Musculotendinous Ultrasound Imaging Applications in Sports Medicine

There is a clearly established role of ultrasound imaging in traditional medical contexts to optimize patient assessment and subsequent care. These same applications have been carried over into sports medicine settings, especially with recent developments in ultrasound portability. Such technological advancements enable athletic trainers and other sports medicine clinicians to perform sideline assessments for athletes who sustain musculoskeletal injuries during sports.

Beyond diagnostic applications of ultrasound imaging, sports medicine clinicians and researchers have begun to adopt this tool as a creative means to assess musculotendinous structures in response to sport and exercise. Ultrasound imaging has advantages over other measurement techniques given that it is relatively inexpensive equipment, fairly easy to operate (especially if you know your anatomy!), and can be rapidly implemented into assessments. Ultrasound imaging also enables clinicians to perform more dynamic assessments with patients to understand functional movement patterns, and noninvasively examine deeper tissue structures. The real-time visual platform uniquely provides the opportunity to enhance patient-clinician dialogue and provide feedback to target key muscle groups during fundamental exercises.

Below, several exemplary studies that leverage ultrasound imaging in musculotendinous contexts are presented to convey the depth and breadth of innovation in the sports medicine field and highlight opportunities for future ultrasound implementation into practice.

Muscle Morphology

Ultrasound has been most frequently implemented in sports medicine research to conduct table-top assessments of musculotendinous structures. This measurement approach provides insights to clinicians on patients’ muscle and tendon changes in response to exercise (eg, weight- and height-adjusted size, fiber arrangement and quality). For example, researchers have been able to examine lower limb musculotendinous responses across long-distance running training.1,2 Beyond training adaptations, clinicians are also able to get some insights into structural tissue changes in the presence of current or future musculoskeletal injury. This has specifically been done to examine musculotendinous adaptations at the shoulder complex,3 foot complex,4 and lumbopelvic hip complex5 across a range of pathological populations. Preliminary work has begun to identify signals in tendon tissue quality that relate to future pain in running athletes.1 Such studies will continue to help inform rehabilitative and training interventions to improve muscle and tendon quality to move toward injury risk reduction in sports medicine.

Dynamic Muscle Function

In addition to the role of ultrasound imaging in more static imaging contexts, ultrasound has been implemented in sports medicine research in more functional contexts. Researchers have inventively started to use foam blocks with Velcro elastic belts to secure portable ultrasound probes on patients to visualize deep lumbopelvic hip muscles across a range of exercises and movements to assess the role of these muscles during fundamental movements (Figure).6 Through this approach, researchers have examined athletes’ transverse abdominis muscle thickness during an abdominal draw-in maneuver across patient positions to determine which activity elicited the most “bang for your buck” in muscle activity.7 Additionally, this measurement approach has been used to assess gluteal muscle function throughout treadmill walking. In these instances, ultrasound videos were obtained to quantify muscle activity throughout movement and identify activity dysfunction among patients with lower limb injuries.8,9 These examples emphasize the utility of ultrasound imaging to supplement typical sports medicine clinical assessments and underscore the opportunity for clinicians to implement ultrasound imaging in more dynamic assessments.

An athlete with ultrasound probes attached to her leg. A screen in the fore ground shows the ultrasound image.

Real-time Feedback

Ultrasound imaging demonstrates great promise as a rehabilitative feedback tool for patients who have difficulty recruiting specific muscle groups as a result of injury.10 The most robust use of ultrasound for feedback has been taking dynamic assessments of the lumbopelvic hip complex muscles a step further and using ultrasound to allow patients to visualize their muscles during abdominal contraction exercises. In this manner, clinicians have been able to show patients their muscle activity, and encourage activation of select muscles during rehabilitative exercises. This approach has been found to be more successful for patient neuromuscular education than other feedback approaches, such as verbal encouragement. The visual interface not only helps patients to see and understand muscle recruitment in real time but also helps clinicians to see when patients are able to activate proper stabilizing muscle groups as opposed to “cheating” on an exercise and using global movers to achieve a movement. While there is less available information on the use of ultrasound for feedback for targeting other muscle groups during rehabilitation, these studies highlight the opportunities for ultrasound imaging to maximize patient benefit during clinical interventions.

The Future of Ultrasound in Sports Medicine

Ultrasound imaging can clearly play a key role in sports medicine assessments and interventions. Continued research is necessary to broaden our understanding of musculotendinous changes in relation to sports injuries and rehabilitation, as current research is still scraping the surface of ultrasound opportunities in sports. Ultrasound assessments may complement other forms of athlete assessments and provide more in-depth insights into muscle and tendon function in relation to performance and injury. It is plausible that with continued technological advancements and the miniaturization of ultrasound units, clinicians may be able to use imaging during more sport-specific activities at higher velocities to unearth real-time musculotendinous changes in physical activity. The prospects of ultrasound are promising, and this tool may continue to revolutionize patient care in sports medicine clinics.


  1. Cushman DM, Petrin Z, Eby S, et al. Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners. Phys Sportsmed. 2021; 49:410–419. doi:10.1080/00913847.2020.1847004.
  2. DeJong Lempke AF, Willwerth SB, Hunt DL, Meehan III WP, Whitney KE. Adolescent marathon training: prospective evaluation of musculotendinous changes during a 6-month endurance running program [published online ahead of print September 29, 2022]. J Ultrasound Med. doi:10.1002/jum.16105.
  3. Thomas SJ, Blubello A, Peterson A, et al. Master swimmers with shoulder pain and disability have altered functional and structural measures [published online ahead of print April 13, 2021]. J Athl Train. doi:10.4085/1062-6050-0067.21.
  4. Fraser JJ, Koldenhoven R, Hertel J. Ultrasound measures of intrinsic foot muscle size and activation following lateral ankle sprain and chronic ankle instability. J Sport Rehabil 2021; 30:1008–1018. doi:10.1123/jsr.2020-0372.
  5. Dieterich AV, Deshon L, Strauss GR, McKay J, Pickard CM. M-Mode ultrasound reveals earlier gluteus minimus activity in individuals with chronic hip pain during a step-down task. J Orthop Sports Phys Ther 2016; 46:277–285. doi:10.2519/jospt.2016.6132.
  6. DeJong AF, Mangum LC, Hertel J. Ultrasound imaging of the gluteal muscles during the Y-balance test in individuals with and without chronic ankle instability. J Athl Train 2019; 55:49–57. doi:10.4085/1062-6050-363-18.
  7. Mangum LC, Henderson K, Murray KP, Saliba SA. Ultrasound assessment of the transverse abdominis during functional movement: Transverse abdominis during movement. J Ultrasound Med 2018; 37:1225–1231. doi:10.1002/jum.14466.
  8. DeJong AF, Mangum LC, Hertel J. Gluteus medius activity during gait is altered in individuals with chronic ankle instability: An ultrasound imaging study. Gait Posture 2019; 71:7–13. doi:10.1016/j.gaitpost.2019.04.007.
  9. DeJong AF, Koldenhoven RM, Hart JM, Hertel J. Gluteus medius dysfunction in females with chronic ankle instability is consistent at different walking speeds. Clin Biomech (Bristol, Avon). 2020; 73:140–148. doi:10.1016/j.clinbiomech.2020.01.013.
  10. Valera-Calero JA, Fernández-de-Las-Peñas C, Varol U, Ortega-Santiago R, Gallego-Sendarrubias GM, Arias-Buría JL. Ultrasound imaging as a visual biofeedback tool in rehabilitation: An updated systematic review. Int J Environ Res Public Health. 2021; 18(14):7554. doi:10.3390/ijerph18147554.

Alexandra F. DeJong Lempke, PhD, ATC, is a clinical assistant professor of Applied Exercise Science, co-director of the Michigan Performance Research Lab, and a member of the Exercise & Sport Science Initiative within the U-M School of Kinesiology.

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

The Potential of Elastography in MSK Ultrasound

Elastography is a method of imaging that detects the compressibility or stiffness of tissues in the imaging field and then overlays a false-color map upon the greyscale image to indicate which tissues are hard/stiff versus soft/compressible. The science behind the technique is beyond the scope of a blog post, particularly as there are several methods by which elastography can be performed.  

In practical terms, elastography is useful in identifying lesions that are sonographically iso-dense compared to their surroundings. Such lesions, while they are therefore visually “iso-grey” (if you will tolerate a neologism), may not be iso-compressible despite their iso-density, and thus when their differential compressibility is identified by elastography it becomes possible to characterize a lesion whose greyscale appearance is not instructive. Among the most common current uses of elastography are the characterization of breast and liver lesions, and indeed the well-known Fibroscan device is, in essence, liver elastography.

There are several instances in the field of musculoskeletal (MSK)/rheumatologic ultrasound in which this technology is appealing, but more work is needed before widespread use will be advisable. I will mention only two of the most obvious examples here. 

Example One

The first example is in the interrogation of a symptomatic tendon or ligament. Such a structure, whose normal function involves incredible amounts of linear tension, when disrupted by trauma or disease, would be expected to lose integrity in the region of the insult and become softer/more compressible than normal in that area.

Traditionally, elastography is not used to measure tendons and ligaments despite the validity of the above statement. The reason for this is that the stiffness of tissue, when measured by elastography, can be expressed in terms of the speed at which a deformation (compression wave) in the tissue propagates, usually in meters per second (there are other units by which stiffness can be measured, but for simplicity’s sake, I will leave it at that).

In the classical case of breast and liver lesions, this is not an issue since the surrounding normal tissue is relatively soft and compressible, so the speed of the propagation of a compression wave is relatively slow. Thus, most elastography measurements top out at a propagation speed of about 10 meters per second, and most normal and abnormal breast/liver tissue will have stiffness values somewhat slower than this. Tendons and ligaments, on the other hand, are by nature very hard/noncompressible. Even in their “relaxed” state, these tissues are so bowstring-tight (relatively) that measuring a normal Achilles’ tendon, for example, will yield only a maxed-out value of “offscale hard” throughout the entire structure. 

It is tempting to say that one could simply recalibrate the machine to measure faster propagation speeds, but, unfortunately, we run into limitations of our current technology. It is simply not possible currently to measure velocities much faster than 10 m/s. 

While we await advancements in technology, the current workaround is to trust that a damaged region of tendon or ligament will be significantly softer, and thus transmit compression waves much more slowly. Therefore, we simply consider any propagation speed that falls out of “offscale” and into the measurable range to be an indicator of pathology.

Example Two

The second example of the potential rheumatologic utility of elastography is in the assessment of systemic sclerosis, commonly known as scleroderma. As the Greek name would suggest, this disease usually includes a characteristic hardening of the skin. The problem is that there is currently no reliable way to quantify skin stiffness. The existing gold standard is a semi-quantitative scoring of skin thickening performed by simple physical examination in which each of several predefined regions of the skin is palpated and assigned a value from 0 to 3. This results in an overall score known as the Modified Rodnan Skin Score (MRSS). Performing Rodnan scoring requires an experienced clinician, and since scleroderma is a rare disease, very few physicians have a large enough cohort in their practice to be able to consider themselves expert Rodnan scorers.

This leads to a host of problems, and one of the worst is that clinical trials in scleroderma (a devastating and potentially fatal disease for which no good treatment exists) are very difficult to conduct because one of the primary endpoints of any trial will be the degree of improvement found in this semi-quantitative and hard-to-perform examination, which is subject to severe inter-rater reliability problems.

When I first started as a rheumatology fellow, I agreed to help with a scleroderma clinical trial in the role of a blinded efficacy assessor. The sponsor brought a dozen or so of us to a hotel for training, and all morning long we cycled through a series of hotel meeting rooms, each containing a volunteer patient for us to score.

It was a disaster.

After lunch, the representative from the sponsor got up to the podium and told us to rip up our afternoon agendas—we were going back to the meeting rooms to examine the volunteers again in an effort to improve the scoring consensus.

Clearly, this situation screams for elastography. The objective measurement of skin stiffness is precisely the datum that is sorely needed. Sadly, our current technology again fails us, as present-day elastography has limitations in resolution and the skin by its anatomic location, will always be very nearly directly applied to the probe face, in a region outside the focal zone of the beam where the measurement physics work best. Further, one of the techniques for performing elastography is highly operator-dependent, because the compression waves being measured are generated by manually varying the pressure of the probe against the skin—definitely a skill that must be learned over time and one that opens the door once more to inter-rater variability.

Overall, elastography holds great promise for MSK/rheumatologic applications in the future, as described in the two examples above. For now, however, it’s currently a technology that is “not ready for prime time” in this field.

This post is intended as a companion to “What Rheumatologists Really Need for Ultrasound Is…”, which discusses advances in ultrasound technology that are sorely needed in the field of MSK ultrasound, and specifically in rheumatology.

Dr. Mandelin is an academic rheumatologist, registered in MSK ultrasound (RhMSUS) by the American College of Rheumatology and certified in MSK ultrasound (RMSK) by the Alliance for Physician Certification & Advancement. He currently serves the AIUM as secretary of the High-Frequency Clinical and Preclinical Imaging Community. Connect with him on Twitter @NU_Rheum_MSK_US.

Do More With Less: Ultrasound

Life is not always easy, sometimes you just have to manage with what you have. To work with limited resources is one of the skills you acquire once you are a primary care physician and particularly in Africa.

This is also true concerning point-of-care ultrasound (POCUS); it is possible to do more with less. If you really understand how it works, you can find new ways to use your tools to get the correct diagnosis.

Now, I want to share with you the case of a 53-year-old male patient whose major complaint was joint pains, particularly in the left wrist and knee. Upon physical examination, the joints were warm, swollen, and painful. I hypothesized that the diagnosis was a primary gout episode but in my health facility I don’t have a uric acid test that I would ordinarily use for confirmation of the diagnosis. I then performed a POCUS examination to confirm the diagnosis by looking for the double contour cartilage line, which is a sign of gout in joints due to uric acid deposit at the surface of bone cartilage. I didn’t have a linear high-frequency probe, so I used an endocavitary probe just as you can see in the pictures.

Ultrasound images of the knee showing the double contour sign indicative of gout.

POCUS can greatly increase healthcare in low-income countries. Usually, the healthcare gap between upper-income and low-income countries is huge but, with POCUS, the same technics can be applied to both, with the same results, if ultrasound devices are available.

However, the problem remains that there is a lack of healthcare professionals who are skilled enough to use it and teach others. The problem is no longer an absence of devices but is now due to an absence of knowledge of how to use them.

Fortunately, due to COVID-19 lockdowns, we know almost everything that can be taught online. Therefore, it is time for us to think about establishing a new way to teach, learn, and practice ultrasound. Many ultrasound societies, such as the AIUM, ISUOG, and EDE, have started to share free POCUS education on their websites. Free online courses should be encouraged since they will lead us to the democratization of ultrasound, particularly in low-resource settings.

Yannick Ndefo, MD, is a general practitioner at St Thomas hospital in Douala, Cameroon.

Interested in learning more? Check out the following posts from the Scan:

A Faster Recovery for Carpal Tunnel Release

Carpal tunnel syndrome (CTS) is a phenomenon that occurs due to impingement of the median nerve at the wrist. It usually presents as numbness, tingling, and/or pain in the hand involving the thumb, index, and middle fingers. It commonly starts as nighttime numbness and tingling that awakens the patient and it can progress to being painful throughout the day. As it worsens in severity, it can produce weakness of the hand and loss of dexterity as well as radicular pain up the arm proximally toward the shoulder. There are several risk factors including repetitive use of the hands, such as with manual labor jobs, as well as obesity and rheumatologic conditions.

CTS is the most common compression neuropathy affecting 1.8–3.6% of the general population and up to 7% of manual laborers in the United States. Over 500,000 carpal tunnel releases (CTRs) are performed annually in the United States for definitive treatment of severe or refractory CTS. Multiple CTR techniques exist with one common goal—cut (ie, release) the transverse carpal ligament (TCL). Releasing the TCL reduces pressure within the carpal tunnel and, thereby, resolves the compression of the median nerve allowing improvement in associated symptoms.

For many years, the gold standard technique was open CTR (OCTR). OCTR is safe and effective but involves a relatively large incision measuring ~2 inches at the base of the palm. The skin of the palm is thick and takes weeks to months to heal, so patients are often out of work and activity for up to 6–8 weeks post-OCTR. Therefore, the mini-open (m-OCTR) technique has become very popular because the incision size is reduced to ~1 inch. This reduces the size of the scar and healing times slightly, but patients are still restricted in activity for at least 4–6 weeks. Endoscopic CTR (ECTR) is an alternative option that involves two smaller ~0.5-inch incisions but has been associated with a higher risk of transient postoperative nerve symptoms and intraoperative neurovascular injury.

Advances in ultrasound (US) technology and training over the past 20 years have catapulted US-guided procedures into realms most never believed possible. Many current US machines provide extremely high-resolution imaging, allowing providers to confidently perform advanced US-guided procedures in a safe and effective manner. Amongst the procedures being successfully implemented into clinical practices across the country is CTR with US guidance.

CTR with US guidance involves making a very small, ~4 mm, incision in the distal forearm as opposed to incising the skin of the palm. The distal forearm skin is relatively thin and heals rapidly, enabling patients to return to full activity within 1 week. Prior to performing CTR with US guidance, the patient is scanned to ensure adequate visualization of major anatomic structures including the:

  1. Median nerve
  2. Palmar cutaneous branch
  3. Thenar motor branch
  4. 3rd common palmar digital nerve
  5. Osseous boundaries of the carpal tunnel (scaphoid, pisiform, trapezium, hook of hamate)
  6. Ulnar vessels within Guyon’s canal
  7. Transverse safe zone (TSZ) between the ulnar aspect of the median nerve and the radial aspect of the ulnar vessels or hook of the hamate, whichever lies more radial
  8. Distal transverse carpal ligament (TCL)
  9. Superficial palmar arterial arch (including Doppler)

If there are no contraindications to undergoing CTR with US guidance, then the procedure may be performed in either an outpatient clinic or an ambulatory surgical center.

CTR with US guidance is usually performed under local anesthetic. The patient is positioned supine with the arm abducted 90 degrees and the wrist slightly extended. Using a #15 blade scalpel, a ~4-mm incision is made at the level of the proximal wrist crease, penetrating the antebrachial fascia. The surgical device is then advanced under direct US visualization into the carpal tunnel, passing it between the hamate and median nerve within the TSZ, similar to ECTR. The distal tip is advanced such that the blade, when activated, will engage the distal TCL. The position of the device relative to the TSZ and surrounding neurovascular structures is confirmed with US. Using the lever handle, balloons are inflated to increase the TSZ. Next, the cutting knife is deployed and advanced in a retrograde fashion using the thumb slide. The TCL is cut distal to proximal using continuous US visualization. Following TCL transection, the device is removed and a sterile dressing is applied.

Following the procedure, Tylenol and/or NSAIDs is sufficient for pain control. No splinting, occupational therapy, or opioids are required. Patients may begin immediate wrist and hand motion and resume normal activities as tolerated. The only restriction is no lifting, pushing, or pulling greater than 10 pounds with the surgical hand for 1 week. This means that those with desk jobs may return to work the next day; manual laborers may return in 1 week.

Incision at level of proximal palmar crease immediately following the procedure.
Incision at the level of proximal palmar crease immediately following the procedure.

In summary, various CTR techniques exist. Although all techniques have good outcomes at 3 months and beyond, the immediate post-op recovery timeline favors the US-guidance technique. The early success of CTR with US guidance being implemented in clinics across the country is exciting for the field of interventional musculoskeletal ultrasound. The sky is the limit!

Brett Kindle, MD

Brett J. Kindle, MD, CAQSM, RMSK, is a sports medicine specialist at Andrews Institute for Orthopaedics and Sports Medicine, as well as the Medical Director of EXOS-Florida, the Associate Program Director for Andrews Institute Primary Care Sports Medicine Fellowship, and a Team Physician for Pensacola Blue Wahoos.

What Rheumatologists Really Need for Ultrasound Is…

After I graduated from a Rheumatology fellowship, I was invited to stay on as junior faculty and several years thereafter the ACR (that acronym stands for American College of Rheumatology – I have no idea why most people who are into ultrasound always think it means something else…) developed an educational initiative aimed at bringing MSK US to every Rheumatology training program in the USA.

The ACR began to invite about 20 training programs per year to nominate one faculty member whose journey through the Ultrasound School of North American Rheumatologists (USSONAR) would be subsidized by the College. The idea was that each USSONAR graduate would then start an MSK US training program at his or her home institution, and since there are only about 120 Rheumatology training programs in the USA, the whole process would only take about 6 years. The rate of adoption among training programs was of course not 100%, and there are several key barriers to the development of an ultrasound training program, but at our institution it worked.

I’ve been doing point-of-care MSK ultrasound ever since I completed USSONAR and passed my certification exams, and our institution now has a required half-day MSK ultrasound clinic in which every Rheumatology fellow spends 6 months as part of their required curriculum. While MSK US certification is not required for graduation or to sit for boards, I’m proud to say that so far three of our Rheumatology graduates have opted to sit for the exam and are now ultrasound certified.

The program has been in place for about 7 years now, so it seems a good time to begin reflecting on my impressions of how MSK US fits into a Rheumatology practice, and more importantly some of the ways in which the current off-the-shelf technology doesn’t fully meet our specialty’s needs.

Clearly, MSK US is a major boon to Rheumatology in terms of needle guidance. Our half-day ultrasound clinic has made it possible for us to stop referring hip injections out to Interventional Radiology or Anesthesia-Pain, and I’m hoping that we will soon be able to bring sacroiliac joint injections back in-house as well. Diagnostically, the most common reason a patient is referred to the ultrasound clinic is for disambiguation of the borderline / nebulous case—that patient who endorses symptoms that sound like active inflammation but whose physical exam is benign. Our most common diagnostic referral is to answer the question of whether or not subclinical synovitis is present in the small joints of the hands, and that leads us to the first instance of current MSK US technology being less than a seamless integration into clinical practice and more of a square peg being jammed into a round hole.

The soft tissues associated with the small joints of the hands are at very shallow depths, usually under 1 cm in most patients. My very first ultrasound machine was a SonoSite M-MSK, and you adjusted the depth with a pair of pushbuttons. The standard procedure (and I would teach the fellows exactly this) was to start up the machine and then just start tapping the “less depth” button over and over.

Image of a finger joint with a ruler indicating the small height of the joint  is less than 2 centimeters.

“Just keep tapping,” I would tell the fellow. “Tap it like you’re playing Space Invaders, and just keep hitting it until the machine starts beeping in protest because the minimum depth has been reached.”

Even at that minimum setting, most ultrasound machines still show a depth of about 2 cm. I often joke with the fellows that this setting would be wonderful if we were trying to look clear through the patient’s hand and figure out what material the cushion on the exam table was made of!

Astute readers will also realize that no matter what the depth on the machine is set to, this puts the target structure (again, usually at a depth of 0.5–1 cm) closer to the probe face than the optimal focal zone distance on many probes—we are giving ourselves a case of technological hyperopia.

A stand-off pad will help keep the tissue at a better focal distance, but these pads can be cumbersome and will make the learning curve for any fellow even steeper than it already is by virtue of obscuring the tactile input, which is integral to the hands-on nature of point-of-care sonography. Ultrasound doesn’t feel like a natural extension of the physical exam with a stand-off pad in the way.

The real solution here is to switch to ultra-high-frequency ultrasound, something in the 50–70 MHz range, where the depth bar at the edge of the monitor is labeled in millimeters instead of centimeters. For small joints, I think this has to be the future of MSK ultrasound. This is why I was interested in the AIUM’s Community on High Frequency Clinical and Preclinical Imaging, and ultimately volunteered to serve among its leadership. Sadly, these UHF machines are expensive and they are often purpose-built for ultra-high-frequency only, meaning that a top of the line Rheumatologic MSK US clinic would need to own two machines, one UHF and one standard.  

This won’t fly in most places.

One of the main reasons why the ACR’s vision for an MSK US curriculum in every Rheumatology training program has not been fully realized is the expense involved in acquiring even one machine.

When we are looking at the hands of that patient whose clinical presentation is ambiguous—whose symptoms don’t seem to match their physical exam and in whom occult synovitis is suspected—we are looking for three telltale sonographic signs of the ravages of inflammation: hypertrophy of the synovium, the presence of a joint effusion, and hyperemia from the irritated joint lining struggling to summon blood flow to meet its elevated metabolic demands. The first two are often lumped together under the umbrella of “grayscale findings,” and the hyperemia is of course measured by Doppler.

The second hurdle for MSK US in the field of Rheumatology, then, is that of Doppler sensitivity. We are trying to examine and even semi-quantify the blood flow in capillaries, using equipment designed to measure the jets from regurgitant heart valves. Power Doppler is helpful here, due to its independence from the angle of insonation, but again we end up playing every trick in the book (starting with turning the wall filter off completely, if the machine even allows it) trying to squeeze every iota of signal out of the noise.

I always start the hand exam with a calibration image, in which I capture the blood flow in the pulp of a fingertip. Sometimes, especially in the midst of Chicago winters, you can’t even tell the Doppler is on at all. Currently, there’s nothing to do in that situation other than to comment in the report that Doppler calibration failed and thus the sensitivity of the study for detecting active synovitis (the very thing for which the study was ordered) is significantly compromised.

Taken together, it would seem that perhaps what we really need is for manufacturers to go beyond a blanket “MSK” setting in their machines and offer a true “Rheum” optimization package.

Dr. Mandelin is an academic rheumatologist, registered in MSK ultrasound (RhMSUS) by the American College of Rheumatology and certified in MSK ultrasound (RMSK) by the Alliance for Physician Certification & Advancement. He currently serves the AIUM as secretary of the High Frequency Clinical and Preclinical Imaging Community.

Where do you think MSK ultrasound is headed? Rheumatologists, where else does the technology not quite work in terms of your practice? Comment below or join in the conversation on Twitter, where my handle is @NU_Rheum_MSK_US.

Interested in learning more from the Scan? Check out the following posts:

The Role of Musculoskeletal Ultrasound in Sports Injuries

Approximately 20% of the U.S. population engaged in sports or exercise on a daily basis from 2010–2019.1 As expected, exercise and sports-related injuries are common, not only in the elite athlete but also in the general population. These injuries frequently lead to sport participation absence (SPA) and often, contact with the health care system. Although history and physical examination are the primary tools of diagnosis, musculoskeletal ultrasound (MSK US) has become the “stethoscope” for evaluation of sports medicine patients.

Even though MSK US has been widely used in Canada and Europe for years, the dramatic utilization increase in the United States has only occurred over the last two decades.2, 3 Between 2003 and 2015, there was a 347% increase in total MSK US volume within the Medicare population.3 The growth in subspecialties such as physical medicine and rehabilitation, rheumatology, and sports medicine has outpaced the growth in radiology. This Point-of-Care Ultrasound (POCUS) by clinicians may help facilitate diagnosis, expedite treatment planning, and reduce patient wait time and number of visits by offering one-stop clinics. 

Cristy Nicole French, MD
Cristy Nicole French, MD

POCUS can be quite useful to evaluate sports injuries. Propelled by advances in technology, the advent of compact, portable, and more affordable ultrasound machines may facilitate prompt diagnosis of sports injuries on the field and in the training room. 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. They also appreciate the immediate findings the physician may be able to provide at the time of imaging. In fact, most patients actually prefer ultrasound to MRI.4 Other unique advantages of MSK US for sports imaging are the ability to easily assess the contralateral side as a control and the capability for dynamic imaging. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies.4 Sports clinicians often encounter a treatment gap for a substantial percentage of young, active patients with a strong desire to return to activity, yet for whom conservative measures have failed and surgery is not indicated. Fueled by media coverage of the treatment of high-profile professional athletes, the field of orthobiologics has exploded in recent years. Ultrasound can provide target localization during administration of a wide array of injectable agents (prolotherapy, autologous whole blood, and platelet-rich plasma) in addition to image-guided peritendinous corticosteroid injections, tendon needling or fenestration, and even percutaneous ultrasonic tenotomy (Tenex).

With the development of high-frequency transducers, MSK US has equal diagnostic accuracy to magnetic resonance imaging (MRI) for evaluation of many superficial tendon and ligament abnormalities. In the current era of cost containment, the utilization of MSK US as an alternative to other more expensive imaging modalities may represent an effective way to save healthcare dollars.5, 6 However, many issues related to accuracy, observer variability, and high-quality training need to be considered, aside from pure economics, to ensure that MSK US is ethically and adequately performed in the best interest of patient care.

As any of us who have picked up a transducer know, some of the most significant disadvantages of ultrasound are the relatively long learning curve and inherent operator dependence. These challenges are compounded in MSK US by the complex anatomy, pathology, and terminology not often included in general ultrasound education programs. Dedicated training and standardized technique can minimize these limitations. Many subspecialty residency and fellowship programs have recognized the necessity of standardized, high-quality training and have strategically designed curricula to become proficient in the core competencies of MSK US.

In recent years, quantitative ultrasound methods, such as shear-wave elastography (SWE) and contrast-enhanced ultrasound, have emerged as an adjunct tool to standard B-mode imaging in the evaluation of various structures throughout the body. In particular, SWE has seen an exponential increase in the number of musculoskeletal applications. Shear-wave elastography can assess tissue stiffness by applying a mechanical stress that generates shear waves, which then travel through the tissue at a speed proportional to its stiffness. By quantifying mechanical and elastic tissue properties, SWE may provide important information about pre-clinical injuries in musculoskeletal tissues as well as tissue healing after injury. Although SWE is FDA-approved on most ultrasound platforms, its use for clinical imaging in musculoskeletal ultrasound has lagged behind research due to lack of standardization in study protocols, techniques, and outcomes measures. Nonetheless, SWE has a promising role in the future of ultrasonography in sports medicine and may help practitioners to better estimate injury severity and individualize the retraining plan for the injured athlete.


  1. Hauret KG, Bedno S, Loringer K, Kao TC, Mallon T, Jones BH. Epidemiology of Exercise- and Sports-Related Injuries in a Population of Young, Physically Active Adults: A Survey of Military Servicemembers. Am J Sports Med. Nov 2015;43(11):2645-53. doi:10.1177/0363546515601990
  2. Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am Coll Radiol. Feb 2012;9(2):141-6. doi:10.1016/j.jacr.2011.09.008
  3. Kanesa-Thasan RM, Nazarian LN, Parker L, Rao VM, Levin DC. Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015. J Am Coll Radiol. Mar 2018;15(3 Pt A):402-407. doi:10.1016/j.jacr.2017.10.015
  4. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. Jun 2008;190(6):1621-6. doi:10.2214/ajr.07.3385
  5. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. Mar 2008;5(3):182-8. doi:10.1016/j.jacr.2007.07.016
  6. Bureau NJ, Ziegler D. Economics of Musculoskeletal Ultrasound. Curr Radiol Rep. 2016;4:44. doi:10.1007/s40134-016-0169-5

Dr. Cristy French (Twitter: @cristy_french) is an Associate Professor in the Division of Musculoskeletal Radiology at Penn State Health Milton S. Hershey Medical Center. She is the Director of Musculoskeletal Ultrasound as well as the Musculoskeletal Fellowship Director.

Sonography and Work-Related Musculoskeletal Disorders

Eighty percent (80%) to 90% of sonographers and ultrasound providers across disciplines indicate they experience pain from musculoskeletal injuries, 1–3 which is a much larger percentage than in just about any other specialty within healthcare. Work-related musculoskeletal disorders (WRMSDs), however, frequently go unreported and can lead to a career-ending injury, so an alliance of 8 organizations* have come together to create the WRSMD Grand Challenge with the intent to stop work-related musculoskeletal disorders resulting from the performance of diagnostic medical ultrasound.

WRMSD Grand Challenge: Stop Work-Related Musculoskeletal Disorders (WRMSD) Resulting from the Performance of Diagnostic Ultrasound

As a part of this alliance, Dr Yusef Sayeed recently spoke about this topic, encouraging us to help promote our specialty, to progress, and to take care of this work-related issue at the very onset before things become pathology. Unfortunately, one of the largest problems within the sonographer community is official reporting of the issue and transparency. Sonographers most commonly don’t report their injuries because they fear it could cost them their job, or they are afraid of the stigma doing so could cause; this reasoning also applies to ultrasound providers and fellows, as well as is true within the healthcare field overall.

Of those injuries that do get reported, the Department of Bureau and Labor Statistics reported that the vast majority of the lost-work-time occurrences in 2016 resulted in major lost work time (11 or more days) with a median of 13 days of lost work time.

The risk factors for work-related musculoskeletal disorders have been identified as the following:

  • Awkward posture
  • Repetitive movements
  • Pinch grips
  • Wrist flexion and extension Placement of the monitor/screen

Musculoskeletal disorders are cumulative trauma disorders and develop gradually over time from repetitive activity (micro tears in the anatomy). To reduce these occurrences, alternate the side from which you scan; always standing on the right puts your right side at risk because of the repetitive motion. Step around rather than reaching across obese patients, because reaching results in you being most abducted, which also predisposes you to injury. And avoid holding the transducer in a pinch grip. In additiona, when your shoulder is abducted and your elbow extended, this puts a great deal of repetitive force on both the cervical spine as well as the shoulder joint.

Employers of sonographers also need to be cognizant of the risk factors they can prevent, such as performing more than 100 scans per month, getting less than 10 hours of rest between shifts, requiring 13 or more hours per day on shift, and night shifts (in general, night shift workers suffer more injuries on the job and have worse metabolic outcomes, ie, they suffer cardiac disease, have higher rates of CVA and MI, etc). Current business models tend to mean more scans and less time between them so sonographers are predisposed to higher rates of work-related injuries. Employees should also be able to report injuries without reprecussions. Another way employers should mitigate risk is by providing personal protective equipment such as cable straps, ergonomic tables, ergonomic chairs, etc.

Changes made in manufacturing would also help, such as making screens mobile and able to rotate and creating lighter-weight and wireless transducers, etc.

To make sonography a more sustainable profession, we need to ensure WRMSD education reaches not just sonographers and their employers but also regulatory agencies and the medical community as a whole. We need to:

  • Increase awareness, education, and transparency;
  • Understand risk factors;
  • Provide tools to prevent and reduce injuries, including forms of hazard control;
  • Engage in research to better understand occupational repetitive motion injuries; and
  • Advocate for our colleagues, patients, and friends.

View Dr Sayeed’s full webinar on YouTube to learn more about the injuries that can be a result of these risk factors:

Work-Related Musculoskeletal Disorders in Sonographers: A Look Back and a Path to Progress


  1. Wareluk P and Jakubowski W. Evaluation of musculoskeletal symptoms among physicians performing ultrasound. J Ultrason 2017; 17:154–159.
  2. Al-Rammah  TY, et al. The prevalence of work-related musculoskeletal disorders among sonographers. Work 2017; 57:211–219.
  3. Horkey J and King P. Ergonomic recommendations and their role in cardiac sonography. Work 2004; 22:207–218.
  4. AIUM Official Statement. Statement on preventing work-related musculoskeletal disorders. Available at:
  5. Sayeed Y, Sully K, Robinson K. Work related musculoskeletal injuries in sonographers and providers: the Grand Challenge. Ultraschall in Med 2020; 41: 1–10.

* The WRMSD Grand Challenge Alliance of Organizations:

  • American Institute of Ultrasound in Medicine (AIUM)
  • American Registry for Diagnostic Medical Sonography (ARDMS) and Inteleos
  • American Society of Echocardiography (ASE)
  • Intersocietal Accreditation Commission (IAC)
  • Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT)
  • Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS)
  • Society for Vascular Ultrasound (SVU)
  • Society of Diagnostic Medical Sonography (SDMS)

Interested in learning more about preventing musculoskeletal injuries? Check out the following posts from the Scan:

Hey, Ultrasound! What Did I Do Without You?

I trained as a physiatrist, which means a great deal of education on musculoskeletal conditions. Over the course of my residency training, I became more and more comfortable with bony and soft tissue landmarks for examination and targeting various joints, nerves, and tendons for therapeutic injections. As I was supervised by attendings, and carefully followed their instructions, there was no doubt in my mind that the tip of my needle was at the target intended. Why would I doubt a common practice that has been in existence for several decades?Mostoufi

As I started my fellowship in spine/pain/musculoskeletal care, I found the love of my life, the fluoroscope!!  Here, I had access to a tool that made life incredibly easy. I actually could visualize my targeted hip, shoulder, or facet joint, and inject some contrast to identify the needle tip within my target. I could precisely deliver therapeutic medications to a particular nerve root, and even identify vascular uptake and avoid procedural complications.

It was then and there that I realized that there were substantial shortcomings in what I learned as “landmark-based injections”. I realized that even though I had learned the proper “blind” procedure technique, there was no confirmation that my medication had reached its intended target. More importantly, if my patient did not respond to the procedure, I could not differentiate between a medical condition that was not responsive to the treatment versus shortcomings of un-guided procedures and inadequate delivery of medications to the targeted tissue/joint. For 12 years, I confidently treated thousands of patients by performing spine and musculoskeletal injections using my fluoroscope. I enjoyed using my C-arm, and life was pretty good.

In 2011, while attending a PM&R national conference, I sat through a 15-minute presentation on overdiagnosis of trochanteric bursitis. The speaker eloquently described fluoroscopic-guided bursa injection. This was something that I did on a regular basis as a diagnostic step. He then used ultrasound (US) images to demonstrate a few cases of gluteus medius tendinopathy and also trochanteric bursitis and how US can be superior to X-ray in therapeutic sub-gluteus maximus bursa injection. While sitting and listening, I recognized that it was virtually impossible to press against the lateral trochanter and be accurate about the diagnosis. It is also not possible to use fluoroscopy and be sure that the steroid or regenerative treatments are correctly delivered to sub-gluteus maximus bursa.

Remembering how helpful fluoroscope was to identify particular bony landmarks and assist with the proper treatment of spine and joint disease, here I was discovering a new tool that can enhance diagnostic and therapeutic skills in musculoskeletal care in particular soft tissue disease (nerves, muscles, tendons). This meant a fundamental change in the way I was going to treat patients but also a change in how I train the next generations of Physiatrists, coming through our residency program.

Fig 3aFig 3b

Learning to use the US, and incorporating it into the practice was much harder than I envisioned and also very expensive. At the time, there were limited well-structured educational resources available, and the learning curve was quite steep. As I was learning, I had to beg (or pay) my kids to become my scanning subjects!!

In contrast to a fluoroscope, it is nearly impossible to recognize an abnormal structure on the US unless you are comfortable with the normal anatomy. With a ton of hands-on workshops, mentorship, practice, and with assistance from my new found love of ultrasound machine, and guidelines from the AIUM, ultrasound has become easier and more enjoyable!! The abnormal findings became more clear and treatments more effective. In this process, I found out that patients enjoy looking at the US screen and being explained about finding on a screen full of gray, gray, and grayer lines and curves.

US has transformed how physiatrists practice and teach musculoskeletal medicine. Point-of-care US imaging allows for the residents and fellows to visualize various organs or structures within an organ, recognize healthy and diseased tissue, and diagnose the problem on the spot. This, in turn, will lead to a quick and targeted treatment and satisfied patients.

Examples of musculoskeletal (MSK) conditions that US has proven to be an effective tool to workup or treat includes rotator cuff and biceps tendinopathy, small or large joint injections, upper extremity nerve entrapments, muscle and tendon tears, peripheral nerve lesions, carpal tunnel syndrome (CTS), intersection syndromes, trigger fingers, plantar fasciitis, piriformis and sciatic complaints, treatments of bursitis or tenosynovitis, iliotibial  (IT) band treatment, ischiofemoral impingement, and many diagnoses for which dynamic testing proves to be beneficial.

Fig 6

Despite its cost and extensive training/certification needs, utilization of US in MSK care is predicted to be a standard of care in the next 5–10 years. As more and more practitioners are trained, its use for diagnostic or therapeutic purposes will become the norm.

Fig 7aFig 7b

I still love my fluoroscope and prefer its use in most spine procedures. Adding US has revolutionized my practice and allows me to be a better diagnostician, a better MSK doctor and a better educator for both my patients as well as future providers that come after me. In short, US has been a game-changer.


Ali Mostoufi, MD, FAAPMR, FAAPM, is an Assistant Prof. in PM&R at Tufts University, and the president of New England Spine Care Associates ( and Boston Regenerative Medicine (  As a spine and sports medicine practitioner, his clinical practice focuses on Interventional Spine, Diagnostic US, US-based therapeutic interventions and Regenerative Medicine in spine and sports.

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


Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.


The Best of the Scan, 5 Years in the Making

The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.MISC_SCAN_5_YR_ANN_DIGITAL_ASSETS_FB

In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.

In honor of this 5th Anniversary, here are some of your favorites:

Top 5 Most Viewed Posts


1. Ultrasound Can Catch What NIPT Misses
by Simcha Yagel
(August 4, 2015)

Sonographer Stretches2. Sonographer Stretches for an ‘A’ Game
by Doug Wuebben and Mark Roozen
(January 31, 2017)

Keepsake3. The Issue with Keepsake Ultrasounds
by Peter Magnuson
(April 30, 2015)

Hip Flexor Stretch4. 3 Stretches All Sonographers Should Do
by Doug Wuebben and Mark Roozen
(January 19, 2016)

Anton5. From Sonographer to Ultrasound Practitioner: My Career Journey
by Tracy Anton
(October 23, 2018)

The Fastest Growing Posts
That Are Not Already in the Top 5

And we have plenty more great posts, such as:

A Major Boon for Physical Therapy

As a second-year physical therapy (PT) student, I was first introduced to ultrasound for musculoskeletal conditions in 2009.

I was immediately intrigued.Headshot

I continued to dabble in musculoskeletal ultrasound (MSKUS) for a couple of years but never really with a focus on becoming good or great at the skill, more on the emphasis of becoming more knowledgeable and comfortable with human anatomy (ie, looking at muscle pennate structure, fibrillar patterns of tendons and ligaments, and identifying what they were).

Then, in 2011, I sought out a mentor for MSK ultrasound whom I had known since PT school, Wayne Smith, who is also a physical therapist with 40 years of experience. Wayne has been doing MSKUS since 2000 and in 2011 was working at Andrews Institute with Josh Hackel in the physical therapy department.

Soon after starting the training, Wayne and I collaborated with my PT clinic owner to help create a physical medicine model combining physiatry with physical therapy; MSKUS was a large piece of this model.

We quickly realized how powerful MSKUS had become and that it had turned into a gatekeeper and point-of-care diagnostic tool. MSK ultrasound is a great adjunct to evaluating a patient at time zero and in the hands of qualified physical therapists with requisite training. MSKUS allowed the clinic to execute and expedite patient plan of care by immediately cutting out unnecessary imaging studies (MRI mainly), streamlining physical therapy plans, aiding the physician with percutaneous-ultrasound-guided needle procedures, and/or immediate referral for surgical consult or advanced imaging if needed.

At this time, the RMSK exam was not on my radar so the training was piecemeal; I made the most out of my time to train with Wayne every 6 weeks while practicing and reading Jon Jacobsen’s Fundamentals of Musculoskeletal Ultrasound book.

In 2014, I took on a part-time trial with an orthopedic surgeon performing MSKUS in his office as well as physical therapy services consisting of evaluation, therapeutic exercise, and home exercise prescription. This business model became very successful and super-charged my learning in MSK ultrasound because I was now able to get feedback not only with other imaging studies, such as MRI, but I was then able to synergize findings in surgery that were based on the MSKUS imaging studies (ie, bursal sided rotator cuff tear vs intrasubstance). This feedback was very valuable and accelerated my learning curve. This orthopedic clinic is now an AIUM-accredited diagnostic center in MSK ultrasound within the state of Arizona.

In the medical model or in a stand-alone outpatient physical therapy practice, incorporating orthopedic physical therapy evaluation, MSK ultrasound evaluation combined with exercise prescription is a very powerful visit for the patient. It cuts out unnecessary imaging, saving the patient money and additional timely medical visits as well as expediting the patient’s plan of care. I’ve since incorporated this business model to many other physician offices in the greater Phoenix area.

Incorporating MSKUS into physical therapy has been a major boon for the profession and for the medical community in general.

My workweek now consists 100% of performing MSKUS scans, teaching at A.T. Still University (Mesa), starting up an online MSKUS training program, and mentoring physical therapists, athletic trainers, general sonographers, and radiology technicians in the field of musculoskeletal ultrasound in their preparation to take the RMSK or RMSKS certification exam.

Interested in reading more about how ultrasound can change physical therapy? Check out Carrie Pagliano’s post, Real-time Ultrasound in Physical Therapy.

Colin Thomas Rigney, PT, DPT, OCS, RMSK, is the Director of MSK Ultrasound for Physicians United as well as a member of both the Residential and Post-Professional Doctor of Physical Therapy Degree Faculty at A.T. Still University in Mesa, Arizona, teaching courses on Radiology and Imaging for Physical Therapy students.


Have you incorporated musculoskeletal ultrasound in your physical therapy practice? What benefits have you experienced? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.