Musculoskeletal Ultrasound: Uses, Benefits and What to Expect

Written and medically reviewed by
Dr Dinesh Sirisena
Consultant in Sports, Exercise & Musculoskeletal Medicine
Triaxis Sports & Joint Clinic

Musculoskeletal ultrasound is an imaging method that uses sound waves to examine muscles, tendons, ligaments, joints, nerves and other soft tissues in real time. It does not use ionising radiation and can sometimes assess structures while they move. However, ultrasound is not suitable for every musculoskeletal problem. Whether ultrasound, X-ray, MRI or no imaging is required depends on the symptoms and clinical assessment.

What is musculoskeletal ultrasound?

Musculoskeletal ultrasound is a medical imaging technique that uses high-frequency sound waves to produce images of structures beneath the skin. It can provide real-time views of selected muscles, tendons, ligaments, nerves, joints and surrounding soft tissues, helping clinicians investigate certain musculoskeletal symptoms and injuries.

During the examination, a handheld device called a transducer or ultrasound probe is placed against the skin with ultrasound gel. Sound waves travel into the body and return to the probe. A computer then converts these signals into images.

Unlike an X-ray, ultrasound does not use ionising radiation. Another useful feature is that images appear in real time, allowing certain structures to be assessed during movement.

However, ultrasound is one part of assessment. A scan finding should be considered together with the patient’s symptoms and examination.

What parts of the body can musculoskeletal ultrasound examine?

Musculoskeletal ultrasound can examine many superficial structures throughout the body, particularly muscles, tendons, ligaments, nerves, joints and other soft tissues. Common areas include the shoulder, elbow, wrist, hand, hip region, knee, ankle and foot, although its usefulness depends on the structure and suspected condition.

Examples include:

Shoulder: rotator cuff tendons, biceps tendon and selected surrounding structures.

Elbow: common extensor and flexor tendons and selected ligaments or nerves.

Hand and wrist: tendons, some ligaments, superficial nerves and soft-tissue lumps such as ganglion cysts.

Hip: selected tendons and superficial structures around the hip.

Knee: quadriceps and patellar tendons, selected ligaments and some superficial joint structures.

Ankle and foot: Achilles tendon, peroneal tendons, other ankle tendons, plantar fascia and selected ligaments.

Some deeper structures cannot be fully evaluated with ultrasound and may require another form of imaging.

What conditions can musculoskeletal ultrasound help assess?

Ultrasound may help evaluate selected tendon injuries, muscle injuries, ligament problems, joint changes, fluid collections, soft-tissue lumps and certain nerve conditions. However, whether it is appropriate depends on the suspected diagnosis, because not every musculoskeletal condition can be adequately assessed with ultrasound.

RadiologyInfo notes that musculoskeletal ultrasound is used in evaluating conditions including tendon tears or tendinitis, muscle abnormalities, ligament injuries, soft-tissue masses and certain nerve-related problems.

Examples encountered in musculoskeletal practice may include:

• Rotator cuff problems
• Biceps tendon conditions
• Tennis or golfer’s elbow
• De Quervain’s tenosynovitis
• Trigger finger
• Ganglion cysts
• Muscle injuries
• Patellar tendon problems
• Achilles tendinopathy
• Selected ankle ligament injuries
• Plantar fascia conditions
• Selected peripheral nerve problems

The scan should answer a clinical question rather than simply be performed because pain is present.

Can ultrasound show muscles, tendons, ligaments and nerves?

Yes. Musculoskeletal ultrasound can provide images of selected muscles, tendons, ligaments, peripheral nerves and joints. Because the images are produced in real time, the clinician may also be able to observe how certain tendons, muscles or nerves behave during movement, which can provide additional information in selected conditions.

This dynamic capability can be useful when symptoms occur only during a particular movement.

For example, a clinician may ask a patient to move the shoulder, wrist, ankle or another joint while observing a relevant structure.

However, visibility varies depending on anatomy and depth. Ultrasound cannot clearly visualise every structure inside a joint or behind bone.

What happens during a musculoskeletal ultrasound?

During a musculoskeletal ultrasound, the patient is usually positioned so the affected area can be examined comfortably. Gel is placed on the skin, and an ultrasound probe is moved over the area. The clinician may examine the structure from several angles and may ask the patient to move during parts of the assessment.

Most examinations require little preparation.

During the scan, the clinician may:

• Identify relevant anatomical structures
• Compare different positions
• Apply gentle pressure with the probe
• Observe a tendon or joint during movement
• Compare with the opposite side where clinically useful
• Use Doppler ultrasound in selected situations to assess blood flow patterns

The findings can then be interpreted alongside the clinical examination.

Does musculoskeletal ultrasound hurt?

Musculoskeletal ultrasound is generally non-invasive, although scanning directly over an already painful or injured area may cause temporary tenderness or discomfort from probe pressure. The examination does not involve ionising radiation, and standard diagnostic ultrasound does not normally require needles or injections.

If a procedure is being performed under ultrasound guidance, that is different from a diagnostic ultrasound examination and may involve a needle.

Patients should therefore understand whether their appointment is for diagnostic imaging, an image-guided procedure, or both.

What is dynamic ultrasound and why can it be useful?

Dynamic ultrasound means examining a musculoskeletal structure while it moves rather than looking only at a static image. Because ultrasound produces images in real time, selected tendons, muscles, joints and nerves can sometimes be observed during movements that reproduce or relate to a patient’s symptoms.

For example, dynamic assessment may sometimes help evaluate:

• Tendon movement
• Tendon subluxation
• Muscle contraction
• Joint-related movement
• Selected nerve movement
• Structures that become symptomatic in a particular position

Dynamic examination does not automatically make ultrasound preferable to MRI. Rather, it provides a different type of information.

Is musculoskeletal ultrasound better than MRI?

Neither ultrasound nor MRI is universally better. They provide different information and are useful for different clinical questions. Ultrasound can provide real-time imaging of selected superficial structures and allows dynamic examination, while MRI can provide detailed images of deeper tissues, bone marrow and structures that may be difficult to assess with ultrasound.

Ultrasound may be considered when the clinician wants to assess a superficial tendon, muscle, ligament or nerve dynamically.

MRI may be more appropriate when deeper structures need evaluation or when the suspected problem cannot be adequately assessed with ultrasound.

Therefore, choosing imaging should start with the clinical question rather than choosing a scan first.

What is the difference between an X-ray, MRI and musculoskeletal ultrasound?

X-rays, MRI and ultrasound examine the body differently. X-rays are commonly used to assess bones and certain joint changes. MRI provides detailed images of many soft tissues, bones and internal joint structures. Ultrasound provides real-time imaging of selected muscles, tendons, ligaments, nerves and superficial joints without ionising radiation.

A simplified comparison is:

Imaging	Common clinical role
X-ray	Bones, fractures, alignment and certain joint changes
MRI	Deeper soft tissues, cartilage, bone marrow and internal joint structures
Ultrasound	Selected tendons, muscles, ligaments, nerves and superficial soft tissues
Dynamic ultrasound	Observing selected structures during movement

The most appropriate test depends on the symptoms, examination and suspected diagnosis.

Do I always need imaging for a sports injury?

No. Many sports and musculoskeletal conditions can initially be assessed through the patient’s history and physical examination without immediate imaging. Imaging may be considered when it could help clarify the diagnosis, investigate a significant injury, assess persistent symptoms or provide information that may influence management.

Ordering more imaging does not necessarily produce better care.

For example, a straightforward injury may have a clinical pattern that can initially be managed without a scan. Conversely, imaging may be useful when the examination raises concern about a more significant injury.

The decision should therefore be individualised.

Can musculoskeletal ultrasound guide injections and other procedures?

Yes. Ultrasound can be used to visualise selected anatomical structures while certain musculoskeletal procedures are performed. This allows the clinician to see the intended anatomical target and surrounding structures in real time. However, an ultrasound-guided procedure should only be considered when clinically appropriate for the individual’s condition.

Ultrasound guidance may be used for selected procedures involving joints, tendon-related structures or other soft tissues.

Importantly, ultrasound guidance does not mean that a procedure is required simply because an abnormality appears on a scan.

Depending on the individual’s condition and clinical assessment, certain procedures may be considered as part of a broader management plan.

Where rehabilitation is relevant, a procedure may be combined with an appropriate exercise and activity plan.

How can ultrasound findings affect rehabilitation?

Ultrasound findings may sometimes provide additional information that helps clarify the structure involved in a musculoskeletal problem. However, rehabilitation should not be based on scan findings alone. Symptoms, strength, movement, function, activity requirements and clinical examination remain important when planning exercise and return to activity.

For example, two people can have similar imaging findings but very different symptoms and physical requirements.

A recreational runner may require a different rehabilitation plan from a competitive footballer, even when the same tendon is involved.

Rehabilitation may include:

• Activity modification
• Mobility exercises
• Progressive strengthening
• Load management
• Movement retraining
• Sport-specific exercises
• Gradual return to activity

The aim is to manage the person and their function, not simply the image.

Is musculoskeletal ultrasound useful for sports injuries?

Musculoskeletal ultrasound can be useful for selected sports injuries involving superficial muscles, tendons, ligaments and other soft tissues. Its real-time imaging capability can also allow certain structures to be examined during movement. However, the choice of imaging depends on the suspected injury and should follow an appropriate clinical assessment.

Sports where musculoskeletal injuries may occur include:

• Running
• Football
• Rugby
• Tennis
• Golf
• Badminton
• Swimming
• Cycling
• Weightlifting
• Cricket

Different sports place different loads on muscles, tendons and joints. Therefore, imaging should be interpreted in the context of how the injury happened and what the athlete needs to return to.

When should I seek assessment for a musculoskeletal problem?

Consider medical assessment when pain follows a significant injury, persists, repeatedly returns or limits normal movement, work, exercise or sport. Assessment may also be appropriate for unexplained swelling, weakness, instability, numbness or loss of function. Whether ultrasound or another investigation is needed can then be determined from the clinical findings.

More urgent assessment may be appropriate after significant trauma or when symptoms include severe swelling, deformity, inability to use the affected limb normally, progressive weakness, fever or a hot and markedly swollen joint.

The purpose of assessment is first to understand the clinical problem. Imaging can then be selected if it is likely to contribute useful information.

How is musculoskeletal ultrasound used at Triaxis Sports & Joint Clinic?

At Triaxis Sports & Joint Clinic, musculoskeletal ultrasound may be considered as part of the assessment of selected sports and musculoskeletal conditions. Its use depends on the patient’s symptoms and clinical findings. Where appropriate, ultrasound findings can be considered together with physical examination, activity requirements and rehabilitation planning.

The clinical process may include:

• Medical and injury history
• Musculoskeletal examination
• Movement and functional assessment
• Sports ultrasound where appropriate
• Discussion of imaging findings
• Patient education
• Rehabilitation planning
• Shared decision-making

Where further investigation such as an X-ray or MRI may be more appropriate, this can be considered according to the clinical situation.

This approach avoids presenting ultrasound as necessary for every patient or every musculoskeletal condition, consistent with factual healthcare communication. Singapore’s healthcare advertising framework requires healthcare advertising to be accurate and truthful and not encourage unnecessary consumption of healthcare services.

Frequently Asked Questions About Musculoskeletal Ultrasound

Can ultrasound detect a tendon tear?

Musculoskeletal ultrasound can demonstrate selected tendon abnormalities, including some partial or complete tendon tears. However, whether ultrasound is the appropriate investigation depends on which tendon is involved, the depth of the structure and the clinical question. MRI or other investigations may sometimes provide additional information. A clinical assessment can help determine which imaging method is appropriate.

Can ultrasound detect ligament injuries?

Ultrasound can assess selected ligaments, particularly those that are relatively superficial and accessible to the probe. Dynamic examination may sometimes provide additional information while a joint is moved. While MRI may be considered for certain deeper or more complex injuries, ultrasound can help guide treatments in real time.

Can ultrasound show inflammation?

Ultrasound can demonstrate changes in selected soft tissues and joints, while Doppler techniques can provide information about blood flow in certain circumstances. However, an ultrasound appearance should not be interpreted in isolation as proof that a particular finding is responsible for pain. Clinical history and examination remain important when determining the significance of imaging findings.

Can ultrasound diagnose nerve problems?

Musculoskeletal ultrasound can visualise selected peripheral nerves and may help assess certain nerve-related conditions. However, nerve symptoms such as numbness, tingling or weakness can have several causes. Clinical neurological examination and, in some situations, other investigations may be needed to understand where the nerve is affected.

Is ultrasound safe?

Diagnostic ultrasound does not use ionising radiation. Instead, it creates images using high-frequency sound waves. It is widely used for medical imaging. Ultrasound complements your clinical and physical assessment.

How should I prepare for a musculoskeletal ultrasound?

Most musculoskeletal ultrasound examinations require little or no special preparation. Wearing comfortable clothing that allows access to the area being examined can be useful. Depending on the body part, you may be asked to remove jewellery or adjust clothing. Specific instructions can be provided if the examination involves a particular procedure.

Will I still need an MRI after an ultrasound?

Not necessarily. Some clinical questions can be addressed through examination and ultrasound, while others are better evaluated with MRI. Occasionally, further imaging may be considered when symptoms remain unexplained or when deeper structures require assessment. The need for MRI should therefore depend on the clinical findings rather than being a routine next step after ultrasound.

Can ultrasound be used during a sports medicine consultation?

Where clinically appropriate and available, musculoskeletal ultrasound may form part of the assessment of selected sports injuries or musculoskeletal conditions. It can provide real-time information about certain soft tissues and may allow dynamic assessment. Ultrasound assessment complements rather than replaces a thorough medical history and physical examination.

About the Author, Dr Dinesh Sirisena is a Consultant in Sports, Exercise & Musculoskeletal Medicine. His clinical work includes assessment and management of sports injuries and musculoskeletal conditions affecting muscles, tendons, ligaments, joints and related structures.

Medical Disclaimer

This page provides general educational information and does not replace an individual medical consultation. Musculoskeletal symptoms can have different causes, and not every condition requires imaging. The choice of investigation and management should depend on the individual’s medical history, symptoms and clinical assessment.