If you have ongoing pain from a muscle, tendon or joint problem, you may have wondered whether you need a scan. Perhaps your injury isn’t improving as expected, the diagnosis isn’t completely clear, or you simply want to understand what is causing your symptoms.
One option is a musculoskeletal (MSK) ultrasound scan.
MSK ultrasound is a quick and highly useful form of diagnostic imaging that allows us to look at many of the muscles, tendons, ligaments, joints and other soft tissues beneath the skin.
However, one of the most important things to understand is that not everybody with musculoskeletal pain needs a scan.
At Wandsworth Physiotherapy, our approach is to combine imaging with a detailed clinical assessment. Several members of our team are dual-trained physiotherapists and musculoskeletal sonographers, which means that, where appropriate, an ultrasound scan can be performed in the clinic alongside your physiotherapy assessment.
What is an MSK ultrasound scan?
Most people are familiar with ultrasound because of its use during pregnancy, but the same technology can be used to examine the musculoskeletal system.
Diagnostic ultrasound uses high-frequency sound waves to create real-time images of structures beneath the skin. Unlike an X-ray or CT scan, it does not use ionising radiation.
Depending on the part of the body being assessed, ultrasound can provide detailed images of structures including:
- Tendons
- Muscles
- Ligaments
- Bursae
- Superficial joints
- Joint fluid and swelling
- Tendon sheaths
- Some superficial nerves
- Cysts and certain soft-tissue lumps
The British Medical Ultrasound Society describes MSK ultrasound as useful for examining muscles, tendons, ligaments, joints and soft tissues, including tendon tears, muscle abnormalities and joint problems, and highlights the ability to examine structures during movement.
What happens during an MSK ultrasound scan?
An ultrasound examination is usually straightforward.
A small amount of ultrasound gel is placed onto your skin and the clinician moves an ultrasound probe over the area being examined. Images appear immediately on the screen.
Your clinician may ask you to change position or move the affected joint while they scan it.
This is one of ultrasound’s major advantages.
Ultrasound lets us assess you while you move
An MRI produces extremely detailed images, but you normally remain still while those images are acquired.
Ultrasound is different because it provides real-time, dynamic imaging.
For example, your clinician may ask you to move your shoulder, contract a muscle, move your ankle or perform another movement while watching the tissues on the screen.
This can be particularly useful when symptoms only appear during a particular movement or activity.
What can an MSK ultrasound scan diagnose?
Ultrasound isn’t suitable for every musculoskeletal condition, but there are several situations where it can be extremely helpful.
1. Tendon problems and tendinopathy
Tendon pain is one of the most common reasons we use diagnostic ultrasound.
Ultrasound can help assess the structure of a tendon and identify changes associated with tendinopathy, as well as looking for partial or full-thickness tears.
Common areas include:
- Achilles tendon
- Patellar tendon
- Rotator cuff tendons
- Tennis elbow/common extensor tendon
- Gluteal tendons
- Hamstring tendons
- Peroneal tendons around the ankle
- Tibialis posterior tendon
Importantly, changes seen on a scan don’t always explain someone’s pain. Some people can have structural tendon changes without significant symptoms.
This is why the scan should be interpreted alongside your clinical assessment rather than being treated as the diagnosis on its own.
2. Shoulder pain and rotator cuff injuries
The shoulder is particularly well suited to ultrasound examination because many of the structures responsible for shoulder pain are relatively superficial.
Ultrasound can help assess the:
- Rotator cuff tendons
- Long head of biceps tendon
- Subacromial-subdeltoid bursa
- AC joint
- Surrounding soft tissues
It can help identify problems such as rotator cuff tendinopathy, calcific deposits, bursitis and partial or full-thickness rotator cuff tears.
A dynamic examination can also show how some of these structures behave as you move your arm.
However, shoulder pain can have many different causes, so the findings still need to be interpreted in the context of your symptoms and physical examination.
3. Muscle injuries and tears
Ultrasound may be useful following a muscle injury, particularly where there is concern about a significant tear.
It can help identify disruption within the muscle fibres, swelling or fluid collections and may sometimes be useful for monitoring healing.
For someone returning to running or sport, imaging may form one part of the overall assessment – but strength, movement, function and confidence remain equally important when deciding when it is safe to return.
4. Bursitis
Bursae are small fluid-filled structures that help reduce friction between tissues.
They can sometimes become irritated and swollen, causing pain.
Ultrasound can assess bursae in areas such as the shoulder, hip, knee and elbow and determine whether there is significant fluid or thickening present.
Again, simply seeing fluid within a bursa does not necessarily mean that it is the sole cause of your pain. Your clinical assessment helps us determine whether the imaging findings are relevant.
5. Ligament and ankle injuries
Ultrasound can assess a number of superficial ligaments and can be particularly useful around the ankle.
If an ankle sprain is taking longer than expected to settle, for example, ultrasound may help assess the injured ligaments as well as nearby tendons.
Dynamic scanning can sometimes be particularly useful because the clinician can assess a structure while the ankle is moved or gently stressed.
6. Joint swelling, fluid and inflammation
If a joint appears swollen, ultrasound can help determine whether excess fluid is present.
It may also demonstrate changes involving the joint lining (synovium) or surrounding tissues.
Depending on the findings and your wider clinical picture, your physiotherapist may recommend treatment, further investigations or assessment by another healthcare professional.
Do I need an ultrasound scan for my pain?
Not necessarily.
This is an important point because more imaging does not automatically mean better care.
For many common musculoskeletal problems, an experienced physiotherapist can make a confident clinical diagnosis from your history and examination and start treatment without imaging.
A scan becomes particularly useful when it can help answer a specific clinical question.
When might an ultrasound scan be worth considering?
You may benefit from discussing diagnostic ultrasound with your physiotherapist if:
- Your pain has persisted despite appropriate treatment
- Your diagnosis remains unclear
- You have experienced a sudden injury and there is concern about a tendon or muscle tear
- You have persistent swelling
- Your symptoms have changed unexpectedly
- Your rehabilitation isn’t progressing as expected
- Your clinician needs more information before deciding on treatment
- An ultrasound-guided injection is being considered
The key question isn’t simply “Can this area be scanned?”
It is “Will the scan give us useful information that changes how we manage your problem?”
MSK ultrasound versus MRI – which is better?
Neither investigation is universally “better”. They provide different information and are useful in different circumstances.
Ultrasound is particularly good for examining many superficial tendons, muscles, bursae and other soft tissues. It is quick, can be performed dynamically and allows the clinician to compare the painful side with the unaffected side immediately.
MRI provides excellent imaging of deeper structures and is generally more appropriate for certain problems involving structures within a joint, bone, cartilage or deeper anatomy.
Sometimes an ultrasound assessment will identify that an MRI – or another investigation such as an X-ray – would be more appropriate.
Our aim is therefore not to scan everybody, but to help you get the right investigation when you actually need one.
The advantage of combining physiotherapy and ultrasound
One of the biggest benefits of having an ultrasound assessment at Wandsworth Physiotherapy is that the scan does not have to happen separately from your clinical assessment.
Our dual-trained physiotherapist-sonographers understand both diagnostic imaging and musculoskeletal rehabilitation.
This means we can start by listening to what has happened, examining your movement, testing the relevant muscles and joints and understanding what activities are causing your symptoms.
If ultrasound is clinically appropriate, we can then use it to investigate a particular question.
The findings can immediately be brought back into your assessment and treatment plan.
For example, if you have shoulder pain, we aren’t simply looking for an abnormality on a screen. We want to know:
- Does the scan finding correspond with where you hurt?
- Does it fit with the way the injury started?
- Does it match your strength and movement?
- Is it something that requires a change to your rehabilitation?
- Do we need another investigation?
- Would injection therapy potentially help?
- Or can we reassure you and continue with physiotherapy?
That integration between assessment, imaging and rehabilitation can make the whole process much more joined-up.
Can I have an ultrasound scan at my first physiotherapy appointment?
In many cases, yes.
At Wandsworth Physiotherapy, diagnostic ultrasound can often be incorporated into your initial assessment when clinically appropriate and when you are booked with one of our suitably qualified clinicians.
This can save you from having to arrange a completely separate scan and then return for another appointment to discuss the findings.
However, if you think you may need an ultrasound scan, please mention this when you book your appointment.
An assessment involving diagnostic ultrasound may require additional time, so discussing it with our reception team beforehand allows us to make sure you are booked with the appropriate clinician and that enough time is available.
You don’t need to decide for yourself whether a scan is definitely necessary. Your physiotherapist can discuss this with you and explain whether ultrasound is likely to add useful information.
Can ultrasound be used to guide an injection?
Yes.
Ultrasound isn’t only used for diagnosis. It can also be used to guide certain musculoskeletal injections.
Ultrasound guidance allows the clinician to visualise the needle in real time and accurately target the intended joint, bursa, tendon sheath or other structure.
Depending on your diagnosis, treatment options may include corticosteroid or other appropriate injection therapies.
However, an injection should not automatically be seen as an alternative to rehabilitation.
For many musculoskeletal conditions, an injection is most useful when it forms part of a wider treatment plan designed to reduce symptoms sufficiently for you to progress with exercise, loading and rehabilitation.
What happens after my ultrasound scan?
The real value of diagnostic imaging is not simply finding something on a scan – it is deciding what to do with that information.
Because your ultrasound assessment can be integrated with your physiotherapy appointment at Wandsworth Physiotherapy, your clinician can explain the findings to you and discuss the next steps.
Depending on the problem, this could include:
- Advice and reassurance
- A structured physiotherapy and rehabilitation programme
- Modification of exercise or training
- Strength and conditioning
- Shockwave therapy where appropriate
- Ultrasound-guided injection therapy
- Further imaging such as MRI or X-ray
- Referral to a GP, sports medicine doctor or orthopaedic surgeon if necessary
For many patients, the scan may actually provide reassurance that there is no major structural injury and that it is safe to progress rehabilitation.