Artifacts at Musculoskeletal US

This manuscript was presented at the 2014 RSNA Annual Meeting as an educational
exhibit (#MKE201).
It was awarded a Certificate of Merit. The manuscript was solicited for publication in the
online-only section of RadioGraphics.
Andrea S. Klauser, MD
Corresponding Author: Department of Radiology
Medical University Innsbruck, Austria
Lana H. Gimber, MD, MPH
Clinical Instructor (Fellow), Musculoskeletal Radiology Russell S. Witte, PhD
Department of Medical Imaging Department of Medical Imaging
University of Arizona College of Medicine University of Arizona College of Medicine
Banner University Medical Center Biomedical Engineering and Optical Sciences
1501 N. Campbell Avenue, P.O. Box 245067 Banner University Medical Center
Tucson, AZ 85724
Phone: (520) 626-7402, Fax: (520) 626-1518 Hina Arif-Tiwari, MD
Email: lgimber@radiology.arizona.edu Department of Medical Imaging
University of Arizona College of Medicine
Coauthors: Banner University Medical Center

David M. Melville, MD Mihra S. Taljanovic, MD, PhD, FACR

Department of Medical Imaging Department of Medical Imaging
University of Arizona College of Medicine University of Arizona College of Medicine
Banner University Medical Center Banner University Medical Center

The authors have disclosed no relevant relationships.

Artifacts at Musculoskeletal US
 Purpose

After viewing this online presentation, the reader will be

able to recognize findings of common artifacts at
musculoskeletal ultrasonography (US) with B-mode gray-
scale and Doppler imaging that can mimic disease or
abnormality, identify several artifacts that frequently
accompany musculoskeletal pathologic conditions, and
list techniques that can help avoid or minimize these
artifacts.
 Topics Covered
• Artifacts at B-mode gray-scale imaging:
–Beam characteristics (side lobe, beam width, anisotropy)
–Velocity errors (refraction , speed displacement)
–Attenuation errors (posterior acoustic enhancement and shadowing)
–Multiple echoes (posterior reverberation, ring down, comet tail, mirror image)

• Artifacts at color Doppler imaging:

–Transducer pressure
–Motion
–Blooming
–Mirror image
–Background noise
–Aliasing
–Twinkling
 Key Concepts
• When the ultrasound beam deviates from the ideal physical assumptions, as
occurs in clinical practice, artifacts are produced.

• B-mode gray-scale artifacts arise because of beam characteristics, errors in

velocity, errors in attenuation, and multiple echoes produced by one
structure. These include side-lobe, beam-width, anisotropy, refraction, speed
displacement, posterior acoustic enhancement and shadowing, posterior
reverberation, ring-down, comet-tail, and mirror-image artifacts.

• Doppler artifacts include transducer pressure, motion, blooming, mirror

image, background noise, aliasing, and twinkling.

• It is important to recognize, minimize, and, when possible, eliminate US

artifacts that can lead to erroneous interpretation of musculoskeletal
structures.
 Learning Objectives
• Recognize US findings of common artifacts at
musculoskeletal US with B-mode gray-scale and
Doppler imaging that can be mistaken for disease or
abnormality.

• Identify several artifacts that frequently accompany

musculoskeletal pathologic conditions.

• List techniques that can help avoid or minimize

artifacts at musculoskeletal US.
 How Does US Work?
**Click to begin animation**

Ideally: Transducer
In Clinical Transducer

Practice:
Side Lobes
and Grating
Main US Beam Lobes

Scanned Object
Incorrect ultrasound beam assumptions that lead to artifacts:
• All echoes detected are from the main ultrasound beam.
• Ultrasound beam travels in a straight line.
• Attenuation of sound in tissue is uniform.
• Speed of sound is the same in all types of tissue.
• Each reflector in the body produces only one echo.
• Depth of an object is directly related to the amount of time it takes the ultrasound
echo to return to the transducer.
 Normal US Features
Cortical Bone
Normal hyperechoic phalangeal
cortical bone with posterior acoustic
shadowing
Muscle
Normal biceps femoris muscle with
hypoechoic muscle bundles separated by
fine hyperechoic fibroadipose septa
a b
Nerve
Normal common peroneal nerve with a
speckled or honeycomb cross-sectional
appearance (a) and relatively hyperechoic
longitudinal appearance (b) relative to
adjacent musculature
Tendon
Normal hyperechoic peroneus brevis
tendon with fibrillar echotexture
 Artifacts at B-mode Gray-Scale Imaging
• Beam characteristics
– Side lobe
– Beam width
– Anisotropy

• Velocity errors
– Refraction
– Speed displacement

• Attenuation errors
– Posterior acoustic enhancement, increased through transmission
– Posterior acoustic shadowing

• Multiple echoes
– Posterior reverberation, ring down, comet tail
– Mirror image
 Artifact: Side Lobe
• Side lobes are secondary ultrasound lobes
outside of the main beam with 1/100 of the
Transducer intensity of the main ultrasound beam.

Side Lobe • Side-lobe beams interact with off-axis highly

Main US Beam reflective acoustic surfaces and create echoes
that are incorrectly recorded as along the path
of the main ultrasound beam.
Scanned
Object
• Examples:
– low-level spurious echoes within cystic structures
– bright specular reflections within cystic or solid
structures
– appearance of multiple needle paths during
biopsy

• Corrective action: Can use alternate plane of

imaging to verify it is an artifact.
US Image
 Artifact: Side Lobe

Long-axis gray-scale US image at the posterior aspect of the knee shows a

Baker cyst (blue arrows). A spurious low-level echo (red arrow) is seen
within the cystic structure secondary to a side lobe outside of the main
beam interacting with a highly reflective acoustic surface (dashed line) and
recorded as if along the path of the main ultrasound beam.
 Artifact: Beam Width
• Main ultrasound beam narrows at the focal
zone before widening distally.
Transducer

• Beam-width artifact occurs when the

ultrasound beam is too wide with respect to
the imaged structure.
Focal zone
• Echoes are generated by a highly reflective
object located outside of the transducer
Scanned margin but inside of the widened distal beam.
Object

• Can cause:
– spurious echoes in a cystic structure
– reduced contrast at lesion borders

US Image
• Corrective action: Minimize artifact by
adjusting focal zone at the level of the
examined structure.
 Artifact: Beam Width
Right: Sagittal
proton-
density–
weighted fat-
saturated MR
image of the
same knee
shows a large
fluid signal
intensity lesion
consistent with
a large ganglion
cyst (arrow).

Left: Beam-width artifact in a large ganglion cyst at the posterior aspect of the medial
femoral condyle. Long-axis gray-scale US image of the posterior aspect of the medial
femoral condyle shows spurious echoes (red arrows) within the large ganglion cyst
and reduced contrast (blue arrowheads) at the lesion border related to beam-width
artifact. Additional low-level faint echoes within the ganglion cyst may be related to
side-lobe artifact or internal debris. Note posterior acoustic enhancement, or
increased through transmission (yellow arrows), artifact deep to the lesion.
 Artifact: Anisotropy
a b (a, b) Anisotropy of the fourth
extensor compartment of the
wrist. Short-axis US images of the
fourth extensor compartment
show normal tendon echogenicity
(red arrows) when the transducer
is properly positioned (a). The
hypoechoic appearance of the
tendons (green arrows) can mimic
tendinopathy and/or tendon tear
c on the image (b) due to anisotropy
Corrective when the ultrasound beam is not
action: heel-toe perpendicular to the examined
maneuver of anatomic structure.
the US probe or
beam steering

(c) Short-axis gray-scale US cine image of the same fourth extensor compartment of the wrist
shows the hypoechoic appearance of the tendons, which can mimic a tendon pathologic finding
when the ultrasound beam is not perpendicular to the examined anatomic structure.
 Artifact: Refraction
**Click to begin animation**
• Refraction artifact causes incorrect positioning
Transducer
of structures on the US image.

• Incident ultrasound beam changes directions

when it encounters an interface between two
materials with different speeds of sound and
misplaces the returning echoes.
Imaged Object

• Corrective action: Minimize artifact by using

multiple imaging planes to examine the object.
Interface

US Image
Artifact: Speed Displacement

Transducer

Speed displacement artifact. Gray-scale US image

of the left deltoid muscle shows a biopsy needle
through a soft-tissue mass. The needle (arrow)
appears discontinuous and focally displaced. The
Soft-tissue Mass ultrasound beam travels more slowly in this region
than in surrounding tissue due to the internal
contents of the mass. The lesion was found to be a
benign soft-tissue myxoma.
Artifact: Increased Through Transmission
**Click to begin animation**

• Increased through transmission

Transducer occurs with imaging of fluid-filled
lesions and some soft-tissue tumors.
– Related to homogeneity and
cellularity of some solid lesions

• There is a relatively lower attenuation

Scanned Weak of sound beam in the imaged lesion
Object Attenuator compared with in adjacent soft
tissues.

Distal echoes • Echoes distal to the weak attenuator

higher in are higher in intensity, which leads to
intensity the relative hyperechoic appearance
of the deep soft tissues.
Artifact: Increased Through Transmission
a b

c Examples of lesions with increased through

transmission. US images show the hyperechoic
appearance of the soft tissues deep to the
lesions. (a) Short-axis US image at the posterior
aspect of the knee shows a Baker cyst.
(b) Long-axis US image of the left deltoid shows
a benign spindle-cell lesion. (c) Long-axis US
image of the volar aspect of the wrist shows a
neuroma of the median nerve.
 Artifact: Posterior Acoustic Shadowing
**Click to begin animation**
• Posterior acoustic shadowing is due to
attenuation of sound by a structure, with a
Transducer resulting anechoic or hypoechoic area deep to
the involved interface.

• This occurs when the ultrasound beam is

reflected, absorbed, or refracted by a strongly
attenuating material.

Scanned Strong • Echoes distal to the material are lower in

Attenuator intensity.
Object
Distal echoes • Examples:
lower in – Interfaces with bone
intensity – Calcification
– Foreign bodies
– Gas
 Artifact: Clean Posterior Acoustic Shadowing
Posterior acoustic shadowing. a b
(a) Lateral radiograph of the wrist
shows a radiopaque foreign body
(circled). (b) Long-axis US image
at the volar aspect of the wrist
shows the same foreign body
(arrowhead) with anechoic
appearance (arrows) of soft
tissues deep to this site.
c
(c) US image during calcific
tendinosis lavage of the shoulder
shows calcifications (blue
arrowheads) with clean posterior
acoustic shadowing (red arrows).
The needle with posterior
reverberation artifact (green
arrowheads) is also seen.
Artifact: Dirty Posterior Acoustic Shadowing
a b

Dirty posterior acoustic shadowing. (a) Long-axis US image of the extensor pollicis
brevis tendon shows sutures with dirty posterior acoustic shadowing (arrows) deep
to the involved interface, which occurs when there is a smooth surface or large
radius of curvature. (b) In another patient, US image of the left thenar musculature
shows a 1.9-cm wood splinter (arrowheads) with resultant dirty posterior acoustic
shadowing (arrows).
 Time-Gain Compensation
• Time-gain compensation is used to a
overcome the effects of attenuation of
deeper echoes.

• Time-gain compensation causes

structures of different depths but with
equally reflective structures to be b
displayed with the same brightness.

• Images with time-gain compensation

appear more uniform in the deep
field.
• Decreased gain masks detail and
produces a darker image.
• Increased gain yields a brighter image.
Time-gain compensation. (a) Long-axis US
image of the biceps tendon (arrowheads in a
and b) shows attenuation of deep structures
(arrows). (b) Long-axis US with time-gain
compensation overcomes the effects of
attenuation with a more uniform image in the
deep field.
Artifact: Posterior Reverberation
Transducer

• Posterior reverberation artifact

results in multiple echoes
beneath the reflecting surface
at regularly spaced intervals.

• This can occur between two

strong parallel reflectors that
cause multiple reflections.

US Image
 Artifact: Posterior Reverberation
a b c

Posterior reverberation. Equally spaced linear reflective echoes deep to a highly reflective
interface are seen in these examples compatible with posterior reverberation. (a) Long-axis
gray-scale US image during lymph node biopsy shows the biopsy needle (arrows) with linear
reflective echoes deep to the needle (arrowheads). (b) Long-axis gray-scale US image of the
shoulder shows a calcium lavage needle (arrows) with deep linear reflective echoes
(arrowheads) at equally spaced distances. (c) Short-axis gray-scale US image at the dorsal
aspect of the wrist shows an iatrogenic metallic foreign body (arrow) in the region of a prior
ganglion cyst repair with a series of linear reflective echoes (arrowheads) deep to the foreign
body.
 Artifact: Comet Tail versus Ring Down
Although both artifacts can have a similar appearance, the mechanisms by which they
are created are different.

Comet Tail Ring Down

• Mechanism: a form of • Mechanism: fluid trapped
reverberation between air bubbles causes
resonant vibration that is
recorded by the transducer
• Due to: metal or calcium
• Due to: gas
• Appearance:
– Individual signals may not be
• Appearance:
perceivable secondary to closely
spaced interfaces and echoes – Line of parallel bands extending
posterior to the gas
– Later echoes may be attenuated
and show decreased amplitude
 Artifact: Comet Tail

Comet-tail artifact. Long-axis gray-scale US image (right) of the proximal lateral

tibia in a patient with plate-and-screw fixation of a lateral tibial plateau fracture
shows a series of continuous reflective echoes (arrows) deep to the highly
reflective metal surface related to orthopedic hardware. Note that the two
reflective interfaces and echoes are so closely spaced that it is difficult to
distinguish individual echoes.
 Artifact: Ring Down
Ring-down artifact related to air in the
infected prosthetic knee joint. Long-axis
gray-scale US image (top left) of the
suprapatellar pouch shows multiple lines of
parallel bands extending posterior to the
foci of gas related to ring-down artifact (red
arrows) within the large joint effusion
indicating presence of intra-articular air.
Note large joint effusion and intra-articular
foci of air (green arrow) on the lateral
radiograph of the same knee (top right).

US image (bottom) shows ring-down

artifact related to air in another patient
with history of intravenous drug use and
subsequent abscess in the left antecubital
fossa. Note the lines of parallel bands
(arrows) extending posterior to the foci of
air with a similar appearance to comet-tail
artifact.
 Artifact: Mirror Image
**Click to begin animation**
• Mirror image artifact is the
Transducer duplication of an image on the
opposite side of a curved highly
Properly reflective surface, or specular
reflected echoes
reflector.
Reverberation Scanned Object

• The duplicated structure is

equidistant from and deep to the
Reflective Interface
strong reflective interface.

• This occurs secondary to reflection

between the reflective surface and
back of a structure with delayed
return of the ultrasound beam to
the transducer.
US Image
 Artifact: Mirror Image
a b

Mirror image. (a) Long-axis gray-scale US image of the shoulder and supraspinatus tendon
shows several foci of increased echogenicity in the supraspinatus tendon consistent with
calcific tendonitis (red arrows) (calcium hydroxyapatite deposition disease). Note an
incompletely portrayed, distorted mirror image (yellow arrows) of the supraspinatus tendon
calcifications projecting in the adjacent humeral head, which is a highly reflective acoustic
interface, secondary to reverberation artifact as a result of scattering of the ultrasound waves.
(b) A similar US image of the supraspinatus tendon in another patient shows a focus of
increased echogenicity (blue arrow) with distorted mirror image (yellow arrow) projecting in
the adjacent humeral head.
Artifacts at Color Doppler Imaging
• Transducer pressure
• Motion
• Blooming
• Mirror image
• Background noise
• Aliasing
• Twinkling
 Artifact: Transducer Pressure
a b

Transducer pressure. (a) Color Doppler long-axis US image of the extensor pollicis
brevis tendon shows sutures and partial tearing with surrounding vessels and
increased vascularity (arrows). (b) Color Doppler US image in the same region with
increased amount of transducer pressure blocks the flow of these vessels, which
are no longer seen.
 Artifact: Motion
a b

Motion artifact. (a) Long-axis gray-scale US image of the extensor

pollicis longus tendon shows a full thickness tear (yellow arrow in a
and b). (b) Long-axis power Doppler image of the extensor pollicis
longus shows erroneous random flashes of color (green arrows) in
the tendon and bone produced by slight patient motion.
 Artifact: Blooming
a
b

Blooming artifact. (a) Long-axis power

Doppler US image of the radial artery c
shows normal caliber of the radial artery.
(b) Subsequent increase of power Doppler
gain in the same region causes artificial
enlargement of the vessel with color
“bleeding” outside of the radial artery.
(c) Similarly, decrease of power Doppler
gain in the same region causes artificial
diminished caliber of the vessel.
 Artifact: Mirror Image
a b

Mirror-image artifact. Observed at conventional B-mode or color Doppler imaging of

any vessel adjacent to a highly reflective surface. (a) Short-axis gray-scale US image
of a dorsalis pedis artery (green arrow in a and b) at the level of the midfoot. (b)
Power Doppler image in the same region shows a uniformly red-colored dorsalis
pedis artery with mirror image artifact (yellow arrow) in the bone secondary to the
highly reflective surface.
 Artifact: Background Noise
a b

Background noise. (a) Short-axis US image

c
along the lateral aspect of the wrist shows
properly set color Doppler gain.
(b) Increasing the gain at color Doppler
imaging shows increased noise with random
direction of flow in the Doppler box.
(c) Increasing the gain at power Doppler
imaging shows a uniformly colored
background in the Doppler box.
 Artifact: Aliasing

Aliasing artifact. Long-axis color Doppler US image (left)) of a brachial artery in the
antecubital fossa shows reversed blue and green color (aliased flow; yellow arrows)
and red color (nonaliased flow) that was eliminated on the power Doppler image
(right), which shows a uniformly red-colored brachial artery (blue arrows). Because
power Doppler imaging does not provide directional flow information, the aliasing
artifact did not occur. Aliasing can be controlled by increasing the pulse repetition
frequency or changing the baseline.
 Artifact: Twinkle
a b c

Twinkle artifact. (a) Short-axis gray-scale US image of the femoral

artery shows calcified plaque (arrow in a–c) along the wall. (b) Color
Doppler image in the region of interest shows color signal in the
region of the calcified plaque without associated real flow related to
twinkle artifact. (c) Long-axis color Doppler image through the same
region also shows color signal in the region of the calcified plaque
related to twinkle artifact.
 Summary Statement

It is important for the radiologist to be able to

recognize and understand how to minimize or
eliminate artifacts that can occur at
musculoskeletal US and may lead to erroneous
interpretation.
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 Suggested Readings
• Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics.
2009;29(4):1179–1189.

• Nilsson A. Artefacts in sonography and Doppler. Eur Radiol.

2001;11(8):1308–1315.

• Rubens DJ, Bhatt S, Nedelka S, Cullinan J. Doppler artifacts and

pitfalls. Radiol Clin North Am. 2006 Nov;44(6):805-35.

• Taljanovic MS, Melville DM, Scalcione LR, Gimber LH, Lorenz EJ,
Witte RS. Artifacts in musculoskeletal ultrasonography. Semin
Musculoskslet Radiol. 2014 Feb;18(1):3-11.