- MICROTRAUMATIC 

- MUSCULOTENDINOUS DISORDER 

- ROTATOR CUFF TENDINITIS 

- EPICONDYLITIS 

- GANGLIAL CYSTS 

- CARPAL TUNNEL SYNDROME 

- DE QUERVAIN'S DISEASE 

- LOCK FINGER 

- TENDINITIS OF THE EXTENSOR CARPI RADIALIS 

- TENDINITIS OF THE FLEXOR CARPIRADIALIS AND FLEXOR CARPI ULNARIS  

- TENDINITIS OF THE FINGER FLEXORS  

The etiology is often unknown for these conditions. However, the presence of a relationship with specific labor tasks is frequently made very clear (polishers, press operators, painters, mechanics, typists and carpenters are all subjected to repetitive wrist movements, prolonged shoulder bending and repeated forearm pronations). The repeated and prolonged application of a force on one muscle group or on one joint with protracted tendinous straining can lead to microlacerations of the soft tissues. The lesions formed and the secondary phlogistic response are able to determine anatomofunctional damage to the muscles, tendons, ligaments and synovial membranes. Alterations in the tendons and their casings are common, especially close to the bone and ligaments, where rubbing is unavoidable. Symptoms are typically dull pains close to the tendons, worsened by the performance of set movements and often accompanied by hyperesthesia to touch in the acute phases. Reddening and localized heat may be present. This clinical picture easily becomes chronic and, after rest and therapy, recovery is slow (5, 6, 7, 8).Tendinitis consists in a phlogistic reaction of the tendon which is found when the muscle/tendon motor unit undergoes intense and protracted strain. Following repeated straining, the tendinous fibers tend to thin down, become disorganized and finally snap. In the uncased tendons, such as in the shoulder, the lesion area tends to calcify. Without adequate rest and therapy to encourage healing, and the restoration of the normal anatomofunctional structure, the tendons will become permanently weakened, with impaired functioning. Apart from the lesions described, these pictures are often associated with damage to neighbouring nerves. This is due both to increased thickness (because of edema or fibrosis) of the structures themselves which then exercise quite a mass effect, particularly on “natural anatomic channels” (e.g. carpal tunnel), and to the inflammation that can extend to strike at the surrounding tissues causing reactive neuritis. In the differential diagnosis of CTDs, it is appropriate to also consider auto-immune or inflammatory systemic conditions (Lupus erythematosis, rheumatoid arthritis, polymyositis, etc.) or metabolic disorders (hyperlipoproteinemia) that often mimic the described pictures. Use of echotomography in upper limb CTD As is well-known, for better spatial definition it is apropriate to use very high-quality ultrasound equipment having linear 7.5 MHz probes, or with greater wave-lengths (at least theoretically - better visualization with 10 MHz probes has not been experimentally demonstrated). Employing a water or silicon space maintainer (KITECHO) is useful, placed between the probe and the skin of the tract to be examined. Because of its nature, the tendon is visualized as a hypoechogenic ribbon-like structure that fades distally into the muscle head, assuming its classical echostructure (4). The phlogistic disorder is not appreciable in the initial phases but becomes so if the results are checked out: enlargement of the tendon due to edema or thickening as a result of the condition becoming chronic; also very noticable are any intramural or peritendinous microcalcifications. The edemas that spread the tendinous membrane apart (tenosynovitis) show up with characteristic “rail track” images, hyperechogenic and hypo-anechogenic spaces. The characteristics in de Quervain's disease are thinning of the tendon, an increased ultrasound signal, excellent appraisal of the degree of swelling if present; the study of the bony cortex of the radial styloid and relationhips between the mentioned structures can also be useful, at rest and during forced movement. The same holds true for synovial cysts of the wrist, which always call for precise discrimination of the relationship between the neoformations with the tendon. At lateral or medial supracondylar level, visualization of the muscles and their insertions is precise and helped by axial and longitudinal scanning planes. To the contrary of the X-rays that are always negative, study of the phlogosis avails of hypo-anechogenic intramuscular images, oval or orbicular, the expression of multi-focal edema. Microcalcifications are another feature, the expression of inveterate epicondylitis. The shoulder is less easily studied, because of its anatomical shape and unfavorable bone/soft-tissue ratio. This is why ultrasonography is partly limited but, with suitable techniques, good visualization can be had of the articular space, rotator cuff, and the muscular venters of the supraspinatus and synovial bursa. The torn articular capsule will show a pathognomonic hyperechogenic interruption in its classic profile. Although traditional radiology cannot be replaced in the studies of anomalies in the chest (supernumerary rib or mega-apophysis), echotomography is valid for examining the morphology of the scalenes and thus of any thickening. Veins and arteries show up well as linear anechogenic images and differentiating between them is easy because of the marked pulsating of the arteries. The brachial plexus can be reached by the echoes through the anatomic acoustic window formed by the intercostal spaces (it should be noted that the use of linear probes handicaps this manoeuvre). The plexus shows up as a hypoechogenic starlike structure well segmented by the surrounding hyperechogenic soft tissues. The possibility should also be remembered in this case of studying the anatomical structures both “at rest” and during the diagnostic manoeuvres that clinically reveal the disorder. The nerve formations are not easily evaluated with ultrasound. The myelinic nervous system is full of echogenic structures and shows up as hypoechogenic or hyperechogenic, often as a consequence of the direction of the scanning (“scattering” phenomenon). More commonly, nerve visualization is with a hyperechogenic binary image and should always be backed up by good anatomotopographical knowledge. Carpal tunnel syndromes are more easily studied. The tendons of the flexor digiti minimi, of relatively large dimensions, the vessels and the bone tissue constitute a good cleavage plane for the identification of the median nerve. Also useful here, is the examination of the above-mentioned tendons that should show typical positioning and a hypoechogenic signal. Where there is a disorder, an increase in nearest fibrous tissue is easily verified, with approximation by attraction of the tendons and their abnormal dislocation. Also easy to find is an increase in the size of the tendons themselves and an anomalous signal demeanor that arises in the still hyperechogenic, thickened tendons, notwithstanding the angulation of the gash and of the probe. Thickening of the transverse carpal ligament is also well visible with transversal scanning at its axis and with the hand fixed in supine flexion. Conclusion The aim was to draw attention to the use of ultrasonography in a class of increasingly detected disorders in occupational medicine and in orthopedics. The fact that the clinical pictures often appear obscured at the periodic employee check-ups carried out by the physician responsible, or are underestimated by the orthopedic physician, and therefore missed, favors the utilization of ultrasound examinations as a first-option procedure following a careful clinical consultation that might pose the suspician. It is fast to perform, scarsely invasive, easily repeatible and has relatively contained costs. Indeed, it should not be forgotten that the described musculotendinous alterations lead to continually evolving pictures where self-limitation is difficult. There is a loss in the ability to work and prolonged absences from the job causes the difficult restitutio ad integrum situation once the condition becomes chronic. Not least, the morphological assessments of the described conditions appear to be only clinically interesting (e.g. epicondylitis) with the possibility of following up the development of the disorder over time and “objectively”, evaluating the efficacy of the therapy and therefore of the worker's recovery.