goals/objectives musculoskeletal ultrasoundofthe footandankle · musculoskeletal ultrasoundofthe...

AUGUST 2012 | PODIATRY MANAGEMENT | 187www.podiatrym.com

History and Physics of UltrasoundNon-audible, high frequency

sound waves greater than 20kHz or20,000 cycles/second are termed ul-trasound and have existed in nature

for over one million years. Bats, forexample, utilize ultrasound to navi-gate and find food. This ability wassuggested in experiments performedby Lazzaro Spallazani (1729-1799),

an Italian priest and physiologist.Spallanzini found a bat could navi-gate better when blindfolded thanwhen its mouth was covered leading

Continued on page 188

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Goals/ObjectivesAfter reading this CME

article, the reader will beable to:

1) Understand the his-tory of ultrasound andits use in the podiatricpractice.

2) Integrate this tech-nology into the podiatricpractice.

3) Increase the aware-ness of the newest trendsin podiatric ultrasound.

4) Understand the dif-ference between transduc-ers and the latest imagingphysics.

5) To utilize the properjargon when describing anultrasound image.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $22.00 per topic) or 2) per year, for the special rate of $169 (you save $51).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 194. Other than those en-tities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be ac-ceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best ef-forts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goalof this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high qualitymanuscripts by noted authors and researchers. If you have any questions or comments about this program, you canwrite or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us [email protected].

Following this article, an answer sheet and full set of instructions are provided (pg. 194).—Editor

MusculoskeletalUltrasound of theFoot and Ankle

BY JOHN COZZARELLI,DPM

This tool is usefulin diagnosing softtissue injuries

of the foot and ankle.

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188 | AUGUST 2012 | PODIATRY MANAGEMENT

to conclude that a bat’s earsfunctioned more efficiently than its

eyes in helping it to navigate. At thetime of the experiment, the exact na-ture of this navigation ability was notwell understood, and “Spallanzani’sBat Problem” remained a mysteryuntil 1938, when Harvard studentsDonald Griffin and Robert Galamboswere able to use a sonic detector torecord the ultrasound directionalnoises that bats make when flying.The term for this ability, “echolation,”describes the application of direction-

al sound reflections to detect objectsand measure distances.

The history of ultrasound tech-nology began with the developmentof piezoelectric effects in 1880. In1912, Reginald A. Fessenden patent-ed a device that used active echola-tion. The first apparatus was built in1914, and the technology was uti-lized after the sinking of the Titanic.During World War I, ConstatinChilowsky and Paul Lanevin con-structed a prototype on an underwa-ter sandwich sound generator thatused quartz crystals and two steelplates, considered the first ultrasoundmachine similar to today’s units. Themilitary adopted this technology for avariety of applications, such asSONAR, (SOund NAvigation andRanging), which was used to detectand sink a German U-boat on April23, 1916. As the military continued torefine ultrasound, they eventually de-veloped what was called a reflecto-scope, or flaw detector. This was uti-lized to detect flaws during the fabri-cation of aircrafts and ships. The con-tinued development of this technolo-gy led to the development of medicalultrasound.

Medical ApplicationsThe first medical application of di-

agnostic ultrasound was utilized byKarl Dussik in 1942 to detect brain tu-

mors. Dussik continued his work, andin 1958 published the first paper onmusculoskeletal ultrasonography. Hemeasured the acoustic attenuation ofarticular and periarticular tissues in-cluding skin, adipose tissue, muscle,tendon, articular capsule, articularcartilage, and bone.

1968 ushered in the developmentof B-mode, Brightness modulation, adisplay of two-dimensional dots andpixels. The amplitude of the echo de-termines the brightness of each dotand pixel. B-mode uses 256 shades of

gray. The gray scale allows our eyesto see the difference in tissue texture.The human eye can only differentiateapproximately 20 shades. Finally, in1984, real-time ultrasound-created im-ages were introduced. These imagesare seen almost instantaneously andchange as the orientation of the trans-ducer to the tissue is being evaluated.This became known as a linear arraypiezoelectric transducer.

Ultrasound imaging of the soft tis-sue is based on the pulse-echo princi-ple. It uses a vibrating source that isreferred to as a piezoelectric crystal in

a transducer. The transducer causesthe molecules in tissue to vibrate. Thevibrations are a series of mechanicalcompressions and rarefactions mov-ing away from the transducer into thetissue. They are commonly known asultrasound waves. When the ultra-sound waves contact an interface theyare reflected back to the transducer.That signal then is sent to the com-puter processing unit to make animage on the monitor. The signal

needs to be perpendicular to the sub-ject being imaged.

Transducers and StandoffsIn general physics, the term

“transducer” refers to a device thattakes electrical energy and converts itto mechanical energy. The transducercrystal takes electrical energy andconverts it to sound waves and viceversa. Ultrasound transducers workon the piezoelectric principle. Piezeinis a Greek word, which means topress or pressure. The configurationor thickness and composition of thecrystals has a unique resonant fre-quency, thus transducers are avail-able at different frequencies (3.5, 5.0.7.5, 10, 12, 15). Linear array trans-ducers are typically 40mm in lengthand are best utilized to view muscu-loskeletal structures. The newesttransducers are now 50 or 52mm inlength. The latest development intransducers is the ability to have vari-able frequency. They have what iscalled tissue harmonic imaging. Thetransducer can have a blended fre-quency from 7.5-10, 8-13, 8-15. Thebeam comes out of the transducerperpendicular to the subject being im-aged, and at the same time, withcompound imaging, there are twoother beams imaging on a thirty de-gree angle. The principle is that if youhave a sphere being imaged, tradi-tional imaging would just provide im-ages of the surface and not the sides.

Ultrasound, however, suffers froman inherent imaging artifact calledspeckle. Speckle is the random granu-lar texture that obscures anatomy inultrasound images and is usually de-scribed as “noise.” Speckle is createdby a complex interference of ultra-sound echoes made by reflectorsspaced closer together than the ultra-sound system’s resolution limit. Con-siderable work has been done to re-


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Echolation describes the applicationof directional sound reflections to detect objects

and measure distances.

The first medical application of diagnosticultrasound was utilized by Karl Dussik in 1942

to detect brain tumors.



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duce speckle in ultrasound systems.Compound imaging allows part of thesphere to be imaged on the sides. It

produces a much smoother image.It was thought that in muscu-

loskeletal imaging, the higher the fre-quency the better the resolution ofthe image that would be obtained.This is true but there is a trade-off.The higher the resolution, the less isthe penetration of the tissue being im-aged. So, if imaging of a foreign bodyin superficial tissue occurs, it is bestimaged with a higher resolutionprobe. If an ultrasound-guided injec-tion is going to be done, a lower fre-quency is best utilized, such as7.5MHz. In vascular applications,lower frequencies are also requiredfor good Doppler sensitivity. Thepoint is that a single frequency probeis not practical. Blended frequencyprobes provide a much more realisticapproach to daily applications in apodiatric practice.

Standoffs utilized today are madefrom a synthetic silicone material.The distance in the latest standoffsare 0.5 cm in thickness. Standoff padsprovide an interface to confirm to anirregular surface of the body. At thesame time, it also pushes the imagedown on the screen about 0.5 cm.This allows the sound signal to quietdown. A standoff pad may be used toinsonate the subcutaneous structures.This is a powerful tool that should beimplemented by every examiner inmusculoskeletal ultrasound.

The Language of MusculoskeletalUltrasound

Talk the talk and walk the walk.The jargon utilized in ultrasoundscanning responds to characteristicfeatures of the anatomic structurebeing scanned. These terms (see boxon this page) are used when describ-ing the echo appearance as seen onthe monitor.

• Tendons are hyperechoic on ul-trasound imaging, demonstrating afibrillar pattern.

• Muscles appear relatively hy-poechoic to tendon fibers. Close ob-servation of the muscle belly revealshypoechoic fibers separated by hyper-echoic septae that converge on a hy-perechoic aponeurosis.

• Ligaments are hyperechoic onexamination.

• The ultrasound beam does notpenetrate the cortex of bone. The verybright echo produced at the interfaceallows the recognition of the cortexbut also can demonstrate fracture,

spurring, hematoma formation,and bone callus bridging. Abnor-mal soft tissue calcification and ossifi-cation also produces bright reflectiveechoes.

• Articular hyaline cartilage ap-pears hypoechoic. The presence offluid within the joint outlying the car-tilage produces a thin bright echo atthis interface.

• Peripheral nerves are hypere-choic relative to muscle.

• Simple fluid on ultrasound scanappears anechoic, and may demon-strate enhanced soft tissue echoesposterior to the fluid collection. Aninflamed metatarsal bursa and cal-caneal bursa depict fluid swelling.

• Ulcerations on an ultrasoundscan will appear as hypoechoic. If asinus tract is present, this structurewill appear hyperechoic as comparedto the surrounding ulceration.

• Absorbable fixation such as Or-

Standoff padsprovide an interface to confirm to an

irregular surface of the body.


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Near Field (anterior) (Fresnel zone)

Far Field (posterior) (Fraunhofer zone)

Hyperechoic (Bright)

Hypoechoic (Dark)

Isoechoic (Doesn’t change echo appearance)

Anechoic (Black)

Echogenic (Bright white)

Anisotrophy (Echogenic signal changes based on the angleof the beam)

Homogenous (Uniform echo appearance)

Heterogenous (Irregular echo appearance)

Longitudinal Scan (Sagittal Scan) (Long Axis)

Transverse Scan (Frontal Scan) (Short Axis)

The higher the resolution,the less is the penetration ofthe tissue being imaged.

strong because there are a lot ofechoes from the skin-transducer inthe immediate subcutaneous tissues.This artifact makes it difficult to eval-uate the superficial structures in the

epidermis. Use of the standoff willavoid this near field artifact.

Shadowing occurs when imaging abone or calcified object. Sound wavewill not penetrate bone, so the entirewave is reflected back. This will dis-play a very echogenic cortex andshadowing will occur deeper to it.

Enhancement occurs when travel-ing through fluid which is not attenu-ated. There is very little reflectionback and most of the waveform isconducted though fluid, thus creatingan increase in amplitude of theechoes distal to the fluid.

Aliasing in pulsed Doppler ultra-sonography is an artifact occurringwhen the velocity of the sampled ob-ject is too great for the Doppler fre-quency to be determined by the sys-tem (Figure 1.)

Ultrasound Imagingof Soft Tissue

Tendons: Ultrasound is consideredmore effective in tendon disease diag-nosis than MRI, especially in theankle. Tears, inflammation, and dislo-

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thosorb® appears as a hypere-choic structure with a surrounding

zone being hypoechoic to the boneand surrounding tissue. This repre-sents the degradation of the fixation.

ArtifactsAnisotropy is the property of

being independent of direction.

Anisotropy is the opposite of isotropy.Something that is anisotropic may ap-pear different or have different char-acteristics in different directions. Thisphenomenon is created if the ultra-sound examiner does not position the

transducer perpendicular to thestructure being imaged. If thetransducer is held on a slightangle, the beam being sent backwill be reflected, resemblingpathology known as an artifact.This is why ultrasound imagingis operator-dependent.

Reverberation is when asound wave trav-els into a struc-ture with acous-tic impedancethat is signifi-cantly differentfrom its neighborand a large amount ofthe sound wave is re-flected back to thetransducer. The rever-berations produce ar-

tifactual echosignals at theinterface. A fracture can produce re-verberations.

Near Field Artifact is when theskin-transducer interface is very

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Figure 3: Tenex Health FAST™ procedure demonstrating proper needle guidance in the Achillestendon at low frequency demonstrating proper reverberation.without aliasing present. Continued on page 191

Figure 2: Foreign Body in 3-D mode using color map-ping. Glass is imaged as hyperechoic with hypoechoicarea surrounding it.

Figure 1: Color flow applied demonstrating proper wall to wall flowwithout aliasing present.

Anisotropy is the ability to createan artifact by angulating the transducer

to the structure being imaged.

cations are visible.Ligaments: Tears of ligaments are

shown that heal more slowly thanbony fractures and may produce long-standing pain.

Joints: Arthritic processes and po-tentially treatable adjacent tendondamage may be serially followed withthis modality. Fluid collections, whichincrease pain, may be diagnosed.

Muscles: Muscle strains may beseparated from more serious muscleruptures. Hematomas and contusionsmay be followed.

Bones: Occultfractures of the footand ankle are rou-tinely detected thatare missed by con-ventional x-rays.

Soft Tissues:Foreign bodies andabscesses are foundand removed. Ultra-sound guidancemay be used todrain fluid collec-tions. Post-traumat-ic neuromas in theforefoot may be di-agnosed. Heel painsyndromes includ-ing plantar fasciitisare quickly imaged.

Nerves: Nerves,centrally and periph-erally, are imaged.Hematomas ormasses adjacent tonerves causing neu-rological findingsmay be disclosed.

UltrasoundGuided Injectionsand/or Aspirations:It has been welldocumented in theliterature that ultra-sound guidance pro-vides a more accu-rate placement of asteroid injection.

Typical MSK Imag-ing on a DailyBasis in a Podi-atric Practice

Typically on aroutine day in a



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busy podiatric practice, diagnosticultrasound is utilized every day.Plantar fasciitis/fasciosis is quickly

and efficiently imaged. Normal fasciais imaged, and the band will mea-sure from 3.2mm to 3.8mm in thick-

ness. Always compare to theasymptomatic side. With heelspur syndrome, ultrasound imaging

has allowed the practitioner to honedown his or her skills to make an ac-curate diagnosis of a medial vs. a

central band fasciitis,and to determine ifthere is a nerve com-pression present. TheAchilles tendon is alsoquickly scanned to di-agnose a tendonitis,partial tear, and orcomplete rupture.

This is a dynamictest, quickly performed.Neuromas are visual-ized most effectively onthe cine loop replay.The higher the bankmemory on the ultra-sound unit, the longerthe loop will be. The dy-namic loop is critical todiagnosing a neuroma.Ankle injuries are alsodynamically scanned.This is a very accurateway to assess if the ATFligament is partiallytorn. Tibilias posteriordysfunction is easily vi-sualized dynamically,which provides excel-lent medical documen-tation. When we look atganglion cysts, it is anexcellent practice man-agement tip to take thetransducer and pushdown on the ganglion tosee if it fluctuates. If itdoes, then the cyst canbe aspirated. If it doesnot compress, then it issolitary and needs tosurgically excised. For-eign bodies are easilyidentified utilizing a


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Figure 4: Achilles tendonitis with tissue harmonics applied along with standoff and speckle re-duction at 15mm.

Figure 5: Partial Achilles tendon tear with standoff, tissue harmonics and speckle reductionapplied on long axis.

The high frequency transducer is best utilized to helpin the removal of the foreign body.

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stand-off pad. The high frequen-cy transducer is best utilized to

help in the removal of the foreignbody. Different color mapping or fil-ters can be used tohelp aid in the visual-ization of the foreignbody (Figure 2).

Latest TechnologyRequiring Ultra-sound AssistedImaging

Ultrasound-guidedextracorporeal shockwave therapy forplantar fasciitis is dy-namically utilizedwhile the procedureoccurs. The endove-nous radiofrequencyablation VNUS® Clo-sure® procedure byCovidien for chronicvenous insufficiencyis completely depen-dent on musculoskele-tal ultrasound withduplex color flow. Focused Aspirationof Scar Tissue (FAST™ procedure byTenex Health) is completely ultra-sound guided. Nerve block guidanceis routinely performed by ultrasoundguidance (Figure 3).

The Future in MusculoskeletalImaging

Ultrasound imaging has undergoneimmense changes within the last 15years. With the use of speckle reduc-tion (Figure 4), tissue harmonic imag-ing (Figure 5), freehand 3-D imaging,triplex Dopplers (Figure 6), blendedfrequency linear array transducers,and unparalled image storage capabili-ties via Dicom, it appears that the po-diatric physician will be well-equippedfor the development of new proce-dures. PM

Bibliography1 Eisenberg, R. Radiology: An Illus-

trated History. St Louis: Mosby, 1992.2 Firestone, F.A. “The Supersonic Re-

flectoscope, An Instrument of Inspectingthe Interior of Solid Parts by Means ofSound Waves.” J. Acoust Soc Am 1945;287-99.

3 Griffin, D.R., and R. Galambos. “TheSensory Basis of Obstacle Avoidance by

Flying Bats.” J Exp Zool 1941;86:481-506.4 Hill, C.R. “Medical Ultrasonics: An

Historical Review.” Br J Radiol1973;46:899-905.

5 Naredo, E. F. Cabero, B. Mondejar,et al. “A Randomized Comparitive Studyof Short-Term Response to Blind InjectionVersus Sonographic-Guided Injection ofLocal Corticosteroid in Patients.”2002;46(Suppl.1);S550.

6 Kremkau, Fredrick W. DiagnosticUltrasound: Principles and Instruments.Philadelphia: W.B. Saunders Co.,Fifth Edi-tion, 1998.

7 Erikson, S.J. “Sonography of theFoot & Ankle.” Foot & Ankle Clinics2000;5:29-48.

8 Rockett, Matthew S. DPM. “TheUse of Ultrasound in Foot & Ankle.” J AmPodiatry Med Assoc 1999;89:331-338.

9 Patel, S, et al. “Artifacts, AnatomicVariants and Pitfalls in Sonography of theFoot and Ankle.” American Journal ofRoetgenology 2002;178:1247-1254.

10 Fornage, B. “The Hypoechoic Nor-mal Tendon. A Pitfall.” Journal of Ultra-sound Medicine 1987:6:19-22.

11 Rawoo, Nankumar M., and LevonN. Nazarian. “Ultrasound of the Ankleand Foot.” Seminars in Ultrasound, CTand MRI 2000;21.3:276-284.

12 Connolly, D.J., L. Berman, andE.G. McNally. “The Use of Beam Angula-tion to Overcome Anisotropy When View-ing Human Tendon with High FrequencyLinear Array Ultrasound.” Br J Radiol2001;74.878:183-5.

13 Akfirat M., C, Sen, and T. Gunes.“Ultrasonographic Appearance of Plantar

Fasciitis.”: J Clin Imaging 2003;275:353-357.14 Morscher, E., and J. Ulrich. “Dick

W. Morton’s Intermetatarsal Neuroma:Morphology and Histological Substrate.”

Foot and Ankle Interna-tional 2000;21.7:558-562.

15 Deutsch AL, MinkJH, Kerr R MRI of theFoot and Ankle RavenPress New York 1992.

16 Neuhold A, SitskalM, Kainberger F et al.,Degenerative Achilles ten-don disease: assessmentby magnetic resonanceand ultrasonography EurJ Radiol 14: 213, 1992.

17 Cozzarelli J., Tha-par J. “MusculoskeletalUltrasound of the Footand Ankle” AardvarkGlobal Publications,Delhi, India 2009.

18 Hsu T, Wang C,Wang T et al., Ultrasono-graphic examination ofthe posterior tibial ten-don Foot and Ankle In-ternational: 18:34, 1997.

19 Maldjian C, Mez-garzadeh M, Roach NA et al., Efficacy of3-dimensional FSE MRI of the ankle AJR168 No 3: 25, 1997.

20 Van Holsbeeck M, Introcaso JHMusculoskeletal Ultrasound MosbySt.Louis 1991.

21 Cheung Y, Rosenberg ZS, Magee Tet al., Normal anatomy and pathologicconditions of ankle tendons: current imag-ing techniques. Radiographics 12:429,1992. 21. Adler R. Power Doppler applica-tions in musculoskeletal ultrasound Pre-sented at 6th Annual Conference of Mus-culoskeletal Ultrasound Montreal 1996.

22 Fornage BD Sonography of periph-eral nerves of the extremitiesRadiol Med85: 162, 1993.

23 Wall RW, Harkness MA, CrawfordA, Ultrasound diagnosis of plantar fasci-itis Foot and Ankle 14: 465, 1993.

Dr. Cozzarelli is a pastadjunct professor in ra-diology at the NewYork College of Podi-atric Medicine. He isconsidered one of thepioneers in the field ofMSK of the foot andankle. He is co-authorwith Dr. Jyotsna Thapar

of Musculoskeletal Ultrasound of the Foot andAnkle which is available at drfoot.tv. He present-ly is in private practice in Belleville, NJ.

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Figure 6: Triplex Power Doppler demonstrating capillary blood flow to verrucae with standoffpad applied.

CME EXAMINATION

1) Echolation describes theapplication of

A) Directional sightB) Directional touchC) Directional soundD) Directional motion

2) In 1942, Karl Dussik wasthe first to use ultrasound todetect

A) Achilles tendon tearB) Bladder cancerC) Brain tumorsD) Plantar fasciitis

3) Ultrasound is non-audible,high frequency sound wavesgreater than

A) 15,000 cycles/secondB) 20,000 cycles/secondC) 25,000 cycles/secondD) 30,000 cycles/second

4) When visualizing muscu-loskeletal structures, the besttransducer to be used is

A) Linear ArrayB) CurvilenarC) Hockey stickD) 3-D

5) Speckle isA) Complex spacing in thepulsed echo theoryB) Random spacing thatenhances the ultrasoundimageC) Random granulartexture that obscuresanatomy in ultrasoundimaging and is describedas noiseD) Described asSONAR

6) Higher Frequency transducersA) Image superficial struc-tures bestB) Image deep structuresbestC) Image deep structuresmost efficientlyD) Image both superficialand deep structures ade-quately

7) The term hypoechoic bestdescribes

A) A decrease in fluid up-take appearing darkB) An increase in fluid up-take appearing lightC) An uptake in fluid ap-pearing darkD) A decrease in fluid ap-pearing light

8) Tendons typically appearA) HypoechoicB) HyperechoicC) AnechoicD) Isoechoic

9) If a tendon is normal, it isdescribed as

A) HeterogenousB) HomogeneousC) AnechoicD) Isoechoic

10) Anisotropy is the ability ofcreating an artifact by

A) Holding the transducerparallel to the structurebeing imagedB) Holding the transducerperpendicular to the struc-ture being imagedC) Angulating the trans-

ducer to the structurebeing imagedD) Using a stand off pad

11) The plantar fascia is nor-mally, how many mm inthickness?

A) 2-2—3.8mmB) 3.2—3.8mmC) 1.5mm—4.0mmD) 3.2—4.0mm

12) Endovenous Radiofre-quency Ablation employs theuse of

A) Free Hand 3-D ImagingB) Color FlowC) High Frequency LinearArray TransducerD) 4-D Imaging Transducer

13) Standoff pads are utilizedto

A) Conform to irregularsurfacesB) Raise the near fieldC) Use when your hand istiredD) Protect the transducer

14) When viewing a neuro-ma, it is best to view it via

A) Sharp loopB) Dull loopC) Cine loopD) Moving loop

15) Articular cartilage is bestdescribed as

A)HypoechoicB) HyperechoicC) AnechoicD) Isoechoic


SEE ANSWER SHEET ON PAGE 195.


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CME EXAMINATION

www.podiatrym.com194 | AUGUST 2012 | PODIATRY MANAGEMENT

16) The near field is also calledA) Anterior, Fresnel zoneB) Posterior, Fraunhofer zoneC) Anterior, Fraunhofer zoneD) Posterior, Fresnel zone

17) The linear array transducer is com-prised of

A) TransistorsB) Piezoelectric crystalsC) CapacitorsD) Heat Sink

18) When pulsed Doppler ultrasonogra-phy is utilized and an artifact occurswhen the velocity of the sample objectis too great for the Doppler frequencyto be determined by the system it iscalled

A) Needle guidanceB) FAST procedureC) InsonateD) Aliasing

19) When giving an ultrasound-guided injection, the best frequencyto use is

A) 10MHzB) 15MHzC) 7.5MHZD) 9MHz

20) When imaging a foreign body inthe near field to quiet the sound signaldown, the following is used:

A) Biopsy guideB) Step offC) Push offD) Stand off

See answer sheet on page 195.

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24 hours a day to 1-631-563-1907. Your CPME certificate will be datedand mailed within 48 hours. This service is available for $2.50 per examif you are currently enrolled in the annual 10-exam CPME program (andthis exam falls within your enrollment period), and can be charged toyour Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME program, thefee is $22 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free service.

Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday throughFriday. Your CPME certificate will be dated the same day you call andmailed within 48 hours. There is a $2.50 charge for this service if you arecurrently enrolled in the annual 10-exam CPME program (and this examfalls within your enrollment period), and this fee can be charged to yourVisa, Mastercard, American Express, or Discover. If you are not current-ly enrolled, the fee is $22 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information, pleasecontact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

Over, please AUGUST 2012 | PODIATRY MANAGEMENT | 195www.podiatrym.com

�

ENROLLMENT FORM & ANSWER SHEET (continued)Co

ntinu

ing

Medica

l Edu

cation

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #6/12Musculoskeletal Ultrasound

of the Foot and Ankle(Cozzarelli)

www.podiatrym.com196 | AUGUST 2012 | PODIATRY MANAGEMENT

goals/objectives musculoskeletal ultrasoundofthe footandankle · musculoskeletal ultrasoundofthe...

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