MSK US PROTOCOLS 1

MSK US SCANNING PROTOCOL CHECKLIST Jay 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 a reference 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 specific joint that includes examination of the muscles, tendons, joints, other soft tissue structures and any identifiable abnormality. 76882 Limited ultrasound of an extremity to evaluate a specific anatomic structure such as a tendon or muscle, or soft tissue mass. General 1) Key anatomical areas & all pathology should be documented in two orthogonal planes. 2) With the exception of the shoulder, examination of specific body regions may be tailored 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 specific structures 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 images b. Dynamic images i. Active motion ii. Passive motion iii. Compression c. Doppler evaluation 5) With respect to masses and fluid collections, the following should be documented: a. Location and relationship to surrounding structures b. Size (three dimensions) c. Presence or absence of Doppler flow d. As indicated, shape, margins, echotexture and compressibility 6) For interventional procedures, the physician should plan the procedure to optimize needle visualization while avoiding sensitive structures and minimizing the distance to the target. Pre-procedure planning should include documentation

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 postprocedure images should be archived.

Shoulder Biceps tendon and muscle Subscapularis muscle and tendon Dynamic exam for biceps subluxation & subcoracoid impingement (as indicated) Acromioclavicular joint Infraspinatus 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 nerve Pronator teres muscle and tendon Radial nerve Brachioradialis muscle Anterior humeroradial joint Radial fossa Dynamic scanning of annular recess of the neck of the radius (supination/pronation) Anterior humeroulnar joint Coronoid 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 muscles Lateral collateral ligament complex Lateral humeroradial joint (including dynamic imaging as indicated) Radial nerve bifurcation and course through supinator muscle Proximal attachment of brachioradialis Proximal attachment of extensor carpi radialis longus

Medial: Medial epicondyle, common flexor-pronator tendon and muscles Ulnar collateral ligament Dynamic 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 space Olecranon 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 nerve Flexor pollicis longus tendon Flexor digitorum profundus and superficialis tendons Dynamic examination with flexion & extension tendon & nerve motion Palmaris longus tendon Flexor carpi radialis longus tendon and radial artery (occult ganglion cyst) Ulnar nerve and ulnar artery within Guyons canal Flexor carpi ulnaris tendon Trace 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

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 recess Hip joint assessment for effusion Sagittal plane Anterior labrum Transverse Femoral vessels and nerve Iliopsoas muscle, tendon and bursa Sartorius and tensor fascia lata tendons and muscles Lateral 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 gracilis A. brevis A. magnus) and tendons Distal iliopsoas tendon Pubic bone and symphysis (joint) Distal rectus abdominis muscle and tendon

Lateral Region (side lying with hip flexed 20-30 degrees) Gluteus maximus fascia lata tensor fascia lata Gluteus 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 nerve Assess 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 bursa Impingement on acetabular component (as indicated) Knee Anterior: Quadriceps tendon and muscles Suprapatellar recess of knee joint Patella and prepatellar bursa Patellar tendon and tibial tubercle Superficial infrapatellar bursa Deep infrapatellar bursa Vastus 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 bursa Medial patellar retinaculum and patellofemoral joint (also with anterior region scan)

Lateral: Iliotibial band and bursa Lateral meniscus and tibiofemoral joint space LCL/fibular collateral ligament Varus stress test (as indicated) Biceps femoris tendon and muscles Popliteus 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 nerves Posterior 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 muscle Peroneus 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 nerve Medial and lateral plantar nerves (as indicated) Tibial artery and veins Flexor hallucis longus tendon and muscle Deltoid ligament and medial tibiotalar joint Lateral: Peroneus (fibularis) longus & brevis tendons and muscles Superior peroneal retinaculum Dynamic assessment for peroneal subluxation (as indicated) ATFL

CFL (including lateral tibiotalar joint and posterior subtalar joint) PTFL (as able and indicated) Sural nerve (as indicated) Posterior: Achilles tendon and paratenon Dynamic 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 views Intermetatarsal 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 plantar Metatarsophalangeal (MTP) joints Interphalangeal (IP) joints

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)

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 to consider 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 Zone o Ease of changing focal zone position and number _____________________________ Gain o Ease of changing gain __________________________________________________ Time Gain Compensation (TGC)/Depth Gain Compensation (DGC) o Ease of changing TGC/DGC _____________________________________________

US MACHINE CHECKLIST 2 Image Archiving o 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 options o Ability to perform post-processing (i.e. saves raw data that can be manipulated following study, such as gain, dynamic range, etc.) Doppler Imaging o Ease of switching to Doppler imaging ______________________________________ Additional Functions o 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 techniques are described utilize common positions and approaches. Not all procedures may be 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 located procedures 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 position i. Supine ii. Hip in neutral rotation b. Transducer position i. Anatomic transverse oblique plane (same plane as the femoral neck) over the femoral head and neck c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Inferolateral to superomedial e. Target i. Anterior joint recess at the femoral head-neck junction f. Pearls/Pitfalls i. Locate and avoid the femoral neurovascular structures

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2. Iliopsoas tendon sheath injection a. Patient position i. Supine ii. Neutral to slight external rotation of the hip b. Transducer position i. Anatomic sagittal oblique plane (same plane as the iliopsoas tendon) c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Distal to proximal e. Target i. Anterior tendon sheath f. Pearls/Pitfalls i. Locate and avoid the femoral neurovascular structures

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3. Psoas bursa a. Patient position i. Supine ii. Neutral to slight external rotation of the hip b. Transducer position i. Anatomic transverse plane over the superomedial aspect of the femoral head and the anterior acetabular rim c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial e. Target i. Psoas bursa between the deep psoas tendon and acetabular rim f. Pearls/Pitfalls i. 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 origin a. Patient position i. Prone with pillows under the patients hips to create some hip flexion b. Transducer position i. Anatomic transverse plane c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial e. Target i. Just superficial to the hamstring tendon origin, in the tissue plane between the tendon and the overlying gluteus maximus muscle f. Pearls/Pitfalls i. Locate and avoid the sciatic nerve

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5. Greater trochanteric (subgluteus maximus) bursa a. Patient position i. Side-lying on asymptomatic side b. Transducer position i. Anatomic transverse plane over the greater trochanter c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Posterior to anterior e. Target i. Tissue plane between the gluteus maximus-iliotibial band (superficial) and the gluteus medius tendon (deep) f. Pearls/Pitfalls i. 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 muscle a. Patient position i. Prone b. Transducer position i. Anatomic transverse-oblique (same plane as the piriformis muscle) c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Inferolateral to superomedial e. Target i. Piriformis muscle f. Pearls/Pitfalls i. 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 insertion a. Patient position i. Side-lying on the asymptomatic side b. Transducer position i. Anatomic coronal plane over the insertion of the gluteus medius tendon on the lateral facet of the greater trochanter c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Superior to inferior ii. Alternatively, inferior to superior e. Target i. Repetitively fenestrate the entire region of tendinopathy f. Pearls/Pitfalls

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8. Needle tenotomy of the hamstring tendon origin a. Patient position i. Prone with pillows under the patients hips to create some hip flexion b. Transducer position i. Anatomic sagittal plane c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Distal to proximal e. Target i. Repetitively fenestrate the entire region of tendinopathy f. Pearls/Pitfalls i. 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 position i. Supine with the knee flexed approximately 20 degrees b. Transducer position i. Anatomic transverse plane over the suprapatellar recess c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial e. Target i. 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 tendon f. Pearls/Pitfalls i. Identification of knee effusion in the suprapatellar recess is enhanced through knee flexion ii. Medial/lateral patellar glides or medial/lateral mobilization of the prefemoral fat can be used to improve identification of the suprapatellar recess

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2. Medial gastrocnemius-semitendinosis bursa (Bakers cyst) aspiration/injection a. Patient position i. Prone b. Transducer position i. Anatomic sagittal plane over the Bakers cyst c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Inferior to superior e. Target i. The Bakers cyst f. Pearls/Pitfalls i. 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 cyst iv. It is possible to use multiple different needle approaches for this procedure. The choice of approach depends on the best acoustic window and proximity of the popliteal neurovascular structures

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3. Distal iliotibial band a. Patient position i. Side-lying ii. Asymptomatic side down iii. Knee flexed approximately 20 degrees iv. Facing away from the physician b. Transducer position i. Anatomic transverse plane over the iliotibial band as it crosses the lateral femoral condyle c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Posterior to anterior e. Target i. Between the iliotibial band (superficial) and lateral femoral condyle (deep) f. Pearls/Pitfalls i. Identify and avoid the common peroneal nerve

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4. Pes anserine bursa a. Patient position i. Supine with knee flexed approximately 20 degrees ii. Hip slightly externally rotated to enable access to the pes anserine bursa b. Transducer position i. Anatomic sagittal oblique plane (same plane as the MCL) over the anterior fibers of the MCL ii. Pes anserine tendons should be seen in an oblique transverse view as they cross the MCL c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Inferior to superior e. Target i. Deep to the pes anserine tendons (central tendon if multiple tendons are seen) and superficial to the MCL f. Pearls/Pitfalls i. Avoid injecting into the pes anserine tendons or MCL ii. Branches of saphenous nerve may be located in this region

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5. Deep infrapatellar bursa a. Patient position i. Supine with the knee flexed approximately 20 degrees b. Transducer position i. Anatomic transverse plane over the deep infrapatellar bursa c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial or medial to lateral e. Target i. Deep infrapatellar bursa f. Pearls/Pitfalls i. Avoid injecting into the patellar tendon

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6. Superficial infrapatellar bursa a. Patient position i. Supine with the knee flexed approximately 20 degrees b. Transducer position i. Anatomic transverse plane over the superficial infrapatellar bursa c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial or medial to lateral e. Target i. Superficial infrapatellar bursa f. Pearls/Pitfalls i. Avoid injecting into the patellar tendon

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7. Popliteus tendon sheath a. Patient position i. Side-lying ii. Asymptomatic side down iii. Knee flexed approximately 20 degrees iv. Facing toward the physician b. Transducer position v. Anatomic coronal oblique plane (in the same plane as the popliteus tendon) over the popliteus tendon origin c. Needle Orientation Relative to the Transducer vi. Long-axis/longitudinal/in plane d. Needle Approach vii. Anterosuperior to Posteroinferior e. Target viii. Superficial or deep aspect of the popliteus tendon sheath f. Pearls/Pitfalls ix. Identify and avoid the common peroneal nerve x. Identify and avoid the lateral collateral/fibular collateral ligament

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8. Proximal tibiofibular joint a. Patient position i. Supine with the knee slightly flexed b. Transducer position i. Anatomic transverse oblique plane over the proximal tibiofibular joint c. Needle Orientation Relative to the Transducer i. Short-axis/transverse/out-of-plane d. Needle Approach i. Inferior to superior e. Target i. Proximal tibiofibular joint ii. Use the walk-down technique f. Pearls/Pitfalls i. Identify and avoid the common, superficial, and deep peroneal nerves

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9. Needle tenotomy of the patellar tendon origin a. Patient position i. Supine with knee slightly flexed b. Transducer position i. Anatomic sagittal plane over the proximal patellar tendon c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in-plane d. Needle Approach i. Inferior to superior e. Target i. Repetitively fenestrate the entire region of tendinopathy f. Pearls/Pitfalls

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Foot/Ankle 1. Ankle Joint Technique 1 a. Patient position i. Supine with the knee flexed approximately 90 degrees and foot flat on table b. Transducer position i. Anatomic transverse plane over the talar dome c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Medial to lateral, deep to the anterior ankle tendons e. Target i. Anterior ankle joint recess between the hyaline cartilage of the talar dome (deep) and the peri-articular fat (superficial) f. Pearls/Pitfalls i. Identify and avoid the deep peroneal nerve and dorsalis pedis artery and veins

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2. Peroneal tendon sheath a. Patient position i. Side-lying ii. Symptomatic side up iii. Facing physician b. Transducer position i. Anatomic transverse plane over the peroneal tendons approximately 2-4 cm proximal to the lateral malleolus c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Anterior to posterior e. Target i. Peroneal tendon sheath f. Pearls/Pitfalls

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3. Plantar fascia a. Patient position i. Side-lying ii. Symptomatic side down b. Transducer position i. Anatomic transverse plane over the plantar fascia origin c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in-plane d. Needle Approach i. Medial to lateral e. Target i. Superficial or deep to plantar fascia origin f. Pearls/Pitfalls i. Avoid injecting into the plantar fascia ii. Identify and avoid the medial ankle neurovascular structures

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4. First metatarsophalangeal (MTP) joint a. Patient position i. Supine b. Transducer position i. Anatomic sagittal plane over the dorsomedial aspect of the joint c. Needle Orientation Relative to the Transducer i. Short-axis/transverse/out-of-plane d. Needle Approach i. Medial to lateral e. Target i. Dorsomedial aspect of the first MTP joint ii. Use a walk-down technique f. Pearls/Pitfalls i. Stay dorsal to avoid medial hallucal nerve

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5. Mortons neuroma a. Patient position i. Prone b. Transducer position i. Anatomic sagittal plane over the neuroma ii. Within intermetatarsal space on the plantar aspect of the foot c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach iii. Distal to proximal e. Target iv. Adjacent to or into the neuroma f. Pearls/Pitfalls v. Identify and avoid adjacent digital artery and veins

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6. Ankle Joint Technique 2 a. Patient position i. Supine with the knee flexed approximately 90 degrees and foot flat on table b. Transducer position i. Anatomic sagittal plane between the anterior tibial and extensor hallicus longus tendons b. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane c. Needle Approach i. Distal to proximal d. Target i. Anterior ankle joint recess between the distal anterior tibia and the hyaline cartilage of the talar dome e. Pearls/Pitfalls i. Identify and avoid the deep peroneal nerve and dorsalis pedis artery and veins

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7. Retro-calcaneal bursa a. Patient position i. Prone with foot hanging over the end of the table b. Transducer position i. Anatomic transverse plane over the retro-calcaneal bursa c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial e. Target i. Retro-calcaneal bursa between the Achilles tendon (superficial) and posterior calcaneus (deep) f. Pearls/Pitfalls i. Identify and avoid the sural nerve ii. Avoid injecting the Achilles tendon

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8. Retro-Achilles bursa a. Patient position i. Prone with foot hanging over the end of the table b. Transducer position i. Anatomic transverse plane over the retro-Achilles bursa c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Lateral to medial e. Target i. Retro-Achilles bursa located superficial to the Achilles tendon and deep to the surrounding subcutaneous tissue f. Pearls/Pitfalls i. Identify and avoid the sural nerve ii. Avoid injecting the Achilles tendon

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9. Flexor hallicus longus (FHL) tendon sheath a. Patient position i. Prone with foot hanging over the end of the table b. Transducer position i. Anatomic transverse plane over the FHL tendon at the level of the posterior process of the talus c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in-plane d. Needle Approach i. Lateral to medial (deep to the Achilles tendon) e. Target i. FHL tendon sheath f. Pearls/Pitfalls i. Identify and avoid the sural and tibial neurovascular bundle and veins

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10.

Sinus tarsi a. Patient position i. Side-lying ii. Symptomatic side up b. Transducer position i. Anatomic transverse plane over the sinus tarsi c. Needle Orientation Relative to the Transducer i. Short-axis/transverse/out-of-plane d. Needle Approach i. Anterior to posterior e. Target i. Sinus tarsi ii. Use the walk-down technique iii. Advance needle until bottom of sinus tarsi is contacted f. Pearls/Pitfalls

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11.

Posterior facet of the subtalar joint a. Patient position i. Side-lying ii. Symptomatic side up b. Transducer position i. Identify the sinus tarsi with the transducer in the anatomic transverse plane over the dorsolateral foot ii. Glide the transducer posteriorly until the anterior margin of the subtalar joints posterior facet is identified just anterior to the lateral malleolus c. Needle Orientation Relative to the Transducer i. Short-axis/transverse/out-of-plane d. Needle Approach i. Anterior to posterior e. Target i. Subtalar joint ii. Use the walk-down technique f. Pearls/Pitfalls

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12.

Needle tenotomy of the Achilles tendon a. Patient position i. Prone ii. Foot hanging off end of the table b. Transducer position i. Anatomic sagittal plane c. Needle Orientation Relative to the Transducer i. Long-axis/longitudinal/in plane d. Needle Approach i. Distal to proximal, alternatively proximal to distal e. Target i. Repetitively fenestrate the entire region of tendinopathy f. Pearls/Pitfalls

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