Msk Us Protocols

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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


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


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


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



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. 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


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



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


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


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


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. 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. Anatomic sagittal plane over the neuromaii. Within intermetatarsal space on the plantar aspect of the footc. Needle Orientation Relative to the Transducer


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


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. Anatomic transverse plane over the retro-Achilles bursac. Needle Orientation Relative to the Transduceri. Long-axis/longitudinal/in plane


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. 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


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


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. Distal to proximal, alternatively proximal to distale. Target

i. Repetitively fenestrate the entire region of tendinopathyf. Pearls/Pitfalls

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