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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 192-195

Sonographic evaluation of knee pain: A prospective observational study


1 Department of Radiodiagnosis, JNMC, Wardha, Maharashtra, India
2 Department of Orthopedics, JNMC, Wardha, Maharashtra, India

Date of Submission30-Apr-2019
Date of Decision20-Jun-2019
Date of Acceptance20-Jul-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, JNMC, Sawangi, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_81_19

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  Abstract 


Context: Ultrasonography (USG) is a noninvasive imaging modality used for the assessment of the musculoskeletal system. The knee is one of the joints which can be extensively explored with ultrasound due to the presence of wide acoustic windows, which allows easy visualization of different anatomical structures. Aims: The aim of the study was to find out the common diseases causing knee pain and to characterize the sonographic features of each cause. Subjects and Methods: In a cross-sectional observational study conducted in Acharya Vinoba Bhave Rural Hospital of JNMC College, Sawangi, Wardha, after obtaining ethical committee clearance, 100 patients who presented with knee pain were evaluated with sonography during a period of 2 years. Results: The most common age group in this study was 31–40 years, followed by 41–50 years. The most common sonographic diagnosis was osteoarthritis, followed by joint effusion and Baker's cyst. Conclusions: USG is an excellent modality for the evaluation of knee pain, which is free of ionizing radiation, and its easy availability and affordability makes it a preferred modality of choice.

Keywords: Knee joint, musculoskeletal pathology, sonography


How to cite this article:
Phatak S, Deshpande S, Mishra G, Madurwar K, Marfani G, Lohchab B. Sonographic evaluation of knee pain: A prospective observational study. J Datta Meghe Inst Med Sci Univ 2019;14:192-5

How to cite this URL:
Phatak S, Deshpande S, Mishra G, Madurwar K, Marfani G, Lohchab B. Sonographic evaluation of knee pain: A prospective observational study. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 May 28];14:192-5. Available from: http://www.journaldmims.com/text.asp?2019/14/3/192/283602




  Introduction Top


Ultrasonography (USG) has become a very important and powerful imaging tool used for the assessment of the musculoskeletal system. It provides clinically useful information on a wide range of pathologic conditions affecting various components of the knee joint, which include the tendons, ligaments, muscles, synovial space, articular cartilage, and surrounding soft tissues. Color and power Doppler techniques have the advantage that it can measure neovascularization within the synovial lining of the joints, tendons, and soft-tissue masses.[1],[2],[3]

The aim of this article was to study the sonographic appearances of common disorders, involving the tendons, ligaments, muscles, menisci, synovium, cartilage, and soft tissues of the knee joint causing knee pain.


  Subjects and Methods Top


A prospective cross-sectional observational study of 100 patients was done in the Department of Radiodiagnosis, Acharya Vinoba Bhave Rural Hospital, DMIMS (DU), Sawangi (Meghe), Wardha. All the patients presenting with knee pain referred to our department were included in the study.

Ultrasonography equipment

High-end color Doppler ultrasound machine, Hitachi Aloka Arietta S70 with musculoskeletal transducers, color Doppler, power Doppler, tissue harmonic imaging, and sonoelastography was used. US evaluation of the knee is primarily performed with the patient in the supine position. For evaluation of the posterior structures, the patient lies prone. Scanning is performed with a high-frequency linear transducer (12–18 MHz). Anterior knee, medial knee, lateral knee, and posterior knee are evaluated systematically.

Ethical approval

Ethical approval was taken from the Ethical Committee, DMIMS, before the commencement of the study.


  Discussion Top


Most of the patients seen in our study were in the group of 31–40 years, followed by 41–50 years and 51–60 years; the least common age group was 11–20 years [Table 1].
Table 1: Age incidence

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In our study, there was a male preponderance. Males were 59%, whereas females were 41% [Table 2].
Table 2: Sex incidence

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Medial collateral ligament injury

The injured ligament appears as a thickened, inhomogeneously hypoechoic structure due to edema and hemorrhage. Tears usually affect the deep fibers lying superficial to the medial femoral epicondyle.[3] The sensitivity of sonography in the detection of medial collateral ligament (MCL) injuries is approximately 94%[4] [Figure 1]. Lateral collateral ligament injury tears of this ligament present as focally tender, hypoechoic, thickened segments, usually adjacent to the fibular attachment.[1],[2],[3] On ultrasound, meniscal lesions can accurately demonstrated especially tears involving the peripheral part of the meniscus. However, magnetic resonance imaging is considered to be more sensitive than ultrasound for the detection of meniscal lesions. A meniscal tear appears as a hypoechoic cleft coursing within the meniscus. It may extend to the femoral or tibial articulating surface of the meniscus [Figure 2]. Changes in the echogenicity and contour of the meniscus may reflect degenerative changes or an intrasubstance tear. Parameniscal cysts are visualized as rounded hypoechoic lesions related to the outer part of the lateral meniscus and connected with the linear hypoechoic meniscal tear[3],[4],[5],[6] [Figure 3]. Synovial effusion sonography can show a very small amount of joint effusions accurately. The fluid within the suprapatellar bursa [Figure 4] should not be ≥2 mm. The fluid can be aspirated accurately with ultrasound guidance. Simple effusions are almost always anechoic. Debris within a joint effusion may indicate the presence of pus, blood clots, fat lobules, or osteochondral fragments[7],[8] Baker's cysts (popliteal cysts). This type of cyst is crescentic in shape and typically involves the medial border of the gastrocnemius muscle and the semimembranosus tendon. The bursa can be divided into two compartments (the semimembranosus bursa and the gastrocnemius bursa) by a central septum [Figure 5]. Complications of Baker's cyst include hemorrhage, ruptures, and loose bodies. Simple cysts are thin walled with thin internal septa, whereas complicated cysts show thick walls, multiple septa, and fluid containing echogenic debris.
Figure 1: Thickened and hypoechoic medial collateral ligament suggestive of tear

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Figure 2: Linear hypoechoic tear in the peripheral part of medial meniscus which was confirmed later on magnetic resonance imaging

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Figure 3: Multiple hypoechoic lesions in the perimeniscal region suggestive of perimeniscal cyst

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Figure 4: Suprapatellar bursa showing hypoechoic fluid suggestive of joint effusion

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Figure 5: A large bilobed Baker's cyst in popliteal fossa showing a narrow neck

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On rupture, the characteristic rounded inferior margin of a Baker's cyst seen as tapered, and fluid can be visualized within the calf between the gastrocnemius muscle and the deep fascia. Doppler plays an important role in differentiating small cysts from popliteal aneurysms. A Baker's cyst is often associated with meniscal tears, especially those involving the medial meniscus, or with degenerative and inflammatory arthropathy.[9],[10] Osteoarthritis is traditionally evaluated by conventional radiography in spite of its limitation that radiography cannot show articular cartilage. Ultrasound can visualize articular hyaline cartilage as a well-defined anechoic band lacking internal echoes.[11] Ultrasound is also very useful in showing pathologic changes in articular cartilage in terms of thickness, transparency, sharpness, and related osteophytes.[11],[12] On ultrasound, Osteophytes are seen as elevated small step-up bony fragment close to joint space [Figure 6].[13]
Figure 6: Ultrasonography of articular cartilage of the knee showing multiple irregular osteophytes in a case of osteoarthritis

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Lipoma arborescens is an uncommonly seen intra-articular lesion consisting of villous lipomatous proliferation of the synovium seen in the knee joint, usually in the suprapatellar pouch. This condition is also seen in the glenohumeral joint, hip joint, elbow joint, and subdeltoid bursa.[14] On USG, a frond-like hyperechoic mass which shows movement during probe manipulation [Figure 7].[15] Synovitis can be defined as noncompressible intra-articular tissue, within synovial recesses. It is visualized in the joint capsules, bursae, and tendon sheaths. The thickened synovium has the appearance of hypoechoic vegetations protruding inside the synovial fluid or completely filling the articular space[16] [Figure 8].
Figure 7: Ultrasonography of suprapatellar bursa showing frond-like hyperechoic mass surrounded by joint effusion suggestive of lipoma arborescens

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Figure 8: Ultrasonography of suprapatellar bursa showing thickened synovium suggestive of synovitis

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Hematoma can be seen as hypoechoic collection which can have septa within [Figure 9].
Figure 9: A large hypoechoic septated lesion over the knee in a trauma patient suggestive of chronic hematoma

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In sonographic findings, osteoarthritis was the most common diagnosis followed by joint effusion, Baker's cyst, medial meniscus tear, MCL tear, and lateral meniscus tear. Other pathologies, which are diagnosed with ultrasound, are lateral collateral ligament tear, synovitis, perimeniscal cyst, hematoma, and lipoma arborescens [Table 3].
Table 3: Ultrasound finding seen in knee

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Osteoarthritis and joint effusion were seen in 14 patients, medial meniscus tear and joint effusion in eight patients, and Baker's cyst with joint effusion in three patients [Table 4].
Table 4: Number of patients having more than one findings on ultrasonography

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  Conclusions Top


Ultrasound is highly accurate in the assessment of knee pain. It shows accurately pathology involving periarticular soft tissue, including ligament, tendons, menisci, as well as articular cartilage. Being noninvasive, it can be used for all age groups. Recent developments in musculoskeletal ultrasound make it the first-line modality of choice in the evaluation of knee pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bouffard JA, Dhanju J. Ultrasonography of the knee. Semin Musculoskeletal Radiol 1998;2:245-70.  Back to cited text no. 1
    
2.
Ptasznik R. Ultrasound in acute and chronic knee injury. Radiol Clin North Am 1999;37:797-830.  Back to cited text no. 2
    
3.
Friedman L, Finlay K, Jurriaans E. Ultrasound of the knee. Skeletal Radiol 2001;30:361-77.  Back to cited text no. 3
    
4.
Lee JI, Song IS, Jung YB, Kim YG, Wang CH, Yu H, et al. Medial collateral ligament injuries of the knee: Ultrasonographic findings. J Ultrasound Med 1996;15:621-5.  Back to cited text no. 4
    
5.
Grobbelaar N, Bouffard JA. Sonography of the knee, a pictorial review. Semin Ultrasound CT MR 2000;21:231-74.  Back to cited text no. 5
    
6.
Rutten MJ, Collins JM, van Kampen A, Jager GJ. Meniscal cysts: Detection with high-resolution sonography. AJR Am J Roentgenol 1998;171:491-6.  Back to cited text no. 6
    
7.
Bonnefoy O, Diris B, Moinard M, Aunoble S, Diard F, Hauger O. Acute knee trauma: Role of ultrasound. Eur Radiol 2006;16:2542-8.  Back to cited text no. 7
    
8.
Fessell DP, Jacobson JA, Craig J, Habra G, Prasad A, Radliff A, et al. Using sonography to reveal and aspirate joint effusions. AJR Am J Roentgenol 2000;174:1353-62.  Back to cited text no. 8
    
9.
Ward EE, Jacobson JA, Fessell DP, Hayes CW, van Holsbeeck M. Sonographic detection of Baker's cysts: Comparison with MR imaging. AJR Am J Roentgenol 2001;176:373-80.  Back to cited text no. 9
    
10.
Torreggiani WC, Al-Ismail K, Munk PL, Roche C, Keogh C, Nicolaou S, et al. The imaging spectrum of Baker's (popliteal) cysts. Clinical radiology. 2002 Aug 1;57:681-91.  Back to cited text no. 10
    
11.
Naredo E, Acebes C, Möller I, Canillas F, de Agustín JJ, de Miguel E, et al. Ultrasound validity in the measurement of knee cartilage thickness. Ann Rheum Dis 2009;68:1322-7.  Back to cited text no. 11
    
12.
Conaghan P, D'Agostino MA, Ravaud P, Baron G, Le Bars M, Grassi W, et al. EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 2: Exploring decision rules for clinical utility. Ann Rheum Dis 2005;64:1710-4.  Back to cited text no. 12
    
13.
Keen HI, Wakefield RJ, Grainger AJ, Hensor EM, Emery P, Conaghan PG. Can ultrasonography improve on radiographic assessment in osteoarthritis of the hands? A comparison between radiographic and ultrasonographic detected pathology. Ann Rheum Dis 2008;67:1116-20.  Back to cited text no. 13
    
14.
Ryu KN, Jaovisidha S, Schweitzer M, Motta AO, Resnick D. MR imaging of lipoma arborescens of the knee joint. AJR Am J Roentgenol 1996;167:1229-32.  Back to cited text no. 14
    
15.
Learch TJ, Braaton M. Lipoma arborescens: High-resolution ultrasonographic findings. J Ultrasound Med 2000;19:385-9.  Back to cited text no. 15
    
16.
Ahuja A, Levine D, Antonio GE, Griffith JF, Chu WC, Wong KT. Musculoskeletal ultrasonography. In: Expertddx Ultrasound. 1st ed., Vol. 13. Amirsys Salt Lake City, UT (US); 2010. p. 37-80.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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