Clinical Review

Use of Musculoskeletal Ultrasound and Regenerative Therapies in Soccer

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  • Improvements in ultrasound technology have increased its use as a therapeutic and diagnostic modality.
  • Ultrasound offers increased accuracy and efficacy with minimally invasive procedures.
  • PRP is a safe and effective treatment for many musculoskeletal injuries, however return-to-play time frames limit its efficacy.
  • While stem cell and amniotic products offer promising results, the paucity in data limits overall use.
  • Care should be taken when discussing regenerative therapy as many products eclipse the concept of “minimal manipulation” and therefore require USFDA trials to establish safety data.




Improvements in ultrasound technology have increased the popularity and use of ultrasound as a diagnostic and therapeutic modality for many soccer-related musculoskeletal (MSK) injuries. As a dynamic imaging modality, ultrasound offers increased accuracy and efficacy with minimally invasive procedures, such as guided injections, percutaneous tenotomy, and regenerative therapies, in the clinical setting. Emerging evidence indicates that regenerative therapies, such as platelet-rich-plasma (PRP), mesenchymal stem cells, and amniotic products, are a promising treatment for many MSK injuries and are gaining popularity among professional athletes. PRP is a safe treatment for a number of MSK conditions and has been included in the standard of care. However, conflicting evidence on return-to-play timeframes and efficacy in certain MSK conditions have led to inconsistent recommendations on indications for use, dose, and timing of treatment. Mesenchymal stem cell therapy, while promising, lacks high-level evidence of efficacy despite its increasing use among athletes. Currently, no data are available regarding the outcome of the use of amniotic products for the treatment of injuries in athletes. Furthermore, preparation of many regenerative therapies eclipses the concept of minimal manipulation and is subject to US Food and Drug Administration phase I to III trials. High-level research on regenerative medicine therapies should be continuously conducted to establish their clinical efficacy and safety data.


Ultrasound (US) was first introduced for musculoskeletal (MSK) evaluation in 1957.1 Since then, US has gained increasing attention due to its ease of utilization in the clinical setting, repeatability, noninvasiveness, capability for contralateral comparison, lack of radiation exposure, and capability to provide real-time dynamic tissue assessment.1 Compared with magnetic resonance imaging or computed tomography, US presents limitations, including decreased resolution of certain tissues, limited field of view, limited penetration beyond osseous structures, incomplete evaluation of a joint or structure, and operator experience. However, advancements in technology, image resolution, and portability have improved the visualization of multiple anatomic structures and the accuracy of minimally invasive ultrasound-guided procedures at the point of care. The use of US for guided hip injections possibly decreases the cost relative to fluoroscopic guidance.2 Other studies have reported that US, as a result of its safety profile, has replaced fluoroscopy for certain procedures, such as barbotage of calcific tendinosis.3 US has been used for diagnostic purposes and guidance for therapeutic interventions, such as needle aspiration, diagnostic or therapeutic injection, needle tenotomy, tissue release, hydro-dissection, and biopsy.3 Given its expanding application, US has been increasingly used in the clinical setting, athletic training room, and sidelines of athletic events.


An epidemiologic review of the National Collegiate Athletic Association (NCAA) men’s and women’s soccer injuries from 1988 to 2003 reported over 24,000 combined injuries. Over 70% of these injuries are MSK in nature and often affect the lower extremities.4,5 Ekstrand and colleagues6 also conducted an epidemiological review of muscle injuries among professional soccer players from 2001 to 2009. They found that 92% of all muscle injuries involved the lower extremities. The portability of US allows it to serve as an ideal modality for diagnostic evaluation of acute MSK injuries. Klauser and colleagues7 developed consensus based on the recommendations of the European Society of Musculoskeletal Radiology (ESSR) for the clinical indication of diagnostic ultrasound. A grading system was developed to describe the clinical utility of diagnostic US evaluation of MSK structures:

• Grade 0: Ultrasound is not indicated;

• Grade 1: Ultrasound is indicated if other imaging techniques are not appropriate;

• Grade 2: Ultrasound indication is equivalent to other imaging modalities;

• Grade 3: Ultrasound is the first-choice technique.

Henderson and colleagues8 conducted a review of 95 studies (12 systemic reviews and 83 diagnostic studies) that investigated the accuracy of diagnostic US imaging on soft tissue MSK injuries of the upper and lower extremities. They reported the sensitivity and specificity of the method for detection of over 40 hip, knee, ankle, and foot injuries and assigned corresponding grades based on diagnostic accuracy by using the same system developed by Klauser and colleagues.7,8 Common MSK injuries of the lower extremity and their corresponding ESSR grades are listed in the Table. This study demonstrated that diagnostic US is highly accurate for a number of soft tissue MSK injuries of the lower extremity and consistently matches the recommendation grades issued by Klauser and colleagues.7 In the hands of a skilled operator, US has become an increasingly popular and cost-effective modality for diagnosis and monitoring of acute muscle injuries and chronic tendinopathies among soccer athletes.

Table. Clinical Indication Grades for Diagnostic Ultrasound Evaluation of Common Lower Extremity Injuries7,8




Synovitis/Effusion: 3

Quadricep tendinosis/tear: 3

Anterior talofibular ligament injury: 3

Snapping hip (extra-articular): 3

Patella tendinopathy: 3

Calcaneofibular ligament injury: 3

Gluteal tendon tear: 3

Pes anserine bursitis: 3

Peroneal tendon tear/subluxation: 3

Meralgia paresthetica: 3

Periarticular bursitis & ganglion: 3

Posterior tibial tendinopathy: 3

Lateral femoral cutaneous nerve injury: 3

Osgood-Schlatter & Sinding-Larsen: 3

Plantaris tendon tear: 3

Femoral nerve injury: 3

Synovitis/Effusion: 3

Plantar fasciitis: 3

Sports hernia: 3

Baker’s Cyst: 2-3

Calcific tendonitis: 3

Morel-Lavallée lesions: 3

MCL injury: 2

Retrocalcaneal bursitis: 3

Muscle injury (high grade): 3

IT band friction: 2

Joint effusion: 3

Trochanteric bursitis: 2

Medial patella plica syndrome: 2

Ganglion cyst: 3

Proximal hamstring injury: 2

Meniscal cyst: 2

Retinacula pathology: 3

Sciatica: 1-2

Common perineal neuropathy: 2

Achilles tendinopathy: 2

Muscle injury (low grade): 1

Distal hamstring tendon injury: 1-2

Haglund disease: 2

Psoas tendon pathology: 1

Intra-articular ganglion: 1

Deltoid ligament injury: 2

Osteoarthritis: 0

Hoffa’s fat pad syndrome: 1

Plantar plate tear: 2

Labral tear: 0

Loose bodies: 1

Syndesmotic injury: 2

LCL injury: 0-1

Morton’s neuroma: 2

Popliteal injury: 0-1

Deltoid ligament injury: 1

Plica syndrome: 0

Spring ligament injury: 1

Full/partial ACL tear: 0

Anterolateral ankle impingement: 0

PCL tear: 0

Posterior talofibular ligament injury: 0

Medial/lateral meniscus tear: 0

Osteochondritis dissecans: 0

Abbreviations: ACL, anterior cruciate ligament; IT, iliotibial; LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.


The use of US at the point of care for needle guidance has led to its widespread application for therapeutic procedures, including injections and multiple regenerative therapies. Intra-articular US-guided injection and aspiration are common therapeutic interventions performed in the clinical setting. In a position statement of the American Medical Society for Sports Medicine, US-guided injections were found to be more accurate (SORT A evidence), effective (SORT B evidence), and cost effective (SORT B evidence) than landmark-guided injections.3 A recent meta-analysis conducted by Daniels and colleagues1 demonstrated the improved accuracy and efficacy of US-guided injections at the knee, ankle, and foot. Injections may serve a diagnostic purpose when anesthetics, such as lidocaine, are used in isolation, a therapeutic purpose, or both.

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