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Diagnostic ultrasound in neuromuscular disease

Francis O Walker, MD
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD


Diagnostic studies for suspected neuromuscular diseases have commonly included blood tests, nerve conduction studies, electromyography, and biopsy. Imaging has been limited to intraoperative observations and occasional MRI and CT scans. However, high resolution ultrasound has opened up this field to clinicians, and modestly priced portable instruments are now routinely available that can provide qualitative and quantitative details about nerve and muscle disease.

This topic will review the use of ultrasound for the evaluation of neuromuscular disease. Electrodiagnostic methods for neuromuscular disease are discussed separately. (See "Overview of electromyography" and "Overview of nerve conduction studies".)


Since its first use in the 1950s for medical practice, ultrasound has evolved into a sophisticated imaging modality employed by specialists to diagnose a broad range of clinical disorders. Early instruments depended on single linear echo latencies to measure fetal head width or midline shift in adults with suspected intracranial mass lesions. Current technology, however, provides real-time two-dimensional images that can be reconstructed into three dimensions (3D) and their change over time (4D) [1]. With the advent of inexpensive, portable units of sufficiently high resolution, the use of ultrasound in the evaluation of muscle and nerve disease is becoming commonplace.

The physics of ultrasound is briefly reviewed here as it is pertinent to the study of muscle and nerve and is discussed in greater detail elsewhere. (See "Echocardiography essentials: Physics and instrumentation" and "Basic principles and safety of diagnostic ultrasound in obstetrics and gynecology".)

The fundamental technique of ultrasound involves the insonation of tissue and analysis of the echoes reflected back to the insonating transducer. Reflected ultrasound occurs at interfaces within or between tissues of different acoustic impedance, a measure directly proportional to the speed at which sound travels through them. Bone conducts sound much faster than soft tissue; soft tissue slightly faster than water, but much faster than air. As such, the brightest echoes in the body are seen between bone and soft tissue. The use of coupling gel between skin and transducer minimizes the reflection that would otherwise occur between skin and air.

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Literature review current through: Nov 2017. | This topic last updated: Apr 26, 2017.
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  1. Tonni G, Centini G, Rosignoli L. Prenatal screening for fetal face and clefting in a prospective study on low-risk population: can 3- and 4-dimensional ultrasound enhance visualization and detection rate? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100:420.
  2. Crass JR, van de Vegte GL, Harkavy LA. Tendon echogenicity: ex vivo study. Radiology 1988; 167:499.
  3. Campbell SE, Adler R, Sofka CM. Ultrasound of muscle abnormalities. Ultrasound Q 2005; 21:87.
  4. Lee JC, Healy J. Sonography of lower limb muscle injury. AJR Am J Roentgenol 2004; 182:341.
  5. Walker FO. Neuromuscular ultrasound. Neurol Clin 2004; 22:563.
  6. Walker FO, Donofrio PD, Harpold GJ, Ferrell WG. Sonographic imaging of muscle contraction and fasciculations: a correlation with electromyography. Muscle Nerve 1990; 13:33.
  7. Ward SR, Lieber RL. Density and hydration of fresh and fixed human skeletal muscle. J Biomech 2005; 38:2317.
  8. Hodges PW, Pengel LH, Herbert RD, Gandevia SC. Measurement of muscle contraction with ultrasound imaging. Muscle Nerve 2003; 27:682.
  9. Zaidman CM. Ultrasound of muscular dystrophies, myopathies, and muscle pathology. In: Neuromuscular Ultrasound, 1st ed., Walker FO, Cartwright MS. (Eds), Elsevier, Philadelphia 2011. p.131.
  10. Arts IM, Pillen S, Schelhaas HJ, et al. Normal values for quantitative muscle ultrasonography in adults. Muscle Nerve 2010; 41:32.
  11. Schwennicke A, Bargfrede M, Reimers CD. Clinical, electromyographic, and ultrasonographic assessment of focal neuropathies. J Neuroimaging 1998; 8:136.
  12. Reimers CD, Finkenstaedt M. Muscle imaging in inflammatory myopathies. Curr Opin Rheumatol 1997; 9:475.
  13. Reimers CD, Schlotter B, Eicke BM, Witt TN. Calf enlargement in neuromuscular diseases: a quantitative ultrasound study in 350 patients and review of the literature. J Neurol Sci 1996; 143:46.
  14. Gunreben G, Bogdahn U. Real-time sonography of acute and chronic muscle denervation. Muscle Nerve 1991; 14:654.
  15. Küllmer K, Sievers KW, Reimers CD, et al. Changes of sonographic, magnetic resonance tomographic, electromyographic, and histopathologic findings within a 2-month period of examinations after experimental muscle denervation. Arch Orthop Trauma Surg 1998; 117:228.
  16. Zaidman CM, Connolly AM, Malkus EC, et al. Quantitative ultrasound using backscatter analysis in Duchenne and Becker muscular dystrophy. Neuromuscul Disord 2010; 20:805.
  17. Pillen S, Arts IM, Zwarts MJ. Muscle ultrasound in neuromuscular disorders. Muscle Nerve 2008; 37:679.
  18. Pillen S, Verrips A, van Alfen N, et al. Quantitative skeletal muscle ultrasound: diagnostic value in childhood neuromuscular disease. Neuromuscul Disord 2007; 17:509.
  19. Aydinli N, Baslo B, Calişkan M, et al. Muscle ultrasonography and electromyography correlation for evaluation of floppy infants. Brain Dev 2003; 25:22.
  20. van den Engel-Hoek L, Erasmus CE, Hendriks JC, et al. Oral muscles are progressively affected in Duchenne muscular dystrophy: implications for dysphagia treatment. J Neurol 2013; 260:1295.
  21. Tieleman AA, Vinke A, van Alfen N, et al. Skeletal muscle involvement in myotonic dystrophy type 2. A comparative muscle ultrasound study. Neuromuscul Disord 2012; 22:492.
  22. Arts IM, Overeem S, Pillen S, et al. Muscle ultrasonography to predict survival in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2011; 82:552.
  23. Reimers CD, Fleckenstein JL, Witt TN, et al. Muscular ultrasound in idiopathic inflammatory myopathies of adults. J Neurol Sci 1993; 116:82.
  24. Hamjian JA, Walker FO. Serial neurophysiological studies of intramuscular botulinum-A toxin in humans. Muscle Nerve 1994; 17:1385.
  25. Caress JB, Walker FO. The spectrum of ectopic motor nerve behavior: from fasciculations to neuromyotonia. Neurologist 2002; 8:41.
  26. Misawa S, Noto Y, Shibuya K, et al. Ultrasonographic detection of fasciculations markedly increases diagnostic sensitivity of ALS. Neurology 2011; 77:1532.
  27. Hobson-Webb LD. Neuromuscular ultrasound in polyneuropathies and motor neuron disease. Muscle Nerve 2013; 47:790.
  28. van Alfen N, Nienhuis M, Zwarts MJ, Pillen S. Detection of fibrillations using muscle ultrasound: diagnostic accuracy and identification of pitfalls. Muscle Nerve 2011; 43:178.
  29. van Baalen A, Stephani U. Fibration, fibrillation, and fasciculation: say what you see. Clin Neurophysiol 2007; 118:1418.
  30. Demondion X, Herbinet P, Boutry N, et al. Sonographic mapping of the normal brachial plexus. AJNR Am J Neuroradiol 2003; 24:1303.
  31. Walker FO, Cartwright MS, Wiesler ER, Caress J. Ultrasound of nerve and muscle. Clin Neurophysiol 2004; 115:495.
  32. Silvestri E, Martinoli C, Derchi LE, et al. Echotexture of peripheral nerves: correlation between US and histologic findings and criteria to differentiate tendons. Radiology 1995; 197:291.
  33. Brown BS. How safe is diagnostic ultrasonography? Can Med Assoc J 1984; 131:307.
  34. Hough AD, Moore AP, Jones MP. Peripheral nerve motion measurement with spectral Doppler sonography: a reliability study. J Hand Surg Br 2000; 25:585.
  35. Zaidman CM, Al-Lozi M, Pestronk A. Peripheral nerve size in normals and patients with polyneuropathy: an ultrasound study. Muscle Nerve 2009; 40:960.
  36. Cartwright MS, Walker FO. Neuromuscular ultrasound in common entrapment neuropathies. Muscle Nerve 2013; 48:696.
  37. Suk JI, Sigur CM, Walker FO. Superficial fibular neuropathy: complementary role of ultrasound. Muscle Nerve 2013; 47:778.
  38. Mohammadi A, Ghasemi-Rad M, Mladkova-Suchy N, Ansari S. Correlation between the severity of carpal tunnel syndrome and color Doppler sonography findings. AJR Am J Roentgenol 2012; 198:W181.
  39. Riazi S, Bril V, Perkins BA, et al. Can ultrasound of the tibial nerve detect diabetic peripheral neuropathy? A cross-sectional study. Diabetes Care 2012; 35:2575.
  40. Liu F, Zhu J, Wei M, et al. Preliminary evaluation of the sural nerve using 22-MHz ultrasound: a new approach for evaluation of diabetic cutaneous neuropathy. PLoS One 2012; 7:e32730.
  41. Breiner A, Qrimli M, Ebadi H, et al. Peripheral nerve high-resolution ultrasound in diabetes. Muscle Nerve 2017; 55:171.
  42. Hobson-Webb LD, Massey JM, Juel VC. Nerve ultrasound in diabetic polyneuropathy: correlation with clinical characteristics and electrodiagnostic testing. Muscle Nerve 2013; 47:379.
  43. Zaidman CM, Seelig MJ, Baker JC, et al. Detection of peripheral nerve pathology: comparison of ultrasound and MRI. Neurology 2013; 80:1634.
  44. Padua L, Aprile I, Pazzaglia C, et al. Contribution of ultrasound in a neurophysiological lab in diagnosing nerve impairment: A one-year systematic assessment. Clin Neurophysiol 2007; 118:1410.
  45. Padua L, Di Pasquale A, Liotta G, et al. Ultrasound as a useful tool in the diagnosis and management of traumatic nerve lesions. Clin Neurophysiol 2013; 124:1237.
  46. Lee CH, Kim TK, Yoon ES, Dhong ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg 2005; 54:20.
  47. Wong SM, Griffith JF, Hui AC, et al. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology 2004; 232:93.
  48. Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology 2003; 61:389.
  49. Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve 2003; 27:26.
  50. Nakamichi KI, Tachibana S. Enlarged median nerve in idiopathic carpal tunnel syndrome. Muscle Nerve 2000; 23:1713.
  51. Cartwright MS, White DL, Demar S, et al. Median nerve changes following steroid injection for carpal tunnel syndrome. Muscle Nerve 2011; 44:25.
  52. Abicalaf CA, de Barros N, Sernik RA, et al. Ultrasound evaluation of patients with carpal tunnel syndrome before and after endoscopic release of the transverse carpal ligament. Clin Radiol 2007; 62:891.
  53. Lee CH, Kim TK, Yoon ES, Dhong ES. Postoperative morphologic analysis of carpal tunnel syndrome using high-resolution ultrasonography. Ann Plast Surg 2005; 54:143.
  54. Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. J Anat 1972; 113:433.
  55. Ochoa J, Danta G, Fowler TJ, Gilliatt RW. Nature of the nerve lesion caused by a pneumatic tourniquet. Nature 1971; 233:265.
  56. Lundborg G, Myers R, Powell H. Nerve compression injury and increased endoneurial fluid pressure: a "miniature compartment syndrome". J Neurol Neurosurg Psychiatry 1983; 46:1119.
  57. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Chronic human nerve compression--a histological assessment. Neuropathol Appl Neurobiol 1986; 12:547.
  58. Dellon AL, Mackinnon SE. Human ulnar neuropathy at the elbow: clinical, electrical, and morphometric correlations. J Reconstr Microsurg 1988; 4:179.
  59. Aziz W, Firrell JC, Ogden L, Breidenbach WC. Blood flow in a chronic entrapment neuropathy model in the rabbit sciatic nerve. J Reconstr Microsurg 1999; 15:47.
  60. El-Karabaty H, Hetzel A, Galla TJ, et al. The effect of carpal tunnel release on median nerve flattening and nerve conduction. Electromyogr Clin Neurophysiol 2005; 45:223.
  61. Erel E, Dilley A, Greening J, et al. Longitudinal sliding of the median nerve in patients with carpal tunnel syndrome. J Hand Surg Br 2003; 28:439.
  62. Beekman R, Wokke JH, Schoemaker MC, et al. Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome. Neurology 2004; 63:1675.
  63. Beekman R, Van Der Plas JP, Uitdehaag BM, et al. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve 2004; 30:202.
  64. Park GY, Kim JM, Lee SM. The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow. Arch Phys Med Rehabil 2004; 85:1000.
  65. Caress JB, Becker CE, Cartwright MS, Walker FO. Ultrasound in the diagnosis of ulnar neuropathy at the elbow. J Clin Neuromuscul Dis 2003; 4:161.
  66. Peer S, Harpf C, Willeit J, et al. Sonographic evaluation of primary peripheral nerve repair. J Ultrasound Med 2003; 22:1317.
  67. Bodner G, Harpf C, Gardetto A, et al. Ultrasonography of the accessory nerve: normal and pathologic findings in cadavers and patients with iatrogenic accessory nerve palsy. J Ultrasound Med 2002; 21:1159.
  68. Bodner G, Buchberger W, Schocke M, et al. Radial nerve palsy associated with humeral shaft fracture: evaluation with US--initial experience. Radiology 2001; 219:811.
  69. Hobson-Webb LD, Walker FO. Traumatic neuroma diagnosed by ultrasonography. Arch Neurol 2004; 61:1322.
  70. Kuo YL, Yao WJ, Chiu HY. Role of sonography in the preoperative assessment of neurilemmoma. J Clin Ultrasound 2005; 33:87.
  71. Pedrazzini M, Pogliacomi F, Cusmano F, et al. Bilateral ganglion cyst of the common peroneal nerve. Eur Radiol 2002; 12:2803.
  72. Boedeker CC, Ridder GJ, Schipper J. Paragangliomas of the head and neck: diagnosis and treatment. Fam Cancer 2005; 4:55.
  73. Young NP, Sorenson EJ, Spinner RJ, Daube JR. Clinical and electrodiagnostic correlates of peroneal intraneural ganglia. Neurology 2009; 72:447.
  74. Vijayan J, Chan YC, Therimadasamy A, Wilder-Smith EP. Role of combined B-mode and Doppler sonography in evaluating neurolymphomatosis. Neurology 2015; 85:752.
  75. Goedee HS, van der Pol WL, van Asseldonk JH, et al. Diagnostic value of sonography in treatment-naive chronic inflammatory neuropathies. Neurology 2017; 88:143.
  76. Heinemeyer O, Reimers CD. Ultrasound of radial, ulnar, median, and sciatic nerves in healthy subjects and patients with hereditary motor and sensory neuropathies. Ultrasound Med Biol 1999; 25:481.
  77. Matsuoka N, Kohriyama T, Ochi K, et al. Detection of cervical nerve root hypertrophy by ultrasonography in chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol Sci 2004; 219:15.
  78. Taniguchi N, Itoh K, Wang Y, et al. Sonographic detection of diffuse peripheral nerve hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy. J Clin Ultrasound 2000; 28:488.
  79. Beekman R, van den Berg LH, Franssen H, et al. Ultrasonography shows extensive nerve enlargements in multifocal motor neuropathy. Neurology 2005; 65:305.
  80. Cartwright MS, Walker FO, Griffin LP, Caress JB. Peripheral nerve and muscle ultrasound in amyotrophic lateral sclerosis. Muscle Nerve 2011; 44:346.