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MSK US PROTOCOLS 1
MSK US SCANNING PROTOCOL CHECKLISTJay Smith, MD
The following document provides scanning protocols for each body region and is
adopted from the AIUM Guidelines for Performance of the Musculoskeletal
Ultrasound Examination (www.aium.org). Please consider this document as areference when learning and performing MSK US examinations. Additional
structures and/or regions should be examined as clinically indicated or based on
practice needs.
For additional reference, please refer to the 2011 CPT codes for diagnostic
ultrasound examinations:
76881 Complete ultrasound of an extremity, consisting of real time scans of a specificjoint that includes examination of the muscles, tendons, joints, other soft tissue
structures andany identifiable abnormality.
76882 Limited ultrasound of an extremity to evaluate a specific anatomic structure suchas a tendon ormuscle, orsoft tissue mass.
General
1) Key anatomical areas & all pathology should be documented in two orthogonalplanes.
2) With the exception of the shoulder, examination of specific body regions may betailored to the indication for the examination. However, examination of any
particular area (e.g. lateral elbow) should follow a set protocol to ensure a
complete examination. The indication for the examination, as well as the specificstructures examined, should be considered for billing and coding purposes (see
above).
3) Comparison with the contralateral side should be performed as indicated.4) When scanning, consider:
a. Static imagesb. Dynamic images
i. Active motionii. Passive motion
iii. Compressionc. Doppler evaluation
5) With respect to masses and fluid collections, the following should be documented:a. Location and relationship to surrounding structuresb. Size (three dimensions)c. Presence or absence of Doppler flowd. As indicated, shape, margins, echotexture and compressibility
6) For interventional procedures, the physician should plan the procedure tooptimize needle visualization while avoiding sensitive structures and minimizing
the distance to the target. Pre-procedure planning should include documentation
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of the target site, including assessment for Doppler flow in the region of the
projected needle path. Optimally, images of the actual procedure as well as post-
procedure images should be archived.
ShoulderBiceps tendon and muscle
Subscapularis muscle and tendon
Dynamic exam for biceps subluxation & subcoracoid impingement (as indicated)
Acromioclavicular jointInfraspinatus tendon and muscle
Teres minor tendon and muscle
Posterior glenohumeral joint (including dynamic imaging as indicated)Spinoglenoid notch (region of suprascapular nerve)
Supraspinatus tendon and muscle, with subacromial-subdeltoid bursa
Dynamic rotator cuff evaluation and impingement testing
Suprascapular notch (as indicated)(suprascapular nerve)Extended field of view supraspinatus & infraspinatus muscle bellies(as indicated)
Elbow
Anterior:
Brachialis muscle
Brachial artery and vein
Median nervePronator teres muscle and tendon
Radial nerve
Brachioradialis muscleAnterior humeroradial joint
Radial fossa
Dynamic scanning of annular recess of the neck of the radius (supination/pronation)
Anterior humeroulnar jointCoronoid fossa
Biceps tendon and muscle, including dynamic scanning
-distal scan via posterior approach, medial approach and/or lateral approach
Lateral:
Lateral epicondyle, common extensor tendon and musclesLateral collateral ligament complex
Lateral humeroradial joint (including dynamic imaging as indicated)
Radial nerve bifurcation and course through supinator muscle
Proximal attachment of brachioradialisProximal attachment of extensor carpi radialis longus
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Medial:
Medial epicondyle, common flexor-pronator tendon and muscles
Ulnar collateral ligamentDynamic valgus stress of ulnar collateral ligament (as indicated)
Humeroulnar joint
Ulnar nerve (also included in posterior region scan)Dynamic flexion-extension (as indicated)
-evaluate for ulnar nerve subluxation
-evaluate for snapping triceps tendon
Posterior:
Triceps tendon muscles
Olecranon fossa and posterior joint spaceOlecranon process
Olecranon bursa
Ulnar nerve (also included in medial region scan)
Dynamic flexion-extension (as indicated)(also included in medial region scan)-evaluate for ulnar nerve subluxation
-evaluate for snapping triceps tendon
Wrist and Hand
Volar:
Carpal tunnel contents
Flexor retinaculum
Median nerveFlexor pollicis longus tendon
Flexor digitorum profundus and superficialis tendons
Dynamic examination with flexion & extension tendon & nerve motionPalmaris longus tendon
Flexor carpi radialis longus tendon and radial artery (occult ganglion cyst)
Ulnar nerve and ulnar artery within Guyons canal
Flexor carpi ulnaris tendonTrace all tendons followed to their sites of insertion if clinically indicated
Joints as clinically indicated (e.g. volar radiocarpal joint)
Ulnar/Medial:
Extensor carpi ulnaris tendon and muscle
Dynamic examination for extensor carpi ulnaris subluxation (as indicated)Triangular fibrocartilage complex and meniscus homologue
Ulnocarpal joint
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Dorsal:
Extensor retinaculum, 6 compartments, 9 tendons and muscles
Dynamic tendon examination flexion/extension of the fingers (as indicated)Dorsal scapholunate ligament
Trace all tendons followed to their sites of insertion if clinically indicated)
Joints as clinically indicated-Radiocarpal (RC), metacarpophalangeal (MCP), proximal interphalangeal (PIP),
distal interphalangeal (DIP)
-Dorsal and volar
Superficial radial nerve (as indicated)
Hip
Anterior Region (patient supine):
Sagittal oblique, parallel to long axis of femoral neck
Femoral head, neck, capsule, and anterior synovial recessHip joint assessment for effusion
Sagittal planeAnterior labrum
TransverseFemoral vessels and nerve
Iliopsoas muscle, tendon and bursa
Sartorius and tensor fascia lata tendons and musclesLateral femoral cutaneous nerve
Rectus femoris tendon(s) and muscles
Dynamic scanning if snapping hip (as indicated)
Medial Region
Supine neutral
Femoral vessels and nerve (unless already examined with anterior region)
Abducted-Externally rotated (frog leg)
Adductor muscles (A. longus and gracilisA. brevisA. magnus) and tendons
Distal iliopsoas tendon
Pubic bone and symphysis (joint)
Distal rectus abdominis muscle and tendon
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Lateral Region (side lying with hip flexed 20-30 degrees)
Gluteus maximus fascia lata tensor fascia lataGluteus minimus tendon and muscle
Gluteus medius tendon and muscle
Greater trochanteric bursa (subgluteus maximus bursa)Dynamic scanning for snapping hip (as indicated)
Consider assessment for hip joint effusion as indicated
Posterior (prone w/wo pillow under hips)
Gluteus maximus muscle and tendon (longitudinal and transverse)Deep short external rotators (as indicated)
Hamstring tendon and muscles
Ischial tuberosity and bursal region
Sciatic nerveAssess posterior hip joint as indicated
Prosthetic Hip (as indicated)
Assess for joint effusions and extra-articular fluid collections
Greater trochanter and integrity of gluteal attachments (as indicated)
Iliopsoas tendon and bursaImpingement on acetabular component (as indicated)
Knee
Anterior:
Quadriceps tendon and muscles
Suprapatellar recess of knee jointPatella and prepatellar bursa
Patellar tendon and tibial tubercle
Superficial infrapatellar bursa
Deep infrapatellar bursaVastus medialis and medial retinaculum (also with medial region scan)
Vastus lateralis and lateral retinaculum (also with lateral regional scan)
Distal femoral cartilage (as indicated)-Assessed at 90 degrees of flexion and dynamically to 30 degrees)
Medial:MCL/tibial collateral ligament
Valgus stress testing (as indicated)
Medial meniscus and tibiofemoral joint space
Pes anserine tendons and bursaMedial patellar retinaculum and patellofemoral joint (also with anterior region scan)
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Lateral:
Iliotibial band and bursa
Lateral meniscus and tibiofemoral joint spaceLCL/fibular collateral ligament
Varus stress test (as indicated)
Biceps femoris tendon and musclesPopliteus tendon and muscle
Lateral patellar retinaculum and patellofemoral joint (also with anterior region scan)
Proximal tibiofibular joint (as indicated)
Posterior:
Popliteal fossa
Popliteal cyst (document communicating stalk)Popliteal artery and vein
Semimembranosus tendon and muscle
Medial & lateral gastrocnemius muscle, tendon, and bursa
Sciatic, tibial, and common fibular nervesPosterior horns of both menisci (as indicated) and tibiofemoral joint
PCL (as indicated) (may be seen in sagittal oblique plane)
Ankle /Foot
Anterior:
Tibialis anterior (from musculotendinous junction to insertion)
Extensor hallucis longus tendon and muscle
Extensor digitorum longus tendon and musclePeroneus tertius (congenitally absent in some patients)
Deep peroneal nerve and dorsalis pedis artery
Anterior joint recess (effusion, loose bodies, and synovial thickening)Anterior joint capsule
Anterior tibiofibular ligament
Medial:
Posterior tibialis tendon and muscle
Flexor digitorum longus tendon and muscle
Posterior tibial nerveMedial and lateral plantar nerves (as indicated)
Tibial artery and veins
Flexor hallucis longus tendon and muscleDeltoid ligament and medial tibiotalar joint
Lateral:
Peroneus (fibularis) longus & brevis tendons and musclesSuperior peroneal retinaculum
Dynamic assessment for peroneal subluxation (as indicated)
ATFL
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CFL (including lateral tibiotalar joint and posterior subtalar joint)
PTFL (as able and indicated)
Sural nerve (as indicated)
Posterior:
Achilles tendon and paratenonDynamic scanning in of Achilles (as indicated to assist with tear evaluation)
Retrocalcaneal bursa
Retro-Achilles/Superficial Achilles bursa
Plantaris tendon (may be absent)(as indicated)Posterior tibiotalar and subtalar joints
Inferior:
Plantar fascia
Plantar fat pad
Interdigital:
Dorsal or plantar approach can be used
Longitudinal and transverse viewsIntermetatarsal bursa (on the dorsal aspect of the interdigital nerve)
Dynamic scanning, applying pressure for Mortons neuroma, and/or ultrasonographic
Mulders click (as indicated)
Digital:
Assess for synovitis, dorsal and/or plantarMetatarsophalangeal (MTP) joints
Interphalangeal (IP) joints
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RESOURCES
Books
Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. New York: Springer,
2007, ISBN 978-3-540-42267-9, 974 pp.
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. Philadelphia: Saunders,
2007, ISBN 978-1-4160-3593-0, 345 pp.
ONeill J (ed.). Musculoskeletal Ultrasound: Anatomy and Technique. New York:
Springer, 2008, ISBN 978-0-387-76609-6, 348 pp.
Websites (including scanning protocols)
American Institute of Ultrasound In Medicine (www.aium.org)
European League Against Rheumatism(www.doctor33lt.eular/ultrasound/guidelines.htm)
European Society of Skeletal Radiology (www.essr.org)
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US MACHINE CHECKLIST 1
US MACHINE INSTRUMENTATION CHECKLIST
Jay Smith, MD 7/4/2012
Name: Date:
The following checklist includes ultrasound machine attributes and functions important toconsider when familiarizing yourself with a new US machine or when considering purchasing an
US machine for MSK US applications. The list is not meant to be comprehensive, but
representative. This checklist may also be used when studying US machine knobology.
Portable or Cart-based_______________________________________________________ Transducer(s)
o High frequency linear array ______________________________________________o
Curvilinear array ______________________________________________________o Small footprint linear array (hockey stick) __________________________________o Ease changing and selecting transducers ____________________________________
Availability of presets & ease of selection________________________________________ Frequency
o Ease of changing frequency ______________________________________________o Effect of frequency change
Decrease frequency ___________________________________________ Increase frequency ___________________________________________
Depth
o Ease of changing depth _________________________________________________o Effective imaging depth _________________________________________________o Effect of increased depth on field of view and frame rate _______________________
_____________________________________________________________________
Focal Zoneo Ease of changing focal zone position and number _____________________________
Gaino Ease of changing gain __________________________________________________
Time Gain Compensation (TGC)/Depth Gain Compensation (DGC)o Ease of changing TGC/DGC _____________________________________________
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US MACHINE CHECKLIST 2
Image Archivingo Method of annotation ___________________________________________________o Ease of saving still images _______________________________________________o Video loop capabilities _________________________________________________o Measuring tools (distance, dimensions, cross sectional area)o Archiving
Hard drive capacity Able to save on flash drive, DVD/CD
DICOM/networking optionso Ability to perform post-processing (i.e. saves raw data that can be manipulated
following study, such as gain, dynamic range, etc.)
Doppler Imagingo Ease of switching to Doppler imaging ______________________________________
Additional Functionso Harmonic Imaging _____________________________________________________o Spatial compounding ___________________________________________________o Beam steering _________________________________________________________o Extended field of view imaging/panoramic imaging ___________________________
Ability to use measurement functions in EFOV/panoramic ____________o Virtual convex/trapezoidal imaging _______________________________________o Additional functions ____________________________________________________
Training support with purchase_______________________________________________ Warranty and Maintenance contract___________________________________________ Machine upgrade capability
o How easy to upgrade ? __________________________________________________o Upgrades free or need to be purchased______________________________________
Additional Notes
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Ultrasound-Guided Lower Extremity Procedure Manual
AIUM-Mayo Clinic MSK US Course 2012
Gerry Malanga, MD
Jon Halperin, MD
Jonathan Finnoff, DO
Jay Smith, MD
This manual is being provided to you as a guide for this course. The techniquesare described utilize common positions and approaches. Not all procedures maybe specifically discussed during the course and alternative positioning and
approaches may be utilized as desired or necessary.
Deeper procedures (ie: hip joint injection) often require a long (e.g., 3.5 inch)intermediate gauge (e.g., 22 gauge) needle, whereas more superficially locatedprocedures often can be performed with shorter (e.g., 2 inch) smaller gauge (e.g.,25 gauge) needles. However, needle choice for a specific procedure is determined
on a case-by-case basis.
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Hip
1. Intra-articular hip injection
a. Patient positioni. Supine
ii. Hip in neutral rotationb. Transducer position
i. Anatomic transverse oblique plane (same plane as the femoral neck) overthe femoral head and neck
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Inferolateral to superomedial
e. Targeti. Anterior joint recess at the femoral head-neck junction
f. Pearls/Pitfallsi. Locate and avoid the femoral neurovascular structures
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2. Iliopsoas tendon sheath injectiona. Patient position
i. Supineii. Neutral to slight external rotation of the hip
b. Transducer positioni. Anatomic sagittal oblique plane (same plane as the iliopsoas tendon)c. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in planed. Needle Approach
i. Distal to proximale. Target
i. Anterior tendon sheathf. Pearls/Pitfalls
i. Locate and avoid the femoral neurovascular structures
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3. Psoas bursaa. Patient position
i. Supineii. Neutral to slight external rotation of the hip
b. Transducer positioni. Anatomic transverse plane over the superomedial aspect of the femoralhead and the anterior acetabular rim
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial
e. Targeti. Psoas bursa between the deep psoas tendon and acetabular rim
f. Pearls/Pitfallsi. Locate and avoid the femoral nerve/artery/vein
ii. May also inject slightly superiorly, at the iliopectineal eminence
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4. Ischial bursa/Hamstring tendon origina. Patient position
i. Prone with pillows under the patients hips to create some hip flexionb. Transducer position
i. Anatomic transverse planec. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial
e. Targeti. Just superficial to the hamstring tendon origin, in the tissue plane between
the tendon and the overlying gluteus maximus muscle
f. Pearls/Pitfallsi. Locate and avoid the sciatic nerve
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5. Greater trochanteric (subgluteus maximus) bursaa. Patient position
i. Side-lying on asymptomatic sideb. Transducer position
i. Anatomic transverse plane over the greater trochanterc. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Posterior to anterior
e. Targeti. Tissue plane between the gluteus maximus-iliotibial band (superficial) and
the gluteus medius tendon (deep)
f. Pearls/Pitfallsi. Slight rotation of the transducer to bring it parallel the the overlying
gluteus maximus may increase the conspicuity of the bursal plane
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6. Piriformis musclea. Patient position
i. Proneb. Transducer position
i. Anatomic transverse-oblique (same plane as the piriformis muscle)c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Inferolateral to superomedial
e. Targeti. Piriformis muscle
f. Pearls/Pitfallsi. Identify and avoid the sciatic nerve and inferior gluteal artery.
ii. Be aware of possible variants in sciatic nerve location
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7. Needle tenotomy of the gluteus medius tendon insertiona. Patient position
i. Side-lying on the asymptomatic sideb. Transducer position
i. Anatomic coronal plane over the insertion of the gluteus medius tendon onthe lateral facet of the greater trochanter
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Superior to inferior
ii. Alternatively, inferior to superiore. Target
i. Repetitively fenestrate the entire region of tendinopathyf. Pearls/Pitfalls
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8. Needle tenotomy of the hamstring tendon origina. Patient position
i. Prone with pillows under the patients hips to create some hip flexionb. Transducer position
i. Anatomic sagittal planec. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Distal to proximal
e. Targeti. Repetitively fenestrate the entire region of tendinopathy
f. Pearls/Pitfallsi. Locate and avoid the sciatic nerve
ii. Some practitioners prefer proximal to distal
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Knee
1. Knee joint injection/aspiration
a. Patient positioni. Supine with the knee flexed approximately 20 degrees
b. Transducer positioni. Anatomic transverse plane over the suprapatellar recess
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial
e. Targeti. Suprapatellar recess between the quadriceps tendon or quadriceps fat
pad (superficial) and prefemoral fat (deep)
ii. US picture show small effusion in recess, just deep to quadriceps tendonf. Pearls/Pitfallsi. Identification of knee effusion in the suprapatellar recess is enhanced
through knee flexion
ii. Medial/lateral patellar glides or medial/lateral mobilization of theprefemoral fat can be used to improve identification of the suprapatellarrecess
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2. Medial gastrocnemius-semitendinosis bursa (Bakers cyst) aspiration/injection
a. Patient position
i. Proneb. Transducer position
i. Anatomic sagittal plane over the Bakers cystc. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Inferior to superior
e. Targeti. The Bakers cyst
f. Pearls/Pitfallsi. Identify and avoid the popliteal artery and veins, and tibial nerve
ii. Can be multilobulated. Be sure to drain all of the different cysts.iii. Slight knee flexion (pillow under shin) may increase conspicuity of the
Bakers cystiv. It is possible to use multiple different needle approaches for this
procedure. The choice of approach depends on the best acousticwindow and proximity of the popliteal neurovascular structures
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3. Distal iliotibial banda. Patient position
i. Side-lyingii. Asymptomatic side down
iii. Knee flexed approximately 20 degreesiv. Facing away from the physicianb. Transducer position
i. Anatomic transverse plane over the iliotibial band as it crosses the lateralfemoral condyle
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Posterior to anterior
e. Targeti. Between the iliotibial band (superficial) and lateral femoral condyle (deep)
f. Pearls/Pitfallsi. Identify and avoid the common peroneal nerve
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4. Pes anserine bursaa. Patient position
i. Supine with knee flexed approximately 20 degreesii. Hip slightly externally rotated to enable access to the pes anserine bursa
b. Transducer positioni. Anatomic sagittal oblique plane (same plane as the MCL) over the anteriorfibers of the MCL
ii. Pes anserine tendons should be seen in an oblique transverse view as theycross the MCL
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Inferior to superior
e. Targeti. Deep to the pes anserine tendons (central tendon if multiple tendons are
seen) and superficial to the MCLf. Pearls/Pitfalls
i. Avoid injecting into the pes anserine tendons or MCLii. Branches of saphenous nerve may be located in this region
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5. Deep infrapatellar bursaa. Patient position
i. Supine with the knee flexed approximately 20 degreesb. Transducer position
i. Anatomic transverse plane over the deep infrapatellar bursac. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial or medial to lateral
e. Targeti. Deep infrapatellar bursa
f. Pearls/Pitfallsi. Avoid injecting into the patellar tendon
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6. Superficial infrapatellar bursaa. Patient position
i. Supine with the knee flexed approximately 20 degreesb. Transducer position
i. Anatomic transverse plane over the superficial infrapatellar bursac. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial or medial to lateral
e. Targeti. Superficial infrapatellar bursa
f. Pearls/Pitfallsi. Avoid injecting into the patellar tendon
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7. Popliteus tendon sheatha. Patient position
i. Side-lyingii. Asymptomatic side down
iii. Knee flexed approximately 20 degreesiv. Facing toward the physicianb. Transducer position
v. Anatomic coronal oblique plane (in the same plane as the popliteustendon) over the popliteus tendon origin
c. Needle Orientation Relative to the Transducervi. Long-axis/longitudinal/in plane
d. Needle Approachvii. Anterosuperior to Posteroinferior
e. Targetviii. Superficial or deep aspect of the popliteus tendon sheath
f. Pearls/Pitfallsix. Identify and avoid the common peroneal nervex. Identify and avoid the lateral collateral/fibular collateral ligament
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8. Proximal tibiofibular jointa. Patient position
i. Supine with the knee slightly flexedb. Transducer position
i. Anatomic transverse oblique plane over the proximal tibiofibular jointc. Needle Orientation Relative to the Transduceri. Short-axis/transverse/out-of-plane
d. Needle Approachi. Inferior to superior
e. Targeti. Proximal tibiofibular joint
ii. Use the walk-down techniquef. Pearls/Pitfalls
i. Identify and avoid the common, superficial, and deep peroneal nerves
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9. Needle tenotomy of the patellar tendon origina. Patient position
i. Supine with knee slightly flexedb. Transducer position
i. Anatomic sagittal plane over the proximal patellar tendonc. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in-plane
d. Needle Approachi. Inferior to superior
e. Targeti. Repetitively fenestrate the entire region of tendinopathy
f. Pearls/Pitfalls
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Foot/Ankle
1. Ankle Joint Technique 1
a. Patient positioni. Supine with the knee flexed approximately 90 degrees and foot flat on
table
b. Transducer positioni. Anatomic transverse plane over the talar dome
c. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Medial to lateral, deep to the anterior ankle tendons
e. Targeti. Anterior ankle joint recess between the hyaline cartilage of the talar dome
(deep) and the peri-articular fat (superficial)
f. Pearls/Pitfallsi. Identify and avoid the deep peroneal nerve and dorsalis pedis artery and
veins
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2. Peroneal tendon sheatha. Patient position
i. Side-lyingii. Symptomatic side up
iii. Facing physicianb. Transducer positioni. Anatomic transverse plane over the peroneal tendons approximately 2-4
cm proximal to the lateral malleolusc. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in planed. Needle Approach
i. Anterior to posteriore. Target
i. Peroneal tendon sheathf. Pearls/Pitfalls
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3. Plantar fasciaa. Patient position
i. Side-lyingii. Symptomatic side down
b. Transducer positioni. Anatomic transverse plane over the plantar fascia originc. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in-planed. Needle Approach
i. Medial to laterale. Target
i. Superficial or deep to plantar fascia originf. Pearls/Pitfalls
i. Avoid injecting into the plantar fasciaii. Identify and avoid the medial ankle neurovascular structures
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4. First metatarsophalangeal (MTP) jointa. Patient position
i. Supineb. Transducer positioni. Anatomic sagittal plane over the dorsomedial aspect of the jointc. Needle Orientation Relative to the Transducer
i. Short-axis/transverse/out-of-planed. Needle Approach
i. Medial to laterale. Target
i. Dorsomedial aspect of the first MTP jointii. Use a walk-down technique
f. Pearls/Pitfallsi. Stay dorsal to avoid medial hallucal nerve
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5. Mortons neuromaa. Patient position
i. Proneb. Transducer position
i. Anatomic sagittal plane over the neuromaii. Within intermetatarsal space on the plantar aspect of the footc. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in planed. Needle Approach
iii. Distal to proximale. Target
iv. Adjacent to or into the neuromaf. Pearls/Pitfalls
v. Identify and avoid adjacent digital artery and veins
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6. Ankle Joint Technique 2a. Patient position
i. Supine with the knee flexed approximately 90 degrees and foot flat ontable
b. Transducer positioni. Anatomic sagittal plane between the anterior tibial and extensor hallicuslongus tendons
b. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
c. Needle Approachi. Distal to proximal
d. Targeti. Anterior ankle joint recess between the distal anterior tibia and the hyaline
cartilage of the talar domee. Pearls/Pitfalls
i. Identify and avoid the deep peroneal nerve and dorsalis pedis artery andveins
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7. Retro-calcaneal bursaa. Patient position
i. Prone with foot hanging over the end of the tableb. Transducer position
i. Anatomic transverse plane over the retro-calcaneal bursac. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial
e. Targeti. Retro-calcaneal bursa between the Achilles tendon (superficial) and
posterior calcaneus (deep)
f. Pearls/Pitfallsi. Identify and avoid the sural nerve
ii. Avoid injecting the Achilles tendon
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8. Retro-Achilles bursaa. Patient position
i. Prone with foot hanging over the end of the tableb. Transducer position
i. Anatomic transverse plane over the retro-Achilles bursac. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane
d. Needle Approachi. Lateral to medial
e. Targeti. Retro-Achilles bursa located superficial to the Achilles tendon and deep to
the surrounding subcutaneous tissue
f. Pearls/Pitfallsi. Identify and avoid the sural nerve
ii. Avoid injecting the Achilles tendon
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9. Flexor hallicus longus (FHL) tendon sheatha. Patient position
i. Prone with foot hanging over the end of the tableb. Transducer position
i. Anatomic transverse plane over the FHL tendon at the level of theposterior process of the talusc. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in-planed. Needle Approach
i. Lateral to medial (deep to the Achilles tendon)e. Target
i. FHL tendon sheathf. Pearls/Pitfalls
i. Identify and avoid the sural and tibial neurovascular bundle and veins
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10. Sinus tarsia. Patient position
i. Side-lyingii. Symptomatic side up
b. Transducer positioni. Anatomic transverse plane over the sinus tarsic. Needle Orientation Relative to the Transducer
i. Short-axis/transverse/out-of-planed. Needle Approach
i. Anterior to posteriore. Target
i. Sinus tarsiii. Use the walk-down technique
iii. Advance needle until bottom of sinus tarsi is contactedf. Pearls/Pitfalls
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11. Posterior facet of the subtalar jointa. Patient position
i. Side-lyingii. Symptomatic side up
b. Transducer positioni. Identify the sinus tarsi with the transducer in the anatomic transverse planeover the dorsolateral foot
ii. Glide the transducer posteriorly until the anterior margin of the subtalarjoints posterior facet is identified just anterior to the lateral malleolus
c. Needle Orientation Relative to the Transduceri. Short-axis/transverse/out-of-plane
d. Needle Approachi. Anterior to posterior
e. Targeti. Subtalar joint
ii. Use the walk-down techniquef. Pearls/Pitfalls
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12. Needle tenotomy of the Achilles tendona. Patient position
i. Proneii. Foot hanging off end of the table
b. Transducer positioni. Anatomic sagittal planec. Needle Orientation Relative to the Transducer
i. Long-axis/longitudinal/in planed. Needle Approach
i. Distal to proximal, alternatively proximal to distale. Target
i. Repetitively fenestrate the entire region of tendinopathyf. Pearls/Pitfalls