The portability, low cost, and non-ionizing radiation associated with medical ultrasound suggest that it has potential as a superior alternative to X-ray for bone imaging. However, when conventional ultrasound imaging systems are used for bone imaging, clinical acceptance is frequently limited by artifacts derived from reflections occurring away from the main axis of the acoustic beam. In this paper, the physical source of off-axis artifacts and the effect of transducer geometry on these artifacts are investigated in simulation and experimental studies. In agreement with diffraction theory, the sampled linear-array geometry possessed increased off-axis energy compared with single-element piston geometry, and therefore, exhibited greater levels of artifact signal. Simulation and experimental results demonstrated that the linear-array geometry exhibited increased artifact signal when the center frequency increased, when energy off-axis to the main acoustic beam (i.e., grating lobes) was perpendicularly incident upon off-axis surfaces, and when off-axis surfaces were specular rather than diffusive. The simulation model used to simulate specular reflections was validated experimentally and a correlation coefficient of 0.97 between experimental and simulated peak reflection contrast was observed. In ex vivo experiments, the piston geometry yielded 4 and 6.2 dB average contrast improvement compared with the linear array when imaging the spinous process and interlaminar space of an animal spine, respectively. This work indicates that off-axis reflections are a major source of ultrasound image artifacts, particularly in environments comprising specular reflecting (i.e., bone or bone-like) objects. Transducer geometries with reduced sensitivity to off-axis surface reflections, such as a piston transducer geometry, yield significant reductions in image artifact.