Category Archives: MSK

Ultrasound’s Hidden Superpowers and Why We Celebrate Them Every October

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Every October, the medical imaging community comes together to observe Medical Ultrasound Awareness Month (MUAM), a period dedicated to raising public understanding of the ultrasound’s vital role in healthcare. Sponsored by organizations such as the American Institute of Ultrasound in Medicine (AIUM), the American Registry of Diagnostic Medical Sonographers (ARDMS), the American Society of Echocardiography (ASE), Cardiovascular Credentialing International (CCI), the Society of Diagnostic Medical Sonography (SDMS), and the Society for Vascular Ultrasound (SVU), MUAM seeks to dispel the common misconception that ultrasound is mainly for pregnancy and to shine a light on its many other life-changing uses.

While many people immediately think of fetal imaging when they hear “ultrasound,” that’s only one of many applications. In fact, ultrasound helps patients at every stage of life, from newborns to seniors, across numerous medical fields. MUAM is a perfect time to celebrate the often-unseen breadth of ultrasound and the professionals who use it.

Why a Special Month for Ultrasound?

Ultrasound is safe, widely available, and cost-effective. Because it doesn’t rely on ionizing radiation (as with X-rays or CT scans), it offers a gentler imaging option, particularly for soft tissues.

The purpose of MUAM is to encourage professionals to educate patients, colleagues, and the public about how ultrasound supports diagnosis, monitoring, and treatment across a diversity of conditions.

Beyond Babies: Diverse Applications of Medical Ultrasound

Here’s a look at just a few of the many ways ultrasound is used outside obstetrics:

1. Cardiac / Echocardiography

  • Ultrasound is widely used to visualize the heart’s structure and function, assess valve integrity, detect fluid around the heart (pericardial effusion), and monitor things like left ventricular ejection fraction.
  • Doppler ultrasound can also show blood flow velocities, helping to detect stenosis or regurgitation in valves.

2. Vascular and Circulatory Imaging

  • Doppler vascular ultrasound can assess veins and arteries, detecting blockages, clots (eg, deep vein thrombosis), or stenosis.
  • It’s used to examine carotid arteries (for stroke risk), peripheral arteries (leg circulation), and vascular grafts.

3. Abdominal and Pelvic Imaging

  • Ultrasound is often used to evaluate organs like the liver, gallbladder, spleen, kidneys, pancreas, and bladder.
  • It can detect gallstones, kidney stones, hydronephrosis, liver masses, or fluid collections (eg, ascites).
  • In the pelvis outside pregnancy, it helps assess uterine/ovarian pathology, fibroids, pelvic fluid, or masses.

4. Musculoskeletal (MSK) Imaging

  • Ultrasound is used to image muscles, tendons, ligaments, joints, and nerves.
  • It helps in diagnosing tendon tears, bursitis, muscle strain, nerve entrapment (eg, carpal tunnel), and joint inflammation.
  • It also guides injections or aspirations.

5. Pediatric Imaging

  • In infants and children, ultrasound is often the first-line imaging for soft tissues, head/neck, hips (developmental dysplasia), and neonatal brain (via fontanelles).
  • Because it’s radiation-free, it’s especially favorable for young patients.

6. Point-of-Care Ultrasound (POCUS)

  • In emergency, critical care, and bedside settings, physicians use handheld or portable ultrasound to rapidly evaluate ailments such as fluid around the lungs (pleural effusion), free fluid in the abdomen, cardiac tamponade, or guidance during central line placement.
  • This real-time use can expedite diagnosis and treatment.

7. Interventional / Intraoperative Ultrasound

  • Surgeons sometimes use ultrasound during procedures to locate lesions, guide resections, or assist in biopsies or ablations.
  • Interventional radiologists may use ultrasound guidance for needle placements (biopsy, drainage) and local therapies.

8. Therapeutic Ultrasound & Special Applications

  • Beyond imaging, ultrasound has therapeutic uses (eg, high-intensity focused ultrasound, ultrasound-assisted drug delivery).
  • In neurology and neuroscience, for example, therapeutic ultrasound is being explored in treating conditions like Alzheimer’s disease or other brain disorders.
  • In space medicine, ultrasound is one of the few imaging options available aboard the International Space Station (ISS). As part of the Advanced Diagnostic Ultrasound in Microgravity project, astronauts use ultrasound to assess various organ systems in microgravity.

How You Can Support Ultrasound Awareness
(Especially This October)

  • Share knowledge: If you’re a clinician or educator, talk with colleagues or patients about the many roles of ultrasound.
  • Use social media: Companies and organizations often use hashtags like #MUAM2025 to share educational images, infographics, or stories.
  • Celebrate sonographers and ultrasound technologists: Recognize the skill, dedication, and meticulous work of these professionals.
  • Invite engagement: Host a webinar, post Q&A content, or distribute simple “Did you know?” facts about ultrasound to patients.

Final Thoughts

Medical Ultrasound Awareness Month is more than a promotional event. It’s an opportunity to correct a common misconception: ultrasound is not just for pregnancy. From the heart to the knees to the kidneys, even to outer space, ultrasound plays a vital, versatile role in modern medicine.

Let’s use October’s spotlight to help people see inside, not just for babies but for better health at every age.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Logo of the American Institute of Ultrasound in Medicine (AIUM) featuring the words 'Association for Medical Ultrasound' and 'American Institute of Ultrasound in Medicine' in blue.

AI as a Clinical Assistant: Enhancing MSK Ultrasound Interpretation and Reporting

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If you haven’t yet tried using an AI assistant in your clinical practice, now is the time to start.

We are standing at the threshold of a shift in how we work. The rise of large language models (LLMs)—text-based AI systems like Chat GPT that can interpret, generate, and summarize content—offers clinicians a remarkable opportunity: to work faster, think broader, and document smarter. I want to be clear that these tools are still evolving, but their usefulness in the day-to-day reality of musculoskeletal ultrasound is already tangible, even resulting in substantial changes.

An AI-generated image of Dr Wilcox scanning a patient with an AI avatar in the background

In my own sports medicine practice, AI has become a quiet but powerful assistant. It’s not replacing clinical expertise; it’s extending it. Over time, I’ve found a sweet spot—not in making decisions for me, but in helping me think more clearly. One of the most practical ways I use LLMs is for differential generation. I paste in my ultrasound findings and impression and ask for a possible differential diagnosis list. The results are consistently thought-provoking. Typically, it reflects five or six diagnoses I already had in mind; throws in a couple I disagree with outright; and adds two or three that surprise me, and deserve a closer look. Especially in complex or uncertain cases that prompt a pause and consideration of something new that can be invaluable.

Some mainstream AI platforms even promise image interpretation. My experience? These are not yet ready for prime time. Results can be inconsistent; accuracy is still highly variable. But for text-based assistance—where language, not pixels, is the primary input—LLMs can make the difference.

One area where AI shines is in reducing the friction of tedious or repetitive tasks. Prior authorizations, for example, used to eat up valuable time and mental bandwidth. Now, I can copy a de-identified clinical summary and the insurance denial into an LLM and request a short appeal letter. It generates a polished draft that often needs only light editing. Occasionally, I’ll even ask the AI why it thinks the request was denied—it often gives helpful insight I can use in peer-to-peer calls.

The same applies to documentation templates. I’ve built standard templates for common joints, but what about when a patient presents with something less routine, such as a region I haven’t scanned often enough to have a template, like the sternoclavicular joint? I give the model an existing template and ask it to adapt it to the new joint. The results? Fast, accurate, and easy to refine. Here’s a quick look at how I use AI in daily practice:

  • Differential support: Expands my diagnostic horizons, especially in unusual or complex cases.
  • Template generation: Converts existing structures into less common regions or patient types with minimal effort.
  • Prior auths & letters: Speeds up appeal writing; reduces emotional exhaustion from repetitive documentation.
  • Note polishing: Transforms shorthand findings into clean, communicative notes for specialists or patients.

But let’s be clear: none of this replaces the responsibility we carry as clinicians. AI is a powerful tool, but it must be used wisely. A recent study from MIT (Your Brain on ChatGPT) found that users writing essays with AI support showed lower brainwave activity, suggesting a reduction in active cognitive processing. The lesson here is sharp: when we outsource too much thinking, our ability to reason, synthesize, and create diminishes.

We cannot allow that to happen in medicine. What we document, what we diagnose—these remain our responsibility. AI can offer suggestions, but only we can make decisions. Every recommendation must be filtered through our personal, sound clinical judgment.

So yes—use AI to sharpen your workflow, expand your thinking, and save time. But use it with intention. Let it challenge your thinking, not do your thinking. Let it shape your creativity, not replace it. When used well, AI doesn’t flatten our clinical voice; it amplifies it. It helps us become more precise, more efficient, and, most importantly, more present with the people we serve.

References: Kosmyna N, Hauptmann E, Yuan YT, et al. Your brain on ChatGPT: accumulation of cognitive debt when using an AI assistant for essay writing task. Preprint. Submitted June 10, 2025. Accessed 7/8/2025. Available from: https://arxiv.org/abs/2506.08872

James Wilcox, MD, RMSK, is a family medicine and sports medicine physician in the United Arab Emirates, where he is the Director of the ProMotion Sports Medicine Clinic at Specialized Rehabilitation Hospital in Abu Dhabi, and Assistant Professor of Family Medicine at UAE University..

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the view of their employer or the American Institute of Ultrasound in Medicine.

Enhancing Diagnostic Accuracy With Musculoskeletal Ultrasound

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Imagine this: a new patient, Sarah, walks into my clinic. She’s a weekend warrior, an avid tennis player, and for the past month, persistent right shoulder pain has kept her off the court. She’s frustrated and a little scared, worried about a serious tear.

During my initial examination, several possibilities jump out—rotator cuff tendinopathy? Subacromial bursitis? Maybe even a partial tear of her supraspinatus? Traditionally, my next step would involve a series of special tests, which can be helpful but sometimes ambiguous.

Now, however, I have a powerful ally: diagnostic musculoskeletal ultrasound. As I gently guide the transducer over Sarah’s shoulder, the structures beneath her skin come alive on the screen. We can see her rotator cuff tendons in real-time. Is there thickening? Fluid? A visible tear?

In Sarah’s case, the ultrasound quickly helped me rule out a significant rotator cuff tear – a huge relief for her! Instead, we observed inflammation around her biceps tendon and a thickened bursa. This clarity was invaluable. Not only did it allow me to formulate a precise plan of care targeting her specific issues, but Sarah was right there, watching the screen with me. Seeing the actual images of her shoulder, with my explanations, transformed her understanding and fostered immediate buy-in for the rehabilitation plan. That “Aha!” moment, for both patient and therapist, is priceless.

My journey incorporating diagnostic musculoskeletal ultrasound into both my sports physical therapy and outpatient settings has been a game-changer, extending far beyond that initial diagnostic puzzle. Its impact on my diagnostic capacity is profound. While our hands and clinical reasoning skills are paramount, ultrasound offers a direct visual confirmation (or refutation) of our hypotheses. It allows me to pinpoint the exact location and extent of soft tissue injuries – a tendinopathy versus a tear, the degree of inflammation in a bursa, or even subtle nerve entrapments.

This isn’t about replacing our clinical skills; it’s about augmenting them, adding a layer of precision that was previously unattainable without more expensive or invasive imaging.

This enhanced diagnostic accuracy directly translates into a greater capacity to carry out effective treatments. Knowing precisely what structure is involved, and to what extent, allows for highly targeted interventions. For instance, if ultrasound identifies a specific area of neovascularization within a tendon (a sign of tendinopathy), I can more accurately guide interventions like eccentric exercises or instrument-assisted soft tissue mobilization to that precise area. 

Perhaps one of the most rewarding aspects of using musculoskeletal ultrasound is the significant improvement in patient rapport and trust. Like Sarah, patients are no longer just passive recipients of my diagnostic opinion. They become active participants in their own understanding. When they can see the image of their injured tendon or inflamed bursa on the screen, and I can point out exactly what’s happening and how our treatment plan will address it, their comprehension and confidence in the plan soars.

This visual evidence demystifies their pain and empowers them. It transforms the conversation from “I think this is what’s wrong” to “Let me show you what’s going on.” This shared understanding builds a stronger therapeutic alliance, leading to better adherence to home exercise programs and a more collaborative approach to rehabilitation.

Musculoskeletal ultrasound has become an indispensable tool in my practice. It sharpens my diagnostic skills, refines my treatment strategies, and, most importantly, empowers my patients by allowing them to truly see and understand their path to recovery. It’s an investment that pays daily dividends in clinical certainty and patient trust.

Pablo Borceguin Jr., PT, DPT, is a doctor of physical therapy with an emphasis on orthopedics and sports.

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the views of their employer or the American Institute of Ultrasound in Medicine.

Ultrasound Imaging in Sport: Seeing the Unseen to Shape the Season

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May – the month when athletic champions are crowned, summer training programs ignite, and our collective spirit turns toward movement – is also National Physical Fitness and Sports Month. As we spotlight peak performance and injury prevention, one tool continues to gain ground in the world of sports medicine: ultrasound imaging.

Ultrasound imaging, long valued as a point-of-care diagnostic tool providing real-time evaluation of a variety of neuromusculoskeletal structures, has rapidly become an important component of the assessment and care of athletes in a variety of fitness and sports settings. Not only is ultrasound imaging used as a diagnostic tool to evaluate soft tissue injuries, but it has become increasingly important in the hands of sports medicine specialists for identifying risk factors for sports injuries before symptoms arise. This is where the conversation gets interesting!

A Season in the Life of a Tendon

A recent study by Savage et al (Inter J Physiother, 2024) used high-resolution ultrasound imaging to examine changes in tendon and bone health among Division I female volleyball athletes across their competitive season. The study examined body regions most injured in competitive volleyball players, including shoulders, knees, ankles, and feet, which have soft tissues that are under the most stress from the cumulative demands of repetitive jumping, landing, and hitting.

The findings? Over 90% of the athletes had preseason tendon or bony abnormalities despite most not reporting significant symptoms. Tendon cross-sectional area changed significantly over the course of the competitive season, particularly the Achilles and patellar tendons.

Ultrasound image displaying intrasubstance defects in a tendon, highlighting areas of concern for sports medicine assessment.

Significantly more athletes ended the season with sonographic abnormalities in four or more body regions than when they began the season.

Ultrasound image showing a cortical defect and hypoechoic tendon thickening in a patient's tendon, aiding in sports medicine diagnostics.

What does this mean? These Division I athletes had sonographic signatures of soft tissue strain and adaptation related to the physical demands of the competitive volleyball season. While many of these athletes remained asymptomatic or mildly symptomatic, most were able to finish the competitive season.

However, recent study by Cushman et al (Orthop J Sports Med, 2024) found that baseline sonographic tendon abnormalities in athletes are predictive of future injury.

Ultrasound as a Performance Barometer

So, what are we looking at when we point the transducer? Tendon thickening? Focal hypoechoic zones? Calcaneal enthesophytes? Perhaps. But more broadly, we are capturing a physiological fingerprint of sport-specific loading. In this context, ultrasound imaging is more than just a diagnostic tool, it becomes a training and screening tool by:

  • Detecting early soft tissue changes before symptoms develop
  • Guiding load management strategies during the competitive season
  • Tracking recovery and response to training and interventions
  • Providing real-time comparison between limbs and soft tissues over time
Ultrasound image showing hypoechoic tendon thickening, indicating possible soft tissue changes.

These are just some examples of the value of ultrasound imaging in fitness and athletic settings, but this conversation echoes a growing trend in the sports medicine world: pairing point-of-care ultrasound imaging with athlete monitoring is an innovative application to better train and manage athletes before an injury sends them to the training room or sports medicine clinic.

Ultrasound image showing a tendon defect and a cortical defect with labeled arrows indicating their locations.

Don’t Diagnose in a Vacuum

Of course, not every tendon or bony abnormality seen on ultrasound imaging is teetering toward meaningful damage or an injury. As with all imaging modalities, ultrasound must be interpreted alongside the clinical examination, sport-specific demands, body composition variables, prior injuries, and functional status. That’s what makes the sports medicine specialist’s job so interesting! Being valuable stewards of this safe and cost-effective point-of-care technology means that ultrasound imaging can be used to amplify our clinical reasoning.

Let’s Keep the Conversation Going
As we celebrate athleticism this month, consider how ultrasound imaging can play a larger role in your sports medicine practice or training program by asking:

  • Can preseason scanning inform an athlete’s training program and load adjustments?
  • Can ultrasound imaging identify athletes at risk for developing an injury?
  • What stories are hidden beneath the surface – Are there other innovative applications of ultrasound imaging that can benefit fitness and sports enthusiasts?
  • How have you used ultrasound imaging to guide decisions about fitness programs or to the training and care of an athlete?

What have you seen? I would love to hear your comments and insights about how you are integrating ultrasound imaging into the science of movement! Comment or connect with me on LinkedIn (www.linkedin.com/in/nathan-savage-wssu) or X (@DrNathanJSavage).

Dr. Nathan J. Savage, PhD, DPT, RMSK, is an Associate Professor of Physical Therapy with expertise in neuromusculoskeletal ultrasound. His research focuses on integrating imaging into clinical decision-making for injury prevention, rehabilitation, and sports performance.

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the view of their employer or the American Institute of Ultrasound in Medicine.

Musculoskeletal Ultrasound: Improving Patient Care in Real-Time

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The ability to diagnose and treat musculoskeletal (MSK) conditions with accuracy and efficiency is crucial for both practitioners and patients. Enter musculoskeletal ultrasound, a tool that has revolutionized how we approach these challenges, offering unparalleled real-time imaging and diagnostic capabilities.

Cristy Nicole French, MD, Chair of the AIUM’s Musculoskeletal Ultrasound Community, encapsulates the essence of this powerful technology: “The real-time nature of ultrasound provides the opportunity to interact with the athlete and correlate symptoms with sonographic findings. Patients enjoy this opportunity to ‘share their story’ and often provide critical information to the diagnostic puzzle.” Her words highlight one of the key advantages of MSK ultrasound—its ability to engage patients actively in their care. The immediate feedback loop between the patient’s symptoms and the visual data from the ultrasound helps clinicians piece together the diagnostic puzzle with greater accuracy.

This sentiment is echoed by Humberto Gerardo Rosas, MD, former AIUM Musculoskeletal Ultrasound Community Chair (2019–2021). He emphasizes the indispensable nature of MSK ultrasound in modern medicine: “Musculoskeletal ultrasound has become an indispensable tool in diagnosing and treating musculoskeletal conditions. It provides high-resolution, real-time imaging of the muscles, nerves, tendons, and ligaments, leading to precise evaluations and accurate diagnosis at a fraction of the cost of other modalities. The dynamic capabilities, unique to ultrasound, not only improves the diagnostic accuracy and assessment of the extent of injury but also helps direct more effective and personalized treatment plans. Additionally, it allows for image-guided interventions that afford precise needle placement and medication delivery. For patients, this means quicker, more targeted interventions and better outcomes, making musculoskeletal ultrasound a vital tool in modern sports medicine and orthopedic care.”

The dynamic nature of ultrasound enhances the accuracy of diagnostics and serves as a guide for interventions, ensuring that treatments are effective and tailored to each patient’s unique needs. This level of personalized care, coupled with ultrasound’s cost-effectiveness and convenience, has made it a cornerstone of patient management in MSK medicine.

As we continue to push the boundaries of what is possible in medicine, MSK ultrasound stands out as a prime example of how technology can enhance the human element of care. By offering a window into the body that is both immediate and detailed, it enables clinicians to make informed decisions that lead to better outcomes for their patients. Whether it’s diagnosing a complex injury or guiding a precise intervention, the impact of musculoskeletal ultrasound is profound and far-reaching, cementing its place as an essential tool in the future of healthcare.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in reading more about musculoskeletal ultrasound? Check out these posts from the Scan:

Understanding the Basics of Medical Ultrasound Safety in Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) is an invaluable diagnostic tool that provides real-time, dynamic imaging of muscles, tendons, ligaments, joints, and soft tissues. Its advantages include being non-invasive, relatively low-cost, and free of ionizing radiation. However, to maximize its benefits and ensure patient safety, it is crucial for practitioners to understand and apply certain fundamental principles, including ALARA (As Low As Reasonably Achievable) and the Mechanical Index (MI). Here, we provide an overview of these concepts and other essential information for new users of MSK US.

ALARA Principle

The ALARA principle stands for “As Low As Reasonably Achievable” and is a cornerstone of safe ultrasound practice. It emphasizes minimizing the patient’s exposure to ultrasound energy while still obtaining the necessary diagnostic information.

Key Strategies to Apply ALARA:

1. Optimize Scanning Parameters: Use the lowest possible settings for power, gain, and exposure time that still yield diagnostic quality images. Avoid unnecessary Doppler applications, which use higher energy levels.

2. Adjust the Probe Position and Angle: Efficient probe manipulation can improve image quality without increasing power output. Use proper ergonomics to maintain consistent and effective contact with the patient’s skin.

3. Limit Scan Duration: Conduct scans efficiently to minimize exposure time. Pre-plan the examination to focus on areas of interest and avoid prolonged scanning.

By adhering to the ALARA principle, practitioners ensure that ultrasound procedures are both effective and safe.

Mechanical Index (MI)

The Mechanical Index (MI) is a parameter used to evaluate the potential for mechanical bioeffects, such as cavitation, which can occur during ultrasound procedures. It is calculated based on the peak negative pressure of the ultrasound wave and the frequency of the ultrasound.

Understanding MI Values:

  • Low MI (<0.3): Safe for sensitive tissues; minimal risk of cavitation.
  • Moderate MI (0.3–0.7): Generally considered safe for routine diagnostic imaging.
  • High MI (>0.7): Increased risk of mechanical bioeffects; should be used with caution and justified by clinical need.

To maintain patient safety, it is essential to monitor and adjust the MI, especially during prolonged or intensive scans.

Thermal Index (TI)

Another crucial parameter in MSK US is the Thermal Index (TI), which estimates the potential for tissue heating. The TI is influenced by the duration of the ultrasound exposure and the intensity of the ultrasound beam.

Categories of TI:

  • TIS (Soft Tissue): Applies to imaging of soft tissues and abdominal organs.
  • TIB (Bone): Relevant for imaging near bone structures.
  • TIC (Cranial): Pertains to imaging the fetal skull or neonatal head.

For MSK US, TIB is the most relevant as it applies to imaging around bones and joints. Maintaining an appropriate TI helps prevent thermal damage to tissues.

Essential MSK US Techniques

1. Probe Selection: Use the appropriate probe for the area being examined. High-frequency linear probes (7–15 MHz) are commonly used for superficial structures like tendons and muscles, while lower-frequency probes are better for deeper structures.

2. Patient Positioning: Proper patient positioning is crucial for optimal imaging. Ensure the area of interest is accessible and the patient is comfortable to avoid movement that can degrade image quality.

3. Image Optimization: Adjust the depth, focus, gain, and time-gain compensation (TGC) to enhance image quality. Clear visualization of the anatomy is essential for accurate diagnosis.

4. Dynamic Examination: Utilize the dynamic nature of ultrasound to assess the movement and function of musculoskeletal structures. Real-time imaging can help identify abnormalities that static imaging may miss.

5. Documentation: Capture and store high-quality images and clips of the relevant findings. Proper documentation supports clinical decisions and facilitates communication with other healthcare providers.

Conclusion

Performing musculoskeletal ultrasound requires a solid understanding of key safety principles, such as ALARA and MI, as well as technical skills in image optimization and patient positioning. By adhering to these guidelines, practitioners can ensure safe and effective use of MSK US, providing valuable insights into musculoskeletal conditions and enhancing patient care.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about the basics of ultrasound? Check out these resources from the American Institute of Ultrasound in Medicine:

An Invaluable Tool in Your Practice: Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) has emerged as a powerful tool that is advancing pediatric sports medicine. Its noninvasive nature, real-time imaging capabilities, and portability make it invaluable for injury assessment and treatment planning. Let’s delve into some key points:

  • Utility in Sports Medicine: The American Medical Society for Sports Medicine (AMSSM) developed a recommended MSK US curriculum for sports medicine fellows in 2010 to help guide programs towards adequate training during their fellowship to meet the requirements of competency outlined by the American Institute of Ultrasound in Medicine (AIUM) Training Guidelines for the Performance of MSK US Examination. This was later revised in 2015 and it was where the term “sports ultrasound” was first introduced to reflect the use of ultrasound by sports medicine physicians for both musculoskeletal and non-musculoskeletal indications.  Since then, sports US has become nearly ubiquitous in sports medicine clinics, training rooms, and at sporting events across the country. Finally, in 2017, ultrasound training was formally added to the Accreditation Council for Graduate Medical Education (ACGME) core program requirements for sports medicine fellowships, including pediatric-based programs.
  • Pediatric Considerations: Skeptics may argue that ultrasound isn’t necessary for evaluating musculoskeletal (MSK) complaints in children, assuming they don’t experience the same amount of pathology as adults. However, as a pediatric sports medicine physician with a decade of ultrasound experience, I can attest that children do encounter similar MSK issues. Children exhibit both common MSK conditions (like tendinosis, ligament tears, muscle injuries, effusions, and fractures) and unique ones related to their growing skeletons (like osteochondral defects, Salter Harris injuries, apophysitis, and avulsion fractures). MSK US can play a role in evaluating all of these conditions at the point of care. 
  • Beyond Pediatric Sports Medicine: MSK Ultrasound is a valuable tool that extends beyond pediatric sports medicine as well. It is widely used in rheumatology clinics, where it helps diagnose conditions like synovitis, arthritis, and enthesitis. Emergency physicians can quickly identify joint effusions and dislocations, full-thickness tendon tears, and fractures, influencing acute management decisions. General pediatricians can benefit from MSK ultrasound, too, and this is not just ordering ultrasounds to rule out hip dysplasia in infants. Simple questions—like distinguishing between solid versus cystic soft tissue masses and assessing joint effusions—can guide primary care clinicians. When families seek answers about their child’s condition and treatment options, especially “How can we get them back to sports safely?” time is of the essence and point-of-care ultrasound (POCUS) becomes even more important!
  • Interventional Possibilities: While the volume of procedures may not match clinics focused on older athletes, there are still opportunities for the pediatrician. US guidance opens the door to injections of not only joints and their recesses but also within tendon sheaths, bursa, and perineural spaces. Therapeutic injections have their obvious role in successful treatment of pathologic conditions, but diagnostic injections can also play a crucial role, especially for patients with chronic pain. Precise targeting using ultrasound ensures accurate delivery of anesthetic injectates that can help inform the clinician of the etiology of pain, which often goes undiagnosed for years in the more challenging patient scenarios.         
  • Safety and Efficiency: Sonologists with diagnostic expertise can now confidently guide needles to precise locations, minimizing risks. Unlike radiography, which involves radiation exposure, ultrasound is radiation-free. This safety aspect is crucial, especially when discussing imaging options with pediatric patients and their families. For example, repeating radiographs or imaging contralateral sides for comparisons may be unnecessary if the pediatric clinician has POCUS in their toolbox.   

In summary, MSK ultrasound is a versatile tool that empowers clinicians across pediatric specialties to make informed decisions and provide better patient care. I challenge you to take advantage of all the great MSK US resources available through the AIUM and ask yourself how you could start incorporating this tool into your practice.

Drew Duerson, MD, RMSK, is a Sports Medicine physician in the Division of Sports Medicine at Nationwide Children’s Hospital. He is also a clinical associate professor of Pediatrics at the Ohio State University. Drew is a board-certified Pediatrician with a certificate of added qualification in Sports Medicine. He also holds a POCUS Musculoskeletal certification from the Alliance for Physician Certification and Advancement. 

Drew.Duerson@nationwidechildrens.org

@pedsmskusdoc

Drew Duerson, MD, RMSK

Interested in reading more about MSK ultrasound? Check out these on-demand webinars from the American Institute of Ultrasound in Medicine (AIUM):

Burnout, the Force Propelling Sonographers Away From Their Calling

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Amidst the bustling corridors and resonant discussions of the 2024 AIUM Ultracon conference, a groundbreaking revelation emerged from the forefront of medical imaging research. Shedding light on the intricate interplay between Work-Related Musculoskeletal Disorders (WRMSDs) and the often-overlooked specter of sonographer burnout, the collaborative inquiry of my colleagues and I sought merely to confirm existing associations but ultimately challenged entrenched assumptions. What materialized from our investigation was a surprising insight: burnout, eclipsing the physical strains of the profession, emerges as the predominant force propelling sonographers away from their calling. This revelation, underscored by the poignant narratives of our colleagues, beckons us to embark on a journey that redefines our understanding of occupational health and demands a holistic approach to safeguarding the well-being of every sonographer.

Professional research informs us that WRMSDs can cause a sonographer to leave the profession and that both WRMSDs and burnout share similar root causes. The intent of our research was to forward the discussion on WRMSDs, by determining if there is an association between the two conditions; an association we did find: burnout was the reason for a sonographer to consider leaving the profession, not a WRMSD. That eye-opening finding reshaped how we viewed our research results. What if the profession, instead of focusing on education and engineering as the way to prevent WRMSDs, looked closer at the psychosocial causes of WRMSDs? 

We were happy to see so many stakeholders, such as radiologists and administrators, express concern for sonographer burnout. While it was gratifying to find so much support from our colleagues, we were saddened by the many sonographers who spoke with us about their own experiences with burnout. During Ultracon, sonographers came up to us and expressed their thoughts of leaving the patient care environment, or that burnout was the reason they had already changed jobs. They voiced concern that pizza parties were viewed as solutions when what they really need is meaningful change to the work and professional culture that prioritizes profits and throughput over people. Sonographers are suffering in silence, and simply want to know someone cares for their well-being.  

How can we move forward knowing that burnout is an issue for the profession and that it is also a factor related to the WRMSD epidemic? Larger research studies are needed on sonographer burnout for us to fully understand not only the scope of the problem but also its root causes.

We encourage other researchers to look at sonographer burnout as a single issue in addition to exploring its relationship to WRMSDs. If we hope to attract young, talented people to pursue a sonography career, we need to show that the career is worth it to them. It is up to us, sonologists, administrators, and sonographers, to work together to ensure that our profession supports the whole sonographer, mind, and body. 

Jennifer Bagley, MPH, RDMS, RVT, FAIUM, FSDMS, is a professor and sonography program director for the College of Allied Health at the University of Oklahoma Health Sciences in Oklahoma City, Oklahoma. She also currently serves on the AIUM Board of Governors.

Interested in reading more about Sonography? Check out these posts from the Scan:

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

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Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

The Potential of Ultrasound: Earlier Noninvasive Type 2 Diabetes Mellitus Detection

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Are you aware that type 2 diabetes mellitus (T2D) affects approximately 537 million adults worldwide, including 37.3 million in the USA? That is over 10% of the U.S. population! Approximately 79% of the people worldwide with T2D are underserved, underrepresented, impoverished, in lower socioeconomic communities, and in developing countries. Furthermore, the worldwide prevalence of T2D is expected to reach an astonishing 783 million by 2045.1–8

Even more shocking is that approximately 50% (232 million) of those people with T2D worldwide are unaware and undiagnosed! This is a major problem since, when T2D is finally detected, at the time of diagnosis, nearly one-half already have one or more irreversible complications resulting in an at least $966 billion global economic burden.

Also, a vast 81% with prediabetes (PreD), more than 77 million in the USA, are undiagnosed and unaware. However, in PreD, earlier lifestyle modifications reduce the risk of developing T2D by greater than 50%. These high numbers of undiagnosed people may be secondary to the lower accuracy of current screening methods in certain conditions and specific populations.

T2D leads to multiple costly serious end-organ complications, including being the leading cause of both end-stage renal disease and non-traumatic lower extremity amputations. Earlier detection is critical as earlier effective glycemic management reduces the risk of associated ophthalmologic, renal, and neurologic diseases by 40%. The urgency of this important matter has even prompted the United States Preventive Services Task Force to update guidelines in 2021 to help improve earlier T2D and PreD detection.1,3,4,9,10

Given its advantages over MRI, including low cost and portability, musculoskeletal (MSK) ultrasound (US) utilization, especially shoulder US, has significantly increased over the past few decades. Shoulder US is often performed on patients with T2D, given the high prevalence of T2D in society and the increased risk of rotator cuff pathology and adhesive capsulitis in individuals with T2D.9,10

As MSK US use increases, a unique opportunity arises for detecting T2D in those unaware, undiagnosed, and presenting for (seemingly) unrelated care. It is our experience and confirmed in our prior publications9,10 that the incidental detection of a hyperechoic deltoid muscle, on routine shoulder US (Figure 1), has on many occasions resulted in the incidental identification of undiagnosed T2D and even PreD. This abnormality was seen in those with and without obesity. Also, in those uncertain of their T2D status or told they were ‘borderline’, most were not treated, despite having this characteristic US deltoid muscle abnormality. Initial experiments also suggest that the hyperechoic deltoid muscle appearance may predate the elevation of HbA1c levels.

Figure 1. Long-axis US image of the right shoulder. a, Normal appearance of a hypoechoic deltoid muscle (solid arrow) in a 43-year-old woman without T2D or PreD. b, Abnormal hyperechoic deltoid (solid arrow) in a 47-year-old woman with T2D. The empty arrows indicate the supraspinatus tendon inserting on the greater tuberosity (arrowheads).

Skeletal muscle insulin resistance is thought to be the primary defect in T2D development, often occurring decades before β-cell failure and apparent metabolic dysfunction.11 Could this earlier-identified skeletal muscle US abnormality represent the noninvasive detection of early muscle insulin resistance and dysfunction, prior to clinically apparent metabolic dysfunction?

We continue to study this novel sonographic abnormality prospectively, including using histologic analyses. We expect our studies will help elucidate this US skeletal muscle abnormality, which could represent the earlier detection of muscle insulin resistance and dysfunction. This could initiate further studies on earlier noninvasive T2D detection, prevention, treatment, and targeted therapies for potential reversal.

References

1.         International Diabetes Federation. IDF diabetes atlas [Internet]. 10th ed. Brussels, Belgium: International Diabetes Foundation; 2021 [cited October 17, 2023].

2.         Centers for Disease Control and Prevention. National Diabetes Statistics Report website. [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2022 [updated June 29, 2022; cited October 17, 2023]. 

3.         National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention. Cost-effectiveness of diabetes interventions [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; 2022 [updated December 1, 2022; cited October 17, 2023].

4.         US Preventive Services Task Force, Davidson KW, Barry MJ, Mangione CM, et al. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA 2021; 326:736–743. PMID: 34427594.

5.         Boyle JP, Honeycutt AA, Narayan KM, et al. Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the U.S. Diabetes Care 2001; 24:1936–1940. PMID: 11679460.

6.         Lin J, Thompson TJ, Cheng YJ, et al. Projection of the future diabetes burden in the United States through 2060. Popul Health Metr 2018; 16(1):9. PMID: 29903012; PMCID: PMC6003101.

7.         Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: insights from yesterday, today, and future trends. Popul Health Manag 2017; 20(1):6–12. PMID: 27124621; PMCID: PMC5278808.

8.         National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Diabetes [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2021 [cited October 17, 2023].

9.         Soliman SB, Rosen KA, Williams PC, et al. The hyperechoic appearance of the deltoid muscle on shoulder ultrasound imaging as a predictor of diabetes and prediabetes. J Ultrasound Med 2020; 39:323–329. PMID: 31423604. https://onlinelibrary.wiley.com/doi/10.1002/jum.15110.

10.       Rosen KA, Thodge A, Tang A, Franz BM, Klochko CL, Soliman SB. The sonographic quantitative assessment of the deltoid muscle to detect type 2 diabetes mellitus: a potential noninvasive and sensitive screening method? BMC Endocr Disord 2022; 22(1):193. PMID: 35897066.

11.       DeFronzo RA, Tripathy D. Skeletal muscle insulin resistance is the primary defect in type 2 diabetes. Diabetes Care 2009; 32(Suppl 2):S157–S163. PMID: 19875544; PMCID: PMC2811436.

Steven B. Soliman, DO, RMSK, FAOCR, is an associate professor and musculoskeletal radiologist at the University of Michigan.

Interested in reading more about MSK ultrasound? Check out these posts from the Scan: