9/18/18. Welcome- MSK Ultrasound Workshop. Introduction to Musculoskeletal Ultrasound. Acknowledgement of Country. The Workshop.

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1 Acknowledgement of Country Welcome- MSK Ultrasound Workshop I would like to acknowledge that this meeting is being held on the traditional lands of the Wurundjeri and Boonwurrung people and pay my respect to Elders past, present and future. Sponsored by Quantum Healthcare Samsung Ultrasound The Workshop Introduction to Musculoskeletal Ultrasound Just some ideas to start the day or What they don t tell you but you need to know Overview # 1. Everyone has 10 tips- MSK ultrasound From anatomy to terminology Experience Levels? Get you thinking.. Muscles Tendons- Connective Bursa Enthesis Connective tissue tendon or ligament and bone. Two types Fibrous - Directly on bone Fibrocartilaginous - Layer/ Chondrocytes Bone Joint Cartilage Synovium Ligaments- Connective/ Capsule Think about function 1

2 # 2. Really learn the anatomy Stepped process Draw the anatomy of the supraspinatus tendon/ muscle at the shoulder IN DETAIL So it will make sense on ultrasound And read an anatomy book Step 1 Step 1 Bone / Bony Attachments 2 points Posterior Bone / Bony Attachments Anterior Step 2 Step 3 Step 2 Cross- Sectional Anatomy book MR 2 points Understand its orientation Function- Abductor Problem- Don t straight here Key r ships Acromion/ CAL Joint 2

3 Step 4: Understand the detail Normal Anatomy of the SSP Fibrous 1mm - formed from CHL (layer 1). Fibrillar pattern Primary load-bearing fibers (layer 2). Closely packed tendon fibers Run in parallel bundles. Interspersed Connective tissue(not tear) Tendon fasicles (layer 3). smaller and obliquely oriented Vessels intervene between layers 2 and 3 Rotator cuff cable (layer 4). Strenthener Runs other way Collagen fibrils- 1mm thick (layer 5). #3 MSK Anatomy: Not as you imagine #4 MSK Anatomy: Highly variable Imagine Individual tendon Supraspinatus Like any anatomy 10mm rule 25mm rule I can t tell the difference Probably not you Think Glut Min Med CEO Distinguishable: footprint # 5. Explain this # 5. Anisotropy The most important concept in MSK ultrasound Short axis 3rd digit flexor tendons 3

4 # 6: Think about surface anatomy as well # 6: Think about surface anatomy as well # 7 High level clinical examination # 8 : Its all about layers Its obvious Draw the medial compartment of the knee Where is it sore Don t be beaten: Diffuse pain One finger/ one spot! # 8: Its all about layers Step 9: The Achilles :What s changed Do it with me- Draw 4

5 # 10 Use consistent terminology in musculoskeletal ultrasound Tendinopathy Clinical description of tendon change Don t use it Tendinitis? Tendonitis/ Epicondylitis etc Where? Doesn t exist Tendinosis Theories : Tendinosis Tendon Degeneration Sonographically Abnormal appearing tendon Clear rules Thickened Reduced echogenicity Fibrillar pattern No sharp margins May have hyperaemia Staged process (Cook 2010) 5

6 Calcific Tendinopathy / Tendinosis Enthesopathy Enthesis is where tendon joins bone Enthesopathy is disease of the entheses. Two sorts of enthesis Fibrous ( Direct ) Fibrocartilaginous ( 4 zones ) Ultrasound/Enthesopathy Clinical significance?? Part of the degenerative process Paratenonopathy Paratenonopathy Tendons: covered by connective tissue Epitenon Contains vascular, lymphatic and nerve supply) Surrounding layer -paratenon Combined they make the peritenon Paratenonopathy pathology of this area, usually inflammation achillie_tendinitis/images/kirsten2.gif Where do we think about this? Tendon Tears Bursitis? Full Thickness Inflammation Partial Thickness All sorts Hone through the day Synovial lining/ sac With fluid Poorly understood Not an ultrasound diagnosis Thickened bursa Bursal metaplasia 6

7 Conclusions 10 themes in MSK US Exceptional knowledge Anatomy Clinical assessment Terminology Consistent Understand the basics Anisotropy/ Colour/ Layers Enjoy the day 7