Chapter
1
Basic Principles of Ultrasound
Francis O. Walker, MD
KEY POINTS
l  In neuromuscular ultrasound, a linear array transducer is
commonly used. This type of transducer typically contains
a row of several hundred crystal or ceramic piezoelectric
elements that convert electrical energy into sound waves,
which then reflect off tissue, and the elements convert
the returning sound back into an electrical impulse. The
transducer is in receive mode, rather than transmit mode,
greater than 99% of the time.
l Sound is a pressure wave that travels at variable speeds,
depending on the tissue in which it is traveling. Ultrasound
devices use the assumption that sound travels at an average
speed of 1540 m/s to calculate the depth of returning
echoes.
l As sound travels through tissue it will reflect, or send
an echo, off of dense structures, but it also attenuates
as it propagates through tissue, with higher frequencies
attenuating more than lower frequencies. For this reason,
higher frequency transducers are capable of producing high
quality images of superficial structures but not of deeper
structures.
l Most neuromuscular ultrasound is conducted using B-mode
(brightness mode) imaging, which is also known as real-
time imaging. Sound is continuously being transmitted and
received by the transducer, and the returning impulses are
assessed by a computer, using assumptions and formulas to
produce a visual display that incorporates spatial and time
resolution, as well as echo intensity.
Few neuromuscular clinicians are familiar with the fun-
damental physical principles of ultrasound. This chapter
is designed to explain them qualitatively in the context of
operating the instrument. The intent is to make explicit
how engineering determines what appears on the screen,
and how understanding this process helps optimize the
image displayed. This introduction will be adequate for
the reader to use and understand the instrument and to
guide further reading for those who see the potential for
further development of the technique. Current instru-
ments have been designed with organs and tissues in mind
other than nerve and muscle, so enhancements in instru-
mentation are possible, given sufficient feedback from
experienced users.
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Overview
The ancient Greeks understood the fundamental relation-
ship of reflected light and sound as revealed in the story of
Echo and Narcissus in which man (Narcissus) is smitten by
reflected light and immune to the nuance of reflected sound
(Echo). It is unlikely that the creator of this story anticipated
the development of underwater sonar or medical ultrasound,
but it seems plausible that she would have understood the
value of echolocation as another way of perceiving the natural
world.
Nature has long recognized and appreciated the perceptual
gift of echolocation, which manifests in the biologic marvels
of bats and whales, creatures that use echoes to map space
in darkness and deep water, areas where sight is uninforma-
tive. The ability possessed by these creatures to experience the
world directly through echolocation will always remain for-
eign to humans. We cannot replicate the vocal, auditory, and
particularly the cortical adaptations required for this type of
experience, so we must settle for a surrogate, which is the use
of reflected sound energy to manufacture a visual representa-
tion of anatomic space. For an in-depth discussion of echo-
location and other unique sensory experiences in nonhuman
mammals, Howard Hughes’ award winning book Sensory
Exotica is highly recommended.1
Almost everyone who is using this textbook will have
already had some experience with ultrasound, but even
for the experienced ultrasonographer, it is helpful to begin
with a review of instrumentation as a means of explaining
how an ultrasound image is created. The discussion begins
with a description of how to get started generating images
with an instrument, followed by discussions of the trans-
ducer and its elements, the behavior of sound and echoes
in human tissue, and how the ultrasound instrument regu-
lates the transducer and translates echoes into an image. In
parallel with these descriptions are some brief comparisons
of ultrasound with electrodiagnostic technology. Neuro-
muscular pathology is largely corroborated, not by other
imaging modalities, but by electrodiagnostic findings, so
an appreciation of this technology is of value. Further,
many readers have considerable experience with electrodi-
agnosis, and this will help them appreciate the mechanics
of ultrasound. There are also some parallel discussions on
the nature of human perception and how that also deter-
mines display characteristics of ultrasound instrumenta-
tion (Fig. 1.1).
1
2 Chapter 1—Basic Principles of Ultrasound

1. Insonation
2. Through-transmission
3. Refraction
4. Attenuation
Transducer Patient
1. Reflection
2. Through-transmission
3. Refraction
4. Attenuation

1. Resistance to compression
1. Filtering 1. Frequency 2. Kinasthetic feedback
2. Persistance 2. Power 3. Location
3. Digitization 3. Duty factor 1. Response to 1. Clinical interview
4. Compression 4. Focusing clinical interview queries
5. Amplification (coded excitation) 2. Physical findings 2. Instructions on
5. Frame rate 3. Response to examination
sonopalpation
1. Position
2. Movement/compression
3. Angle of insonation

1. Control panel
Instrument Ultrasonographer
2. Display

A
Needle movement
induces insertional activity
EMG needle Patient
electrode Patient relaxes or
contracts muscles

Kinesthetic feedback

Resistance to insertion
Response to
Amplification questions
Interview
Filtering questions
Physical findings

Digitization Instructions
Response to
needle insertion
Trace memory Needle position
(pain)

Control panel
EMG instrument Electromyographer
Display
B (audio and visual)

Fig. 1.1.  A, This figure describes ultrasound imaging using the four key elements involved: the transducer, the instrument and its controls, the
patient, and the ultrasonographer. The ultrasonographer coordinates the interaction of all four elements during an examination. B, Electromy-
ography, which can be described by a similar grid, is sometimes considered an extension of the physical examination, a role also exemplified by
neuromuscular ultrasound. The directional arrows denote the multiple feedback loops that make these techniques so interactive. EMG, Electro-
myography.

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Fig. 1.3.  Probe on wrist, the fingers cover the edge indicator on the
transducer, and the transducer is held to obtain a cross-sectional image
of the median nerve at the wrist.
B C
Fig. 1.2.  Control panels of several different ultrasound instruments, all
circa 2010. A, Philips IU22. B, Biosound Esaote MyLab gold. C, GE Logiq.
Although modern instruments are digital, instrument controls can either
involve continuous adjustment or incremental steps. The time gain com-
pensation panel on each instrument is indicated by arrows.
Getting Started: Obtaining
an Image
Ultrasound instruments have an impressive array of switches,
dials, and buttons that can be daunting to the novice (Fig. 1.2).
Even finding the on/off button to the instrument, which is
invariably in a covert location to avoid inadvertent deactiva-
tion, adds to the challenge. Once the instrument is turned on,
however, users quickly find that the instrument is quite intui-
tive and can be quickly put to use. The first step is to identify
the active transducer on the instrument and then to coat it with
coupling gel. It can then be placed over the wrist as shown in
Figure 1.3. Note that every linear array transducer has a mark-
ing on one side, which corresponds to a marking on the dis-
play screen. The marking on the display should always be in the
upper left corner of the screen, and the probe should be posi-
tioned such that the marker on the probe is pointed cephalad
to the patient for sagittal imaging and to the ultrasonographer’s
left side for cross-sectional imaging. This will produce images
that are oriented in the same fashion as computed tomogra-
phy (CT) or magnetic resonance imaging (MRI). However, it
should be noted that this convention has not been routinely
followed in neuromuscular imaging, so not all of the older
images in this text are oriented in this fashion. In particular,
sagittal imaging of the median nerve at the wrist frequently has
been depicted in the opposite fashion in the literature, with
the left side of the display screening showing the distal portion
of the wrist, but that is an undesirable orientation, based on
ultrasound convention, and should be avoided.2 See Box 1.1 for
other general considerations when performing neuromuscular
ultrasound.
When imaging the wrist, the base of the palm should rest
comfortably on the patient’s forearm or other supported
structure. An image of the contents of the carpal tunnel, and
possibly the radial and/or ulnar artery should appear. The
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Chapter 1—Basic Principles of Ultrasound 3
Box 1.1  General Considerations
for Neuromuscular Ultrasound
1. Use a linear array transducer with a frequency ≥ 12 MHz.
2. Set up the exam room so the ultrasonographer can see
bothination the patient and ultrasound device in the same
view (see Fig. 1.25).
3. Always position the marker on the transducer, which
corresponds to the upper left corner of the ultrasound
display screen, to the ultrasonographer’s left side with cross-
sectional imaging and to the patient’s head with sagittal
imaging.
4. During the study, the depth, focus, gain, and time gain
compensation should be adjusted to optimize imaging of the
structure of interest.
5. If available, Doppler should be used to confirm flow in
vessels.
6. Obtain and save images of each structure of interest in at
least two views. For example, in patients with carpal tunnel
syndrome, both cross-sectional and sagittal images of the
median nerve should be assessed and saved.
7. Label structures of interest using the annotation capabilities
of the ultrasound device, and save key images. These
images can be printed, saved to the hard drive of the
ultrasound device, or uploaded to a picture archiving and
communication system.
width of the image corresponds to the footprint of a lin-
ear probe (Fig. 1.4) or the radial angles of the probe if it is
curved (see Figs. 4.2 and 4.14). The coupling gel, in addition
to enhancing sound penetration, allows the probe to slide left
or right or distal or proximal to find the optimal image of the
tissue in the neighborhood of the initial contact of the probe.
The probe can also, with slight pressure, be angled proximally
or distally. In general, structures are viewed with the probe
perpendicular to the skin surface, but angular adjustments are
of considerable interest as is discussed later. No more pres-
sure than necessary should be used to scan; excessive pres-
sure may deform structures of interest and can be tiring to
the ultrasonographer and uncomfortable for the patient (Fig.
1.5). To help others orient to an image, it can help to include
a recognizable landmark as well (vascular bifurcation, bone
edge, etc.).
4 Chapter 1—Basic Principles of Ultrasound

M
R M
T

Hockey stick probe Hockey stick probe

Hockey stick probe cross-sectional view sagittal view

M M
R
T
U
R

Standard sized probe Standard sized probe

Standard size probe cross-sectional view sagittal view

Fig. 1.4.  This figure shows the difference between probe footprints. The top row shows a hockey
stick (small footprint) probe on the wrist, and the cross-sectional image it generates. A sagittal image
at the wrist from this probe is also included. The second row shows the standard probe and its
cross-sectional image and sagittal image at the wrist for comparison. The bottom image is a direct
comparison of the two types of probes. Note the extended field of view of the larger probe, which
includes both the radial (R), and ulnar (U ) arteries, and associated veins, the median nerve (M ), and
multiple tendons, whereas the smaller probe can only encompass the radial artery by sacrificing the
lateral border of the median nerve. Notice how much more of the median nerve (and underlying
bones in the hand) are apparent with the standard than hockey stick probe on the sagittal views.
Note the reverberation artifact beneath the radius in the second row. Also note in the sagittal
images that distal is to the left, as these are older images that do not follow standard convention.

N N
T APB
T
T T
T T

APB

A B
Fig. 1.5.  These images show the effects of compression on nerve and muscle. A, Both images are axial views of the median nerve at the distal wrist
crease. Note that with minimal downward pressure (left image) and maximal downward pressure (right image) there is little change in nerve thickness
or shape even though the distance between the nerve and radius is less with higher pressure. B, Both images are axial at the middle of the metacarpal
(arrows) through the abductor pollicis brevis muscles. The left image is with minimal transducer pressure, the right image is with maximal transducer
pressure. Note that the pressure decreases abductor pollicis brevis thickness by almost 50%. Maximal pressure at the carpal tunnel causes less deforma-
tion than over the abductor pollicis brevis because tendons and nerves are less compressible/displaceable than skleletal muscle.

Several simple adjustments can be made to change the
display once the desired image is obtained. One knob on the
ultrasound instrument panel adjusts the depth of the field
of view.3 The depth should be sufficient to encompass the
structure(s) of interest. The display screen is calibrated to
indicate depth and serves as a useful reference in images for
publication (see Fig. 1.4). The zoom feature of an instrument
allows the user to focus in on the detail of interest, expand-
ing it to encompass the screen with a slight improvement in
resolution. Unlike MRI and CT, which are designed to auto-
matically record standard body slices, ultrasound requires the
operator to scan using multiple probe positions and angles
and operating controls to capture the most informative two-
dimensional (2D) images for documentation. Greater depth

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Fig. 1.6.  Images of the median nerve in the forearm, at the level of
the bifurcation of the brachial artery deep to the pronator teres. In the
image on the left the focal zone is at the level of the median nerve and
on the right, the focal zone is just below the surface (large flanking black
arrows). Note that the detail of the structure of the median nerve is
better defined on the left (upper green arrow), as is the outline of the
brachial artery (lower green arrow) than it is on the right.
of field (low magnification) and zoom (higher magnification)
are analogous to lens power on a microscope—lower magni-
fication is useful for orientation and screening for abnormali-
ties, and higher magnification is used to capture the essence
of the pathologic change. If the pathology is diffuse, lower
magnification (greater depth of field, as in the case of diffuse
muscle pathology) may be preferred.
The brightness of the image can be controlled by the
power and gain dials on the instrument.3 The power dial
controls the amount of sound energy transmitted to the tis-
sue and the gain dial the amplification of the sound echoes
that return. These dials have similar but not identical func-
tions and need to be set to optimally display the structures
of interest. The dials have an analogy with photography: The
power dial in this case controls the strength of the flash, and
the gain dial in essence controls the film speed (with faster,
e.g., more sensitive, film speeds being equivalent to increased
gain). In electrodiagnosis, the power dial controls stimulus
intensity 4, and gain is used to display the amplitude of the
nerve conduction study response. In both ultrasound and
electrodiagnosis, excessive intensities do little to enhance the
outcomes of the study.
The focal zone, typically indicated by horizontal marker(s)
on the display screen, helps with resolution.3 The level of
focal zones (which are horizontal) should encompass the
structures of interest (Fig. 1.6). The freeze button on the
instrument will stop the real-time action of the machine and
display a single frame. Most instruments store (in an adjust-
able fashion) several seconds of data at any given time, so it
is possible, once an image is frozen, to rewind slowly through
multiple previous frames to capture the optimal image for
storage. Of interest, the rewind and replay features of ultra-
sound instruments have been an industry standard for many
years, yet this simple function has only recently become
available on electromyography (EMG) instruments. Any
frozen image can be saved for later viewing, and a variety of
postprocessing capabilities for analysis and labeling are pres-
ent on many instruments as well.
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Chapter 1—Basic Principles of Ultrasound 5
The Transducer
The generic term transducer refers to something that converts
one type of energy into another. Biologic receptor organs are
all transducers, converting different types of physical energy
into electrical impulses in nerves; the retina converts light,
the cochlea sound, nerve endings heat, and so on. Muscle is
a transducer that operates in reverse to a sensory transducer
because it converts electrical energy into mechanical energy. It
does this, aided by ample reserves of adenosine triphosphate
(ATP), with remarkable leverage. The act of lifting heavy
objects begins as a few central nervous system (CNS) neuro-
nal discharges on the order of microvolts, and these discharges
are quickly transformed into hundreds of pounds of force. In
a similar fashion, the thyroarytenoid muscles, with the help
of forced air from the lungs, convert electrical impulses from
neurons into sound energy. In the world of devices, convert-
ing electricity to sound is usually done with speakers, and con-
verting sound to electricity is done with microphones. These
instruments require diaphragms and electromagnets that are
too bulky for medical ultrasound. Instead piezoelectricity is
used.
Piezoelectric elements convert electrical energy into a
pulse of sound wave energy and then converts the resulting
sound wave echoes back into electrical energy.3 An array of
piezoelectrical elements creates the sound energy needed to
generate echoes, and the electrical signals elicited by their
return to the probe characterizes the remarkable function.
of the ultrasound transducer—the device placed on the skin
to deliver and receive sound pulses. It is helpful to contrast
an ultrasound transducer with the contact elements used in
electrodiagnosis. EMG and nerve conduction studies (NCS)
electrodes are of much simpler construction because they
record and carry electrical signals without the need of con-
verting to a different type of energy. For nerve conduction
studies, there is a pair of electrodes for delivering electrical
energy and a pair for recording it.4 These electrodes consist
of exposed metal in rings, disks, or needles (Fig. 1.7). Once
electrical signals are obtained, either directly in electrodiag-
nostic instruments, or indirectly with an ultrasound trans-
ducer, the signals are filtered and amplified by the respective
instrument to generate a display for interpretation. At this
point, both instruments convert electrical energy into light
energy to create an image. In electrodiagnosis the display is of
a single point of constant intensity that varies in vertical dis-
placement (amplitude) over time, whereas in ultrasound the
image is a 2D sea of points that vary in brightness over time.
In EMG there is conversion of the display into sound energy
as well. Sound is typically part of the display in ultrasound
only with Doppler blood flow studies. As would be expected
from their more complex design elements, ultrasound trans-
ducers are significantly more expensive and more fragile than
electrodiagnostic electrodes.
EMG textbooks often devote several pages to describing
the unique features of EMG electrodes because subtle dif-
ferences in structure can lead to minor, but argued over,
differences in recording characteristics (see Fig. 1.7).4 With
ultrasonography the function of the transducer is more
complex than a simple recording electrode and intimately
linked to the instrument, so ultrasonographers tend to fix-
ate less on the predictable consequences of minor design
variations and more on figuring out the best way to create
6 Chapter 1—Basic Principles of Ultrasound

an optimal image with the technology at hand. The fol-

lowing discussion of transducers serves to highlight their
limitations and possibilities in evaluating patients with neu-
romuscular disease.
A shape. A hockey stick probe, which is a linear probe with a
Compound Structure
An ultrasound probe actually contains an array of multiple
tiny component piezoelectric transducers each providing a
single line of ultrasound data (Fig. 1.8). By seamlessly stitch-
ing together each of these lines of data, the display creates a
2D image in the same way that old television screens created
images from parallel lines of display.3 Ultrasound transducers
come in many shapes. When using ultrasound to study the
heart it helps to have a curved surface so that when the probe
is placed against the ribs, it is able to scan a larger tissue area
through a narrow aperture.2 Internal probes for vaginal, rec-
tal, and esophageal imaging have shapes that conform to the
anatomic requirements of their use.3 At the greatest extreme,
intravascular ultrasound probes can be used to examine arte-
rial walls.5 All involve different arrays of transducers or a
motorized transducer or set of transducers. For neuromuscu-
lar imaging, the most commonly used probe is a linear array
probe because most imaging planes are compatible with this
smaller footprint and extended handle, is sometimes useful for
imaging around bony surfaces, such as the medial epicondyle.

Miniaturization with Piezoelectricity

B electron orbits, and consequently shape changes in the under-
Fig. 1.7.  A, The devices required for performing electrodiagnostic stud-
ies: a measuring tape for measuring the distances between stimulation
sites and stimulation and recording sites, tape for securing surface elec-
trodes, a variety of surface recording electrodes (ring, bar, disk, plate),
and a stimulating electrode. Two types of electromyography needle
electrodes, the longer one is monopolar, the shorter is concentric; alco-
hol for decontaminating the skin, and electrolyte paste for reducing the
impedance of the skin. B, The ultrasound transducer that is used to con-
tact the skin of the patient, along with the gel used to enhance sound
transmission through the skin. Of note, ultrasound gel works well as
conducting paste for electrodiagnosis, but the reverse is not true. Not
surprisingly, the set-up time for ultrasound is less than that for electro-
diagnosis.
The critical principle underlying ultrasound transducers is
piezoelectricity, a property inherent in different types of spe-
cial materials.3 This phenomenon was first described in quartz
crystals. Whereas noncrystalline quartz contains a disordered
arrangement of silicon dioxide molecules, quartz crystals
have an orderly lattice that is determined by the electrostatic
charges of the individual molecules, which incidentally have
an asymmetric polar configuration. Application of a current
across this lattice leads to absorption of energy, changes in
lying crystal (Fig. 1.9). This abrupt dimensional change cre-
ates a sound pulse. The application of mechanical stress to a
quartz crystal, in a reverse fashion, causes an electrical cur-
rent, making this material ideal for use in phonograph pickup
needles or ultrasound transducers.
Currently, lead zirconate titanate,3 a piezoelectric ceramic,
is used for ultrasound transducers. Although this chemical
is not naturally piezoelectric, when it is heated to more than
approximately 350° C in an electromagnetic field, the mole-
cules can quickly be induced to assume a dipole-driven lattice
that confers piezoelectric properties. When cooled, the appli-
cation of a voltage across this material causes it to thicken or
thin as the suspended molecules turn their dipoles toward or

Fig. 1.8.  A drawing of an ultrasound transducer that has had the impedance matching material and cover removed. Note the multiple transducer
elements, each with its own electrical contact. The thickness of the ultrasound power cord (see Fig. 1.7) reflects the fact that most transducers need
wiring for hundreds of elements.

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away from the electrostatic charge. This shape change, in a
small wafer of material, generates the sound pulses used in
modern ultrasound transducer probes. These small wafers
can be arrayed in a linear fashion, each with its own separate
wiring, to create the typical ultrasound transducer.
The Transducer Shell
The casing of the ultrasound probe holds a number of ele-
ments including the individual transducers, the wiring to
these transducers, and several layers of material.3 Note that the
cable that connects the transducer to the instrument is quite
thick (see Fig. 1.4) because it contains both inputs and out-
puts to the hundreds of miniature transducers that make up
a typical linear array transducer. Damping material is placed
at the base of the transducer to help control the duration of
the sound pulses emitted by the probe. Shorter sound pulses
are associated with better resolution. Piano strings use damp-
ers to enhance a staccato effect of a key strike; when these are
raised by engaging the sostenuto pedal, the string vibration
is prolonged, causing sounds and notes to slur together. As
such, the damper material enhances the discrimination pro-
vided by pulsed sound.
Between the contact face of the probe and the underlying
transducer array, matching layers are inserted.3 These help
reduce the impedance mismatch of the transducer and the
skin, a phenomenon further aided by the use of coupling gel.
These steps enhance through-transmission of sound into the
body, and without these steps more than 80% of the sound
would be reflected back to the transducer at the skin surface.
A more detailed discussion of acoustic impedance matching
can be found elsewhere.6
Sound Pulse Technology
At its simplest, echolocation involves a single sound pulse,
followed by an evaluation of the timing and intensity of any
returning echoes.1 Bats use their vocal cords to emit short
pulses of sound to create echoes. Humans, ill-equipped for
this task, can shout into a deep well and infer from the delay of
the sound return something about its depth, and by the qual-
ity of the sound something about the reflecting materials in
the well. If there are smooth stone sides and a water reservoir
− − − − −
+ + + + +
+ Sound: Fundamental Principles
+ and Its Behavior in Tissue
− − − −
+ + + +
− which the direction of the amplitude (vertical) is out of plane
− with the direction of travel (horizontal), sound waves consist
− − − − −
+ + + + +
Fig. 1.9.  This is a schematic of how piezoelectric materials respond to an
electrical current. Because of the inherent asymmetry of the underlying
chemical structure, when a current is applied there is a shift in molecular
dipoles, causing a change in the shape of the piezoelectric element.
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Chapter 1—Basic Principles of Ultrasound 7
at the bottom, a sharp crisp echo will return. If instead moss
covers the walls and leaves coat the bottom, a muffled softer
sound will be heard.
Ultrasound relies also on single sound pulses to create an
echo trace.3 The sound is produced by the transducer ele-
ment, the sound penetrates soft tissues, and as the sound
passes through the body, tissue interfaces at different levels
create multiple echoes of different intensities. At each inter-
face, some sound is reflected and some is transmitted. The
echoes return at different times to the transducer element,
which converts them to a trace signal. The latencies of the
echoes provide information about spatial relations (depth of
the reflective surface), and the intensity of the echoes provides
information about the types of reflecting surfaces.
Humans primarily use sight to map space, and this is why
ultrasound data are displayed as an image. Most vision is
based on a source that bathes a scene with a constant flow
of light energy, such as the sun or a light bulb. This contrasts
with ultrasound, which maps space with pulsed sound; its
equivalent would be a fast-pulsing strobe light. An echo is a
reflection of an entire sound pulse, so the shorter the pulse,
the less likely an echo will return during the pulse itself, and
the less likely that early and late components of sequential
pulses will interfere with each other.3 Typically a B-mode
ultrasound pulse is 2 to 3 cycles of sound energy in dura-
tion, and at 10 MHz, this takes about 0.2 to 0.3 μs. Of inter-
est, bat calls are of much longer duration: 0.2 to 100 μs, but
their calls cover much greater distances, perhaps 50 meters
or more. Appropriately, call duration shortens, improving
localization, as a bat approaches a target of culinary interest,
such as a moth.
Ultrasound transducers emit many pulses of sound per
second, which constitutes the pulse repetition frequency.3
It can be thought of as similar to the frame rate on a video
camera, and it is of importance in determining the temporal
resolution in an image. Duty factor is a term that calculates the
percentage of time the transducer is actually emitting pulses,
which is substantially shorter than the time it spends receiving
echoes. The total energy emitted by a transducer correlates
directly with the duty factor and determines certain physical
effects such as tissue heating.
Tissue responds to insonated sound pulses by generating
echoes. It is the job of the instrument to re-create an image
from this information. How the instrument does this requires
an understanding of how pulsed sound behaves in human
tissue.
Speed of Sound
Sound is a traveling pressure wave. Unlike an ocean wave, in
of alternating compressions and rarefactions of molecules in
the medium through which it travels (Fig. 1.10). Such changes
can be measured by pressure, density, or particle vibration,
all of which can be considered acoustic variables.3 As with
any wave, sound has intrinsic detectable wavelengths, peri-
ods, and frequencies, all of which are interrelated. The speed
of sound propagation, however, is not a property of the type
8 Chapter 1—Basic Principles of Ultrasound

Transverse wave

Compression wave

Fig. 1.11.  This is another way to compare a transverse and compression

wave; the bottom figure resembles that of a Slinky toy.

Table 1.1  Speed of Sounds in Different

­Substances
Material Velocity (m/s)
Air 331
Fig. 1.10.  This is a schematic comparing a traveling wave (the superim- Fat 1450
posed sine wave) with the alternating compression and rarefaction of Water (50° C) 1540
molecules that are seen with the compression wave of sound energy.
Human soft tissue 1540
Brain 1541

of sound energy, but rather of the medium of transmission. Liver 1549

Sound propagation speed is related to stiffness of a tissue, or
more precisely, hardness. As such, it travels slowly in easily
compressed gases, more rapidly in fluids and body tissues,
and fastest in solids. An intuitive sense of sound propagation
is readily derived from experience with a Slinky, a toy origi-
nally constructed of a wound coil of flexible metal (Fig. 1.11).
Mechanical energy creates standing waves of alternating rar-
efactions and compressions of successive spirals of the coil;
these waves travel faster if the coil is tightly wound with harder
metal. Tightly wound Slinky toys travel down steps faster than
less tightly wound and looser versions (e.g., plastic).
The variation of sound propagation in different materials is
of significance both generally and clinically. An approaching
train can be detected sooner by putting one’s ear to the rail
than by listening through air for the sound it makes. On aver-
age, sound travels about four times faster through metal than
through human soft tissue, which is minimally faster than
through sea water, and in turn about four times faster than
in air. The hardest substance known to man, diamond, also
conducts sound the fastest at 12,000 m/s (Table 1.1).
Ultrasound Range Finding
A key goal of ultrasound is an accurate representation of
spatial characteristics of human tissues. To measure depth
(range), ultrasound relies on the timing of the return
echoes.3 As mentioned above, ultrasound makes a number of
assumptions to calculate depth. It assumes that sound travels
in a straight line from the transducer to the target and back,
that enough echoes are reflected back to the transducer from
relevant tissue structures to be captured and measured, and
that the speed of sound in soft tissue is sufficiently consis-
tent across tissues to generate an accurate measurement. In
general these observations hold true, and particularly for the
more superficial structures studied in neuromuscular ultra-
sound. In a fashion similar to an F-wave when performing
electrodiagnostic studies,4 an echo reflects a round trip of
sound from the transducer to the structure of interest, and
back again to the transducer. All ultrasound instruments
assume that sound travels through tissues at a constant rate
Kidney 1561
Blood 1570
Muscle 1585
Lens of eye 1620
Tendon 1650
Ice 3152
Skull bone 4080
Brass 4490
Aluminum 6400
Diamond 12,000
of 1540 m/s, and images from echoes are constructed based
on this calculation. It may be easier to understand this num-
ber expressed differently: for each centimeter of depth, the
average round trip travel time for an echo in human soft tis-
sue is 13 μs.3
The width on an ultrasound image represents the summed
thickness of the individual transducer elements within a lin-
ear ultrasound probe (see Figs. 1.4 and 1.8).3 In some ways
width measures in tissue may be slightly more accurate than
depth measurements in that they do not assume constant
sound speed in tissue. However, because width measures do
not take refraction of sound into account, there can be distor-
tion of width as sound passes through tissue layers of different
sound transmission speeds, if these are oblique to the angle of
insonation (see oblique echoes later).
For practical purposes, the variation of sound speed is rarely
important. However, if someone is measuring the depth to
the sacrum in two patients, one with minimal body fat and
one with 7.5 cm of fat over the gluteus maximus (not unusual
in obese patients as measured by EMG needle length), there
would be a subtle effect. Ultrasound travels slower through
fat than through the “average” human tissue, and as such,
ultrasound tends to overestimate the thickness of a fat layer
by about 6% (1541/1450), and underestimate the thickness of
muscle by about 3% (1541/1585) (see Table 1.1).

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 Chapter 1—Basic Principles of Ultrasound 9

Table 1.2  Average Attenuation Coefficients

A in Tissue
Mean
­Attenuation Intensity Intensity
B ­Coefficient Reduction Reduction
Frequency for Soft in 1-cm in 10-cm
(MHz) Tissue (dB/cm) Path (%) Path (%)
C 2.0 1.0 21 90
Fig. 1.12.  In nonlinear propagation, propagation speed depends on 3.5 1.8 34 98
pressure. A, Higher-pressure portions of the wave travel faster than the 6.0 2.5 44 99.7
lower-pressure portions. B and C, The wave changes shape as it travels.
This change from the initial sinusoidal shape introduces harmonics that 7.5 3.8 58 99.9
are even and odd multiples of the fundamental frequency.

It would be tempting to speculate that the speed of sound Table 1.3  Attenuation Coefficients of Biologic
in nerves would be somewhat less than that of average human Substances (at 1 MHz)
tissue because of its high fat content, but at this time this value
is unknown. However, the speed of ultrasound in brain is 1541 Material α(dB / cm)
m/s, and most nerves are sufficiently thin as to make any special Water 0.0022
adjustments for size moot. Special techniques, using ultrasound
Amniotic fluid 0.0053
radiofrequency analysis for measuring body tissue and fat thick-
ness may be of value for addressing questions of this type.7 4.5% albumin 0.019
Discrepancies in sound transmission speed affect area Blood 0.18
and volume measurements more than linear measurements Fat 0.63
because area is related to the square, and volume the cube,
of the linear measurement. This may account for some of Brain 0.85
the slight variation in estimated thickness of muscle or fat by Liver 0.94
ultrasound and by other imaging modalities such as MRI or Kidney 1.0
CT. At this time, standard volume measurements are not rou-
Bone 20
tinely calculated for muscle or nerve, but they are for inter-
nal organs based on a set of standard linear measures from Lung 41
2D ultrasound. The kidneys,8 for example, use the product of
0.5{A-P diameter} × {transverse diameter} × {height} to pro-
duce a fairly reliable estimate of kidney volume. Adjustments deeper structures through ribs, there is less artifact with har-
for variations in speed of sound in neuromuscular tissue could monic frequencies, and analyzing return echoes only at these
be incorporated into mathematical models of this type when higher frequencies may enhance the imaging of deep structures.
it becomes routine to calculate volumetric measurements.
Another factor that influences sound speed in tissue is tem-
perature. This is most striking for fat—the warmer the tem- Attenuation
perature, the slower the sound speed—but the reverse holds Attenuation refers to the reduction of sound intensity as it
true in other tissues, although to a lesser degree.9 In general, passes through tissue. Some of this energy is lost through
temperature effects are of limited significance during routine reflection or backscatter, but the majority is lost through
imaging. Of interest, there is some evidence that fat in humans absorption of the sound energy.3,9 The degree of attenuation
simultaneously exists in solid, liquid, and melting phases, per- can be measured in several ways and is expressed as deci-
haps with a key transitional phase occurring at 35° C.10 bels (dB) of sound energy attenuated over distance (dB/cm).
A number of factors influence attenuation and backscat-
ter. For example, attenuation is frequency dependent, such
The Relationship Between that higher sound frequencies are dissipated through distance
much quicker than lower frequencies (Table 1.2).3 Sounds in
Propagation and Harmonics the audible range show similar properties, which is why blaring
In practice, the propagation speed of a wave is not even. As music in a passing car is heard primarily in lower-pitched base
the wave travels through any medium, its higher pressure com- tones, and why thunder from distant lightning is a low-pitched
ponent travels faster than its lower pressure component, so its rumble, whereas a nearby lightning strike has a high-pitched
progress through space is somewhat nonlinear.3,9 As a result, and ominous crack. The most critical principle explained by
the wave acquires superimposed higher frequency harmonic this phenomenon is that higher-frequency ultrasound has a
components that increase over the distance covered (Fig. 1.12). lower effective depth of penetration for imaging than lower
Harmonic frequencies consist of multiples of the original or frequency.2,3,9
fundamental frequency of the sound. The concept is of clinical Each body tissue attenuates sound to a different degree
relevance in situations in which the primary frequency creates (Table 1.3). The relationship between frequency and absorp-
problematic artifacts. For example, sometimes when imaging tion in a given tissue is typically linear over standard ultrasound

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10 Chapter 1—Basic Principles of Ultrasound
frequencies, with an increase in attenuation with higher fre-
quencies. The slope of this effect, however, varies between dif-
ferent tissues10,11 and across species. In fact, the attenuation
coefficient itself may not be entirely uniform for the same tis-
sue in a different location in the same individual. For some
tissues, such as tendon and skeletal and cardiac muscle, the
attenuation coefficient nearly doubles if the tissue is imaged
in a plane parallel to the direction of muscle (tendon) fibers as
compared with a cross-sectional image.12 One might imagine
how sound energy might be redistributed more easily among
cellular molecules from insonating a small cross section of
hundreds of muscle fibers, than insonating a few muscle fibers
along their entire length.
The phenomenon of absorption is critical for therapeutic
applications of ultrasound. As sound energy is absorbed by
tissue, it is converted to heat. Ultrasound therapy was intro-
duced to the specialty of physical medicine and rehabilitation
many years ago, specifically for this purpose. Because sound
energy is more readily absorbed by tendons, ligaments, and
bones, it is a means of providing direct heating to deep struc-
tures that are vulnerable to common musculoskeletal inju-
ries3,13 and often the last to be warmed by surface heating.
(Refer to other sources for further information about this type
of therapeutic ultrasound.14-19) However, it should be noted
that with increasing amounts of insonated energy, additional
safety precautions are needed.20
One of the most interesting theoretic applications of ultra-
sound energy is the ability to activate microencapsulated
drug release with an ultrasound beam.21-25 Microencapsu-
lated drugs injected intravenously circulate throughout the
entire body, but the capsules release the drug only in tissues
being actively insonated, thereby significantly enhancing
concentration at the target site. This approach can be used to
quite selectively deliver drug to a tumor, for example, while
minimizing its distribution in other healthier tissues. Other
interventional applications of insonation and local micro-
cavitation, such as enhanced healing of bone injury26-29 or
as a tool to possibly facilitate muscle regeneration are under
active study.29
Echo Behavior
Perpendicular Echoes and Acoustic
Impedance
As sound energy courses through tissue it creates echoes.
The simplest scenario to consider is one that involves
a perpendicular incidence of the direction of the ultra-
sound sound wave to a smooth interface of two layers of
tissues (Fig. 1.13). A significant portion of sound energy
is transmitted and continues in the same direction. How-
ever, the reflected energy at this interface reflects back in
the opposite direction directly toward the transducer.3 The
amount of reflected energy is proportional to the differ-
ence of acoustic impedance of the two layers; the greater
the difference, the greater the reflected energy. When
looking through water at a jellyfish, the change in acous-
tic impedance between air and the surface of the water is
much greater than that between water and the surface of
the jellyfish. As such, the air-water boundary is much easier
to discern than the water-jellyfish boundary, because more
light is reflected at the former. The ratio of reflected to
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incident energy is the intensity reflection coefficient. The
ratio of the transmitted energy to the incident is the inten-
sity transmission coefficient. The sum of these two ratios
is one (an assumption that assumes that there is very little
if any absorption of sound energy at that particular bar-
rier). Acoustic impedance, measured in rayls, relates to the
speed of transmission of ultrasound in a particular tissue
or layer. More thorough discussions of the complex topic
of acoustic impedance, both characteristic and specific, can
be found elsewhere.3,30-31
Oblique Echoes
If the angle of incident sound is oblique, and the bound-
ary is smooth, the angle of incidence and angle of reflection
(compared to perpendicular) are equal—a phenomenon
analogous to a pool ball ricochet.3,30-31 The angle of transmis-
sion is also related to acoustic impedance. If the deeper layer
conducts sound faster than the superficial layer, the sound
bends toward the boundary, and if it is slower, sound bends
toward the perpendicular. These are examples of refraction
(Fig. 1.14).
Scattering
Of course, smooth boundaries are not the rule in biologic tis-
sues. Rough boundaries and heterogeneous materials tend to
cause multidirectional transmission of incident sound (scat-
tering) and reflection (backscattering).3,30-31 Most light reflec-
tors are not smooth; a flashlight aimed at a wall can provide
a diffuse dim light for a room because of its backscatter (Fig.
1.15). Fog, an example of heterogeneous materials in air,
causes both scattering of transmitted light and backscattering
of reflected light, which is why headlights set on high beam in
fog are not the advantage they are in clear weather. Speckle is
a consequence of the random backscattering of sound pulses
in an imaged plane of tissue. These waves can interfere posi-
tively or negatively with each other or with waveforms that
have been reflected perpendicularly back to the transducer,
causing random decrements and enhancements of brightness,
or speckle.
80 dB 39 dB 41dB
Echo
Incident sound level = 80 dB
Transmitted
Reflected sound level = 39 dB sound level = 41dB
Fig. 1.13.  Demonstration of sound passing through a door. Note that
the sum of the transmitted and reflected sound equals the intensity of
the incident sound.
 Chapter 1—Basic Principles of Ultrasound 11

Contrast Agents leakage of contrast into perfused tissues, the echogenicity of

Ultrasound contrast agents are examples of small heteroge-
neous materials that can be injected into tissues and cause a
local increase in the echogenicity of tissue vasculature with
multiple backscattered echoes. Unlike radiographic contrast
agents (intravenous pyelography dye) or MRI contrast agents
(gadolinium) that work in solution and can demonstrate
Incident sound beam Reflected sound beam
θi θr
Air
ultrasound contrast agents is based on their reflective proper-
ties, which means that they must be particulate, too large to
cross capillary gaps, and too small and too pliable to obstruct
blood flow. Typically these consist of microbubbles of gas
encapsulated within a lipid or protein.22,32,33 As such, they can
demonstrate areas of increased blood flow within tissue, but
not areas of capillary leakage. Of interest, unlike other con-
trast agents, intravascular adhesion and retention of micro-
bubbles may occur in areas of vascular wall inflammation.32,33
Thus vascular wall changes that lead to fibrinogen or platelet
adhesion and clot formation may be more sensitively detected
by certain types of ultrasound contrast agents than by solu-
ble contrast materials used in MRI and CT. It is possible that
ultrasound contrast may find new applications in neuromus-
cular disorders such as inflammatory muscle or nerve disease.

Glass
θt
Transmitted sound beam
Fig. 1.14.  This figure represents the transmission and reflection of
sound energy from air to glass, when the incident sound is oblique to
the reflecting material. Note that θi equals θr, and that θt is determined
by the relative ratio of the acoustic impedance of air to glass.
Focusing
Ultrasound beams can be focused in one dimension to mini-
mize beam width (the width of the sound out of plane with
the image created).3,30,31 This type of focus is different than
optical focusing, which occurs in three dimensions, a prop-
erty readily demonstrated with paper, a magnifying glass, and
bright sunlight. The end result of ultrasound focusing, like
optical focusing, is enhanced resolution. By narrowing the
width of the sound, there is a reduction in the out-of-plane
averaging that takes place within an image, and therefore
resolution is improved. For imaging focal swelling in a nerve
in a cross-sectional image, this property is of value because it
allows for more precise identification of the point of maximal

A Backscattering B Backscattering, with low anisotropy

C Backscattering, with high anisotropy D Backscattering, with complete

anisotropy (mirror)
Fig. 1.15.  This figure shows how structures with no (A), mild (B, as in nerve), marked (C, as in tendon) , and complete (D) anisotropy reflect incident
energy, showing an inverse relationship of backscattering to inherent anisotropy (structures with high anisotropy have little backscatter; see Fig. 1.23
for comparison).

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12 Chapter 1—Basic Principles of Ultrasound
enlargement of the cross-sectional area of the nerve. Focusing
can be done by shaping the array in a convex fashion, phas-
ing the sound wave pulses of the individual elements in the
transducer and by careful study of the natural focusing that
follows any sound beam. Multiple focal zones can be obtained
in some images, but this requires that different pulses are
used for different focal distances, which therefore reduces the
frame rate (see temporal resolution).
For the ultrasonographer, the optimal focus of the ultra-
sound beam is often illustrated on screen by a small arrow
to the right of the image (see Fig. 1.6). It points to the depth
where the image quality is typically optimal, and can be
adjusted in terms of depth and in terms of how thick the
band of focus is. When measuring small structures, such as
nerves, it is important to optimize the focus to the appropriate
depth. For example, when following the median nerve from
the wrist through the forearm, several changes in focal depth
are necessary to optimize the image of the nerve as it passes
under the flexor digitorum superficialis and then the pronator
teres.34 Novice clinicians frequently forget to adjust the focal
zone, an error that makes following a nerve as it approximates
the surface or dives beneath muscles more challenging. More
detailed discussions of probe design and focusing are available
elsewhere.3,30,31
Resolution
The goal of ultrasound is optimizing resolution of structures
of interest. An objective test of this ability can be provided
by a phantom, which is conceptually similar to an eye chart.
A phantom is any type of tissue model that can be scanned.3
Such items often are agar filled, with suspended smaller objects
that simulate tissue structures that can be readily imaged with
ultrasound, and different designs are available for purchase.
The ability to resolve such smaller items (either objects in the
phantom or letters on an eye chart) is a measure of resolution.
A phantom can be used to compare resolution of different
transducers and different instruments.
In ultrasound, axial resolution refers to the ability to
distinguish nearby objects in the direction of sound travel;
lateral resolution is in the direction perpendicular to this
(which would be across scan lines). Axial resolution is
related primarily to the pulse length of the emitted sig-
nal, which is frequency dependent, and the lateral resolu-
tion relates to beam width, which relates more to focusing.
Therefore, when evaluating different instruments, it is
critical to look beyond a single technical reference (such as
transducer frequency), and to compare image quality in tis-
sues of interest.
Temporal resolution in ultrasound refers to the ability of
ultrasound to discriminate quick motions in tissue.3 Higher
frame rates allow for better imaging of motion and smoother
definition of it. Higher temporal resolution involves narrower
focuses and reduction of persistence and averaging of images.
The latter provide a means of controlling random artifacts
such as speckle, but tend to reduce temporal resolution.
Because the quality of a static image is easily compared with
MRI or CT, there is a bias to design ultrasound instruments to
maximize static image quality. Interventional/vascular radi-
ologists and clinical subspecialists have provided much of the
impetus for real-time motion and blood flow detection. Given
the complexity and flexibility of ultrasound instrumentation,
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enhancements in temporal resolution are not only possible
but may be critical for studying subtle quick movements, such
as fibrillation potentials in muscle,35 and adaptive instrument
design may be of future value.
Ultrasound Instrument Function:
Driving the Transducer and Image
Display
The ultrasound machine carries out a number of important
tasks, some of which have been discussed already, such as
sound pulse frequency and phasing and image display. The
complexity or accuracy of these functions is not dependent
on the size of the instrument nor its display screen, but rather
the sophistication of its underlying technology. Some instru-
ments are now run by laptop computers and provide com-
petitive image resolution. Ultrasound instrumentation can be
broken down into efferent and afferent functions, which will
be described in sequence.
Efferent Ultrasound Functions: Beam
­Formers, Pulsers, Coded Excitation,
­Amplifiers, and Transmit/Receive
Functions
The efferent functions of ultrasound instruments are sim-
pler than its afferent functions and begin with the beam for-
mer.3,33,34 The generation of a sound pulse requires several
devices. The first is a pulser that takes power line electricity
and translates it into brief pulses of voltage. The device is
not dissimilar to the stimulator on an EMG machine, which
delivers single or multiple timed pulses of voltage or amper-
age of a set duration. In the ultrasound instrument, how-
ever, this is somewhat more complex. Ultrasound probes
consist of arrays of piezoelectric transducer elements, and
each element receives a separate input from the pulser (one
per scan line). As such, an ultrasound instrument’s pulser
operates hundreds of channels, rather than the single or dual
stimulator systems found in most electrodiagnostic instru-
ments (see Fig. 1.8). To further complicate the process, for
the purposes of multiple focusing and image enhancement
there are often coded timing variations (coded excitation)
in the order in which the transducers are activated. Thus a
series of pulse delay switches are automatically built into the
instrument.
In tandem with the pulser is the amplifier, which deter-
mines the intensity of the insonated sound. Once the pulse
sequences are ready for relaying to the transducer, there is a
final gate. This is a transmit/receive switch in the instrument
that following each pulse sequence automatically switches off
the emit (efferent) function of the transducer and turns on its
receive (afferent) function, so it can analyze returning echoes.
The transducer is in the receive mode the vast majority of the
time—typically 99.0% to 99.9% of the time—although more
emit time is required for Doppler imaging. Pulse duration,
sequencing, and on/off time cycles are preset based on the
type of imaging (Doppler versus B-mode), transducer type,
focusing, and imaging depth used. Direct operator control is
usually restricted, however, to only modulating the amplitude
of the emitted signal.

Afferent Functions of the Instrument
Once the tissue has been insonated with a single pulse, the
instrument switches to receive and responds to the return-
ing echoes. The instrument then switches back to deliver-
ing sound pulses. This cycle is repeated continuously during
imaging.
Amplifiers and Time Gain Compensation
After the piezoelectric elements convert returning echoes
into electrical impulses, they need to be amplified to create a
display. Most instruments also contain a time gain compen-
sation panel to modify the process when needed by the ultra-
sonographer. The echogenicity of unmodified distant echoes
is much less than that of near echoes. This is because of the
A high-frequency sounds from the bandwidth for returning
S S
S
H
H
B
Fig. 1.16.  These two figures provide examples of shadowing. A,
B-mode cross section of the anterior tibialis about halfway between the
knee and ankle. The two images show the same data, on the left dis-
played in color (white being brightest, then green, then red, then blue
being darkest). On the right is a standard gray-scale image. The promi-
nent, echogenic, and collagen-dense central aponeurosis of this muscle
reflects a greater proportion of incident sound than expected and as
such, the muscle deep to this layer, particularly in the lower right por-
tion of the image where the membrane is thicker is less echogenic (or
more blue). On the upper left, where there is no aponeurosis, the muscle
is somewhat hyperechoic (green). These changes are subtle, but are of
some importance if analyzing tissue echogenicity. Color display is not
routinely used, but in this case highlights the subtle shadowing associ-
ated with an aponeurosis. The bone edge of the tibia completely reflects
sound, so the bone substance appears as black in both images. B, A
cross section through the deltoid in a patient with post-traumatic myo-
sitis ossificans. The calcification in muscle (arrow) causes significant
shadowing (S ) in some areas shadowing out the otherwise prominent
presence of the bone edge of the humerus (H ).
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Chapter 1—Basic Principles of Ultrasound 13
attenuation of ultrasound energy as it passes through tissue,
both in transmission to the target and in reflection back to the
transducer. As such, instruments are all designed to amplify
later echoes based on a standard estimate of the degree of soft
tissue attenuation (see Tables 1.1 and 1.2). However, some
tissues cause more or less absorption of sound than the pre-
determined average, and in these cases, prudent adjustment
of near and far gain on the time gain compensation panel
can result in a more representative image of the structures
of interest.3 Alternatively, adjustments are sometimes help-
ful for reducing noise from certain irrelevant layers in an
ultrasound image. The time gain compensation panel (see
Fig. 1.2), has a characteristic display control, and it controls
the degree of amplification at different depth layers. Adjust-
ments to this panel are most helpful when imaging through
tissues that excessively attenuate sound, such as fibrous tis-
sue, or fail to attenuate it, like cystic or vascular structures
(Figs. 1.16 and 1.17).
Filters
Ultrasound instruments also use filters to enhance images.
As mentioned, attenuation is frequency dependent, with
higher frequency signals being disproportionately attenu-
ated as sound traverses a distance. Also, sounds emitted by
a transducer have a modest range or bandwidth of frequen-
cies. As echoes return from deeper structures in tissue, the
highest-frequency sounds are attenuated more than the low-
est-frequency sounds in this bandwidth. As such, the ratio of
high frequency noise to high-frequency signal is increased in
deeper tissues. Many instruments selectively filter out more
echoes of increasing latency, such as the ones from deeper lay-
ers.3 This graded use of the filter with depth improves the sig-
nal-to-noise ratio. Harmonic imaging can also be useful. As
Fig. 1.17.  This figure provides an example of enhancement. A cross-
sectional image of the medial gastrocnemius. On the right, the image
is taken with only minimal pressure applied to the transducer, and a
large vein is present. Deep to this is an area that is relatively hyperechoic
(arrows). On the left, the image is taken with increased pressure, the
vein is compressed and the hyperechoic area disappears, indicating that
this is an enhancement artifact secondary to the presence of relatively
hypoechoic blood in the overlying venous structure.
14 Chapter 1—Basic Principles of Ultrasound

indicated, sometimes harmonics of the insonated frequency

are less subject to distortion than the fundamental frequency,
and this can be used to advantage in certain types of ultra-
sound imaging.

Persistence
Persistence is a form of image averaging over time in ultra-
sound that improves spatial resolution. This removes random
speckle (the unpredictable echo changes that result from the
positive or negative interference of backscattered sound), and
other artifacts. However, as persistence increases, temporal
resolution decreases.3 Instruments that appear to be ideal
because of simplified panel configurations have more preset
and unalterable imaging features. Such preset configurations A
may emphasize persistence and stability of an image, and
therefore temporal resolution may be sacrificed. If the need
of an instrument is to detect rapid tissue or needle movement,
more setting flexibility may be helpful.

Amplitude (A)-Mode Imaging

Both EMG and ultrasound began with the use of oscil-
loscopes3,4 (Fig. 1.18) using a standard A-mode display. In
A-mode a single line of ultrasound data only is displayed,
with the X axis representing echo latency (which corresponds
to distance or depth) and the Y axis representing echogenicity
(e.g., echointensity amplitude). This should be familiar
because it is the typical display for EMG or NCS, where the
X axis is latency and the Y axis is amplitude of the electrical
signal (voltage). For an electromyographer it can be puzzling
to understand how ultrasound evolved into a real-time 2D
image, while EMG has remained as a single real-time linear
display. With ultrasound, a change in amplitude comes from
an echo, which is generated by a fixed anatomic structure in a
distinct spatial and temporal relation to the transducer’s inci-
dent sound pulse. With electrodiagnosis, a change in ampli-
tude comes from measurable progressive ion movements
along the length of excitable tissues within any radius of the
recording electrodes. Although it is possible to triangulate
bioelectrical signals and to localize them accordingly, this is
complex and not routinely performed with electrodiagnostic
instruments. The key difference is that in ultrasound, ampli-
tude variations (echoes) occur in a temporal pattern deter- B
mined by the location of the reflecting anatomic structure,
which immediately lends itself to spatial display. In electrodi- Fig. 1.18.  These are photographs of oscilloscopes used in original ultra-
agnosis, spatial relationships can only be inferred. sound research at Wake Forest University in the late 1960s. A, This image
shows how images were captured using a Polaroid camera. B, This image
shows the traditional A-mode display familiar to most ­electromyographers.
Brightness (B)-Mode Imaging
One alternative to A-mode imaging is B-mode, or brightness
mode imaging. In this case, instead of displaying amplitude a 2D map of width and depth. However, this type of display
by variations in signal amplitude on the Y axis, amplitude is does have some minor limitations.
represented by varying the brightness of the trace. Higher-
amplitude signals are brighter than lower-amplitude signals.
The audio recording of an EMG signal parallels B-mode Compression
imaging in that the louder the sound of the sound of the EMG Displaying amplitude as brightness instead of vertical dis-
signal, the greater its amplitude. Because time, in ultrasound, placement is somewhat more problematic than one might
is equivalent to distance, if one uses brightness to represent expect. The human eye can readily distinguish subtle varia-
amplitude it opens up a display screen for multiple paral- tions in height but distinguishes variations in light intensity
lel A-mode recordings. As a composite, this allows varying poorly by comparison. Further, although there is a direct lin-
degrees of brightness to represent anatomic structures within ear relationship between measured and perceived height, the

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relationship between measured and perceived brightness is
exponential36 and intuitively much less clear. A simple experi-
ment helps clarify this. In the dark, a single flashlight has a
substantial effect on the ability to see, an effect that is far from
doubled by the addition of a second flashlight. In fact, it is not
clear exactly how many flashlights would be needed to double
the perceived intensity of ambient light. As a result, to repre-
sent brightness on a display screen in a proportionate way, it
cannot simply be linear; it must be an exponential increase.
Furthermore, the increase needs to be adjusted to compensate
for any pupillary constriction that accompanied the increased
brightness. Not surprisingly, there are no simple formulas
for doing this in such a way as to provide the same intuitive
sense of proportion of height and amplitude as in A-mode. Of
interest, the formulas used for determining how amplitude is
translated into brightness vary from manufacturer to manu-
facturer and instrument to instrument, and are often empiri-
cally determined by image aesthetics of select tissues of the
manufacturer’s choice.
A-mode is commonly used in ultrasound of the eye and
orbit.37 The technique provides a more quantitative approach to
assessing echogenicity. It not only provides an accurate assess-
ment of reflective strength from structures within the eye but
also a means of comparing reflective strength from a known
ocular structure (such as the posterior scleral wall) and that of
an unknown mass within the eye. Unlike B-mode gray scale
parameters, A-mode amplitude to decibel ratios (compression
metrics) are standardized across different instruments and man-
ufacturers in ophthalmology ultrasound devices. There remain
problems, however, with ceiling effects of the display as appar-
ent in Figure 1.19. At this time, A-mode is not routinely avail-
able on most commonly used nonophthalmology instruments.
M-Mode Imaging
M-mode is useful for measuring latency changes in moving
tissue. This technique depends on selecting a single chan-
nel of information from B-mode ultrasound and displaying
how it changes over time (Fig. 1.20).3 This display is more
like an electrocardiogram (ECG) tracing, with the time base
measured in tenths of seconds. This technique can be used
to measure muscle contraction or fasciculation contraction
time.35 It should be noted that electrodiagnostic techniques
measure the duration of the muscle action potential, which is
a surface membrane–only event lasting on the order of 10 ms,
whereas ultrasound measures actual mechanical contraction
and relaxation time, on the order of 200 to 300 ms.
Digital Conversion
All modern ultrasound instruments use analog digital conver-
sion to display signals. This permits averaging for persistence
as well as for interpolation or smoothing.3 Such adjustments
can affect perceived echogenicity. Some instruments provide
user control of these functions, and adjusting these controls
may help enhance imaging of different types of structures.
3D and 4D Imaging
With computer-based technology, 2D images can be recon-
structed into 3D and 4D images. The technique is at its
most dramatic when creating realistic videos of fetal facial
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Chapter 1—Basic Principles of Ultrasound 15
Posterior
vitreous
detachment
Choroidal detachment
Vitreous
blood
A
Vitreous Choroidal
detachment with detachment
blood layering
Sclera and
orbital
tissues
Vitreous
blood
B
Fig. 1.19.  B-mode (A) and A-mode (B) images of the orbit. The A-mode
image is from a horizontal beam in the center of the image. Note that
A-mode records amplitude variations in only one linear direction and
that the amplitudes correspond to variations in brightness. It is difficult,
however, to interpret the echogenicities displayed because the peak
amplitude of the signals cannot be determined as a result of a limited
range of display mode (ceiling effect). Also note the substantially greater
information conveyed by B-mode. (From Waldron RG, Aaberg TM: B-scan
­ cular ultrasound, eMedicine from webMD. Updated January 2009. Available at
o
www.emedicine.medscape.com/article/1228865-overview.)
expressions and movement. The presence of a face surrounded
by amniotic fluid is an ideal environment for the technology
(Fig. 1.21).3 In clinical practice, however, most ultrasound
imaging is still done in 2D planes (although technically this
is really 3D imaging—depth, width, and time). Video is not
routinely included in most published ultrasound papers and
3D images are relatively uncommon. As such, readers of the
literature do not routinely find such images other than as
online supplements.38 At this time little has been published
on the use of 3D imaging in nerve or muscle.
Color Doppler
Many ultrasound instruments have the capacity to demon-
strate tissue movement and blood flow using the Doppler
effect.3 The Doppler effect is a change of the frequency of
16 Chapter 1—Basic Principles of Ultrasound
A Future Doppler technology may assist in the assessment of
5 mV
5 ms
B
Fig. 1.20.  A, A cross-sectional B-mode image of the tibialis anterior
midway between the knee and ankle. The thin green vertical line in
this image is used to create the M-mode display below which shows
changes in this single line as the muscle changes over time. The plus
signs mark the onset of a compound muscle action potential cre-
ated by supramaximal stimulation of the peroneal nerve at the fibu-
lar head. The duration of the actual mechanical contraction of the
muscle is 241 ms, which is much longer than the compound muscle
action potential duration, and only reflects the timing of electrical
changes across the membrane. Also note that the peak displacement of
the muscle (peak contraction time) occurs about 71ms after onset. B, The
compound muscle action potential of the same muscle recorded with
stimulation of the peroneal nerve at the fibular head and surface elec-
trodes straddling the plane of this image. Note the striking difference
in duration; by ultrasound the duration is 241 ms; by nerve conduction
studies it is 10 ms, demonstrating the difference between the mechani-
cal and electrical behavior of muscle.
sound energy by a moving object, familiar as the increasing
pitch of a train whistle as a train approaches (and its decreas-
ing frequency as it recedes). Returning echoes demonstrate a
similar effect, and Doppler principles are used to generate the
timing mechanisms of automatic sliding glass door openers.
The physics of ultrasound Doppler are complex and its
details are beyond the scope of this text because at this time few
papers have been published on blood flow or tissue motion in
nerve or muscle. Nonetheless, this is an area of likely growth
in the field of neuromuscular ultrasound. Initially much of the
focus of color Doppler was on the detection of abnormal vas-
cular blood flow, for the purpose of identifying critical occlu-
sion or pending occlusion of major vessels. For the purpose
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of neuromuscular ultrasound, it turns out that most of the
information is coded by 2D dimensional color-flow Doppler
or Doppler power displays. When examining tissue, such as
nerve, for increased blood flow, it is often helpful to use power
Doppler imaging. This type of imaging is less subject to noise
contamination, and is better for detecting slow flow and look-
ing at smaller or deeper vessels than spectral Doppler imaging.
The results of Doppler power displays are mainly qualitative
and may vary somewhat across instruments. Nonetheless,
these displays provide a simple and reliable means for assess-
ing for the presence or absence of changes in tissue vascularity.
Of interest, ultrasound color allows for information coding in
terms of hue and saturation in addition to brightness (lumi-
nance), and color displays therefore allow for coding of use-
ful information not available from simple gray scale imaging.
muscle contraction and nerve movement. Readers wishing to
explore color Doppler imaging in greater detail may find Fred-
erick Kremkau’s textbook a useful starting point.3
Image Storage and Manipulation
Many modern instruments can store a final image and allow
postprocessing manipulations.3 At their simplest these include
annotation (arrows and text) and distance measurements, but
many instruments can further alter the display by changing
other features such as gray scale and compression. Such prop-
erties are useful for record keeping and research.
Quantifying Ultrasound Findings
Spatial Dimensions of Tissue
Ultrasound instruments are ideal for measuring spatial vari-
ables such as thickness, width, depth, area, and volume. Edge-
to-edge resolution with ultrasound is more precise than that
obtained with CT or MRI, and all instruments are designed
to make measuring spatial parameters simple and quick. In
practical use a few simple linear measures of structures such
as the kidneys can be used to estimate kidney volume based on
formulas established in cadaveric studies,8 but similar formu-
las have yet to be developed for muscle or nerve. A few cave-
ats are warranted with linear measures: The first is that depth
measurements are based on the speed of sound in tissue, and
this varies slightly among different types of tissue. Width mea-
surements depend on the assumption that ultrasound waves
are transmitted through tissue in a straight line, yet refraction
does occur when sound crosses planes of tissue with different
acoustic impedance (such as muscle and fat). In calculating
volumes, any linear errors of measurement are magnified by
multiplying width, length, and depth, which should be cor-
rected for if comparing ultrasound volume measurements
with CT or MRI. Measurement error in ultrasound therefore
is minor and, to some extent, predictable. Understanding
ultrasound physics can be useful in addressing such minor
errors if clinically indicated.
Quantifying Tissue Movement
Although ultrasound provides accurate estimates of the
movement of blood in the cardiovascular system readily and
quickly,3 solid tissue movement is not easily calculated39 This
 Chapter 1—Basic Principles of Ultrasound 17

Fig. 1.21.  This is an example of a 3-dimensional (3D) image now routinely available for depicting the detailed surface anatomy of a fetus. In practice,
3D imaging is most informative for structures surrounded by fluid or involving fluid filled structures. The technology is still evolving. (From Wladimiroff
JW, Eik-Nes SH, editors: Ultrasound in Obstetrics and Gynaecology, Edinburgh, UK, Elsevier.)

does not necessarily imply that tissue movement is more dif-
ficult to measure than blood movement, but rather reflects
the years of engineering invested in ultrasound technology
for studying hemodynamics. Although ultrasound-based
calculations of blood flow are not exact measurements they
are reliable enough surrogates to be used routinely in clini-
cal decision making. Nerves and muscles move, including fas-
ciculations, fibrillations, nerve subluxation, and nerve sliding,
and standard ways to measure these movements have yet to be
developed. Descriptive rating scales are occasionally used and
can be reliable even if they are not fully validated. Research
in this area is progressing, however, and in the future more
quantitative measures of muscle and nerve movement may
become standardized using technology such as color tissue
Doppler imaging.
Quantifying Echogenicity
Since Heckmatt and Dubowitz40 described the increased echo-
genicity of affected muscles in Duchennes muscular dystrophy
30 years ago, investigators have been intent on finding ways to
measure echogenicity. Despite the substantial improvements
in instrumentation in these three decades, quantifying echo-
genicity remains problematic. The reasons for this relate to the
tension between the use of ultrasound to optimize image aes-
thetics and the use of ultrasound to measure physical parameters
of insonated tissue. Antiglare sunglasses are a useful analogy.
These reduce apperception of total light intensity (glare) in
one’s environment for the benefit of enhancing the ability to
see objects within it; a trade-off most users feel is worthwhile. A
similar trade-off has been made with current ultrasound instru-
mentation, but such an approach has drawbacks.
Ultrasound instruments are designed to maximize tis-
sue recognition and diagnosis. Recognition is defined as
an awareness that something perceived has been perceived
before (e.g., recognition). This definition is similar to what
we typically mean by diagnosis, in which it is implied that we
have seen a similar disease pattern before. Although it would
seem that quantifying the physical aspects of one’s environ-
ment would go hand in hand with recognizing it or perceiving
it, in fact, they are by no means equivalent. This distinction is
a focus of an entire field, Gestalt psychology, which explores
the nature of recognition. In the world of human experience,
quantifiable aspects of sensation are separate from the more
subjective aspects of perception:
The variables of sensory discrimination are radically different
from the variables of perceptual discrimination. The former are
said to be dimensions like quality, intensity, extensity and dura-
tion; dimensions of hue, brightness and saturation, of pitch,
loudness, and timbre, of pressure, warm, cold and pain. The
latter are dimensions of the environment, the variables of events
and those of surfaces, places, objects, of other animals and even
of symbols. Perception involves meaning: sensation does not.
To see a patch of color is not to see an object, nor is seeing the
form of a color the same as seeing the shape of an object. To see
a darker patch is not to see a shadow on a surface…to have a
salty taste is not to taste salt…to feel a local pain is not to feel
the pricking of a needle, to feel warmth on one’s skin is not to
feel the sun on one’s skin.
—J. J. Gibson41
Ultrasound instruments have been designed to maximize
perceptual discrimination, not pure sensory discrimination.
This process, by design, sacrifices accurate representation of
tissue echogenicity if it detracts from accurate perception.
In like manner, human eyes sacrifice brightness discrimina-
tion by the design of the pupillary reflex, which constricts or
dilates the pupil to minimize the distracting effects of changes
in ambient illumination. Further, some quantifiable visual
variables are of greater importance than others in daily life.
For example, size discrimination is, in general, of greater
importance than brightness discrimination. A 10-fold varia-
tion in brightness of the environment, which happens com-
monly because of relative cloud cover, does little to influence
behavior, but a 10-fold variation in the size of a nearby pri-
mate demands immediate attention (Fig. 1.22).
Different ultrasound instruments use different algorithms
to relate display brightness to echogenicity, and these are not
standardized across instruments. Only in A-mode instru-
ments used for ophthalmologic examinations has there been
an attempt by manufacturers to adhere to an imaging standard
in this regard. Of course, brightness is also easily manipulated
by angle of insonation (see Tissue Anisotropy, as follows),
gain or power settings, time gain compensation settings, and

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18 Chapter 1—Basic Principles of Ultrasound

2000 POPULATION DISTRIBUTION IN THE UNITED STATES

One dot = 7500 people

B
Fig. 1.22.  Two separate types of population density maps. A, This is a B-mode map, showing population density as a manifestation of brightness. The
problems discussed in the text are readily apparent in this image because it is difficult to ascertain which of the following four cities has the greatest
population density: Atlanta, Chicago, Minneapolis, or Dallas. B, This is a bump map showing the same data displayed in terms of height. Here it is
possible to easily distinguish population density levels in different cities and to clearly see that New York has the greatest population density by far of
all the cities represented. The human eye is simply better designed to analyze height ratios than brightness ratios.

selection of transducer frequencies. Further complicating
the display of brightness is the influence that tissue param-
eters have on brightness display; thicker layers of fat, skin, or
overlying tissues by necessity will alter the intensity of echoes
returning from a deep structure, and it is difficult to com-
pensate accurately for such effects. Given the multiplicity of
these variables, the display of echogenicity has been used to
primarily enhance resolution rather than as a measure of the
intensity of reflected echoes.
Of interest, the amplitude/intensity problem has a parallel in
electrodiagnosis. The changes in the amplitude of electrically
recorded signals from nerve or muscle tend to convey much
less information than do changes in their temporal profile.
For example, the placement of surface or needle electrodes
has profound effects on amplitude.4 Slight movements of sur-
face electrodes may change the recorded compound muscle
action potentials by 50% or more, and slight EMG needle
movements lead to even more profound motor unit action
potential changes. Such movements have relatively little effect
on latencies, conduction velocities, durations or interpoten-
tial intervals,4 parameters, free of such random variation, that
are more likely to convey meaningful information regarding

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 Chapter 1—Basic Principles of Ultrasound 19

A B
Fig. 1.23.  Cross-sectional images of the median nerve at the wrist. A, An image in which the angle of insonation of the probe is just slightly off the
vertical. In this situation the tendons are hypoechoic compared with the nerve. On the right, the transducer is perpendicular to the tendons at the
wrist; here they are hyperechoic compared with the median nerve. B, An M-mode trace (shown in the top image, divided by a thin green line) as
the transducer is moved from the off perpendicular plane (top figure on the left), through the perpendicular (top figure on right) and off perpendicular
in the other direction, and then reversed and brought back to the perpendicular three times. Note that the nerve does demonstrate some anisotropy
in that it is slightly brighter when the transducer is perpendicular, but the difference with the tendons is far more striking. The tendency for the human
eye to enhance contrast makes it more difficult to see the nerve anisotropy in the B-mode image (A) as opposed to the M-mode image (B).

pathology than signal amplitudes. Furthermore, selection
of different filter settings, thickness of intervening skin and
fat, or even directional changes in needle electrodes, all have
profound influences on recorded amplitudes in a fashion not
dissimilar to that seen with ultrasound. Electrodiagnostic
instruments are designed to measure amplitudes (intensity)
more precisely than ultrasound instruments, but in fact, even
when amplitude is measured accurately, it is not as informa-
tive as temporal data.
The brightness problem in ultrasound is a choice of instru-
ment design. It is possible to engineer instruments to reliably
measure and record variables such as echogenicity in a stan-
dardized fashion, but until there is adequate evidence to sug-
gest that this would be of clinical significance, it will not be
pursued. The development of color Doppler and blood flow
analysis was a more complicated task. The brightness problem
of ultrasound is an accepted limitation of current technology,
but the fact that it is rarely a subject of debate or discussion
should not imply that future research and improvisation in
the area will be unfruitful.
Artifacts
Ultrasound imaging is associated with a variety of artifacts,
many of which are self evident and few of which lead to sig-
nificant problems when interpreting images. It is helpful to
identify and name some of the more common artifacts to
facilitate operation of the instrument and provide accurate
descriptions of image display.
Tissue Anisotropy
Tissue anisotropy can create an apparent artifact, but actu-
ally, it turns out to be a rather valuable aspect of ultrasound
imaging. Each tissue is different in terms of how it reflects
light. Some create much more backscatter3 (Fig. 1.23; also see
Fig. 1.15) and some act more like mirrors, reflecting almost all
the incident sound at an angle equal to the angle of incidence
in reference to a central axis. Tissues that have high levels of
backscattering have low anisotropy and tend to look the same
regardless of the angle of incident sound, whereas tissues that
act more like a pure reflector and have high anisotropy look
much brighter when the transducer is perpendicular and
much darker when it is not. Unlike routine MR or CT images
in which the directional source of imaging energy is relatively
constant, with ultrasound subtle changes in the angle of inci-
dence of the transducer reveal variations in anisotropy in tissue
(see Fig. 3.4), can help distinguish different types of adjacent
tissues, such as tendon (high anisotropy) and nerve (low
anisotropy). This relationship is demonstrated in Figure 1.23.
Skilled ultrasonographers use these shifts in transducer angle
to provide valuable eye-hand feedback that not only helps
interrogate tissue but also interprets what is reflected back.
Shadowing
Other artifacts result from signal attenuation. A classic exam-
ple occurs with calcified tissues, such as calcific arteries. These
tissues do not transmit any sound and either reflect it back to
the transducer or backscatter it in other directions. As such,
no returning echoes are seen deep to the calcific tissue, but
instead a shadow appears with linear edges.3 Shadows are use-
ful because few changes in tissue are dense enough to cause
them to appear, and they immediately draw attention to
pathology (see Fig. 1.16).
Enhancement
Enhancement is the inverse of shadowing. Some structures,
for example cysts, generate no echoes and transmit virtu-
ally all the sound energy that is directed through them (see
Table 1.2). This tends to make the structures immediately
deep to the cyst appear brighter.3 This is because the instru-
ment is programmed to expect a certain loss of sound energy
as it passes through tissue, and when this does not occur,

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20 Chapter 1—Basic Principles of Ultrasound
Fig. 1.24.  This is a cross-sectional image of the radius taken at the level
of the mid-forearm. On the left, the image is obtained with an 18-MHz
probe, and on the right a 10-MHz probe. Note the series of small linear
reflections beneath the bone edge. These represent serial reflections of
the sound off the transducer and then the bone. More lines more closely
interspaced are seen on the left because of the higher frequency of the
transducer and the multiple superficial reflectors. The artifact is sensitive
to the angle of the transducer because if it is held just off the perpen-
dicular to the bone the sound echoes reflect away from the transducer.
the default mechanism of the instrument displays the result
as distal enhancement. Recognition of this phenomenon is
useful in drawing conclusions about the tissue superficial to
the enhancement. Increased echogenicity deep to a structure
raises the possibility that it is a cyst or vascular structure (see
Fig. 1.17). Color flow Doppler is often helpful in distinguish-
ing between static fluid in a cyst and slow flowing blood, as
in the case of arteriovenous malformations or pseudoaneu-
rysms. This distinction is best made before performing a nee-
dle aspirate of a suspected cystic lesion.
Other Artifacts
Reverberation artifact occurs when the transducer or some
superficial tissue structure acts as a sound reflector (Fig. 1.24).3
The effect, like looking into a three-way mirror, causes multi-
ple equally spaced images of a reflection to appear. These have
a naturally artifactual appearance and are generally easy to
recognize. Other artifacts occur but generally are self evident.
Like their counterpart of optical illusions studied by psychol-
ogists, understanding ultrasound artifacts can enhance practi-
cal appreciation of the mechanics of ultrasound display.
Practical Considerations Regarding
Neuromuscular Ultrasound
Selecting an Instrument for Purchase
Almost everyone who uses, or wants to use, ultrasound develops
an interest in strengths and weaknesses of commercially avail-
able instruments. Because these range in price from $20,000 to
$200,000, such interest seems warranted. This portion of the
chapter highlights the different commercially available features
of an instrument that may influence purchasing decisions.
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Cost
Two factors tend to drive the cost of an ultrasound instru-
ment. The first is image quality, the second is the range of
functions. The most expensive instruments tend to have
both high-quality image displays and numerous ranges of
functions. In neuromuscular ultrasound the image qual-
ity of superficial soft tissue structures is probably the most
valuable feature. Color Doppler blood flow capabilities are
secondary, and yet likely to be an important capability as
illustrated in subsequent chapters. Range of frequencies, 3D
imaging, large display screens, ergonomic utility, gel warm-
ers, multiple transducers, postprocessing capabilities, and
portability are of less concern, but can be important to the
needs of the individual user. It is sometimes difficult for
novice ultrasonographers to fully appreciate the exact needs
they have for instrumentation, so leasing a new machine or
purchasing a used one may provide useful experience with
the technology that can help guide a subsequent purchase.
For accounting purposes, most instruments can be assumed
to have at least 4 years of effective use, yet many instruments
continue to be of value for several more years. Ultrasound
technology is advancing at a moderate pace, and investing
in the best appropriate technology is critical. Performing an
ultrasound examination takes time, and better equipment
enhances efficiency, accuracy, and patient care, factors that
need to be given due consideration when deciding on how
to invest.
Instrument manufacturers in ultrasound vary from large
multinational corporations (General Electric) to moder-
ate-sized companies (Esaote) and any number of smaller
companies. The largest companies compete in the manu-
facturing of multiuse premium instruments with multiple
features, whereas smaller companies tend to focus on niche
markets. Here the competition is less intense, and innova-
tions are more likely to be forthcoming. Larger companies
sometimes follow the fortunes of the smaller companies that
are competing in niche markets, and buy up the ultimate
winner. Product development is continual in newer areas
of ultrasound, so careful attention to newer manufactur-
ers, and familiarity with instrumentation principles are of
importance in purchasing an instrument for neuromuscular
ultrasound.
Service and Training
For novice users in particular, but for all users, access to
service and the stability and quality of ultrasound represen-
tatives are considerations in selecting an instrument. For
physicians in large group practices or academic centers, there
is often an ultrasound manufacturer that already has an insti-
tutional presence, and this is a good place to start when look-
ing at instruments. An established representative tends to be
available and in a strong position to discount the instrument
or to provide attractive lease or used equipment options. The
representative also provides a standard for comparing other
potential vendors (and representatives). An unsatisfactory
representative can lead to difficulties that negate many tech-
nical advantages available on an instrument, so this aspect of
equipment purchase should not be overlooked. It should be
noted that relatively few representatives at this time under-
stand the nature of neuromuscular ultrasound, and educating

them will help them demonstrate aspects of the instrument
that are most relevant to neuromuscular patients.
Instrument Size
Instrument size is problematic because larger instruments use
up more space, generate more heat, and are hard to use outside
of a central location. If the ultrasonographer intends to share
the instrument with another user, or to use it off-site, size is
even more problematic. For practical reasons, physicians who
wish to use ultrasound and who also perform EMG and NCS
will want to have ready access to the instrument in the EMG
laboratory. Particularly for new users, this ready availability
is critical because it is difficult to resist the temptation of set-
tling for the limitations of electrodiagnosis if it means waiting
for access to imaging. Of particular help is the use of a por-
table battery strip, so the instrument need not be unplugged
and restarted as it moves from room to room. Anything that
delays mastering the initial learning curve for ultrasound will
delay the return on the investment of time and resources in
the instrument, so making the instrument accessible is criti-
cal. Larger or brighter display screens on some instruments are
occasionally of interest, particularly if the instrument is used
for teaching residents or fellows. Image quality and resolu-
tion are more important than screen size, and many modern
instruments are equipped with ports for an LCD projector that
can provide broadcasting of images for use in teaching con-
ferences. Ergonomic features are easier to design on the large
instrument platforms and are of importance for repetitive use.
Training EMG Technologists in Ultrasound
A trained, nonphysician, ultrasonographer is unlikely to be able
to perform neuromuscular ultrasound at first because this is
rarely an area of emphasis for most training programs or radiol-
ogy practices. On the other hand, they bring useful instrumenta-
tion skills to the job. Because ultrasonography technologists are
among the highest paid technologists in clinical medicine, how-
ever, such assistance comes with a price. In the author’s experi-
ence, electrodiagnostic technologists can be trained to perform
ultrasound of common nerve entrapments, and their ability to
correlate electrodiagnostic findings with the results of the elec-
trodiagnostic studies, along with their level of comfort with
instrumentation and neuromuscular patients make them quick
learners. Ultrasound also helps make them better in electrodiag-
nosis because it provides feedback on the anatomy of structures
that are routinely under study. As with any procedure, however,
it is tantamount that the interpreting physician have sufficient
experience and training to be able to perform the procedures
independently, supervise technician conduct of procedures,
troubleshoot technical problems, keep up with advances in
instrumentation, and apply new discoveries as they evolve.
The American Association of Neuromuscular and Electro-
diagnostic Medicine (AANEM) is working on standards of
training suitable for physicians who wish to perform neuro-
muscular ultrasound.42
Safety
Ultrasound is the safest imaging modality in use, and there
are few, if any, reports of any physical harm resulting from the
technique.3 It is the standard imaging procedure for looking at
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Chapter 1—Basic Principles of Ultrasound 21
the fetus. The theoretic risk of ultrasound relates to its ability
to heat tissues. Of tissue, perhaps the most vulnerable to ultra-
sound is the eye.43-45 With even very brief bursts of high-inten-
sity ultrasound, cataracts may be induced. Imaging the optic
nerve or eye requires that the ultrasonographer be well versed
in the proper instrumentation for the procedure and its risks.
Temperature probes or hydrophones are available to measure
heat increases in tissue and ambient sound energy for those
wishing to quantify thermal effects of ultrasound imaging.
Who Should Acquire an Ultrasound
Instrument?
This book highlights the role of ultrasound in the evaluation of
a variety of common neuromuscular disorders. Any physician
who practices electrodiagnostic medicine, or who sees patients
with common neuromuscular problems, is likely to improve
the care of patients by acquiring an instrument and learning
how to use it. Not only is it useful for identifying neuromuscu-
lar pathology, it also has the potential to identify musculoskel-
etal pathology in those with normal electrodiagnostic studies.
Those with a responsibility for educating students or residents
will find that the instrument significantly enhances their appre-
ciation of local anatomy and stimulates an interest in pathol-
ogy. The experience at the author’s academic electrodiagnostic
laboratory has shown that ultrasound has helped residents learn
electrodiagnosis in a more flexible and less rote manner, and
enhances their ability to participate in interventional proce-
dures such as botulinum toxin or steroid injections. The abil-
ity to have ready access to the instrument while seeing patients
who might benefit from imaging, and the presence of a suit-
able amount of time and inclination for a physician to master
the learning curve are critically important (Fig. 1.25). Given
the growing quality of imaging instruments and rapid growth
of imaging technology, it is likely that imaging will occupy an
increasingly important role in the diagnosis and management
of patients in the future, and experience with ultrasound will be
invaluable in promoting better use and interpretation of more
sophisticated imaging technologies such as positron emission
tomography (PET), MRI, or CT. Given the current price and
advantages of ultrasound imaging equipment, those interested
in neuromuscular imaging would be ill-advised to delay incor-
porating this technology into their clinical practice.
Conclusion
Like EMG, ultrasound is an active, interrogatory technology.
There is something fundamentally different about looking at
a frozen image on a screen and actually performing a study in
real time. In part, this is because of the motion of the trans-
ducer and kinesthetic feedback involved in holding it, elements
that contribute to our ability to inform vision. The image that
we see when performing ultrasound is more than just a series
of brighter and darker pixels on our retina, it’s a cortically
derived reconstruction of space reconstructed from a series of
multiple angles and movements of the transducer and of tis-
sue. Studies of how humans view a complex structure, such as
the face, reveal that it is composed of a mosaic of multiple eye
movements taking in not just an image, but multiple close-ups
and wide angle views of the finished whole.46 Felipe Fernan-
dez-Armesto,47 in Truth, A History and Guide for the Perplexed
22 Chapter 1—Basic Principles of Ultrasound
Fig. 1.25.  Image showing the ease of transition from electromyography
(EMG) to ultrasound in the care of patients and education of house staff.
uses a lyrical metaphor in this regard that expresses the process
eloquently. Although he talks about viewing the past, the lan-
guage describes seeing with ultrasound as well:
“I tried to adopt multiple perspectives, seeing the past from
multiple points of view closer to the events. For history is
like a nymph glimpsed bathing between leaves: the more you
shift perspectives the more is revealed. If you want to see her
whole you have to dodge and slip between many different
viewpoints.”
In fact, ultrasound imaging is just that, reconstructing a
multidimensional concept from many viewpoints. Unlike
CT or MRI in which these viewpoints are predetermined and
based only on static images, ultrasound provides a freehand
look at mobile structures from whatever perspectives the ultra-
sonographer chooses. Those wishing to couple this freedom
with their wit and imagination are those who will contribute
most to the care of their patients and the evolution of the field.
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