissues. Nerves have a prominent vascular supply
formed by an interwoven system of perineural vessels
that course longitudinally in the external epineurium and
branch among the fascicles (endoneurial vessels).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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