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The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Patients and physicians have increasingly sought minimally invasive procedures such as ultrasound-guided injection for the treatment of peripheral nerve entrapment syndromes. In this series, we assessed subjective outcome data in 14 patients who underwent ultrasound-guided perineural hydrodissection and steroid injection for pronator syndrome secondary to median nerve entrapment in the pronator tunnel. Excellent symptomatic relief (≥75% improvement) was achieved in 70% of nerves with 3-month follow-up data, with no significant change in symptoms between 3 and 6 months. These outcomes suggest that this technique could play a role in the management of pronator syndrome due to median nerve entrapment.

Utrasonography is emerging as a core method to evaluate musculoskeletal problems. It is best used for imaging superficial structures limited to 1 quadrant of a joint. It has several advantages over other imaging methods: lower cost, ability to perform dynamic examinations, higher spatial resolution of superficial structures, better patient comfort, and essentially no contraindications.

We sought to determine whether there are ultrasound parameters that differ between knees with symptomatic fat pad synovial impingement and asymptomatic knees.A prospective study was performed in patients with clinical signs and symptoms of fat pad synovial impingement and asymptomatic controls. Eleven symptomatic knees and 10 asymptomatic controls were evaluated. Ultrasound imaging was performed before and after exercise. Evaluated parameters included largest fat lobule compressibility, subjective assessment of vascularity, largest vessel diameter, and subjective assessment of dynamic fat pad motion during flexion and extension. Receiver operating characteristic (ROC) curve analysis was used to assess whether changes in these parameters were different between symptomatic and asymptomatic knees.Change in the largest vessel diameter was greater and trended toward dilation in asymptomatic knees compared to symptomatic knees (mean: 0.83 vs. -0.02; P0.001). No significant differences were observed between symptomatic and asymptomatic knees with respect to pre-exercise versus post-exercise states in subjective assessment of vascularity (P=0.131), fat pad motion (P=0.115), or percent change of the largest fat lobule (P=0.241). However, overall compressibility of the fat pad lobule was significantly diminished in the pre-exercise state in symptomatic knees compared to asymptomatic controls.This study demonstrated a statistically significant change in the largest vessel diameter from pre- to post-exercise states between symptomatic and asymptomatic knees, as well as abnormal pre-exercise fat lobule compressibility in symptomatic knees. These findings show promise that with further research, ultrasound could have clinical utility in diagnosing infrapatellar fat pad impingement.

Background The medial patellofemoral ligament (MPFL) is an important soft tissue constraint to preventing patellar dislocations in young athletes. The anatomy of the MPFL has been investigated in cadaveric studies and magnetic resonance studies. No studies to date have provided anatomical data of the MPFL on ultrasonography. Purpose To investigate the feasibility of musculoskeletal ultrasonography for the evaluation of the MPFL, and to determine interrater and intrarater reliability for MPFL ultrasound measures. Methods Ten control participants (20 knees) 20 to 50 years underwent ultrasonography performed by 3 researchers (musculoskeletal ultrasound radiologist, athletic trainer/biomechanist, primary care sports medicine physician) from 3 different institutions for interrater reliability testing. Intrarater reliability testing was performed at 2 separate institutions by 4 physicians, each performing the same knee ultrasound protocol on 20 knees in 10 study participants 2 to 3 weeks apart. In total, 180 images were created for interrater reliability, and 480 images for intrarater reliability. Examinations were performed with linear high-frequency transducers (10-18 MHz) with the participant in the supine position and the extremity flexed at 45°. Measurements included ligament length (long axis to ligament) from the patellar to the femoral attachment sites, ligament width (short axis to ligament) at the patellar attachment, and ligament thickness (long axis to ligament) midway between the patella and femur. Mean and SD were calculated for all measurements. Intraclass correlation coefficient (ICC) analysis was used to assess intrarater and interrater reliability. ICC values < 0.40 indicated poor reliability, whereas those between 0.40 and 0.75 indicated fair to good reliability, and those > 0.75 indicated excellent reliability. Results The mean US value for MPFL length was 44.83mm (SD 6.68), mean thickness 2.66mm (SD 0.85), and mean width 11.76mm (SD 2.99). The overall ICC values for interrater reliability testing indicated fair to good reliability for length measures (0.7) and poor reliability for thickness (–0.1) and width (0.3; Table 1.1). Overall ICC values for intrarater reliability indicated fair to good reliability for length (0.5), excellent for thickness (0.9), and poor reliability for width (–0.3; Table 1.2). Conclusions Musculoskeletal ultrasonography is a feasible and reliable office-based method of measuring MPFL length and thickness. These quantitative measures set the groundwork for establishing normative anatomical measures of the MPFL in athletes and establish a protocol for testing and measuring the MPFL using musculoskeletal ultrasonography. Table 1.1. Intraclass Correlation Coefficients (ICC) for testing reliability between physicians (inter-rater). ICC Length Thickness Width Overall 0.708(0.291, 0.898) -0.047(-0.452, 0.442) 0.253(-0.179, 0.652) xx vs xx 0.833(0.562, 0.937) -0.055(-0.312, 0.309) 0.062(-0.389, 0.498) xx vs xx 0.297(-1.246, 0.776) -0.014(-0.385, 0.447) 0.253(-0.130, 0.672) xx vs xx 0.707(0.053, 0.907) 0.032(-2.554, 0.704) 0.286(-0.874, 0.756) *Data analyzed using two-way mixed, absolute agreement analysis. Expected value is shown, along with lower and upper bounds of 95% confidence intervals. Table 1.2. Intraclass Correlation Coefficients (ICC) for test-retest (intra-rater) reliability among individual physicians. Length Thickness Width Overall 0.492*(0.190, 0.681) 0.858(0.772, 0.912) -0.319(-0.056, 0.566) Physician 1 0.589(-0.024, 0.842) 0.400(-0.300, 0.754) 0.386(-0.241, 0.756) Physician 2 0.014(-0.393, 0.447) 0.260(-0.965, 0.722) -0.097(-0.683, 0.432) Physician 3 -0.085(-2.104, 0.604) 0.463(-0.228, 0.786) -1.910(-7.683, -0.027) Physician 4 0.792(0.467, 0.918) 0.634(0.053, 0.857) -0.224(-1.272, 0.435) *Data analyzed using two-way mixed, absolute agreement analysis. Expected value is shown, along with lower and upper bounds of 95% confidence intervals.

OBJECTIVES The purpose of this study was to define and report on the effect of a comprehensive musculoskeletal sonography training program to improve accuracy (sensitivity and specificity) for the diagnosis of rotator cuff tears in relatively inexperienced operators. METHODS Before the training program was implemented, radiologists (n = 12) had a mean of 2 years (range

A. Background Functional popliteal artery entrapment syndrome (fPAES), a cause of exertional leg pain, has a clinical presentation and clinical findings that are often indistinguishable from those of other leg pain causes (1). This condition may also coexist and overlap in symptomatology with other leg pain causes, further complicating the diagnosis (2). Although fPAES is usually considered a rare cause of leg pain (3), the true incidence of this condition is unknown, and fPAES is likely underdiagnosed and underreported (4). A missed diagnosis may result in disease progression and the use of unnecessary invasive procedures (3), and untreated fPAES may lead to popliteal artery damage, embolization, and limb ischemia (5). Although a diagnostic method using a combination of dynamic ultrasound and MR imaging/MR angiography has been described for fPAES (5), to our knowledge, no investigational studies have been performed to assess the dynamic ultrasound findings in this entity. This study sought to evaluate the usefulness of dynamic plantar flexion and dorsiflexion of the calf and the effect on the popliteal artery Doppler waveform in patients with clinically suspected fPAES and no structural abnormality. B. Methods We performed a retrospective review of ultrasound studies in patients who presented with clinically suspected PAES over a 3-year period. The ultrasound studies consisted of an anatomic survey of the popliteal. Dynamic nonresistant dorsiflexion and plantar flexion evaluations of the popliteal artery plus spectral Doppler evaluations of the popliteal artery obtained in neutral, plantar flexion, and dorsiflexion positions were performed before and after patients exercised. Patients with anatomic abnormalities were excluded. The following parameters were assessed: The proportion of symptomatic knees versus asymptomatic knees in which plantar flexion and/or dorsiflexion of the foot resulted in popliteal artery compression. The peak systolic velocity (PSV) of the popliteal artery in all positions for knees with and knees without dynamic popliteal artery compression. The absolute value change in PSV of the popliteal artery from neutral to plantar flexion and from neutral to dorsiflexion in the pre- and postexercise state for knees with and knees without dynamic popliteal artery compression. ROC analysis for clustered data was used to assess the ability of PSV to distinguish between knees with and knees without arterial compression. C. Results A total of 88 knees (77 symptomatic, 11 asymptomatic) in 45 patients were included in the study. Dynamic arterial compression was observed in 38% (29/77) of symptomatic knees. No compression seen in asymptomatic knees. Both pre-exercise and postexercise knees with arterial compression had significantly higher absolute changes in PSV from neutral to plantar flexion versus knees without arterial compression (Table). There was a smaller significant change in PSV from neutral to dorsiflexion in the pre-exercise state. There was no significant change in PSV in the postexercise state from neutral to dorsiflexion or with respect to PSV values at any position between knees with and knees without arterial compression. D. Conclusions/Significance In patients with clinically suspected PAES without anatomic abnormality, dynamic ultrasound demonstrated compression of the popliteal artery in 38% of knees. No dynamic arterial compression was seen in asymptomatic knees. There was a significant elevation in PSV from neutral to plantar flexion in pre- and postexercise states and from pre-exercise neutral to dorsiflexion positions in knees with arterial compression versus knees without arterial compression. Tables [Table: see text] References Joy SM, Raudales R. Popliteal artery entrapment syndrome. Curr Sports Med Rep. 2015;14(5):364-367. Hislop M, Kennedy D, Cramp B, Dhupelia S. Functional popliteal artery entrapment syndrome: poorly understood and frequently missed? A review of clinical features, appropriate investigations, and treatment options. J Sports Med (Hindawi Publ Corp). 2014;2014:105953. Gaunder C, McKinney B, Rivera J. Popliteal artery entrapment or chronic exertional compartment syndrome? Case Rep Med. 2017;2017:6981047 Hislop M, Brideaux A, Dhupelia S. Functional popliteal artery entrapment syndrome: use of ultrasound guided Botox injection as a non-surgical treatment option. Skeletal Radiol. 2017;46(9):1241-1248. Williams C, Kennedy D, Bastian-Jordan M, Hislop M, Cramp B, Dhupelia S. A new diagnostic approach to popliteal artery entrapment syndrome. J Med Radiat Sci. 2015;62(3):226-229.

Bowler's thumb is a rare traumatic neuropathy of the ulnar digital nerve of the thumb. We present a case of bowler's thumb in a 21-year-old male recreational bowler who presented with a painful mass on the ulnar side of the right thumb. Magnetic resonance (MR) imaging of the hand was inconclusive. However, subsequent ultrasound (US) showed asymmetric enlargement of the ulnar digital nerve of the thumb with marked epineural thickening corresponding to the palpable mass, confirming the clinical diagnosis of bowler's thumb. Although this condition is typically diagnosed clinically, imaging can help to clarify clinical findings. In our experience, MR imaging is a clinician's preferred choice when further evaluating physical findings of digital nerve pathology despite the lack of evidence to support MR as a primary imaging modality for these patients. This case illustrates the role that US can play as an initial imaging modality for the evaluation of small peripheral nerves.

The purpose of this article is to report 3 cases of Kager's fat pad scarring and tethering to the deep surface of the Achilles tendon in patients with Achilles tendinosis symptomatology. The 3 patients were diagnosed sonographically by the use of a dynamic maneuver we described and named the "Kager's squeeze" technique. The key finding for diagnosis is the deformation and bowing of the deep fibers of the Achilles tendon during dynamic squeezing of Kager's fat pad. After diagnosis, the patients were treated with ultrasound-guided hydrodissection and scar release to restore normal motion between Kager's fat pad and the Achilles tendon. All 3 patients experienced significant clinical improvement shortly after treatment. Therefore, we suspect that Kager's fat pad scarring with Achilles tendon tethering may mimic or exacerbate Achilles tendinosis symptomatology and should be considered a possible diagnosis when conservative treatments for Achilles tendinosis fail. We demonstrate that Kager's fat pad scarring with Achilles tendon tethering can be diagnosed and treated with a simple in-office hydrodissection technique, leading to improved patient outcomes.

The use of high-frequency (high-resolution) musculoskeletal ultrasonography is increasing and has shown promising utility in many areas of medicine. The utility of musculoskeletal ultrasonography for foot and ankle complaints has not been widely investigated, however. Although some conditions of the foot and ankle are easily diagnosed by physical examination, others can have nonspecific examination findings, making optimal treatment decisions difficult. We hypothesized that high-resolution musculoskeletal ultrasound scanning of the foot and ankle can affect the diagnosis and/or treatment for patients presenting with foot or ankle complaints. Retrospectively, the cases of 98 patients who had undergone musculoskeletal ultrasound scanning of the foot or ankle were reviewed. The pre-ultrasound clinical diagnosis and treatment were compared with the post-ultrasound diagnosis and treatment. In 64% of the patients, the diagnosis or treatment changed after the ultrasound examination. In 43% of patients, both the diagnosis and the treatment changed after ultrasound scanning. For those patients for whom the diagnosis and treatment were unchanged after the ultrasound examination, the ultrasound findings were concordant with the pre-ultrasound clinical diagnosis for 100% of the patients. These results suggest that in a large proportion of patients, high-resolution musculoskeletal ultrasonography of the foot or ankle can facilitate appropriate diagnosis and management.

Background. We routinely observed “isolated” laryngeal penetration (ILP) on upper GI studies in infants with no risk for aspiration. Objective. To determine whether “isolated” LP (LP during the pharyngeal phase of swallowing) is a benign process in infants and therefore not a predictor of aspiration as it is known to be in adults. Patients and methods. Two radiologists retrospectively reviewed videotaped upper GI studies done over a 2-year period on patients less than 2 years of age. A total of 110 studies was reviewed, which produced a study group of 34 patients who had no history or clinical suspicion for swallowing dysfunction. Results. Of the 34 patients in the group, 33 demonstrated ILP without radiographic or clinical evidence of aspiration. Conclusion. ILP is a benign, normal process in infants likely due to immaturity of the swallowing mechanism. It is not a reliable predictor of aspiration as it is in adults.