Clinical indications for musculoskeletal ultrasound updated
in 2017 by European Society of Musculoskeletal Radiology (ESSR)
Luca Maria Sconfienza
Fernando Facal de Castro
Elena E. Drakonaki
Andrea Sabine Klauser
Rebeca Mirón Mombiela
Rosa de la Puente
Alberto Stefano Tagliafico
Received: 13 March 2018 /Revised: 2 April 2018 /Accepted: 11 April 2018
European Society of Radiology 2018
Objectives To update the 2012 European Society of Musculoskeletal Radiology (ESSR) clinical consensus guidelines for
musculoskeletal ultrasound referral in Europe.
Methods Twenty-one musculoskeletal imaging experts from the ESSR participated in a consensus study based on a Delphic
process. Two independent (non-voting) authors facilitated the procedure and resolved doubtful issues. Updated musculoskeletal
ultrasound literature up to July 2017 was scored for shoulder, elbow, wrist/hand, hip, knee, and ankle/foot. Scoring of ultrasound
elastography was included. The strength of the recommendation and level of evidence was scored by consensus greater than 67%
or considered uncertain when the consensus was consensus less than 67%.
Results A total of 123 new papers were reviewed. No evidence change was found regarding the shoulder. There were no new
relevant articles for the shoulder, 10 new articles for the elbow, 28 for the hand/wrist, 3 for the hip, 7 for the knee, and 4 for the
ankle/foot. Four new evidence levels of A were determined, one for the hip (gluteal tendons tears), one for the knee (meniscal
cysts), one for the ankle (ankle joint instability), and one for the foot (plantar plate tear). There was no level A evidence for
elastography, although for Achilles tendinopathy and lateral epicondylitis evidence level was B with grade 3 indication.
Conclusions Four new areas of level A evidence were included in the guidelines. Elastography did not reach level A evidence. Whilst
ultrasound is of increasing importance in musculoskeletal medical practice, the evidence for elastography remains moderate.
• Evidence and expert consensus shows an increase of musculoskeletal ultrasound indications.
• Four new A evidence levels were found for the hip, knee, ankle, and foot.
• There was no level A evidence for elastography.
Elasticity imaging techniques
ESSR European Society of Musculoskeletal Radiology
In 2012, the European Society of Musculoskeletal Radiology
(ESSR) published Delphi-based consensus guidelines on the
clinical indications of musculoskeletal ultrasound in European
Radiology . Given the increased use of musculoskeletal
ultrasound in medical practice and emphasis on “evidence-
based imaging” and precision medicine , we have prepared
an update to the existing evidence on the clinical indications
for musculoskeletal ultrasound. Musculoskeletal ultrasound,
* Luca Maria Sconfienza
Extended author information available on the last page of the article