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 NOTICE
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MCGH353-FM_pi-xvi.indd 2 30/07/15 4:49 PM

 ULTRASOUND OF THE FOOT AND ANKLE
EDITED BY

Nathan H. Schwartz, DPM

Private Practice
The Center for Foot and Ankle Care
Smyrna, Georgia

New York  Chicago  San Francisco  Athens  London  Madrid  Mexico City

New Delhi  San Juan  Singapore  Sydney  Toronto

MCGH353-FM_pi-xvi.indd 3 30/07/15 4:49 PM

Copyright © 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be
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 DEDICATION

To my wife, Debbie

To my sister-in-law, Anita Schwartz, retired senior editor for National Geographic

School Publishing, for her invaluable assistance.

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 CONTENTS

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 6. Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Nathan Schwartz
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
7. Soft Tissue Masses and Foreign Bodies . . . 73
Nathan Schwartz

1. Basics of Ultrasound: Physics and Artifacts . . 1 8. Skin, Fat, and Bone . . . . . . . . . . . . . . . . . . . . . . 79

Janak R. Goyal Nathan Schwartz

2. Ultrasound Image Optimization . . . . . . . . . . . 9 9. Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Patrick Meyers Nathan Schwartz

3. Ergonomics and Probe Handling . . . . . . . . 17 10. Neovascularization . . . . . . . . . . . . . . . . . . . . . . 97

Nathan Schwartz Todd P. Stitik, Gloria Hwang, Varun Patibanda,
Nandkumar Rawool, and Bryan Kong
4. Muscles and Tendons . . . . . . . . . . . . . . . . . . . 23
Nathan Schwartz 11. Interventional Uses of Ultrasound
in the Foot and Ankle . . . . . . . . . . . . . . . . . . 109
5. Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Nathan Schwartz
Nathan Schwartz
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

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 CONTRIBUTORS

▶▶ Janak R. Goyal, MD ▶▶ Varun Patibanda, MD

Clinical Assistant, Professor of Medicine
Robert Wood Johnson Medical School
New Brunswick, New Jersey
Director Division of Rheumatology
Raritan Bay Medical Center
Perth Amboy, New Jersey
▶▶ Gloria Hwang, MD
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Bryan Kong
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Patrick Meyers, BS, RDMS, RVT
Clinical Science Specialist
Musculoskeletal Ultrasound, LLC
Aurora, Colorado
Radiology Imaging Associates
Denver, Colorado
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Nandkumar Rawool, MD, RDMS
Associate Professor
Department of Radiologic Science
Thomas Jefferson University
Philadelphia, Pennsylvania
▶▶ Nathan H. Schwartz, DPM
Private Practice
The Center for Foot and Ankle Care
Smyrna, Georgia
▶▶ Todd P. Stitik, MD, RMSK
Professor, Department of Physical Medicine and
Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey

MCGH353-FM_pi-xvi.indd 9 30/07/15 4:49 PM

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Diagnostic ultrasound has been my best teacher, allowing me
to better understand the mechanics and pathomechanics of
the foot and ankle. There are many observations I have made
with this technology that have allowed an understanding of
pathology that was not previously recognized. Diagnostic
ultrasound takes the guesswork out of diagnosis and treat-
ment. No longer is it acceptable to diagnose a condition purely
by location, as ultrasound allows the clinician to actually see
the pathology and its implications. Utilizing ultrasound inter-
ventionally is equally valuable. The procedure, whether injec-
tion or surgical, is observed non-invasively, verifying accuracy.
The foot and ankle is probably the most challenging ana-
tomical area for ultrasound examination. I have addressed
MCGH353-FM_pi-xvi.indd 11
PREFACE
this subject from a clinical standpoint, which relies on an
understanding of the anatomy from multiple perspectives.
My goal in this text is to show the value of diagnostic and
interventional ultrasound in the foot and ankle and pres-
ent the information in a comprehensible format.
The greater the understanding of ultrasound’s capa-
bilities the more valuable it will become in your practice.
I know that this tool will continue to develop, and its
clinical applications will multiply. I consider this the
beginning of an exciting future in ultrasound of the foot
and ankle. This text will provide the tools for the devel-
opment of your skills. Your imagination will provide the
journey.
30/07/15 4:49 PM
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A comprehensive book on ultrasound of the foot from the
viewpoint of the podiatrist is overdue. Nathan Schwartz,
DPM, fills that void with this newly edited tome. This work
places accepted concepts in text next to superb images.
Richly illustrated and neatly organized in 11 chapters,
“Ultrasound of the Foot and Ankle” lifts the reader to a level
of higher understanding in this complex region of the anat-
omy. The initial few chapters introduce the necessary con-
cepts of physics, image optimization, ergonomics, and probe
handling. The different histologic layers of tissues, which
play a role in the pathology of the foot, are each discussed
separately in a methodical approach of detecting disease.
MCGH353-FM_pi-xvi.indd 13
FOREWORD
Ultrasound’s unique capability in detecting neovasculariza-
tion requires its own chapter and so does intervention, as it
is an ever-growing field of our practice. Annotated videos
prompt the reader to try these techniques out unabashedly.
After all, ultrasound of all imaging appeals as the more play-
ful one. Dr. Schwartz convinces us that once you get access
to the tissues under the skin a new world surfaces, a world
you can search without endangering the patient’s cells and
your own life by radiation. Nathan Schwartz, DPM, who
practices magic when he is away from the office shows with
this work that he can set a podiatry office on fire by using
the ultrasound transducer as his magic wand.
Marnix van Holsbeeck, MD
Head, Division of Musculoskeletal Radiology
Professor of Radiology
Wayne State University School of Medicine
Henry Ford Hospital, Detroit, Michigan
30/07/15 4:49 PM

I would like to give tribute to the deceased who have
donated their bodies for the furthering of medical edu-
cation. On the accompanying website there are cadaveric
demonstrations of the ankle’s lateral, collateral ligaments.
These videos clearly show the dynamics and pathome-
chanics of these structures. I would also like to thank
MCGH353-FM_pi-xvi.indd 14
ACKNOWLEDGMENTS
the ­University of Irvine’s medical school, department of
anatomy, where the dissection was performed and videos
were taken.
I also thank Sound Consulting and Esaote of North
America for their diagnostic ultrasounds, which yield
incredible images.
30/07/15 4:49 PM
 BASICS OF ULTRASOUND:
PHYSICS AND ARTIFACTS
JANAK R. GOYAL
SOUND
Sound waves are mechanical waves and are generated only
by movements. There is no sound in vacuum because there
is nothing to move. Everything around us, including air,
is made of small particles. Sound waves are created by the
movements of these particles and travel in straight lines.
They are transmitted by the waves of compression and rar-
efaction of these particles.
▶▶ Sound Waves
Many different parameters are used to describe the various
aspects of a sound wave. Amplitude, power, and intensity
measure a sound wave’s strength. Parameters associated
with the speed of sound are wavelength, period, and fre-
quency. Changing these parameters affects the quality of an
ultrasound study. We now consider these parameters and
their importance in such studies.
For a proper understanding of the most of the param-
eters of sound waves, consider the sound wave as a sort of a
footstep of the sound. Sound wave parameters include the
following (Figure 1-1):
• Wavelength
• Period/frequency
• Speed
• Amplitude
• Power/intensity
The period is the time taken by sound to travel though
a cycle of compression and rarefaction. It is measured in
microseconds. Period can be compared to the time needed
to take one step during walking.
Frequency is the number of cycles or waves per sec-
ond, a unit known as hertz (Hz). One hertz is one cycle
per second; 1000 cycles per second is one kilohertz (kHz).
MCGH353-Ch01_p1-8.indd 1
1
One megahertz (MHz) is 1 million cycles per second.
Medical diagnostic sonography uses sound of very high
frequency, in the range of 1 to 30 MHz. The frequency
can be compared to the number of steps taken in 1 second
while walking.
Period and frequency have a reciprocal relationship.
The number of waves per second decreases as the time for
a wave to pass increases; hence, with an increased period,
there is a decreased frequency.
Compare it to the walking example again If the time
taken for one step is half a second, then the frequency is two
steps per second. If the time taken to take a step increases to
1 second, there will be only one step in a second.
1
Period ∝
frequency
The choice of proper frequency is important for imag-
ing tissues at different depths. High-frequency sound gives
better resolution but lacks penetration. On the other hand,
low-frequency sound penetrates more deeply but has less
resolution.
WHAT IS ULTRASOUND?
Sound is classified based on the range of frequencies audible
to humans: between 20 Hz and 20 kHz. Any sound above
20 kHz is called ultrasound. Medical diagnostic ultrasound
uses frequencies of 1 to 30 MHz.
The speed of sound, or propagation velocity, is the dis-
tance sound travels in 1 second. Although the speed of
sound varies in different tissues, for the purpose of calcula-
tions the speed of sound in soft tissues is presumed to be
1540 meters (1.54 km) per second.
The wavelength (k) is the physical length of a sound
wave measured in millimeters. It is the distance traveled
23/07/15 12:11 AM
 2 CHAPTER 1
Power/intensity/
amplitude
Wavelength/period
Figure 1-1 Diagram of a sound wave.
by sound during a single cycle of compression and rar-
efaction. Wavelength can be compared to the distance
traveled by taking one step while walking. The wavelength
equation is:
c other and all describe the strength of a sound wave. Ampli-
λ∝ (λ : wave length , c : speed of sound , f : frequency )
f
Wavelength is inversely proportional to frequency. When
the speed of sound remains constant, its wavelength
decreases with increased frequency and vice versa. If a
person is walking at a speed of 1 meter per second (m/
sec) and taking only one step per second, the length of
the step must be 1 m. If two steps are taken per second
to travel a distance of 1 m, the length of the step will be
0.5 m.
1 focus. Beyond the focus, the beam progressively widens as
Wavelength ∝
Frequency
Wavelength is directly proportional to the speed of
sound. When the frequency remains unchanged, the
wavelength increases with an increased speed of sound
and vice versa. While traveling with a speed of 1 m/sec,
taking two steps per second, the length of the step will be
0.5 m. If the speed of walking is increased to 2 m/sec but
still taking two steps per second, the length of the step
must increase to 1 m.
Power is the energy in watts, and intensity is the power
per square centimeter of the beam area. Output power is
the energy generated by the machine to drive the trans-
ducer. Power output is adjusted by the sonographer. The
lowest possible power output should be used, to minimize
the biologic effects of sound.
Returning echoes are very small; amplification is used
to increase the overall strength of returning echoes.
Both output power and amplification (gain) can be used
to adjust the brightness of the image. Gain should be
increased before increasing power output when the image
is too dark; power output should be decreased before
decreasing gain when the image is too bright to minimize
biologic effects.
MCGH353-Ch01_p1-8.indd 2
Speed
Wavelength =
Frequency
▶▶ Amplitude/Voltage
Amplitude is a measure of the peaks and troughs of the
sound wave. Voltage is the electrical equivalent of amplitude.
Power, intensity, and amplitude are directly related to each
tude describes the strength in terms of the physical height
and depth of sound waves, and voltage is the electrical rep-
resentation of that physical parameter. Power is directly pro-
portional to the square of the amplitude (power ∝ voltage2).
▶▶ Sound Beam
Waves of sound generated by the transducer travel in the
tissues in the form of a beam that varies in shape as it trav-
els (Figure 1-2). The sound beam narrows progressively
like a funnel until it reaches its smallest diameter at the
it travels.
Narrow beams give better lateral resolution. The focus or
focal point, the point of narrowest beam diameter, is thus
the point of best lateral resolution.
The part of the sound beam from the transducer face to
the focus is known as the near zone or Fresnel zone. The
part of the sound beam that extends deeper from the focus
is called the far zone or Fraunhofer zone.
The focal length is the distance from the transducer face
to the focus. It is also called focal depth or near-zone length.
The focal zone is the region around the focus where the
beam is relatively narrow. Half of the focal zone is in the
near zone and half in the far zone.
Modern transducers are capable of creating multiple
areas of focus electronically at different imaging depths
surrounded by focal zones that can be adjusted by the
sonographer.
RESOLUTION
Resolution is the ability to resolve the difference between
two objects or signals. Resolution is better when the resolved
difference is smaller. The difference may be defined as the
23/07/15 12:11 AM

Fresnel zone (Near zone)
Focal zone Focus
Fraunhofer zone (Far zone)
Figure 1-2 Fresnel and Fraunhofer zones of a sound beam.
distance separating the objects, the difference in the sig-
nal strength (voltage), or the separation by time of occur-
rence, as seen in a heart rhythm with one beat coming after
another. If the heart rhythm becomes too fast, as in ven-
tricular fibrillation, it becomes hard to appreciate individual
beats as separate beats.
▶▶ Spatial Resolution
There are two aspects of spatial resolution:
1. Resolution of the screen in terms of pixel density, and
2. Resolution of the signal within the pixel.
More pixels with a smaller distance between individual pix-
els define better screen resolution.
The number of gray shades within the individual pixel
defines the gray-scale resolution of the signal. Different
terms are used to define the three-dimensional aspects of
gray-scale resolution.
Resolution along the depth of the tissue is known as axial
resolution. It depends on the transducer frequency. High-
frequency sound gives better axial resolution but poor pen-
etration to deeper tissues.
Lateral resolution is the resolution from left to right
of the image, along the long axis of the transducer. L­ ateral
resolution depends on the beam width. Narrow beams
provide better lateral resolution. Focusing decreases the
side-to-side dimensions of the sound beam and improves
lateral resolution. Focus is the narrowest area of the beam.
MCGH353-Ch01_p1-8.indd 3
BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 3
The beam area just before and after the focus (the focal
zone) is relatively narrower than the rest of the beam.
Modern ultrasound machines are capable of making mul-
tiple areas of focus and hence multiple focal zones by elec-
tronic focusing.
Elevational resolution is the resolution from front to
back along the imaging plane, which is not seen on two-
dimensional (2D) imaging.
▶▶ Temporal Resolution
Temporal resolution is accuracy in time. It is the ability to
accurately locate moving structures at any particular instant
in time. Temporal resolution is determined by frame rate
(Figures 1-3 and 1-4).
A frame is an image generated by sending sound pulses
into the tissues. The number of frames per second depends
on the depth of imaging and the number of focal zones.
Increased depth of imaging requires more time to create an
image because it takes longer for the echoes to return from
deeper tissues. Multiple focal zones require more pulses, a
pulse for every focal zone. For a particular depth of imag-
ing, two focal zones will require twice as much time as sin-
gle focal zone, and so on.
To increase the number of frames per second for best
temporal resolution, the depth of imaging should be as
shallow as possible and the number of focal zones as low
as possible.
▶▶ Contrast Resolution
Contrast resolution is the ability to distinguish the differ-
ence in brightness of various parts of an image. It defines
Transducer crystals
Frame
Figure 1-3 One focal zone. A frame created by 8 echoes and
8 sound pulses. Each double arrow represents a pulse echo.
23/07/15 12:11 AM
 4 CHAPTER 1
Transducer crystals
Frame
Figure 1-4 Two focal zones. There are two pulses per scan
line, corresponding to two focal zones. This frame takes twice as
much time as the frame in Figure 1-3, thus decreasing the frame
rate and temporal resolution.
the difference between the echo strengths represented by
varying degrees of gray shading in the image. Contrast res-
olution is used to describe the image quality in terms of
both image contrast and resolution.
Resolution is better when a greater number of gray
shades are visible, with smaller differences between them.
On the other hand, the image looks sharper when the dif-
ference between the signals is larger, as in a high-contrast
image.
Log compression or dynamic range compression is used
to control contrast and resolution. A high-contrast image
has a low dynamic range and low resolution.
DYNAMIC RANGE
Returning echoes are converted to gray shades of varying
brightness. Each range of echo amplitudes, for instance 0–1
microvolt, is assigned a different gray shade.
Dynamic range is the logarithmic ratio of the maxi-
mum to the minimum echo amplitudes. In gray-scale
imaging, it is the ratio of the signal strength of the bright-
est and the darkest signals converted to a logarithmic
scale.
The dynamic range of echoes coming from tissues is
very large: Typically, for gray-scale imaging, the largest
echo ­signal is 10,000 times larger than the smallest echo
signal, with a dynamic range of 80 decibels. Dynamic range
compression decreases the ratio between the largest and the
smallest signal voltage, improves contrast, and decreases
resolution.
MCGH353-Ch01_p1-8.indd 4
DOPPLER ULTRASOUND
Doppler sonography is used to image blood flow. A gray-
scale signal is caused by reflection from tissue interfaces,
whereas a Doppler signal is caused by blood flow and tissue
movements. The best gray-scale image is obtained when
the sound beam hits the interface at 90 degrees, but the best
Doppler signal is obtained when the sound beam is parallel
to the blood flow.
The Doppler effect is a change in frequency of a sound
beam due to relative motion between a sound source and
a receiver. In diagnostic medical sonography, the sound
source is the ultrasound transducer, and the receiver is the
flowing blood. The change in frequency is known as the
Doppler shift or Doppler frequency:
Doppler shift = Received frequency – transmitted frequency
The Doppler equation states the relationship between
different variables that affect the Doppler shift, including
the transducer frequency or operating frequency, the veloc-
ity of the blood, and the angle between the sound beam and
blood flow:
Doppler Shift = 2 F0V cos θ/c
where F0 is the transducer frequency, V the velocity of
blood, c the speed of sound, and θ the angle between the
sound beam and the direction of flow.
▶▶ Common Modes of Doppler
Sonography
Spectral Doppler (Figure 1-5) records the tissue movements
in the form of a graphic recording, whereas color Doppler
records tissue movements as a visual display of colors.
Spectral Doppler is not discussed in detail here, because it
is not used in musculoskeletal sonography.
Color flow and color power Doppler (Figures 1-6 and
1-7) is useful in musculoskeletal sonography to look for
low-velocity flow in inflammatory conditions such as gout
Figure 1-5 Spectral/pulse Doppler.
23/07/15 12:11 AM

Figure 1-6 Color Doppler.
and rheumatoid arthritis. Color flow Doppler provides
information about the direction of flow, whereas power
Doppler provides visual information about the strength of
blood flow and gives no information about the speed and
direction of flow.
Optimum settings for a good-quality Doppler image
include the following:
• Maximize power output
• Increase the gain until random noise appears, and then
lower it until the noise just disappears
• Try different frequencies until the best signal is obtained
(higher frequencies are more sensitive to flow but are
subject to attenuation).
• Use a low number of pulses per second (the pulse
repetition frequency or PRF (0.5–1 kHz)
• Use the smallest color box
• Avoid pressing the transducer into the tissue during
scanning to maintain blood flow
Figure 1-7 Power Doppler of an inflamed talonavicular joint.
MCGH353-Ch01_p1-8.indd 5
BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 5
THE ULTRASOUND TRANSDUCER
An ultrasound transducer contains an array of piezoelec-
tric crystals. These crystals vibrate to produce sound when
an electric voltage is applied across them. They generate
electrical energy when they are mechanically deformed by
sound.
Depending on the clinical situation, transducers are
operated to produce a continuous or a pulsatile sound.
Continuous sound cannot produce anatomical images. Pul-
satile sound is used to create gray-scale anatomical images.
Short pulses of sound are transmitted to create an anatomi-
cal image
An ultrasound image is created by processing echoes
received from the body tissues. Echoes are generated by the
reflection of sound from the tissue boundaries (interfaces).
The most important factors that determine the amount
of reflection (echoes) are the strength of the transmitted
signal, the angle of incidence of the sound beam, and the
difference in the impedance of the tissues at the interface.
Impedance is the product of the density of the medium
and the speed of sound in that medium. A greater differ-
ence in impedance generates a greater reflection.
Air has very low density (1.25 kg/m3) as compared to soft
tissue (1060 kg/m3). The speed of sound in air is approxi-
mately 340 m/sec, and the speed of sound in soft tissue on
average is 1540 m/sec. Thus there is a huge difference in the
calculated impedance of air and soft tissues This huge dif-
ference creates a highly reflective air and soft tissue inter-
face—99% of sound is reflected at the interface. The use of
acoustic gel eliminates air from the interface, dramatically
decreasing reflection and ­increasing t­ ransmission.
Most body tissues are made of a specific tissue paren-
chyma and supporting connective tissue framework, creat-
ing multiple connective tissue and parenchyma boundaries
(interfaces). Tissues have different histological and sono-
graphic characteristics based on the arrangement of con-
nective tissue framework and parenchyma. For example,
tendons appear bright because they have densely packed
fibers and multiple interfaces to reflect sound. Body fluids
appear dark because they have no connective tissue frame-
work and hence no interfaces to reflect sound.
The arrangement of different tissues in the body creates
tissue boundaries (interfaces). The reflection of sound dif-
fers based on the difference of impedance of two tissues at
the interface. The greater the difference in impedance, the
greater the reflection. Normally, for most tissue interfaces,
less than 1% of sound is reflected, and the rest is transmit-
ted for imaging of deeper tissues. However, 99% of sound
is reflected from a tissue-air interface and about 50% from
a soft tissue–bone interface because of larger differences in
impedance.
The strength of the reflected echo also depends on the
strength of the original signal from the machine and the
attenuation of sound as it travels through the tissues. Attenu-
ation is progressive weakening of the signal as it travels to the
deeper tissues. Attenuation depends on the type of tissue, the
frequency of the sound, and the depth of the target tissue.
23/07/15 12:11 AM
 6 CHAPTER 1

A B

Figure 1-8 (A) Short-axis view of the tarsal tunnel with speckle reduction. (B) Same view as Figure 1-8A without speckle reduction.

Different tissues attenuate sound at different rates, but Speckle is a grainy appearance of the image. It is a form
for the purpose of calculation and machine standard- of noise that results from constructive and destructive
ization, the attenuation in soft tissue is assumed to be interference of small-amplitude reflections from many tis-
0.5 decibel (dB)/MHz/cm. sue reflectors (Figure 1-8A and B). Speckle appears as a tis-
Biologic fluids attenuate sound far less than soft tissues, sue texture close to the transducer.
which results in enhancement of tissues deep to fluid-filled Shadow is a lack of echoes from structures deep to an
structures because of the compensation applied to the object with a high attenuation rate (Figure 1-9). It is a
returning echoes based on the assumed attenuation. hypoechoic or anechoic region extending downward par-
Bone has a high attenuation rate due to absorption. allel to the sound beam deep to a structure such as calci-
Sound has very poor penetration to structures deep to bone fication. Anatomic details are missing in the region of the
because of attenuation by reflection at the highly reflective shadow because nothing is visible within it.
soft tissue–bone interface and because of the high rate of
absorption of sound by the bone.
Compensation is variable amplification to compen-
sate for the increased attenuation of sound with increased
depth. Echoes returning from superficial tissues undergo
less attenuation compared to echoes returning from deeper
tissues because one of the key factors that determine atten-
uation is the depth of the target tissue.
The ultrasound system calculates the attenuation based
on the depth of origin of the echo and applies amplification
based on calculated attenuation; echoes from deeper tissues
are amplified more than the echoes from superficial tissues
to compensate for their loss.
Compensation is also known as time gain compensation
(TGC) or depth gain compensation (DGC) or swept gain.
Although the machine automatically applies compensation
to the returning echoes, there are also TGC controls on the
machine for the sonographer to further adjust compensa-
tion if needed.

SONOGRAPHIC ARTIFACTS
Many different types of artifacts have been described in
gray-scale and Doppler imaging. Here we discuss only the
artifacts that are commonly encountered in the everyday
practice of musculoskeletal sonography.
Figure 1-9 Short-axis view posterior to the calcaneus
demonstrating the Achilles tendon with calcifications. Note
the anechoic area (acoustic artifact) deep to the calcifications,
which have a high attenuation rate.

MCGH353-Ch01_p1-8.indd 6 23/07/15 12:11 AM

 BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 7

Figure 1-10 Short-axis view of the Achilles tendon revealing an

edge artifact (arrow).
Figure 1-12 Reverberation artifact.

Characteristics of shadows include the following: deeper tissues (Figure 1-11) due to lack of attenuation
by fluid media.
• Hypoechoic or anechoic
Reverberation is caused by bouncing of a sound beam
• Deep to a structure with abnormally high attenuation rate between two strong specular reflectors positioned parallel
• Prevents visualization of true anatomy deep to the to the beam axis (Figure 1-12). Multiple echoes result in
shadow-producing object multiple equally spaced artificial reflectors on the display at
increasing depths parallel to the main axis of the beam. All
Edge shadow (Figure 1-10) is created by refraction of
tissues between the reverberating specular reflectors can
sound from the edges of a curved structure commonly seen
be replicated. The first of the two reflectors is usually the
at the edges of superficial subcutaneous veins and torn
transducer face.
edges of tendons. The edge shadow disappears with the
Comet-tail artifact is a reverberation artifact with the
change in the direction of ultrasound beam.
spaces squeezed out (Figure 1-13). It appears as a solid
Enhancement is a hyperechoic appearance of tis-
hyperechoic line directed downward and parallel to the
sues due to lack of attenuation of the sound beam dur-
sound beam’s main axis. The vibrations are caused by the
ing propagation. It is the reciprocal of shadowing. More
bouncing of the sound beam between two closely spaced,
sound energy returns to the transducer from tissues
highly reflective interfaces. The sequential echoes are so
deep to a low-attenuation medium. Returning echoes
are amplified based on depth assuming a constant rate
of attenuation. Structures such as a full bladder, cyst,
abscess, or joint effusion result in ­ enhancement of

Figure 1-11 Through transmission enhancement of a ganglion. Figure 1-13 Comet-tail artifact.

MCGH353-Ch01_p1-8.indd 7 23/07/15 12:11 AM

 8 CHAPTER 1

Figure 1-14 Ring-down artifact that also displays some comet-

tail artifact. Ring-down looks like a solid line with no spaces; in a Figure 1-15 Double imaging of the calcaneus.
comet tail, the spaces are very small.

close together that individual signals do not appear sepa-
rate. The width and strength of echoes diminishes in the
deeper tissues, resulting in a triangular conical artifact.
The phenomenon is caused by the sound beam reflect-
ing from metal objects such as a prosthesis or needles,
or from highly reflective foreign bodies and tissue
­calcifications.
Ring-down artifact is considered a variant of comet-tail
artifact because of its similar appearance (Figure 1-14). It
appears as a continuous echo deep to a highly reflective
interface mostly due to gas.
In a mirror-image artifact, a highly reflective interface
can act as a mirror and create a virtual image of the super-
ficial reflectors deep to it, just like an actual mirror (Figure
1-15). A mirror-image artifact is a virtual copy of the true
reflector deep to the highly reflective interface acting as a
mirror. The true reflector and the artifact are at equal dis-
tance from the highly reflective interface (mirror).
Anisotropy is an angle-dependent artifact of a specu-
lar structure (Figure 1-16A and B). For example, fibers
are echogenic when perpendicular to the sound beam, but
hypoechoic or anechoic when oriented obliquely, giving a
false impression of pathology.
Tendons are strongly anisotropic. Anisotropy of tendons
helps differentiate tendons from surrounding fat when
echogenicity of fat approximates that of the tendons.

A B

Figure 1-16 (A) Plantar aspect of the flexor hallucis longus tendon with the hallux plantar flexed, placing the flexor hallucis longus
tendon almost parallel with the probe and showing the fibular pattern of the tendon. (B) Same location as Figure 1-16A, but the hallux
is dorsiflexed, creating an angle between the probe head and tendon. The ultrasound waves now ricochet off the tendon and do not
contribute to the image. The location of the tendon is still visible, but it is dark (arrow).

MCGH353-Ch01_p1-8.indd 8 23/07/15 12:11 AM

 ULTRASOUND IMAGE
OPTIMIZATION
PATRICK MEYERS
There are few published data on the qualities that make an
acceptable image. However, there are basics of image pre-
sentation and quality that are essential to get a diagnostic
quality image. This chapter discusses image presentation
and basic image quality components.
IMAGE PRESENTATION
Regardless of the appearance of the image or the ultra-
sound system manufacturer, there are defined items that
are fundamental to all ultrasound systems. The most basic
and fundamental is that the ultrasound system begins with
the conversion of electrical energy to acoustic energy. The
electrical pulse excites the crystals in the transducer, which
emits sound waves from the transducer face that are trans-
mitted into the body. The waves strike different tissue inter-
faces with varying tissue density and are reflected back to
the surface of the transducer. The energy returning to the
transducer is converted back to electrical energy and is sent
to the system display to be viewed. A way to think of the dis-
played image is from the top of the image to the bottom in a
temporal sense. Structures that are closest to the transducer
surface, which is where the beam originates and terminates,
are displayed at the top of the screen. Regardless of where
the transducer is placed on the body, whatever structure is
first encountered and reflected back to the transducer will
be at the top of the display (Figure 2-1).
As the sound travels through the body and returns, it loses
energy as a result of multiple factors. Some of the reasons for
loss of return signal are compensated for by controls avail-
able to the imager. Today’s modern ultrasound equipment
has made intricate and time-consuming image-quality
tweaking obsolete. Largely because of automated image
optimization controls, increases in computational power
of modern computer chips, and knowledge of ultrasound,
image optimization has become decidedly easier. However,
MCGH353-Ch02_p09-16.indd 9
21
a basic understanding of sound interaction with tissue and
the controls most systems provide to improve the diagnostic
quality of the image is provided here.
The first rule to understand is that ultrasound is energy,
and care should be taken to limit the amount of energy
directed into the body. The U.S. Food and Drug Administra-
tion (FDA) has strict thermal and mechanical indices that
all companies must abide by. As recommended by guide-
lines established by the U.S. Nuclear Regulatory Commis-
sion (U.S. NRC), the lowest amount of energy should be used
during any study. This is referred to as ALARA, an acronym
for “as low as (is) reasonably possible.”
The acoustic output control (AO) controls the amount
of energy released from the transducer into the body. For
musculoskeletal imaging, acoustic output is seldom if ever
adjusted.
GAIN CONTROL
In contrast, the most common control adjusted in image
optimization is the gain control. The gain control is an
amplifier of the returning signal from the body and makes
the overall image brighter or darker (Figure 2-2). The gain
control is analogous to the volume control on audio devices.
The gain control amplifies all returning signals, but does
not increase the amount of energy emitted into the body.
TGC CONTROL
A secondary control, not found on all equipment, is the TGC
or “time gain compensation” control. This control allows for
horizontal gain control that increases or decreases gain in
segmented parts of the image (Figures 2-3 and 2-4). Con-
sidered a second-level control, the TGC allows the user to
“balance” the image brightness from top to bottom. The TGC
23/07/15 12:12 AM
 10 CHAPTER 2
Figure 2-1 An ultrasound system with an image displayed. The
yellow-brown arrow at left shows the direction of the ultrasound
beam and how anatomy that is closest to the transducer is
displayed at the top of the screen. The yellow and orange arrows
at right indicate the direction of the original pulse and the
direction of the returning pulse.
C
MCGH353-Ch02_p09-16.indd 10
controls are generally represented as a series of slide pods or
digital controls that can be individually adjusted. They are
similar in fashion to the rear speaker controls on an audio
system, allowing for increases in segmental brightness.
PRESETS
A common question for new users to ultrasound is, “Where
do I start in optimizing my image?” With advances in auto-
mated controls on modern equipment, a user can start by
selecting an imaging preset. Presets can be thought of as
shortcuts to first-level image optimization. The presets
may be grouped by specialty, location, or patient/joint size.
Presets act like station selection controls on audio systems.
The preset controls will automatically set a predetermined
gain and a number of imaging options. It is one of the first
controls that a user should become accustomed to selecting
(Figure 2-5).
Figure 2-2 (A) Long axis of muscle with gain control set too
high. (B) Long axis of gastrocnemius muscle with correct gain.
(C) Long axis of gastrocnemius muscle with overall gain too low.
23/07/15 12:12 AM

A B
Figure 2-3 (A) Mechanical TGC (time gain compensation control) pods seen inside yellow oval. (B) Electronic TGC pods on a tablet
system (yellow oval).
The general purpose of the preset control is to set your
system in a “ballpark” state for imaging. It will be the quick-
est route to initial system optimization. Adjustments to the
preset can be made based on user tastes and tissue sub-
stance after it is selected. Imaging presets in many newer
systems allow for users to build user-defined presets that
allow for customization of specific tasks.
The ultimate goal of image optimization is to achieve the
best diagnostic-quality image with the system as quickly as
possible. Many more controls may be available for optimi-
zation, but they are beyond the scope of this chapter.
DEPTH OF FIELD
The top-level controls just discussed—gain, TGC, and
presets—are the most important first-level parameters in
image quality. Preset values are, as stated earlier, ballpark
parameters. Because body habitus can be significantly
different within a preset parameter (for example, “knee”
would include an elite athlete as well as a morbidly obese
patient) the ability to adjust these factors is essential. We
begin with depth of field or viewing area. Think of depth
of field over (FOV) as the area that will be displayed on the
monitor. Remember, once the sound leaves the transducer,
MCGH353-Ch02_p09-16.indd 11
ULTRASOUND IMAGE OPTIMIZATION 11
it continues in the body until all energy is used. Adjust-
ing the viewable area on the machine is a function of the
depth control and has two main functions. The first is to
set the depth to include targeted anatomy and sufficient
surrounding structures. Second, proper depth adjust-
ment helps the machine work more efficiently. The system
pulses a signal and waits for all returning echoes before a
second pulse can be sent. If the system pulses before the
vast majority of energy from the previous pulse is com-
pleted, negative artifacts may be encountered. Therefore,
a depth set improperly deep will unnecessarily slow down
the image refresh rate, otherwise known as frame rate. A
frame rate that is too slow results in the image refreshing
too slowly, with image lag or what is known as a “wind-
shield wiper” effect. Setting the depth too shallow will
result in the full range of target anatomy not being dis-
played (Figure 2-6A and B).
A good rule of thumb is to adjust image depth such that
target anatomy fills two thirds of the display area and, if
appropriate, include osseous (bone) anatomy for orienta-
tion. Remember that the depth of field is an adjustable wall
that can be moved either way with the depth control button.
Once proper depth is selected, adjustments in overall gain
and TGC can be made.
23/07/15 12:12 AM
 12 CHAPTER 2

B
A

Figure 2-4 (A) Properly balanced image brightness with overall

brightness equal from top to bottom. (B) Far field too bright
compared to near field. (C) Far field gain too low compared to
C
near field.

A B

Figure 2-5 (A) Electronic preset showing application and depth of target anatomy (upper left side of display, “MUSCULOSKELETAL”,
“VERY SUPERFICIAL” inside yellow oval). (B) Selection for preset button is located on the lower left side of the keyboard (yellow circle).

MCGH353-Ch02_p09-16.indd 12 23/07/15 12:12 AM

 ULTRASOUND IMAGE OPTIMIZATION 13

A B

Figure 2-6 (A) Depth of field is set too shallow and not enough anatomy is seen to properly identify location in this long-axis (LAX)
view of the flexor tendon of the finger. (B) Depth of field is set correctly, and adequate anatomy is seen to identify bone and soft tissue
structure of the flexor tendons in the finger.

FOCAL ZONES OTHER PARAMETERS

Some machines have the ability to increase the resolution
of the image in a specific horizontal aspect of the image.
These controls, much like focusing light with a lens, pro-
vide the ability to focus the energy from side to side for
increased image resolution at a specific depth. Figure 2-7
is an illustration of what happens when focus depth is not
adjusted properly. Adjusting the focal zones in the image
increases resolution as well as brightness of the image at
the level of the focal zones. Proper focal zone adjustment
should be made by placing the focal zones at the level of the
target anatomy or just below.
One may wonder why the machine does not have focal
zones cover the entire image instead of a specific area. The rea-
son is that adding more focal zones slows down the frame rate.
The next line of image parameters that can be adjusted
are available on some but not all systems. These features
include imaging maps, frame averaging, and reject. These
three controls are often adjusted to user tastes and seldom
have dramatic effects on the diagnostic quality of the image
unless used at extreme ranges of selection. Map selection
may produce an image emphasizing the black or bright
reflections. Map selection is primarily a visual prefer-
ence for display. Only the extreme ends of map selection
may affect diagnostic image quality. Frame averaging is a
method to remove speckle artifact, the salt and pepper foci
in an image. Frame averaging is more of an obsolete con-
trol and should not be considered a primary image adjust-
ment option.

A B

Figure 2-7 (A) Correct focal zone position across from patellar tendon (yellow hourglass). Tendon fibers are seen as discrete
structures (blue arrow). (B) Incorrect focal zone position. Focal zone set too deep (yellow hourglass). Tendon fibers are blurry and blend
in with other fibers (blue arrow).

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 14 CHAPTER 2

A B C D

Figure 2-8 Common form factors for transducers. A, curved Figure 2-10 LAX view of the anterior adult hip illustrating the
linear array; B, sector/phased array; C, micro linear array; D, typical trapezoidal wide-format image display of a curved linear
50-mm linear array. array transducer.

FREQUENCY transducer and operating frequency are often considered

A primary imaging control that is a combination of machine
and transducer is imaging frequency. The higher the fre-
quency, the better the spatial resolution. Modern machine/
transducer combinations accommodate multiple frequency
selections for each transducer. The trade-off in frequency
is the higher the frequency, the greater the spatial resolu-
tion, to the detriment of penetration. In other words, tissue
structure will be sharper at the expense of seeing deeper into
the body. During imaging, it is not unusual to change fre-
quencies to observe the benefits. Presets for each area gen-
erally provide the best compromise.
TRANSDUCERS
There are two final factors regarding image optimization,
transducer selection and operating frequency of trans-
ducer. Up to this point, methods to optimize the image
have focused on the displayed image. Choosing the correct
first steps, but transducer selection and operating frequency
can be changed during the examination to help improve the
diagnostic quality of the image. The format, or form factor,
of the transducer selection is discussed first.
Figure 2-8 illustrates the common form factors of trans-
ducers. Commonly used transducers come in three basic
formats: linear array, curved linear array, and sector array.
Linear array transducers, those with flat faces, come in for-
mats with small contact surfaces, often referred as micro
linear or “hockey stick” form factor. The micro linear arrays
are generally employed in evaluations of the hands, feet, and
wrist. The small footprint or face allows for easy placement
of the transducer in small spaces such as between fingers
and toes and while working around protruding bone sur-
faces such as the malleoli. This form factor is often used in
ultrasound guidance in the joints of the fingers and toes.
Its small footprint allows for easy manipulation. Although
it is not required for evaluation of any particular joint, its
light weight and easy maneuverability make it ideal for

A B

Figure 2-9 (A) LAX view of the flexor tendon in the hand at the metacarpal-phalangeal joint space with micro linear array transducer.
(B) Larger linear format demonstrates a larger side-to-side format, and more anatomy can be seen.

MCGH353-Ch02_p09-16.indd 14 23/07/15 12:12 AM


A B
Figure 2-11 (A) Flexor tendons in the finger showing indistinct tendon fibers (blue arrows). (B) Same image as Figure 2-11A, but with
spatial compounding activated. Greater distinction of tendon fibers in the flexor tendons is seen.
providers focused on the hands, feet, and wrist. Because of
the superficial nature of anatomy in this area, the operat-
ing frequency of this transducer ranges from 8 to 30 MHz
and beyond. Although ideal for getting into tight places, the
small footprint of the transducer provides a small field of
view and, with the higher frequency range, limits the depth
of penetration.
The second and most common form factor is the stan-
dard linear array format. The footprint of linear array in
general is between 29 and 50 mm. The footprint, although
slightly larger than the micro linear, can be used in prac-
tically all the same applications as the micro linear. The
larger footprint has the advantage of a wider field of view
for display (Figure 2-9A and B).
Depending on the study being performed, the curved lin-
ear array may be the transducer of choice when larger field
of view is needed, both in deep anatomy and in some situ-
ations where the anatomy is close to the transducer, such as
the sacroiliac (SI) joint, where the curved linear array would
have advantages. In general, the curved linear array trans-
ducers have a lower operating frequency band and will have
less spatial resolution when compared to the linear array
(Figure 2-10).
The operating frequency or frequencies is referred to
as the bandwidth of the transducer. Modern transducers
are broadband—in other words, they have a good range
of operating frequencies that a user can select. Although
there is a relationship between the ultrasound machine and
the frequency range of the transducers, that relationship is
beyond the scope of this chapter.
The key element of operating frequency of a transducer
is that the higher the frequency, the better the spatial reso-
lution (axial and lateral resolution) of the image. The nega-
tive of high-frequency imaging is that as frequency goes
higher, the penetration of the ultrasound waves decreases.
The best rule of thumb is to use the highest frequency
available to adequately image the target anatomy. In gen-
eral, high frequency is considered to be a range greater
than 7 MHz and low frequency lower in the 1- to 6-MHz
range.
MCGH353-Ch02_p09-16.indd 15
ULTRASOUND IMAGE OPTIMIZATION 15
SPATIAL COMPOUNDING
One other technology that has a direct effect on image
quality is spatial compounding. Spatial compounding is
an image acquisition technique—in other words, when the
system is sending the wave into the body. What is unique
about spatial compounding is that the system sends waves
from different angles and combines them into a single dis-
played image (Figure 2-11).
The value of this technique is that it improves the defini-
tion of the borders of structures, improves contrast resolu-
tion, and has the added benefit of minimizing anisotropy
encountered in tendons and other anatomy. The aniso-
tropic effect is discussed in detail in other chapters of this
book.
SUMMARY
In summary, the optimization of the ultrasound image
requires the user to have a basic understanding of how the
controls on the ultrasound system work. A practical algo-
rithm for beginning an exam would be the following:
1. Enter patient information
2. Select the closest available preset that matches the body
part being examined
3. Choose an appropriate transducer type and operating
frequency
4. Adjust the depth control, if needed, over preset to image
slightly deeper than the target anatomy
5. Use the gain control, and TGC controls if available,
to adjust the brightness of the image and good image
brightness balance
Although this chapter has not provided exhaustive coverage
of image optimization, the most basic concepts and most
common image controls have been explained. Importantly,
developing a consistent method to achieve a diagnostic-
quality image will increase efficiency and consistency in
scanning.
23/07/15 12:12 AM
This page intentionally left blank
 ERGONOMICS AND
PROBE HANDLING
NATHAN SCHWARTZ
At first glance this chapter may appear to be one to skip.
However, this chapter is one of the most important. Obtain-
ing the best picture is critical in diagnostic musculoskeletal
imaging. In order to execute this properly, one must be able
to control and stabilize the probe efficiently. The foot and
ankle is probably the most challenging of all body parts to
scan because of irregular surfaces and awkward positions.
Optimal positioning of the clinician, patient, and ultra-
sound machine is very important. The operator should be
comfortable and in control at all times.
This chapter contains two parts one on ergonomic posi-
tioning and the other on handling of the probe.
ERGONOMICS
Some clinical settings will not be as easy to work with as
others. If there is an adjustable-height cart and an adjust-
able patient chair, this will facilitate efficient ergonom-
ics. It is important that the clinician be able to complete
the examination without being interrupted because of
poor positioning, lack of gel, poor visualization, and so
on. Accordingly, if the clinician is looking over his or her
shoulder to see the monitor (Figure 3-1), this is a com-
promise. Having the monitor straight ahead or slightly to
one side will yield optimal positioning for the examination
(Figure 3-2).
It may be necessary to rearrange the position of the ultra-
sound machine, adjust the height of the patient chair, and/
or sit down in order to obtain the best ergonomics. An
example is having the patient prone for an Achilles tendon
examination. Time spent preparing will save more time
during scanning.
Being ambidextrous will prove to be a big asset. If you are
right handed, teaching your left hand specific tasks is not as
difficult as you might think. Along with accuracy, this also
will save time, giving the clinician more flexibility.
MCGH353-Ch03_p17-22.indd 17
31
HANDLING OF THE PROBE
Placing gel between the probe and the body part creates a
slippery environment. Therefore, stabilization of the probe
on the foot or ankle is extremely important. If you are mov-
ing the probe in an examination, the foot must be stationary
and vice versa. Accordingly, it is necessary that the opera-
tor have dry fingers on the patient’s dry skin while holding
the probe. Additional parts of the hand can act as stabiliz-
ers. For example, the probe may rest in between the thumb
and first finger (Figures 3-3 and 3-4), and the palm can rest
against the foot for additional stability (Figure 3-5).
The probe should be handled as close to the scanning sur-
face as possible, obtaining the greatest control. Figure 3-6
shows improper handling, with the probe grasped too far
from the scanning surface. It is not necessary to grasp the
probe tightly. It is optimal to control the probe effectively
with the least possible amount of grasping pressure. This is
accomplished by controlling the probe in the most efficient
manner. Practice and evaluating how a specific task can be
better accomplished will lead to refinement and perfection.
In addition, the weight of the cord from the probe can
also create an unwanted force. Placing the cord over your
neck or having an assistant hold the cord can eliminate that
adversity.
If the clinician is scanning a tendon from the myotendi-
nous junction to insertion, it is best to start with the wrist
straight, allowing more flexibility during the examination.
Figure 3-7 shows the wrist improperly bent, limiting flex-
ibility. It may also be helpful to mimic the full scanning
technique to make sure that there will be no physical or
mechanical restrictions.
There are several scanning techniques. First, compres-
sion of the probe (sono pressure) yields valuable informa-
tion. This may show the consistency of the tissues being
examined and whether or not the lesion is fluid filled. Heel-
toe (Figure 3-8) mobilizes the soft tissues beneath, allowing
23/07/15 12:12 AM
 18 CHAPTER 3

Figure 3-1 Improper positioning for scanning technique. Because Figure 3-2 Proper position for scanning technique. By moving
of his sitting position, the clinician has to look over his shoulder to the chair to the left of the patient, the clinician is facing the
see the screen. His wrist is bent, again by virtue of his position. screen and wrist position is improved.

Figure 3-3 Proper handling of the probe. Lesser fingers are Figure 3-4 Proper handling of the probe by positioning the
touching the patient for stability. hand in a stable manner on the patient’s leg. The Achilles tendon
can be a challenging area to scan because of the triangular
shape of that portion of the leg.

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 ERGONOMICS AND PROBE HANDLING 19

Figure 3-5 Proper handling of the probe by placing the Figure 3-6 Improper handling of the probe by grasping the
clinician’s hand stably on the patient’s heel. probe far from the scanning surface.

Figure 3-7 Improper handling of the probe because of the bent

wrist and poor stabilization.

MCGH353-Ch03_p17-22.indd 19 23/07/15 12:12 AM

 20 CHAPTER 3

A B

Figure 3-8 (A–B) Heel-toe maneuver is performed by rocking the probe along the lengthwise plane of the probe.

A B

Figure 3-9 (A–B) Toggling the probe is performed by rocking the probe along the widthwise plane of the probe.

MCGH353-Ch03_p17-22.indd 20 23/07/15 12:12 AM


better visualization of the soft tissue planes and structures.
In addition, the altered angle of the probe may adjust for
anisotropy, evaluating whether or not an artifact is present.
Swiveling the probe is necessary to stay on top of a tendon
or other structure that is changing direction. If you are fol-
lowing a structure and the leading edge is fading off, this
indicates that the probe is moving in a different direction
than the structure you are observing. Changing direc-
tion by swiveling the leading edge of the probe (keeping
the trailing edge stationary) will put the operator back on
track. Toggling the probe (Figure 3-9) allows the scan to be
optimized by obtaining the desired 90 degrees of the ultra-
sound waves to the structure being examined. Movements
should be broad at first, then less and less until the desired,
sharpest image is obtained.
MCGH353-Ch03_p17-22.indd 21
ERGONOMICS AND PROBE HANDLING 21
EDGE TECHNIQUE
Many times the patient is unsure of the exact location of
the complaint. The patient may give you a starting point,
but because location is extremely significant, exactness is
imperative. In addition, there may be several different areas
with pathology, and the patient may be only focusing on the
most significant. A technique to correlate the ultrasound
findings with clinical significance is obtained by position-
ing the probe such that either edge on the long side of the
probe is directly over the area of interest on the ultrasound
scan. Then, with digital or probe pressure at that point,
symptoms will be elicited if the area of concern is clinically
significant. This is utilizing the “edge technique” with sono
pressure.
23/07/15 12:12 AM
This page intentionally left blank
 MUSCLES AND TENDONS
NATHAN SCHWARTZ
Skeletal muscles comprise about 40% of the total body
weight, with men usually having a larger muscular per-
centage than women. The muscle fibers are not nearly as
echogenic as the supportive connective tissue. Muscles are
grouped together in fascicles. The perimysium surrounds
the individual fascicle and the epimysium surrounds the
whole muscle. Within the muscle there are intramuscular
septa that define the internal structure of the muscle (uni-
pennate, such as extensor digitorum longus; bipennate, such
as flexor hallucis longus; and circumpennate, such as tibialis
anterior1). There is significant fluid content in muscle fibers.
As a result, they appear dark on ultrasound imaging. The
muscle appearance under ultrasound is mainly due to the
connective tissue. With atrophy of muscle, the appearance
is overall more echogenic because of the decreased muscle
mass and increased percentage of connective tissue. At the
distal end of the muscle, the intramuscular septa join to form
an aponeuroses and then develop into tendon. Tendons are
made up of longitudinal fibers that are echogenic and insert
usually into bone, allowing the muscle, when contracted, to
effect the appropriate response. In most instances, tendons
glide within a sheath that is lined with tenosynovium.2 Near
the insertion, many of the synovial covered tendons are
bound down, and less motion occurs within the sheath at
that site. When injured, an increase in synovial fluid around
these tendons occurs (tenosynovitis) (Figures 4-1 and 4-2).
This is best observed in short axis. If evaluation of tenosy-
novitis is performed in long axis, directly over the tendon,
increased fluid within the tendon sheath will be visible
superior and inferior to the tendon. Scanning just adjacent
to the tendon will allow visualization of fluid alongside the
tendon, allowing a more comprehensive view in this plane. It
is always good to check abnormalities in both planes.
In contrast to synovium-lined tendon sheaths, sur-
rounding the Achilles tendon (Figures 4-3 and 4-4) there
is a paratenon,3 which does not have a synovial lining. A
MCGH353-Ch04_p23-38.indd 23
41
Scan to view video
from chapter or go to
www.FootAnkleUS.com
pathological Achilles tendon therefore cannot develop a
tenosynovitis; instead, paratendinitis4 occurs. The fluid in
a tenosynovitis is maintained within the sheath, in contrast
to the diffuse swelling in a paratendinitis (Figure 4-5). In
addition, the paratenon is not as efficient in allowing the
tendon to glide. Motion necessary for ankle dorsiflexion and
plantar flexion involves movement through tissue planes
and muscular layers. Also, when the paratenon becomes
thickened and diseased, this further compromises gliding
of the Achilles tendon.
In evaluating tendons, diagnostic ultrasound has distinct
advantages over magnetic resonance imaging (MRI). The
sonographer can examine every aspect of a given tendon at
every level both in long and short axes. One can also quan-
tify the amount of pathology at a given level. Because of the
dynamic capabilities of diagnostic ultrasound, this imaging
modality allows visualization of restricted or unrestricted
motion within a tendon sheath. When the tendon becomes
diseased, a long-axis view clearly demonstrates thickening
or fusiform change in shape along with increased distance
between fibers and fiber fragmentation (Figures 4-6 and
4-7). This leads to a hypoechoic appearance of the tendon
within the pathologic region. The short-axis view is com-
plementary, allowing observation of isolated areas of fiber
damage at a specific location. A quantitative estimate of
the extent of damage of a tendon at a specific level can be
made in this axis as well. This information can become very
important with interventional applications.
POWER DOPPLER
Power Doppler allows the clinician to obtain a more com-
prehensive understanding of the pathology in tendon dis-
ease. The chronic and inflamed tendons can be identified,
giving the information necessary to obtain a more accurate
7/25/15 4:13 PM
 24 CHAPTER 4

A
A

B B

C C

Figure 4-1 Long axis of the peroneal tendon. (A) Transducer Figure 4-2 Short-axis image taken at the peroneal tubercle.
placement. (B) Corresponding ultrasound image. (C) Distal (A) Transducer placement. (B) Corresponding ultrasound image.
to the fibular malleolus (A), the arrow is pointing to the (C) The peroneus brevis is visible (B) showing altered fiber signal
synovitis (B). and tenosynovitis (A). Peroneal tubercle is indicated by (C).

MCGH353-Ch04_p23-38.indd 24 7/25/15 4:13 PM

 MUSCLES AND TENDONS 25

A
A

B
B

C
Figure 4-3 Normal Achilles tendon long axis. (A) Transducer
placement. (B) Corresponding ultrasound image. (C) Notice the
homogenous fiber signal (A), flexor hallucis longus muscle (B),
and tibia (C).
C
Figure 4-4 Normal Achilles tendon short axis. (A) Transducer
placement. (B) Corresponding ultrasound image. (C) Achilles
tendon indicated by (A).

MCGH353-Ch04_p23-38.indd 25 7/25/15 4:13 PM

 26 CHAPTER 4

A
A

B
B

C
Figure 4-5 Retro-Achilles paratendinitis. (A) Transducer
placement. (B) Corresponding ultrasound image. (C) Achilles
tendon (A), calcaneus (B), paratendinitis (C).
C
Figure 4-6 Long axis of the Achilles tendon demonstrating
severe tendinopathy. (A) Transducer placement. (B) Corresponding
ultrasound image. (C) Tendinopathy indicated by (A) and less
damaged fibers by (B). Note the fusiform shape of this tendon.

MCGH353-Ch04_p23-38.indd 26 7/25/15 4:13 PM

 MUSCLES AND TENDONS 27

treatment plan. This technology and its benefits are covered

in greater detail in Chapter 10, Neovascularization.

ANISOTROPY
As mentioned previously, tendons are most affected by
anisotropy. This can be deceptive and useful. When the
tendon loses its parallel relationship with the probe, the
tendon will be visualized as being deeply hypoechoic. This
hypoechoic appearance can be confused with pathology
(Figure 4-8). This is apparent at the insertion of the Achilles
tendon and plantar fascia as their fibers curve as they insert
into the calcaneus. In order to detect this artifact, adjusting
the angle of the probe will allow the sonographer to position
the probe parallel to the tendon, thus more accurately visu-
alizing these fibers as they insert into the calcaneus. Con-
versely, in short axis, when the tendon is isoechoic to the
adjacent soft tissue structures, it may be difficult to visualize
the perimeters of a tendon. By angling the probe and creat-
ing an anisotropic effect, the tendon becomes hypoechoic,
A thus making it easier to distinguish the periphery of the ten-
don relative to the surrounding tissue. Once identified, the
angle of incidence of the probe relative to the tendon can be
restored to 90°, allowing proper evaluation of the tendon
fibers at that level (Figures 4-9 and 4-10).

TENDON SCANNING
When examining a tendon from the musculotendinous
junction to the insertion in long or short axis, it is neces-
sary to adjust the angle and direction of the probe to accom-
modate changes the tendon takes within its path. Tendons
may twist, change direction, and dive deep. Therefore, as
the probe is progressed, it may be necessary to readjust
the angle and direction of the probe frequently in order to
B obtain a 90° relationship of the probe to the structure. In
addition, it is mandatory that the sonographer attempt to
obtain the best (closest to normal) image in order to avoid
creating the appearance of disease that is not present. When
trying to locate a tendon in a difficult location (e.g., flexor
hallucis longus at the master knot of Henry), it would be
best to start posterior to the ankle or at the first metatar-
sal phalangeal joint where this tendon is easily located, and
then proceed either distally or proximally to the location of
interest. When learning musculoskeletal ultrasound, it is a
good exercise to scan a tendon from the musculotendinous
junction to insertion both in long and short axes. The pero-
neus longus tendon is the most difficult, because of its deep
plantar course.

C MALLEOLAR FRACTURES
With ankle fractures, both medial and lateral secondary
Figure 4-7 Short axis of the Achilles tendon demonstrating
tendinopathy with the altered fiber signal. (A) Transducer tendon involvement can be posttraumatic sequelae. The
placement. (B) Corresponding ultrasound image. (C) The posterior peroneals and posterior tibial tendons normally glide along
aspect of the Achilles tendon (most superficial) shows minimal a fibrocartilaginous surface. If a fibular or medial malleolar
fibrous content (A), less damaged Achilles (C), and edge artifact (B). fracture occurs, these surfaces can be altered, creating an

MCGH353-Ch04_p23-38.indd 27 7/25/15 4:13 PM

 28 CHAPTER 4
C
Figure 4-8 Anisotropy. (A) Transducer placement.
(B) Corresponding ultrasound image. (C) Note that the fibers
of the Achilles tendon (A) as they curve into the calcaneus
(C) are hypoechoic, demonstrating anisotropy. In addition, a
retrocalcaneal bursa is also visualized (B).
MCGH353-Ch04_p23-38.indd 28
C
Figure 4-9 (A, B, C) The peroneals, short axis (B) at the styloid
process of the fibula (A) with the angle of incidence at 90°,
showing how difficult it is to visualize the margins of these
tendons.
7/25/15 4:13 PM
 MUSCLES AND TENDONS 29

Figure 4-10 (A, B) By altering the angle of the probe in

Figure 4-9 and creating an anisotropic effect, this allows easier
observation of the peroneal tendon’s margins.
B

irregularity (Figure 4-11), which can affect efficient gliding

of the respective tendons and subsequent trauma to those
respective tendons. Accordingly, when evaluating a tendi-
nopathy after an ankle fracture, observing the osseous sur-
face that the tendon glides on is very important.

TENDON STRESS
High-stress tendons are most subject to pathological changes
(i.e., Achilles,5–7 posterior tibial,8 and peroneals). Calcifica-
tion can commonly occur at the insertion of the Achilles
tendon (Figures 4-12 and 4-13) and, to a lesser degree, the
posterior tibial tendon insertion onto the navicular. As the
posterior tibial tendon inserts onto the navicular, it also
extends into the lesser tarsus, augmenting the plantar liga-
C
mentous structures and diffusing the stress at the navicular.
Just proximal to the head of the talus, the posterior tibial
Figure 4-11 (A, B, C) Postmedial malleolar fracture creating
has noticeable fluid within the sheath (Figure 4-14). This is
irregular surface (A) for the posterior tibial tendon (color overlay
a normal finding and should not be confused with inflam- B), adjacent degenerative changes (C).
mation. The extensors are less common as they function
mostly during the swing phase of gait and are not subject to
as much tension. However, the anterior tibial and to a lesser

MCGH353-Ch04_p23-38.indd 29 7/25/15 4:13 PM

 30 CHAPTER 4

A B C

Figure 4-12 (A, B, C) Short-axis view of the Achilles tendon just proximal to the insertion into the calcaneus (B), revealing areas of
calcification (A) with their acoustic artifact, and degenerative changes within the Achilles tendon (C).

A C

Figure 4-13 (A, B, C) Long-axis view of the posterior aspect of the calcaneus (C) revealing a retrocalcaneal spur (D)
and calcification of the Achilles tendon (B); most proximal aspect of the Achilles tendon in this scan is (A).

MCGH353-Ch04_p23-38.indd 30 7/25/15 4:13 PM

Another random document with
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 The Indian nodded, smiling vacuously, and the bottle went around
the table, each man helping himself. When it came back to its owner
he rose with it, and crossed to the door, going out into the street. The
men at the table looked at one another with a grin and one of them
examined the hand of cards that the Indian had left behind him. He
had just laid it down again when the Papago came back, and the
game was resumed.
“Wouldn’t that rattle your slats now?” Sandy Larch asked,
disgustedly.
“Joe,” he continued, “don’t dast drink even his own lickker in here.
It’s agin the law for an Indian; an’ Jim Bracton wouldn’t stand fer ’t;
he goes outside to take a drink, while them buzzards swills it in here,
right before him; an’ they’re gittin’ his wad, too.”
Gard made no reply. He had more than once glanced at the group,
while he and the foreman were talking, and now he watched them
interestedly, an intent look in his deep eyes. A moment later he had
turned, and was moving toward the players.
“Thinkin’ o’ sittin’ in?” Sandy Larch asked, jestingly. “They’s sure
need of an honest-notioned man to deal them cards. But it’d be
ticklish business.... Good Lord!”
He was staring in earnest, now, and instinctively reached for the
gun in his back-pocket, though he did not draw it. The stranger had
approached the poker-players, and stood over them, his big, empty
hands outspread upon the table before them.
The men whom he had interrupted looked up in surprise. The
prospectors who had been discussing the Peg-leg suddenly became
silent. The dominoe-players ceased the rattle of their game and
stared. A hush was upon the whole room, a tense feeling of pending
excitement. One or two men instinctively measured their own
distance from the door, and from the center of coming activities. Jim
Bracton stared open-mouthed from behind his bar.
“Who is the feller?” he demanded. “Friend o’ yourn, Larch?”
“Not that I knows,” was the foreman’s reply. “I never saw him
before, but I’m sure willin’ to sit in to any game where he holds a
hand.”
He started forward, ready to draw on the instant, but the stranger
seemed not to see him. He had gathered the eyes of the poker-players
in his own indignant gaze, and now addressed them collectively:
“Gentlemen,” he said, quietly, “you ought not to be doing this.”
“Glory be!” groaned Sandy Larch under his breath, “now wha’ d’
you think o’ that fer a simple speech?”
The astounded men to whom Gard spoke sat silent, not one of
them making a move. They were held spell-bound by the gentle
quality of his fearlessness.
“Somebody ’s been breaking the law, and selling this Indian
whiskey,” Gard went on, in a matter-of-fact tone. “It was a mighty
bad thing to do, and you are doing something a heap wickeder. He is
drunk now, and he doesn’t rightly sense what he’s doing. You ought
not to play cards with him. You’re drinking his liquor and helping
him to get drunker; and—you’re cheating him, out of his money.”
The big wheel-of-fortune had ceased to whirr now, and the silence
of the room was broken only by a snarling question from one of the
men Gard had addressed.
“What in hell o’ your business is it?”
“It’s every man’s business when another man breaks the law,” was
the quiet reply. “You’d better quit playing now, friend,” Gard
continued, turning to the Papago. “You’d better quit right off, while
you’ve got something left, and go home.”
“You stay where you be, Joe,” growled the man who had asked the
question. “Don’t you climb out fer no tenderfoot. I’ll settle the—”
He stopped speaking as the stranger’s eyes blazed full upon him
for an instant.
“You go now, Joe,” Gard said, in a low, even voice.
Like a man in a dream old Joe rose, slipping into his pocket the
coins he had been about to put into the game when Gard interfered.
The tenseness of the situation had brought him to some measure of
sobriety, and he did not reel as he left the room. A moment later the
patter of his pony’s unshod feet came to the listening ears within.
Gard still held the other men in a gaze that seemed to search and
estimate the hidden thought of each.
“Now they’ll kill him, sure,” Sandy Larch thought, slipping nearer,
but the stranger took no notice of him.
 “Friends,” he said, breaking at last the tense silence that ruled the
room, “There’s a law against making an Indian drunk, and there’s a
law against robbing him. They’re white men’s laws; and white men
ought to keep ’em.”
“It ain’t right”; he went on, still leaning upon the table, and the
men listened, as if hypnotized. “There’s things a man can’t do
without getting lower down than any man wants to be, and cheating
a drunken Indian is one of ’em. That’s the truth of it. You ought not
to do it, and when you do somebody’s got to make you stop. That’s
why I interfered.... There ain’t any reason though,” he added, as if an
after thought, “why you shouldn’t go on with your game, now; I’m
going to say good-night.”
He straightened up, and turning his back upon the group walked
quietly toward the door. Half-a-dozen men were ready, now, to draw
in his defense, but there was no need. Not a man of those whom he
had brought to book moved. They sat like men dazed, until the door
had closed upon Gard; then, with an oath, one of them seized upon
the cards.
“What th’ Almighty ’s the matter with you fools?” he growled.
“Whose deal is it, anyhow? Git int’ the game, you. This ain’t no
damned kindergarten!”
They resumed their playing, sullenly, and the spell upon the room
was broken. Sandy Larch wiped his damp forehead upon a huge red
handkerchief, and turned to the bar.
“Jim,” he said, feebly, “set down that there bottle o’ whiskey, will
ye? I sure need it in my business right now.”
He measured a liberal potion and swallowed it.
“An’ he said he wa’nt no sin-buster,” he muttered. “He sure was on
the job, though.”
“But wa’nt that a sweet line o’ talk to hand out to men folks, Jim?
How’d it come they didn’t kill ’im?”
“Search me,” was the barkeeper’s reply. “I had my gun all
limbered. I sure expected the place ’d be shot up.”
“He tells ’em it wasn’t right,” Sandy mused, absently refilling his
glass. “He tells them b-a-a-d men ’twasn’t right! An’ there they sits,
like they was throwed an’ hog-tied, while he turns ’round his back to
’em an’ walks out like they ain’t a thing on earth to be afraid of. Lord!
He can have me!”
He drained his glass and departed, leaving the Happy Family to its
own devices.
Gard, meantime, had walked out beyond the town to the open
desert. His spirit was full of trouble, hot with indignation at what he
had seen, oppressed with a sense of the complexity of the life into
which he was so suddenly plunged. It was hard to realize that the
still, bright stars above him were shining, as well, upon the clean
peace that dwelt in the glade. His thoughts turned thither like
homing birds, and he walked on across the cactus-dotted sands, until
he could look toward the shadowy bulk of the far mountains, visible
in the marvelous desert starlight. Somewhere in that direction, he
knew, the glade lay, and gradually a feeling came to him of quiet, and
of renewing strength. He was able to think calmly of the sudden
complication in his plans, and to consider the best course to pursue.
He would see Morgan Anderson as soon as possible. In the
meantime Mrs. Hallard would write to Westcott. He would probably
be obliged to talk with the lawyer for her: the mere thought set his
nerves tense; until this matter was settled his own affairs must wait.
Of this there was no question in his mind as he directed his steps in a
wide circuit back to the town.
He was nearing its outskirts when he felt a light touch upon his
arm. One of his hands was seized in two small, clinging ones, and
covered with soft, hot kisses. He turned quickly, freeing himself with
a little shake, and looked into the upturned face of ’Chita, the dancer.
The bright stars lighted her face to a mystic, witching glow; her
eyes gleamed upon him in soft summons as she leaned toward him,
seeking again to possess herself of his hand.
He drew back, ever so little, and seeing this she stretched both
arms out to him in a wide, pleading gesture, her smiling lips parted
in mute supplement to the invitation of her gleaming eyes.
Still as a graven man he stood, regarding her steadily, and she
came no nearer. Instead, she shrank a little, her hands dropping to
her sides, her dark eyes fastened upon his. Gard’s stern eyes softened
and he came a step closer, brooding over the trembling girl without
touching her.
 “Child,” he said, “haven’t you any mother? Isn’t there anybody to
take care of you?”
Only her heaving shoulders answered him.
“Don’t cry,” Gard said, his voice full of pity. “I—I don’t like to hear
little girls cry.”
She shivered toward him again, and reaching quickly, her arm
stole round his neck, the other hand seeking his face. “I love you,”
she whispered. Her fingers pressed his lips, and he put her back,
firmly.
“Don’t,” he said sharply. “You don’t understand. Why—you’re only
a little girl. Where is your home, child? I am going to take you there.”
She sprang back with a cry, and her anger flashed out upon him.
“Oh!” she stamped one foot upon the sand. “Do I not understand?
Think you I do not? You miserable! You have never the heart of a
caballero. You are but hombre, after all!”
She caught her breath.
“Gringo swine!” she hissed. “Hombre! It is not the heart of a
caballero!”
“I haven’t got the heart to crush little girls,” he answered, “if that’s
what you mean. Tell me where you live. I’m going to take you home.
You must not be out here alone.”
He spoke now with protecting concern. The girl’s mood had
changed again, and she was sobbing passionately.
“Do you live in the town?” Gard persisted, and she shook her head.
Half unconsciously she was walking beside him as he moved
forward.
“Hush!” she suddenly cried, checking her sobs.
Across the desert came the sound of a man’s voice, calling angrily.
’Chita put out a hand, arresting Gard’s steps.
“It is my father,” she whispered. “He is blind; but he has ears of the
coyote. If he hears you—if he knows—he will beat me!”
She was but a child, now, in her terror, and Gard reassured her.
“He’ll never know,” he said. “No one will ever know. You go back,
now, like a good girl. And remember: you must never do a silly thing
like this again. Will you promise me?”
 She lifted a pale face toward his, in the starlight. Her eyes were
luminous, now, with new, strange emotion.
“Señor,” she whispered, “it is the heart of a caballero. Señor—you
are good.”
“You will promise?” Gard persisted.
Again that summoning voice rang across the desert. The girl called
in Spanish that she was coming.
“I promise,” she cried, with a sobbing catch of the breath. “Buenos
noches, Señor.”
She caught Gard’s hand again, for an instant, resting her cheek
against it, the fraction of a second.
“Buenos noches,” she whispered again, and sped away into the
soft, starry gloom.
 CHAPTER III

The desert was a marvel of mauve and yellow and rose-color, under a
canopy of blue. The sun was not too hot, and the air was vital and
sustaining. Helen Anderson, riding over the hard plain, sniffed it
joyously. She loved the smell of the desert, that intangible,
indescribable odor that is yet so permeating: one of the fixed facts of
the region. She had missed it, hungrily, during four years of exile
from the Palo Verde.
She lifted her eyes to the sapphire-blue mountains on the horizon
and laughed aloud for sheer joy, with a sense of physical well-being,
as her vision ranged from these to nearer scenes. She was passing a
Papago’s hut, a tiny structure of cream-colored adobe, with a dark
roof of thatch. The hut itself was hardly larger than its own big
chimney, and squatted on the yellow sand, in its little patch of shade,
was an Indian woman.
She wore a skirt of dark blue stuff, and a white reboso was wound
about the upper part of her body and carried over her dark hair. Her
dusky arms were bare, and her brown hands patted and shaped and
smoothed a pot of red clay, soon to be baked in the little kiln where a
fire was already glowing.
Helen called a gay greeting to her and she looked up, showing her
white teeth in a broad smile. Then she paused in her deft handling of
the wet, red clay, to flip a bit gently at the inquisitive nose of Patsy,
Helen’s fox terrier, who was minded to investigate the pottery
operations. Helen called the dog and lifted her pony to a gallop. So
the three went scampering off in a wild race over the level sand. A
mile was measured before the girl drew rein again, with a blissful
sigh of pure happiness.
“And to think,” she told herself, with a little feeling of unreality
about it all, “that back in New England there is snow on the ground,
and fire in the furnaces, and people who must be out of doors are
thumping their arms, to keep warm, and telling one another what a
glorious, bracing climate they have.”
She fell into a brown study and her reins lay loose upon the pony’s
neck while she went back over the four happy years she had spent in
the land of snow. How strange it seemed that so short a while ago the
east, New England, even college itself, had been to her mere names.
Then, for four years, they had been such happy entities. What a
beautiful memory her whole college life was!
“And now,” she mused, “it seems as if it were all fading back into
the dream again, yet I know things are as real, back there, as they
ever were, and the real me, that Radcliffe helped make, is here in a
real place, with the realest sort of things to do.
“For one thing,” she said, half aloud, “I can keep right on making
Father glad I’m home for good, and showing him that he need not
worry about me.”
That thought checked a growing wistfulness in her mood. Morgan
Anderson was glad to have his girl back, even though he had his
well-defined doubts as to the desert being the best place for her. Her
college years had been weary years to the lonely man, and his
happiness in the new order was a beautiful part of Helen’s home-
coming.
The girl could scarcely remember her mother. There had always
been Jacinta, her half-Spanish nurse, now the household factotum,
in the background of her childish years. In the foreground was the
well-loved figure of her father, who had been her friend and constant
companion. It was he who had taught her to read and to write, and to
do plane and solid geometry: to ride hard, to shoot straight, and to
tell the truth. Beyond these her education, other than what old
Jacinta could impart, had been received at the hands of one of the
cowboys on the range, a college graduate with a love for the plains.
Aunt Everett had been horrified at this arrangement. Aunt Everett
was her father’s relative, who, on two formidable occasions, had
descended upon the rancho and undertaken to revolutionize the
household. This she did out of a sense of duty to Helen, who, she
declared, was growing up in sheer savagery and ignorance.
Helen was twenty years old when Aunt Everett paid her second,
and last, visit. It was then the momentous decision was reached that
the girl should go to college. It was for the sake of his own youthful
dream of Harvard, that had never come true, that Morgan Anderson
had fixed upon Radcliffe, and Helen’s four beautiful years had
become a fact.
 She sighed again, recalling those years.
“They were so lovely,” she murmured, “and they have sent me back
—how is it old Marcus Aurelius phrased it?—‘free from all discontent
with that to which thou returnest.’
“Free from discontent?” she cried, taking in another deep, long
breath of the buoyant air, “I should say I am! I was never in my life
so aboundingly happy!”
The pony was walking slowly, and as Helen looked about she
became aware that Patsy was not in attendance upon them.
She halted, anxiously, the dog was a recent acquisition, given her
by Sandy Larch, on her return from college, she was training him to
keep with her. This was the first time she had really forgotten him.
She reproached herself as she rode back over the way they had come,
for letting her wits go wool-gathering.
She called the terrier, reining in from time to time, but there was
no response, and becoming at last thoroughly alarmed, she
dismounted, dropping the pony’s reins over his head to the ground,
and started on foot to investigate among the cacti.
“He’s found a gopher-hole somewhere,” she said to herself, as she
went whistling about among the greasewood and cacti.
She ceased to whistle, presently, vexed at Patsy’s lack of response,
and continued her search in silence until, rounding a cactus-grown
knoll, strewn with loose stone, she suddenly halted, warned by a
familiar, burring sound that for an instant made her heart jump.
A few yards away from her was the terrier, rigid, immovable, the
hair along his back, even the loose skin between his shoulders, stiffly
erect. His lips were drawn back from his white teeth; his ears were
pricked forward, and his whole body shuddered with the vibration of
his low, continuous growling.
Near the dog, lying prone, his face turned toward her, Helen saw a
man, and still beyond him, alert, motionless, save for the minute
quiver of that ominous, buzzing tail, a huge rattler was coiled, its
cold, wicked little eyes fixed upon the dog.
“I must not scream; I must not faint,” the horrified girl told
herself, trying to stand steady, and to think quick.
 If the dog or the snake saw her neither made any sign. They glared,
unmoving, at each other, across the helpless man. Neither dared
attack, or retreat, and Helen knew that any move on either her part
or the man’s, would cause the snake to strike—the dog to spring.
The man lay exactly in the storm-center, when trouble should
come, and it seemed as though neither dog nor snake could much
longer maintain the horrid statu quo. Patsy’s low growling was
dreadful to hear, and the snake’s steady rattle brought the sweat of
sheer fright to her forehead.
She glanced again at the man and his gaze met hers steadily. It was
clear that he was alive to the full peril of his position, yet there was
no sign of agitation in his face. Rather, his glance seemed meant to
reassure her. Shamed by her own fears, Helen summoned her
faculties to meet the situation.
She had grown up in the desert. She had known rattlesnakes
before ever she went to college, and her four years of sophistication
had not crowded out that earlier knowledge. Her brain seemed
suddenly to clear, her nerves to harden. She knew what could be
done, if she could but trust Patsy to hold steady. She remembered
Sandy Larch’s boast, that the dog was game. Now was the time to
show it, if he was.
“Steady, Patsy; steady, boy; quiet; quiet, boy!”
Over and over she whispered the words, oh, so gently, that she
might not startle the young dog, and all the while she was slowly,
slowly, raising her right hand, in which was her riding-whip. She was
too thorough a plainswoman to use such a thing on a horse, but she
carried it to use in training the terrier.
“Steady, Patsy; down, boy; down!”
The whip was extended in front of her, now, and she was moving it
gently from side to side. The snake had caught sight of it, and was
following it with its eyes, swaying in unison with the whip’s motion.
Never staying the steady movement of her arm, Helen crept
forward, whispering reassurance to the dog, until at last, still waving
the whip, she dropped to one knee and slipped her fingers under his
collar. He stopped his growling and nestled to her with a little
whimper. When she commanded him to charge he dropped to his
belly and lay perfectly still, his eyes fixed upon the snake.
 “If you can manage to turn the thing’s head a bit, little girl;—” it
was the man who spoke, in a low, level voice—“so he can’t notice
what I’m doing, I’ll fix him.”
With a little nod, Helen stood up and began moving sidewise, still
swinging the whip. Thoroughly hypnotized, the snake swayed with its
movement, those beady little eyes never leaving it. The rattler did not
see the stealthy glide of the man’s hand, or the gleaming steel that
was presently leveled at that flat, venomous head. An instant after
there was a sharp report, and the snake was whipping the desert in
its death struggle as Helen again caught the terrier by the collar. The
man essayed to rise, and sank back with a sharp exclamation of pain.
“I guess I’ve hurt my foot,” he said, answering Helen’s look of
inquiry.
“I—my horse took to pitching, and slung me here,” he went on,
sitting up. “I can’t think what got the fellow, or me either,” he added,
with a look of chagrin. “I never thought I needed a bucking-strap; but
it seems as if I did.”
He spoke lightly, partly to hearten the girl, who was white and
shaken, after her horrid experience, and partly to draw her attention
from the victim of his shot, now stretched on the desert.
Another effort and he got to his feet; but the first attempt to step
brought him to one knee, frowning with pain.
“And I don’t suppose there’s a stick in sight, that would give me
any support,” he said, looking about.
“I’m afraid not,” Helen answered, following his glance; and then
she remembered.
“I can bring up my horse,” she cried. “I left him by the mesquite
when I dismounted to look for Patsy, here.”
“Patsy’s sure an enterprising little dog,” the man said, smiling, “I
don’t just know whether I have to thank him for stirring up the little
difficulty a while ago, or for keeping it from being worse before you
came.”
“I’m afraid it was he that roused the rattler,” replied Helen,
ruefully. “He is young, yet, and has his sense to get.”
The man laughed. “I was a little stunned when my horse landed me
here,” he explained, shyly. “First thing I knew I was sort of waking-
up, and that was the tableau I beheld. I didn’t do much that was
strenuous, from then on.”
Helen was wondering, curiously, who the man could be. He was
evidently not a cowboy, or a prospector, and she knew that if he were
a cattleman or a mining expert, a stranger in that part of the country,
he would naturally have been the hacienda’s guest. Such visitors in
the neighborhood were always for her father. Perhaps he was on his
way to him, now.
“Were you going to the Palo Verde?” she asked, impulsively. “I am
Helen Anderson. Father will be sorry you have had an accident.”
“I thought you must belong there,” he said, simply, “and I was
going to tell you my name. It’s Gard—not a very long one,” with a
smile, “and I was going to the Palo Verde, though your father doesn’t
know me. I wanted to see him on business.”
“Then the best thing we can do,” Helen said, briskly, “is to get
there at once. I’m going to ask you to keep Master Patsy here, while I
go for the horse.”
She was already speeding down the knoll, and a moment later she
returned leading Dickens, the pony, who had stood patiently where
she left him.
For a time it looked as though the stranger was not going to get
into the saddle. Dickens was restless and nervous over his awkward
approaches, and the pain in Gard’s foot was excruciating, but after
many agonized attempts he finally mounted. He was white and faint,
after the effort, but he smiled resolutely down upon the girl while he
adjusted the stirrup he could use.
“I am glad you ride this way,” he said, indicating her military tree.
“I thought I’d have to sit in one of those queer dishes ladies usually
ride on.”
Helen laughed. “If I waited to have horses gentled to the side-
saddle,” she answered, “I should never get anything to ride. It’s the
only way, here in the desert, and Father always thought it was the
safer way.”
She was walking beside the pony, her broad-brimmed felt hat
pushed back, that she might look up at her guest. “I used a side-
saddle back east,” she added.
 “I think this way is a lot better,” Gard replied. He wished she
would look up again. It seemed to him that his eyes had never beheld
anything more delicious than her upturned face, with its background
of broad hat-brim.
He could only glimpse it when she looked straight ahead, as she
was doing now. Her nose had a little tilt, that made him think her
always just about to look up, and kept him in a pleasant state of
expectation. He could not see her mouth and chin without leaning
forward, and he shrank, shyly, from doing that, but he studied the
firm brown cheek, where just a touch of deep color came and went,
and the neat sweep of fair hair back into the shadow of the broad hat,
and he had noted when she looked up that her eyes were gray,
looking out friendly-wise under level brows.
“You were a mighty plucky little girl to tackle that rattler,” he said,
with a sudden realization of her courage. Her short riding-habit
misled him and he did not think of her as grown up.
Helen stiffened, resentful of what seemed like a too familiar
address. Then she recognized his mistake, with a curious little sense
of pleasure in it.
“That was nothing,” she answered, with a lighthearted laugh,
“Sandy Larch taught me the trick. I played that way with more than
one rattler when”—“when I was a child,” she had been about to say,
but she changed it, and added, “before I went away to school.” “No
use dragging in ‘college’” she told herself. “He might think I was
trying to seem important.”
“I know Sandy Larch,” Gard said. “He’s a good man.”
“So are you,” was the thought that flashed through the girl’s mind
as she glanced upward again. She dismissed it instantly, with a
feeling of astonishment at herself. She was not given to speculate in
such wise on the quality of chance acquaintances.
“Sandy’s just Sandy,” she replied. “One of the best friends I ever
had. I can’t remember the time when he wasn’t on hand looking after
me.”
There was silence for a while, till Gard spoke again.
“I hate to make you walk,” he apologized, “You’ll be all tuckered
out.”
 “Not a bit,” she declared, stoutly. “You must be new to the desert,
if you don’t know what miles people can walk here, without getting
tired.”
The bronze of his face was tinged with a faint red.
“No,” said he, “I ain’t new to the desert. Not much I ain’t new; even
—” with a mortified laugh—“if I did let my bronco throw me. I guess,
though, I’m new to little girls,” he continued. “Seem’s if you ought to
be tired. You don’t look so very big.”
“I’m strong, though.” Somehow, his assumption that she was a
little girl gave Helen a pleasant sense of ease in his company. She
glanced up at him again, and was startled to see how pale he had
grown, under his tan. His forehead was knit with pain, and his teeth
were set against one lip.
“I wish I could do something for you!” she cried, in quick
sympathy. “But we’re nearly there; and Father’s as good as a doctor,
any day.”
“It’s all right,” he muttered. “I was just a fool. I thought I’d see if I
couldn’t get down and walk; so I tried putting that foot in the
stirrup.”
“That was a clever thing to do,” Helen scolded, “I see you do not
know how to believe people when they say they are not tired.”
She quickened her pace, that he might see how far she was from
weariness.
“I’m sorry,” he said, humbly. “I didn’t mean to do anything to set
you running off like that.”
No reply. They went on again in a silence that lasted for several
moments.
“Ain’t you going to forgive me?” he asked, presently.
Helen considered; not what he had said however. She was more
deeply interested in deciding why his “ain’t” was not offensive to her
college-bred ears.
“After all,” she thought, deliberating it, “those things do not matter
so much when people themselves are real.”
“I won’t do it again,” the voice beside her pleaded, in an
exaggeration of penitence, and she laughed, looking up at him.
 “I didn’t think you’d be such a hard-hearted little girl,” Gard said,
reproachfully.
“I am not,” she replied. “I am only sensible. You should believe
what people tell you.”
He made no reply. He was trying to decide how old the child could
be.
“I guess,” he thought, with an effort to recall little girls he had seen
—ah, how long ago it was that he had seen any!—“she’s most likely
about twelve. She’ll be mighty pretty when she grows up.”
His foot still hurt, cruelly, in consequence of his rash experiment,
but fortunately they were at the rancho. A few moments later they
had reached the casa, where Morgan Anderson took charge of his
guest with skilful good-will. Like all cattlemen, he was fairly expert at
attending to hurts; could set a bone, on a pinch, and it did not take
him long to discover that one of the small bones of Gard’s foot was
dislocated. With Sandy Larch’s aid he set the matter to rights, and
bandaged the foot in a way that would have done credit to
professional skill.
He would not hear of his patient’s riding back to Sylvania that day.
“Not a bit of it!” he cried, when Gard proposed it. “That’s going to
be one unmercifully sore foot by to-morrow; and suppose—”
He checked himself before voicing the suggestion that another
accident might possibly put the foot badly out of commission. He had
the plainsman’s idea that a horseman should stay with his mount; so
he merely said that he wanted to keep an eye on the foot.
“You can’t be sure one of the little bones may not be broken,” he
explained, “and anyway, we’re mighty glad to see folks here; so I
guess we’ll have to keep you.” And Gard, more willing than at the
moment he realized, accepted the invitation.
It was Manuel Gordo who, riding in from the upper range, saw the
stranger’s horse, lathered and excited, wandering afield, and threw a
rope over him. When he got the bronco to the Palo Verde corrals and
took off the saddle, he gave a low, comprehending whistle. Under the
blanket, well back, but yet where a rider’s weight would press, was a
bit of cholla, the vicious fish-hook cactus of the desert, so disposed as
to cause the horse exquisite pain.
 Manuel swore a rolling Mexican oath as the thing caught his
fingers, and stamped it into the desert before giving attention to the
bronco’s back. This, later, he showed to Sandy Larch, with a vivid
explanation.
“The blame cowards!” the foreman commented. “So they thought
they’d git ’im that way, did they? It seemed mighty queer to me that
he couldn’t sit anything four-legged he was likely to git in the
ord’nary run, in Sylvania; but that pinto must ’a’ raged considerable
with that on its back.”
“Who you think do-a that?” Manuel asked, and the foreman told
him of the scene in the Happy Family Saloon. “Some o’ that gang’s
been tryin’ to get even,” he finished, and Manuel growled assent.
“I—I see that señor before to-day,” he ventured, hesitating, “He
one good man.”
“Where ’d you ever meet up with ’im?” demanded Sandy. “Where
’d he come from?”
“Quién sabe?” Manuel’s shoulders lifted. “It is at Sylvania I see
heem,” he added, non-committally, and understanding dawned upon
the foreman.
“You did, eh?” he laughed, “An’ he got after you an’ made you quit
that spree you was headed on, I bet. That what you come home so
quick for? How’d he round you up?”
The Mexican grinned, shamefacedly, and Sandy laughed again.
“He’s sure a sin-buster,” he commented, admiringly, “But he done
you a good turn that time, Manuel. The patron’d given me orders to
everlastingly fire you next time you showed up after a spree, an’ I’d
’a’ sure done it if you hadn’t ’a’ been on hand that mornin’ same ’s
usual!”
Manuel was busy smearing axle-grease on the bronco’s back, to
keep the flies from its hurts.
“The señor, he good man all right,” he said, not turning around,
and Sandy Larch, being shrewd, walked away without further
comment.
 CHAPTER IV

As Morgan Anderson had predicted, the condition of Gard’s foot next

day was such as to make him a captive. The cattleman, surveying it
after Jacinta had given the patient his breakfast, prescribed rest, and
forbade any thought of leaving the rancho inside of a week.
“You say you came to see me on business,” he said, as he stood
looking down upon Gard where he lay in bed in a big, low-ceiled
room of the casa, “Well, I’m off to the upper range to-day, to pick out
some work-cattle. I shall not be able to talk business till night; so that
settles to-day.”
“You’re mighty good,” was Gard’s reply, “but that business o’ mine
is only to ask you a question that you can answer in half a minute.
You mustn’t think it’s some matter of consequence—to anybody but
me, that is,” he added.
“All right; so much the better. It’ll keep, and we can keep you.”
Morgan Anderson had taken a liking to his unexpected guest, and
made him welcome with true western hospitality. It was long since
Gard had talked with a man of his stamp, and the mere sound of
Anderson’s pleasant, easy voice was a joy to him. It was good just to
lie there and listen; at the same time, he was concerned about his
foot. He wanted to be up and about Kate Hallard’s business. He had
not calculated that the delivery of the deed which he had found in
Arnold’s coat-pocket two years before, would involve him as it had
done.
He had come back to civilization with a strong purpose. He meant
to make every effort to reinstate himself in the eyes of the law, and he
realized that he must do all that he could before some chance
recognition should work to hinder his efforts. Nevertheless, he told
himself, the claim of this woman came first. Kate Hallard had no one
to fend for her, and the responsibility, in this particular matter, had
been laid on him, Gabriel Gard.
Later in the forenoon, when Anderson had ridden away with his
men, Wing Chang, the Chinese cook, acting upon the patron’s
instructions, established Gard in a long steamer-chair, under the
cottonwoods beside the casa. Hither, when he was settled, came
Helen, bearing a little tray on which were biscuits and a grape-fruit.
Gard smiled as he saw her coming around a corner of the casa, and
answered her greeting with a cheery “good-morning.”
“I wondered where you’d got to,” he began, and stopped, suddenly,
the quick color rushing to his face.
“Now I just beg your pardon, Miss,” he stammered, in piteous
confusion, “I mistook—I thought—I thought you were your little
sister.”
“I am,” laughed Helen, putting the tray on a chair by his side.
“No, no: you mustn’t move your foot”—for Gard was struggling
forward in his steamer-chair.
“If you do,” she threatened, “I shall have to scold you harder than I
did yesterday.”
He sank back, a look in his face of mingled chagrin and wonder.
Helen was arrayed in white, the simplest sort of a shirt-waist suit,
with a touch of brown at neck and belt and shoes; but to his
bewildered senses she was a radiant vision of unguessed daintiness
and beauty. There was something incredible, to him, in the idea of
this unearthly being offering him food. He glanced from her to the
tray, and back again.
“I don’t know what that is,” he said, indicating the grape-fruit,
“and I ain’t sure I know what you are. I thought yesterday you were a
little girl, and now you seem like a young lady; and I don’t seem right
sure you won’t turn into a fairy in a minute, and run away.”
“Oh, Oh!” Helen cried, “What three-fold flattery!”
Then it was her turn to experience a shock; for, as she stood
looking down upon him, it suddenly became apparent to her that this
man was young.
She had thought nothing about the matter, in the excitement of
yesterday’s encounter, and when she had walked beside him, seeing
his bearded face in her brief, upward glances, she had taken it for
granted that he was middle-aged, at least. There was something
disconcerting about the unexpected revelation of youth in those
eager brown eyes, in the clear olive of the face above the strong, short
beard, and in the firm curve of red lips just visible under the
moustache. She could think of no further retort to his pretty speech,
and busied herself with showing him how to eat the grape-fruit,
wondering, vaguely, where he could have been, in the desert, not to
have encountered pomelos.
“These are from over the border,” she explained. “One of the boys
smuggled them in last week; think how wicked we are! But by New
Year’s we shall have some of our very own.”
“They’re mighty good,” Gard said, with no idea of what the fruit
tasted like. He was still wrestling with the awesome fact that Helen
had prepared it, and was teaching him to eat it. He took more sugar
when she told him to, though years of abstinence from sugar had
blunted his taste for it, and he shook his head with very proper
commiseration when she told him of the way eastern folk spoil the
fruit in preparing it.
“I never was back there,” he said, “I was raised on the prairie; but
this is good enough for me.”
He looked beyond the fringe of cottonwoods, out across the plain,
quivering in the mid-forenoon heat.
“Don’t you like it?” he asked.
“I love it! It’s so big, and beautiful, in spite of its dreadfulness; it’s
so positive!” Helen was sitting on the ground, her hands in her lap,
her eyes turned toward the far mountains. Gard considered her
words.
“Positive:” he repeated, thoughtfully, “Yes: it’s sure that. There
ain’t any half-way place,” he added, drawing a deep breath. “A man,
he gets big, or he gets little, living in it.”
“Oh!” cried she; “you must have been a long time in the desert to
find that out!”
She went on, with youthful, unconscious arrogance: “I’ve lived
here all my life; but I never realized that until after I came back from
college this last time.”
“Have you been here long?” she added.
“I haven’t been ’round the level much,” Gard answered, and after a
pause he added:
“I’ve been in the mountains most of the time.”
“Then you must have been prospecting: I hope you struck pay
dirt?”
“I did.”
 “Good! So you are a mining-man—I wondered.”
She had wondered about him. Gard turned the thought over in his
mind, the while he told her something of his discovery in the
mountains. It seemed a marvelous thing that she should have
thought of him at all. Almost unconsciously he began telling her of
finding his claim; of working it; and of Jinny.
Helen listened with rapt interest. She knew that men did go off
into the mountains as she supposed Gard must have done. She had
talked with prospectors, in her lifetime, but never with one like this.
“I suppose you will be wonderfully rich when you begin working
your claim in earnest,” she said, at last, slowly, “Shall you like that?”
“I think so. There are some things I want a good deal”—Ah, how
much he wanted them: the right to freedom; the right to hold up his
head among men. Gard’s desire for this was increasing with every
moment that he sat talking to this fair, unconscious girl. As he looked
at her, sitting before him on the sparse grass, it came home to him
with fearful force that it would be hard to have friends if his past life
must always be a secret from them.
“I suppose there are,” Helen was saying, half wistfully, “Money
brings so many opportunities to a man.”
“Not unless he’s a real man to start with,” replied Gard.
“There’s a lot to be thought about,” he went on. “I used to think
that to give a man plenty to eat, and wear, and good things round
him; nice, beautiful things such as we read about—and I guess that
you’ve always seen,” he explained,—“would help make a better man
of him.
“I don’t believe it’s altogether so,” he went on, following a train of
thought that he had often mulled over, in the glade, “All the good
things that you can put a man into won’t make any better man of
him, if when he didn’t have ’em he wasn’t trying to make a better
man of himself.”
Helen pondered his saying in some surprise.
“I never thought of it that way before,” she said, at last, “but it
seems as if it ought to be true.”
“I guess it’s true enough,” Gard frowned a little, deep in thought.
“Jinny and I, we used to figure out ’twas, when we talked things