The Use of Ultrasound in Sports Traumatology

Carlos H. Yacuzzi, MD, ARGENTINA Franco Della Vedova, MD, ARGENTINA

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Introduction

Interest in ultrasound in sports medicine has grown dramatically in recent years, largely due to significant advances in imaging quality. In contrast to static modalities such as magnetic resonance imaging (MRI) and computed tomography (CT), ultrasound allows for real-time, dynamic assessments. Other advantages include affordability, ease of transport, minimal interference from metallic implants, and the ability to obtain scans quickly. This has resulted in an increasing number of orthopaedic surgeons and sports medicine physicians incorporating this method into their everyday clinical practice, both in the office and as team physicians on the field. Another significant application of ultrasound is its use in performing procedures, particularly those involving regenerative therapies.

This article explores the benefits of ultrasound in everyday clinical practice, focusing on its role in the diagnosis and treatment of sports medicine injuries.

Diagnostic and Therapeutic Applications of Ultrasound in Sports Traumatology

Ultrasound offers unparalleled advantages for diagnosing musculoskeletal injuries in athletes. The ability to produce high-resolution, dynamic images in real-time allows clinicians to assess tissues during movement, providing a comprehensive understanding of the injury.

Currently, the primary focus of ultrasound application in sports medicine lies in diagnosing acute injuries to muscles and tendons as well as injuries caused by repetitive strain or overuse.

Muscle Injuries

While MRI remains the gold standard for diagnosing musculoskeletal injuries, ultrasound provides a quick and accurate initial diagnosis and helps to guide future treatment. As ultrasound is usually more readily available than MRI, it is particularly suitable for initial diagnosis and for repeated follow-up examinations in popular and elite sports to ensure close monitoring of training or early detection of complications.

Muscle injuries caused by direct trauma, such as those common in contact sports like football and rugby, typically result in intramuscular hemorrhage without fiber tearing, manifesting as contusions or, in severe cases, lacerations. Ultrasound is a critical tool for identifying and documenting these injuries, enabling consistent follow-up with longitudinal, cross-sectional, and panoramic imaging. Additionally, ultrasound-guided puncture of hematomas can alleviate pain, expedite recovery, and provide insights into structural damage.

In contrast, injuries caused by indirect trauma, often due to overstretching during eccentric contractions, can lead to muscle fiber ruptures. While ultrasound is reliable for detecting structural injuries, it is less effective than magnetic resonance imaging (MRI) for assessing the full extent of damage or identifying minor, non-structural injuries. Injuries involving the myotendinous junction, particularly in the lower extremities, highlight the importance of evaluating tendon segments for prognosis. Ultrasound is valuable for short-term follow-up and intervention, especially when used alongside MRI. However, its ability to detect minor injuries (grades 1 and 2) is limited, often resulting in discrepancies compared with MRI findings. Despite these limitations, ultrasound remains an effective tool for ruling out severe injuries (grades 2 and 3) and supporting initial clinical assessments. In cases in which clinical symptoms and ultrasound findings do not align, MRI provides greater sensitivity and diagnostic clarity.

Ligament and Tendon Injuries

Ultrasound has been a well-established diagnostic tool for ligament and tendon injuries for decades, offering dynamic imaging, high spatial resolution, and Doppler capabilities. It is particularly effective for superficial structures like the Achilles tendon, patellar tendon, quadriceps tendon, and knee ligaments. Ultrasound is now the preferred method for diagnosing tendinopathies, such as jumper’s knee and Achilles tendinitis.

Patellar tendinopathy, common among jumping athletes, can be diagnosed by identifying hypoechoic areas, increased vascularity, and tendon thickening. Neovascularization may indicate that a patient could benefit from recently described therapies. Similarly, rotator cuff tendinosis can be diagnosed by detecting hypoechoic areas, calcifications, and tears. Ultrasound is a preferred choice in many clinical settings due to its sensitivity and specificity. Ultrasound also can identify biceps tendon abnormalities, including tendon sheath effusion, subluxation, or dislocation.

Calcific tendinosis of the rotator cuff is commonly observed in clinical practice. Both ultrasound-guided needle aspiration and extracorporeal shockwave therapy improve outcomes. Compared with shockwave therapy alone, aspiration combined with shockwave therapy resulted in better Constant scores and lower rates of progression to surgical debridement. The dynamic nature of ultrasound also enables the assessment of tendon functionality during movement, thereby providing additional diagnostic information that is unavailable from static imaging.

The capability of diagnosing rotator cuff pathology through ultrasound has been demonstrated to be highly dependent on the diagnostic expertise of the user. The use of ultrasound for the diagnosis of rotator cuff tears may be confined to academic centers with radiologists who have received comprehensive training in this field.

Ultrasound also effectively differentiates between partial and complete ligament or tendon tears with high precision. For less-common injuries, such as those affecting the aponeuroses of the gastrocnemius or soleus muscles, ultrasound offers optimal characterization due to their superficial location. Overall, these advancements ensure that ultrasound continues to be an indispensable tool for the diagnosis and monitoring of ligament and tendon injuries.

Ultrasound as a Versatile Diagnostic Tool for Various Musculoskeletal Conditions

In the shoulder, ultrasound is effective for identifying abnormalities of the rotator cuff, biceps tendon, glenohumeral joint, and acromioclavicular joint. Its sensitivity for diagnosing labral tears ranges from 67% to 95%, and it can also detect paralabral cysts, which may compress nerves, emphasizing the need to evaluate periarticular structures such as the spinoglenoid and suprascapular notches (Fig. 1).

Fig. 1 An orthopaedic surgeon conducting an in-office ultrasound examination of the shoulder to diagnose and subsequently inject a partial tear of the supraspinatus tendon with platelet-rich plasma.

In the knee, ultrasound is valuable for detecting peripheral meniscal tears, ligament injuries (e.g., MCL sprains), and conditions such as patellar or quadriceps tendinopathy, bursitis, and Baker cysts. It also aids in identifying less-common abnormalities, such as ganglion cysts, which can occur in atypical locations like the proximal tibiofibular joint or tendon sheaths.

In the elbow, ultrasound can detect partial or full-thickness tendon tears, tendinosis, epicondylitis, ligament damage, ulnar nerve entrapment, olecranon bursitis, and effusions, making it a comprehensive diagnostic option.

In the hip, it is particularly effective for evaluating snapping hip syndrome caused by external, internal, or intra-articular factors, as well as for assessing abductor muscle injuries such as tendinosis or tendon tears.

Ultrasound is equally effective for diagnosing Achilles tendon issues, such as tendinosis, tears, and Haglund syndrome. It also visualizes nearby structures, including the plantaris tendon and retrocalcaneal bursa, aiding in comprehensive assessment.

Dynamic imaging further enables the identification of peroneal tendon subluxation, crucial for early intervention, while the diagnosis of plantar fasciitis is enhanced by the ability of ultrasound to detect hypoechoic changes and increased plantar fascia thickness in symptomatic patients. This highlights the overall utility of the modality in evaluating a wide range of musculoskeletal conditions.

Ultrasound as a Tool in the Office

The use of ultrasound is becoming increasingly prevalent in the offices of orthopaedic surgeons and sports medicine physicians. The ease of accessibility and the relatively short learning curve associated with this technology make it a highly valuable tool in the clinical setting. At present, point-of-care ultrasound (POCUS) confers several advantages for patients, including the avoidance of additional diagnostic procedures, a reduction in healthcare expenditure, and an enhancement of patient satisfaction.

It is evident that a shoulder surgeon with fundamental training can accurately diagnose rotator cuff injuries with a sensitivity that is comparable with that of an ultrasound specialist. In the field of sports medicine, ultrasound is the preferred diagnostic and monitoring tool for tendon and muscle pathologies. Furthermore, it is an invaluable tool for the detection of occult fractures.

The advent of portable ultrasound devices has made them more affordable for healthcare professionals, offering user-friendly functionality with excellent image resolution. The incorporation of ultrasound training into the curricula of residency programs across a range of specialties has resulted in enhanced recognition and comprehension of normal anatomy. In particular, the incorporation of ultrasound training into orthopaedic residencies has led to a notable increase in interest in utilizing this method.

The Use of Ultrasound by Team Physicians

The advancement of portable ultrasound technology, which can now connect seamlessly to tablets or even smartphones, has made it increasingly practical to have these devices available in any sports setting.

Ultrasound has proven to be an invaluable tool for team physicians. It can be utilized by a specialist in imaging within the medical team or through targeted training of the team physician to perform diagnostic evaluations during practices and games. Key applications include diagnosing muscle injuries and confirming fractures that may be challenging to identify clinically.

Furthermore, ultrasound offers significant utility for performing procedures such as guided injections or draining acute traumatic hematomas, whether immediately after an injury or a few days later.

Another important use, with basic training, is the ability to diagnose abdominal or thoracic pathologies, which can be critical in acute or emergent scenarios.

This integration of portable ultrasound in sports medicine enhances the ability of team physicians to deliver precise and immediate care, improving outcomes for athletes in competitive settings (Fig. 2).

Fig. 2 An ultrasound examination of the shoulder and hamstrings was conducted on two athletes in a locker room setting during a tournament. The examination confirmed the presence of an injury and provided additional information for the management of the player throughout the event.

Ultrasound-Guided Injections

The use of ultrasound for the administration of injections has markedly enhanced the efficacy of most procedures. This is particularly relevant in the context of orthobiologics and other regenerative therapy injections. For example, in the case of platelet-rich plasma, the existing literature is primarily focused on investigating the optimal concentration of platelets, the potential benefits of incorporating leukocytes, and the recommended volume for administration. It is notable that there is a paucity of studies that describe the infiltration technique. This is, in our opinion, a crucial factor in determining the efficacy of the treatment (Fig. 3).

Fig. 3 Percutaneous aspiration of a parameniscal cyst and subsequent injection of triamcinolone into the affected region in a patient presenting with a horizontal tear of the medial meniscus.

Another crucial aspect is that the utilization of ultrasound facilitates a reduction in procedural discomfort, as the needle is accurately positioned and, according to various studies, fewer punctures are required than is the case in the absence of ultrasound guidance.

In the shoulder joint, ultrasound-guided injections—particularly in the glenohumeral and acromioclavicular joints, the bicipital groove, and for neural blocks—have demonstrated superior effectiveness, reduced patient discomfort, and notably improved clinical outcomes. While the efficacy of subacromial injections is comparable regardless of whether the injections are performed with or without ultrasound, studies have indicated that ultrasound-guided procedures yield better clinical results and higher patient satisfaction.

Tendinopathies are among the conditions that benefit most from the use of ultrasound. This imaging modality enables targeted treatment of tendinosis and partial tendon tears while allowing precise delivery of medications to the peritendon. Such precision is especially valuable in the application of regenerative therapies.

Moreover, ultrasound has facilitated the performance of regenerative treatments for muscle injuries, which would otherwise be unfeasible.

Finally, ultrasound provides the ability to perform highly accurate diagnostic injections. By selectively anesthetizing specific structures with small doses of lidocaine, clinicians can confirm a diagnosis with absolute certainty if the patient experiences symptom relief.

The disadvantages of this method are that it increases the costs and time required for the procedures to be performed, as well as the necessity for extreme aseptic precautions due to the addition of more elements within the sterile field.

Conclusion

Ultrasound imaging is a vital tool in sports traumatology, offering significant benefits for both diagnosis and treatment. Its non-invasive nature, capacity for real-time dynamic imaging, and effectiveness in guiding therapeutic interventions render it indispensable in contemporary sports medicine. With ongoing advancements and greater accessibility, ultrasound is set to assume an even more prominent role in the management of sports-related injuries.

This method has experienced exponential growth within our specialty, to the point where it is now often referred to as the orthopaedic surgeon’s stethoscope. We believe that much like in other specialties such as cardiology, gynecology, and obstetrics, orthopaedic surgeons will be the ones performing these procedures in our offices, ultimately enhancing patient care and satisfaction.

References

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