Ultrasound Imaging of Neovascularization in Musculoskeletal Pathologies: Why and How Should We Do It?

Ultrasound Imaging of Neovascularization in Musculoskeletal Pathologies: Why and How Should We Do It?

Neovascularization, the formation of new blood vessels, is a common feature in various musculoskeletal pathologies. While it plays a crucial role in tissue repair and healing, abnormal neovascularization can also indicate chronic inflammation, injury, or disease. Ultrasound imaging has become a valuable tool for detecting and evaluating neovascularization in musculoskeletal conditions, providing real-time, non-invasive insights that aid in diagnosis and treatment planning. In this blog post, we will discuss the importance of ultrasound imaging for neovascularization in musculoskeletal pathologies and outline how this technique is performed.

Why Ultrasound Imaging of Neovascularization?

1. Early and Accurate Diagnosis

Neovascularization often accompanies musculoskeletal injuries and diseases, such as tendinopathies, arthritis, and soft tissue tumors. Detecting these new blood vessels early can provide critical information for accurate diagnosis and timely intervention, potentially improving patient outcomes.

2. Monitoring Disease Progression

In chronic musculoskeletal conditions, monitoring neovascularization can help assess disease progression and activity. For example, in conditions like rheumatoid arthritis, the presence and extent of neovascularization in the synovium can indicate the level of inflammatory activity, guiding treatment adjustments.

3. Evaluating Treatment Efficacy

Ultrasound imaging allows clinicians to monitor the effectiveness of treatments targeting neovascularization. By visualizing changes in blood flow and vessel density, healthcare providers can determine the success of interventions such as anti-inflammatory medications, physical therapy, or surgical procedures, and make necessary adjustments.

4. Non-Invasive and Safe

Ultrasound is a non-invasive imaging modality that does not use ionizing radiation, making it safe for repeated use. This is particularly beneficial for ongoing monitoring of chronic conditions and for patients who require frequent imaging.

5. Cost-Effective and Accessible

Compared to other imaging techniques like MRI or CT scans, ultrasound is more cost-effective and widely available. This accessibility allows for routine use in various clinical settings, including outpatient clinics and at the bedside, making it a practical choice for both diagnosis and follow-up.

How to Perform Ultrasound Imaging of Neovascularization

1. Equipment and Settings

High-Resolution Ultrasound
High-resolution ultrasound machines are essential for detailed visualization of musculoskeletal structures and neovascularization. These devices provide clear images of soft tissues, allowing for precise assessment of new blood vessel formation.

Doppler Ultrasound
Doppler ultrasound, including color Doppler and power Doppler modes, is particularly useful for assessing blood flow within newly formed vessels. These modes can visualize the direction and velocity of blood flow, highlighting areas of increased vascularity indicative of neovascularization.

2. Patient Preparation and Positioning

Patient Preparation
Patient preparation for ultrasound imaging is generally straightforward. Patients should wear loose-fitting clothing and remove any jewelry or accessories that could interfere with the imaging process. Specific instructions may vary depending on the area being examined.

Proper Positioning
Proper patient positioning is crucial for obtaining optimal images. The area of interest should be easily accessible and adequately exposed. For example, when examining a shoulder for rotator cuff tendinopathy, the patient may be asked to sit or lie in a position that allows the best access to the shoulder.

3. Imaging Procedure

Application of Gel
A water-based gel is applied to the skin over the area being examined. This gel helps to transmit the ultrasound waves and ensures good contact between the transducer and the skin.

Scanning Technique
The ultrasound transducer is moved over the skin to obtain images of the underlying tissues and blood vessels. For Doppler ultrasound, the transducer may be angled to optimize the detection of blood flow within the new vessels. Real-time imaging allows the clinician to adjust the transducer position and settings to obtain the best possible images.

Identifying Neovascularization
Neovascularization is identified by its characteristic features on ultrasound, including:
- **Increased Vascularity:** Seen as areas of enhanced blood flow on Doppler imaging.
- **Tortuosity of Vessels:** Newly formed vessels often appear more twisted or coiled compared to normal vasculature.
- **Changes in Blood Flow:** Abnormal flow patterns, such as increased velocity or turbulence, may be observed in the new vessels.

4. Interpretation and Reporting

Analyzing Images
The obtained images are analyzed to assess the extent and characteristics of neovascularization. Key parameters include the number and density of new vessels, the pattern of blood flow, and the anatomical relationship with surrounding tissues.

Documenting Findings
Findings from the ultrasound exam are documented in a detailed report, which includes descriptions of the vascular changes, any abnormalities detected, and recommendations for further evaluation or treatment if necessary. Comparative images may also be included to illustrate the findings.

Applications of Ultrasound Imaging of Neovascularization in Musculoskeletal Pathologies

1. Tendinopathies

In conditions such as Achilles tendinopathy or rotator cuff tendinopathy, ultrasound imaging can detect neovascularization within the tendon. This helps in assessing the severity of the condition and guiding treatment strategies, such as eccentric loading exercises or sclerotherapy.

2. Arthritis

In inflammatory arthritis, such as rheumatoid arthritis, ultrasound can visualize neovascularization in the synovium, indicating active inflammation. This information is crucial for monitoring disease activity and adjusting anti-inflammatory treatments accordingly.

3. Soft Tissue Tumors

Ultrasound imaging can help differentiate between benign and malignant soft tissue tumors by assessing the pattern of neovascularization. Malignant tumors often exhibit chaotic and excessive vascular growth, which can be visualized using Doppler ultrasound.

4. Chronic Wounds

For patients with chronic wounds or ulcers, ultrasound can evaluate the extent of neovascularization around the wound. This information is valuable for planning treatments that promote vascular growth and wound healing, such as hyperbaric oxygen therapy or growth factor treatments.

Learning how to use Doppler to scan neovascularization:

Join Marc Schmitz in this 90 minute online lecture where he'll guide you through the ins and outs of Doppler imaging. You will learn how to identify, quantify and interpret neovascularization in musculoskeletal injuries. Gain a deep understanding of the physics, pitfalls, artifacts, and best practices when using Doppler imaging. With Marc's tips and tricks, you'll become a skilled MSK sonographer and elevate your practice. Don't miss this opportunity to learn from the best in the field!


Ultrasound imaging of neovascularization in musculoskeletal pathologies is a powerful tool that offers numerous benefits for diagnosis, monitoring, and treatment planning. Its ability to provide real-time, non-invasive, and cost-effective assessment makes it an invaluable resource for clinicians. By leveraging high-resolution and Doppler ultrasound capabilities, healthcare providers can accurately identify and evaluate neovascularization, ultimately improving patient care and treatment outcomes. As technology continues to advance, the role of ultrasound imaging in assessing neovascularization is set to expand, promising even greater contributions to musculoskeletal health.