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.

Advanced Imaging of the Fetal Heart

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Following the first demonstration of the fetal face in 1989 and the advent of fast processors around 2000, 3D and 4D ultrasound have become important tools in obstetric imaging over the past decade. Unlike 2D imaging, 3D ultrasound provides a volume of a region of interest that contains an infinite number of 2D planes. Mechanical and electronic transducers have the ability to acquire volumes of target organs through sweeps, and fast processors are able to display the acquired information within seconds. The operator can then choose to display this information in a multiplanar format of 2D images or as a spatial volume projecting the external or internal anatomic features on the screen.

Static 3D, spatiotemporal image correlation (STIC), or 4D imaging can be used to acquire a cardiac volume with a mechanical or electronic transducer. The best cardiac volumes are acquired using the STIC technique. Ideally, it can be used for offline assessment of cardiac structures and movements. Color Doppler, power Doppler, bidirectional power Doppler (high-definition flow), and B-flow modes can be combined with STIC acquisitions.

These volumes can be displayed with the color information alone, the grayscale information alone, or a combination of both, referred to as “glass-body” mode. A light source can emphasize the effect of depth.

If anomalies involving the four-chamber anatomy can be visualized similarly to the 2D image with color Doppler, anomalies involving the great vessels clearly demonstrate the superiority of 3D. Size difference, flow direction, and spatial relationship of the great vessels are some of the information that can be visualized with 3D color Doppler and “glass-body” mode. 3D imaging can, therefore, be used to explain anomalies to future parents and explore treatment options with colleagues.

The major limitations of the STIC technique include delayed acquisition time and movement artifacts due to fetal movements or maternal breathing movements.

Here are two examples where 3D color Doppler and “glass-body” mode are superior to 2D imaging in the assessment of fetal heart anomalies. 

A double aortic arch results from the persistence of right and left aortic arches. The left ductus arteriosus persists while the right ductus arteriosus regresses. Each aortic arch gives rise to a subclavian and a common carotid artery. A double aortic arch forms a tight vascular ring around the trachea and esophagus. This condition requires surgical intervention postnatally.

3D ultrasound image displaying major fetal heart structures, including the left and right aortic arches (LAo and RAo), pulmonary artery (PA), ductus arteriosus (DA), and superior vena cava (SVC).
3D ultrasound with the grayscale information alone in a fetus with the diagnosis of double aortic arch. The aorta can be seen bifurcating into a right and left aortic arch, forming a complete vascular ring around the trachea.

The part of the complete ring behind the trachea is not seen in this plane. It is better demonstrated with 3D color Doppler.

3D ultrasound image showing a fetus diagnosed with a double aortic arch, labeling the right aortic arch (RAo), left aortic arch (LAo), ductus arteriosus (DA), and pulmonary artery (PA). The image highlights the complete vascular ring formed around the trachea.
3D ultrasound in color Doppler in the same fetus. Note the bifurcation of the aortic arch into right and left aortic arches with the left ductus arteriosus, thus forming a vascular ring surrounding the trachea.

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a cardiac chamber or a great vessel.

3D color Doppler ultrasound image showing the positioning of the pulmonary artery (PA) and aortic arch (Ao) in fetal heart anatomy.
3D color Doppler image showing fetal aortic arch (Ao) and pulmonary artery (PA) with visual indicators of blood flow direction.
3D ultrasound image of a fetal heart showing the right ventricle (RV), left ventricle (LV), right atrium (RA), and left atrium (LA) with color Doppler overlay.

3D color Doppler and “glass-body” mode allowed the visualization of the CAF over an entire cardiac cycle.

References:

Chaoui R, Heling K-S. 3D Ultrasound in Prenatal Diagnosis: A Practical Approach. 2nd ed. Berlin, Germany: DeGruyter; 2024.

Abuhamad A, Chaoui R. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 4th ed. Philadelphia, PA: Lippincott-Williams Wilkins; 2022.

Tekesin I, Uhlemann F. Prenatal diagnosis of coronary artery fistula using 2D and 3D/4D ultrasound. Ultrasound Obstet Gynecol 2017; 51:274-275.

Vladimir Lemaire, MD, RDMS (Ob/Gyn, FE), is a Maternal-Fetal Medicine Sonographer at UT Southwestern Medical Center in Dallas, Texas.

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.

Focused Ultrasound as a Therapeutic Tool

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Ultrasound, long regarded as a diagnostic mainstay, is now poised to reshape how the medical community approaches treatment, particularly in the field of neurology. In a keynote presentation at the American Institute of Ultrasound in Medicine (AIUM) annual meeting, Dr. Ali Rezai of West Virginia University offered a compelling overview of how focused ultrasound is rapidly gaining traction as a therapeutic tool. His message was clear: the future of ultrasound will not be limited to imaging. It will play an increasingly vital role in treating complex brain disorders.

Used with permission from AuntMinnie.com

The use of focused ultrasound, whether high- or low-intensity, is opening new avenues in managing diseases like Parkinson’s, Alzheimer’s, epilepsy, and even addiction. These technologies deliver targeted soundwaves to precise regions of the brain, allowing clinicians to modify neural activity, open the blood-brain barrier for drug delivery, or ablate diseased tissue, all without a surgical incision.

High-intensity focused ultrasound (HIFU), which uses frequencies ranging from 20 kHz to 200 MHz, is already being used to treat patients with movement disorders such as essential tremor and Parkinson’s disease. The procedure is performed under MRI guidance, with patients wearing a specialized helmet containing around 1,000 ultrasound transducers. These transducers concentrate energy on specific brain structures involved in abnormal motor control. According to Dr. Rezai, patients often see immediate improvement, regaining function within hours and returning home the same day, an outcome that significantly reduces both recovery time and risk.

On the other end of the spectrum, low-intensity focused ultrasound (LIFU) is being investigated for its ability to transiently open the blood-brain barrier, which is a major challenge in the treatment of central nervous system conditions. This technique allows therapeutic agents that would otherwise be blocked to reach their targets more effectively. One area of active research is Alzheimer’s disease. Clinical trials suggest that LIFU can reduce amyloid plaque burden, a hallmark of the disease, simply by enabling targeted delivery or enhancing the brain’s own clearance mechanisms. In one study led by Dr. Rezai, patients receiving both focused ultrasound and anti-amyloid antibody therapy experienced greater reductions in plaque levels with minimal side effects.

LIFU is also being explored for neuromodulation—altering brain activity to treat psychiatric and behavioral disorders. By targeting deep brain structures involved in reward and craving, ultrasound has the potential to help patients with substance use disorders or behavioral addictions. Preliminary data from a small clinical study show that even a single treatment session aimed at the brain’s nucleus accumbens reduced cravings, with some patients reporting sustained effects.

Dr. Rezai emphasized that these breakthroughs are not theoretical. His team at the Rockefeller Neuroscience Institute is performing these procedures weekly, and demand is increasing. “We’re in desperate need for therapeutic strategies because people are living longer,” he said.

As this field matures, the implications extend far beyond traditional neurology. Focused ultrasound for therapeutic use is drawing interest from neurosurgeons, psychiatrists, biomedical engineers, and data scientists. The integration of real-time imaging, precision targeting, and noninvasive energy delivery makes it a uniquely versatile platform. It may not be long before therapeutic ultrasound becomes a standard tool in multidisciplinary care, ushering in a new era where sound not only reveals what’s happening inside the body but also helps restore function and quality of life.

The future is very bright for therapeutics and using focused ultrasound
— Dr. Ali Rezai

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

Abdominal Aortic Aneurysms and Ultrasound

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An abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta that, if undetected or untreated, can lead to life-threatening rupture. Often asymptomatic, AAAs can lead to catastrophic outcomes if they rupture, making early detection and monitoring crucial. Fortunately, ultrasound imaging plays a central role in early diagnosis, ongoing surveillance, and even postoperative management, making it a cornerstone in efforts to reduce AAA-related deaths.

What is an Abdominal Aortic Aneurysm?

The abdominal aorta is the largest artery in the abdomen, supplying blood to the lower body. An AAA occurs when a segment of this artery becomes weakened and bulges outward. An aortic diameter of 3.0 cm or more is typically considered aneurysmal. Risk factors include age (especially over 65), male sex, smoking, high blood pressure, and a family history of aneurysms.

Because most AAAs do not cause symptoms, routine screening is essential in high-risk populations. Men over 65 who have ever smoked are commonly advised to undergo a one-time screening, which is most effectively conducted using ultrasound.

The Role of Ultrasound in Diagnosis

Ultrasound is the first-line imaging modality for AAA screening due to its noninvasive nature, lack of ionizing radiation, cost-effectiveness, and accuracy. It can detect an aneurysm with high sensitivity and specificity, and provide precise measurements of the aorta’s diameter, helping determine whether an aneurysm is present and how large it is.

A recent study published in an article in the Journal of Ultrasound in Medicine (JUM; doi:10.1002/jum.15401) underscores the value of ultrasound in identifying aortic pathology early. This study showed that ultrasound training using low-cost, realistic phantoms improved detection accuracy, supporting the widespread use of ultrasound screening programs and skill development among clinicians.

In emergency settings, ultrasound can be deployed at the bedside for rapid diagnosis in patients with suspected AAA rupture. This is particularly valuable in hemodynamically unstable patients, where time is critical. Real-time imaging allows clinicians to confirm the presence of an aneurysm and initiate life-saving interventions without delay.

Monitoring and Surveillance

Not all AAAs require immediate surgery. For aneurysms under 5 cm in diameter, regular monitoring is typically recommended. Ultrasound allows for safe, repeatable, and accurate measurements over time to assess growth rates and determine when intervention is necessary.

Postoperative Follow-Up

In cases in which surgery was needed, however, ultrasound is also integral in post-treatment monitoring, especially following endovascular aneurysm repair (EVAR). It can identify complications such as endoleaks—continued blood flow into the aneurysm sac outside the stent graft—which may increase the risk of rupture. Surveillance protocols often rely on ultrasound to reduce the need for repeated CT scans, limiting patient exposure to radiation and contrast agents.

Another article in the JUM (doi:10.1002/jum.16374) examined advanced ultrasound methods for identifying endoleaks, highlighting how innovations like coded-excitation imaging can improve diagnostic clarity and reliability in follow-up care.

Ultrasound image showing a localized abdominal aortic aneurysm (AAA) with measurements indicated, displaying the cross-section of the aorta.

Evolving Techniques and Considerations

Ultrasound technology continues to evolve. For instance, recent investigations into the effects of transducer pressure on aortic wall stiffness measurements (arXiv:2312.07980) indicate that even subtle operator-dependent variables can impact results. Standardization in measurement techniques will enhance consistency and accuracy in monitoring AAAs, particularly as stiffness metrics gain interest for their potential to reflect aneurysm stability.

Additionally, the development of realistic and inexpensive ultrasound phantoms has facilitated better training and demonstration of aortic pathology detection, improving diagnostic accuracy and clinician proficiency.

Final Thoughts

Ultrasound’s versatility, safety profile, and diagnostic precision make it indispensable in the detection and management of abdominal aortic aneurysms. From identifying at-risk individuals during routine screenings to guiding urgent interventions and long-term follow-up, ultrasound’s role in vascular care continues to grow. As research and technology refine its capabilities, the potential to further improve outcomes for patients with AAAs becomes ever more promising.

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.

Understanding the Impact of Preeclampsia on Fetal Heart Health

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Preeclampsia, a serious condition marked by high blood pressure and potential organ damage during pregnancy, affects about 4–5% of pregnancies worldwide. While its dangers to mothers are well-documented, growing attention is being paid to how it affects unborn children, particularly their heart health.

A study in 2023 explored how the severity of preeclampsia and the level of proteinuria (protein in urine) influence fetal cardiac function.

Why Fetal Heart Health Matters in Preeclampsia

The fetal heart plays a critical role in adapting to the stressors of an abnormal intrauterine environment caused by preeclampsia. With placental blood flow compromised due to poor vascular development and high resistance, the fetus often experiences hypoxia and increased pressure. These conditions can subtly alter heart function even before birth.

Previous research has suggested that fetuses exposed to preeclampsia may have a higher risk of cardiovascular disease later in life. But how early do these changes start? And does the severity of the mother’s condition make a difference?

Signs of Stress in the Fetal Heart

In the 2023 study, fetuses in the preeclampsia group showed notable changes in both systolic (pumping) and diastolic (filling) heart functions compared to the control group. Specifically, the researchers observed:

  • Reduced ventricular relaxation and compliance — evidenced by lower early and late diastolic velocities (E and A waves) and longer isovolumetric relaxation times.
  • Diminished myocardial contractility — reflected in reduced mitral and tricuspid annular plane systolic excursion (MAPSE and TAPSE) and lower systolic velocities (S0 values).

These findings suggest that even before birth, the hearts of fetuses in preeclamptic pregnancies may be under increased strain.

The Role of Proteinuria and Severity

Interestingly, the study also revealed that more severe preeclampsia and higher proteinuria levels (>3 g/24 hr) were associated with more pronounced changes in fetal heart function. This is especially relevant given that proteinuria was removed from the official diagnostic criteria for preeclampsia in 2013. Yet, clinical observations and studies like this one highlight its continued relevance in assessing risks to both the mother and the fetus.

For example, fetuses in the group with higher proteinuria had significantly lower values in key diastolic function markers, suggesting reduced ventricular compliance. This could mean that fetuses in these pregnancies rely more on atrial contraction to fill their ventricles, which is an early sign of cardiac strain.

A Call for Enhanced Monitoring

One of the study’s most significant takeaways is the value of tissue Doppler imaging (TDI) in detecting early and subtle changes in fetal heart function. Because TDI can assess the movement of myocardial tissue independently of blood flow, it’s particularly useful in identifying subclinical dysfunction before more overt signs of distress appear.

Given these findings, enhanced fetal cardiac monitoring may be warranted in pregnancies complicated by preeclampsia, especially those with higher levels of proteinuria or classified as severe. Earlier detection could guide better perinatal care and potentially inform follow-up strategies after birth.

For More Information

The full research article, titled “Evaluation of Fetal Cardiac Functions in Preeclampsia: Does the Severity or Proteinuria Affect Fetal Cardiac Functions?” by Derya Uyan Hendem et al., is published in the Journal of Ultrasound in Medicine (2023). You can read the detailed study here.

Overcoming Common Ultrasound Scanning Challenges: Practical Tips for Sonographers

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Ultrasound is an essential imaging tool in modern medicine, offering visualization of soft tissues, organs, and vascular structures. However, even the most experienced sonographers encounter obstacles that can make obtaining clear images difficult. From excessive bowel gas obscuring structures to scanning patients with high body mass indexes (BMIs), these challenges require skill, adaptability, and technical adjustments. Here are some of the most common ultrasound scanning challenges and practical solutions to optimize imaging.

1.  Imaging the Aorta in Gassy Patients

Few things are as frustrating as trying to visualize the aorta when excessive bowel gas gets in the way. Gas scatters ultrasound waves, making it difficult to see vascular structures clearly.

Solutions:

  • Use an Intercostal Approach: Instead of scanning anteriorly, try navigating through the intercostal spaces on the right side to bypass gas-filled loops of bowel.
    • Apply Steady, Firm Pressure: Pressing gently on the abdomen can help displace gas and improve sound wave penetration.
  • Change the Frequency: A lower-frequency transducer (such as a curvilinear probe at 1–6 MHz or 2–5 MHz) allows deeper penetration, sometimes improving visibility despite gas interference.

Video Link: Watch here

2.  Scanning High BMI Patients

Larger patients present challenges due to increased soft tissue thickness, which can reduce image resolution and penetration.

Solutions:

  • Use a Lower Frequency Transducer: A 1–6 MHz or 2–5 MHz curvilinear transducer enhances penetration, even if it sacrifices some resolution. This is especially useful when scanning larger patients, such as when ruling out lower extremity DVTs. While linear probes are common for vascular imaging, don’t hesitate to use whatever transducer best visualizes the patient’s anatomy, whether it’s curvilinear, phased array, or another alternative.
    • Increase the Time Gain Compensation (TGC): Adjusting the TGC enhances contrast and clarity in deeper structures.
  • Optimize Patient Positioning: Having the patient roll onto their side allows gravity to shift excess tissue, improving visualization. Right Lateral Decubitus (RLD) positioning works well for imaging the spleen and left kidney, while Left Lateral Decubitus (LLD) positioning is ideal for the right kidney, gallbladder, and the dome of the liver.
  • Utilize Harmonic Imaging: This setting helps reduce artifacts and enhances contrast resolution for clearer imaging.
Ultrasound image showing a longitudinal view of the proximal aorta, used for evaluating vascular structures and potential obstructions.
Photo: This image shows the aorta of a patient with a BMI of 50+, captured using an intercostal approach. (Fun fact: “Intercostal” just means between the ribs!)

3.  Evaluating Deep or Small Vessels

Poor acoustic access can make visualizing small or deep vessels, such as the popliteal artery or small renal arteries, difficult.

Solutions:

  • Use Color and Power Doppler: Increasing Doppler sensitivity helps detect slow-moving blood flow in deep or small vessels.
  • Optimize the Angle of Insonation: Keeping the Doppler angle between 45 and 60 degrees improves velocity accuracy.
  • Apply Gentle Compression: This technique helps differentiate veins from arteries and optimize visualization. I frequently use this when assessing ankle-brachial index (ABI) ratios in calcified arteries near the ankle.

4.  Differentiating Cysts From Solid Masses

Distinguishing between cystic and solid structures can be tricky, especially when artifacts mimic fluid-filled lesions.

Solutions:

  • Use Multiple Imaging Planes: Scanning from different angles helps confirm whether a structure is truly cystic or solid. Always assess the kidneys from multiple planes—exophytic masses and cysts love to hide where you least expect them.
  • Apply Color Doppler: Cysts will not show internal blood flow, while vascularized solid masses will have detectable Doppler signals.
  • Adjust Gain Settings: Lowering overall gain can help differentiate hypoechoic solid structures from fluid-filled cysts.

Conclusion

Ultrasound scanning challenges are inevitable, but a skilled sonographer can overcome them with the right techniques. Adjusting transducer settings, modifying patient positioning, and using alternative scanning approaches can significantly improve image quality. By staying adaptable, sonographers can ensure optimal imaging, leading to more accurate diagnoses and better patient outcomes.

Let’s Stay Connected!

Theresa Jenkins, BS, RDMS, RVT

I hope these tips help you tackle ultrasound challenges with confidence! Connect with me on LinkedIn or check out my YouTube channel, Path2Passing, for more ultrasound insights and updates!

🔗 LinkedIn: Theresa Jenkins
🎥 YouTube Channel: Path2Passing
✍ Author: Theresa Jenkins, BS, RDMS, RVT

Theresa Jenkins BS, RDMS, RVT, is a seasoned sonographer with nearly seven years of experience, having worked in top facilities nationwide. Credentialed in general, vascular, and pediatric ultrasound, she is also an educator and author with plans to become a leading voice in sonography.

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.

Workplace Conflict in Medical Imaging

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I’m going to tell you all a secret: I enjoy conflict.

No, I don’t enjoy creating conflict, and I certainly don’t enjoy being involved in conflicts with peers or my students. But I love studying it, mainly “why” conflict happens and how it impacts our organizational systems and daily interactions. Perhaps I’m naïve and hold an idealistic view that if we solved specific problems, the world would be run more effectively, and people would have more time to improve themselves and their environments. Wild, right?

I began looking into workplace conflict in hospitals in 2019 while shopping around for a dissertation topic, combining my knowledge from two fields of expertise: Vascular sonography and conflict resolution. Little did I know this task would become Herculean in scope as I quickly discovered how allied health professionals were marginalized in literature exploring conflict in hospitals.1 I found this odd and wanted to dive into this topic, puzzled by this literature that should have known conflict did not occur in a vacuum. Additionally, all the unresolved conflicts in healthcare would inevitably spiral out of control, leading to systemic conflicts that were much harder to resolve.

Many folks use the word “systemic” without understanding complex systems theory.2 Have no fear; I won’t bore you to tears with an explanation of systems theory and the differences between open and closed systems. However, I will explain that not only are you a system, but our healthcare professions are systems, our medical imaging departments are systems, and hospitals are systems. Sometimes, these systems work in harmony, but sometimes, they do not function as intended, leading to two types of social conflict: interpersonal and interprofessional.1 These conflicts demoralize hospital staff and probably impact patient care delivery from physicians, nurses, and allied health professionals who could be suffering from stress and burnout.1

We are all familiar with interpersonal conflict; it is unavoidable and, in many ways, necessary for personal growth. It is interprofessional conflict that should warrant more attention, particularly in hospital settings, as there is a tendency for healthcare professionals to be tribal in their group behavior, meaning they stick with their “own” and have an in-group preference. Medical imaging departments are not exempt from this phenomenon.1 Based on existing literature exploring conflict in hospitals,3,4 most reported conflict is interpersonal and intraprofessional, meaning the conflict most often occurs between peers, eg, nurse versus nurse. Interprofessional conflict reported in the literature also involved nurses versus physicians and occasionally involved allied health, including medical imaging professionals.1

The origins and antecedents of conflict within medical imaging are multifactorial: They combine personal factors specific to individuals with work-related issues exacerbated by high-stress, unpredictable work environments.1 Interprofessional conflict is particularly troubling as it suggests a difference in professional values between professions or a divergence of interests between patient care and the need to generate revenue.1 In those situations, a phenomenon known as “dual agency”1 may explain some interprofessional conflicts as medical imaging professionals struggle to advocate for patients while also serving the interests of their employers. This does not explain all of the interprofessional conflict, but it does suggest a need for medical imaging professionals to consider their roles in the larger healthcare system and if they are truly serving the best interests of their patients.

So, how do we address workplace conflict in medical imaging? Unfortunately, I see no “one size fits all” solution, but I propose a template for resolving many issues that contribute to conflict: Dispute systems design.5 Dispute systems design is a tailor-made analysis of a unique, conflict-prone environment that could identify problem elements within the system and provide opportunities for long-lasting resolution. Managing conflict is a misnomer, as the key to lasting conflict resolution is collaborative conflict resolution between conflicted parties.6 I am confident that introducing dispute systems design into hospitals and medical imaging departments can elicit many positive changes, potentially reducing burnout and staff turnover.

References

  1. Moody RC. Medical Imaging Professionals Experiencing Workplace Interprofessional Conflict: A Phenomenological Study. Davie, FL: Nova Southeastern University; 2023.
  2. Meadows DH. Thinking in Systems: A Primer. White River Junction, VT: Chelsea Green Publishing; 2008.
  3. Almost J, Wolff AC, Stewart-Pyne A, McCormick LG, Strachan D, and D’souza C. Managing and mitigating conflict in healthcare teams: an integrative review. J Adv Nurs 2016; 72:1490–1505. doi:10.1111/jan.12903
  4. Kim S, Bochatay N, Relyea-Chew, et al. Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. J Interprof Care 2017; 31:282–290.
  5. Rogers NH, Bordone RC, Sander FE, and McEwen CA. Designing Systems and Processes for Managing Disputes. Frederick, MD: Wolters-Kluwer; 2013.
  6. Katz NH, Lawyer JW, Sweedler M, Tokar P, and Sosa K. Communication and Conflict Resolution Skills. 3rd ed. Dubuque, IA: Kendall Hunt Publishing; 2020.

Robert Moody, PhD, MS, RVT, is an Assistant Professor of Cardiovascular Sonography at Nova Southeastern University (NSU) in Fort Lauderdale, FL.

Hydrops Fetalis and the Role of Ultrasound in Its Diagnosis and Management

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Hydrops fetalis is severe swelling (edema) in a fetus or a newborn baby, and it is a life-threatening problem. There are two types; immune and nonimmune depending on the cause.

Immune hydrops

The immune version is usually a consequence of Rh incompatibility between the mother and fetus, leading to hemolytic disease of the fetus and newborn (HDFN). If the mother is Rh-negative and is having an Rh-positive baby, the mother’s immune system attacks the unborn baby’s red blood cells. This causes anemia. Hydrops occurs if the developing fetus’s organs are not able to overcome the anemia. Large amounts of fluid will build up in the fetus’s tissues and organs and the heart likely will begin to fail. This type of hydrops is not common today because Rh-negative women are often treated with Rh immunoglobulin to prevent this problem.

Nonimmune hydrops

This is the more common type of hydrops. This type can be caused by many other diseases or complications that may interfere with how a fetus manages fluid. Most of the conditions that can cause nonimmune hydrops are

  • Severe anemia,
  • Infections present before birth,
  • Heart or lung abnormalities,
  • Chromosomal abnormalities and birth defects, and
  • Liver disease and twin-to-twin transfusion.

During pregnancy, symptoms may include large amounts of amniotic fluid, thickened placenta, and ultrasound of the unborn baby may show enlarged liver, spleen, or heart. It may also show fluid buildup around the fetus’s abdominal organs, heart, or lungs.

Post delivery, symptoms include pale coloration, overall severe swelling, especially in the baby’s abdomen, trouble breathing, enlarged liver and spleen.

How to Diagnose Hydrops Fetalis

Ultrasound: This test uses sound waves to create images of blood vessels, tissues, and organs of the fetus. The healthcare provider will use the ultrasound to look at how a fetus’s internal organs are working and can see how blood flows through different vessels.

The first sign of hydrops fetalis on ultrasound is usually the abnormal accumulation of fluid in fetal compartments. This can include skin edema (thickening of the skin), ascites (fluid in the abdomen), pleural effusion (fluid around the lungs), and pericardial effusion (fluid around the heart). These findings are often accompanied by polyhydramnios (excess amniotic fluid) and placental thickening.

Fetal blood sampling: This is done by placing a needle through the mother’s uterus and into one of the fetus’s blood vessels or the umbilical cord.

Amniocentesis: This test is done by removing some of the amniotic fluid around the fetus for testing.

Assessment of Severity: Once hydrops fetalis is identified, ultrasound is used to assess the severity of the condition. Measurements such as the cardiothoracic ratio, the thickness of the skin edema, and the amount of fluid in each compartment help determine the extent of the disease. Doppler ultrasound is also utilized to evaluate fetal blood flow, particularly in cases of suspected anemia or cardiac issues, providing insights into the fetus’s hemodynamic status.

Determining the Underlying Cause: While ultrasound can easily identify the presence of hydrops fetalis, determining the underlying cause requires a more comprehensive approach. For instance, fetal echocardiography, a specialized form of ultrasound, can assess structural heart defects or cardiac dysfunction. In cases of suspected genetic abnormalities, ultrasound findings may prompt further testing, such as amniocentesis or chorionic villus sampling, to analyze the fetal karyotype.

How is hydrops fetalis treated?

Treatment of hydrops depends on the cause. During pregnancy, hydrops may be treatable only in certain cases. The management of hydrops fetalis is complex and depends largely on the underlying cause, gestational age, and the severity of the condition. Ultrasound continues to play a crucial role in monitoring the fetus and guiding therapeutic interventions.

Fetal Monitoring: For ongoing pregnancies, serial ultrasounds are essential to monitor the progression of hydrops fetalis. Regular assessments of fluid levels, fetal growth, and Doppler studies help guide clinical decisions, such as the timing of delivery. In some cases, ultrasound-guided procedures may be performed to relieve fluid accumulation, such as thoracentesis for pleural effusions or paracentesis for ascites.

Intrauterine Interventions: In certain cases, intrauterine interventions may be considered to improve fetal outcomes. For example, in cases of severe fetal anemia, ultrasound-guided intrauterine transfusions can be performed to deliver blood to the fetus. These procedures are highly specialized and require careful planning and execution.

Delivery Planning: The timing and mode of delivery for a fetus with hydrops fetalis are critical and must be carefully planned based on ultrasound findings. In cases of severe hydrops or fetal compromise, early delivery may be necessary to prevent stillbirth or to provide neonatal care. Ultrasound aids in determining fetal lung maturity and guiding the decision on whether antenatal corticosteroids should be administered to enhance fetal lung development. A mother may need to deliver the baby early.

In a newborn baby, treatment may include:

  • Help for breathing problems. This may be with extra oxygen or a breathing machine (ventilator).
  • Removing extra fluid from spaces around the lungs, heart, or inside the belly using a needle.
  • Fetal blood transfusion in cases with immune hydrops.

The Complications of Hydrops Fetalis

The severe swelling that occurs with hydrops can overwhelm the baby’s organ systems. Approximately 50% of live-born babies with hydrops don’t survive and for those that do, there are risks for other problems. Survival often depends on the cause and treatment.

Key Points on Hydrops Fetalis

  • Hydrops fetalis is severe edema in a fetus or newborn baby.
  • It is a life-threatening problem.
  • Hydrops develops when too much fluid leaves the fetus’s blood and goes into the tissues.
  • It is almost always diagnosed during pregnancy or right at birth.
  • Treatment of hydrops depends on the cause.
  • Approximately 50% of live-born babies with hydrops don’t survive.

Conclusion

Hydrops fetalis is a serious and often fatal condition that requires prompt diagnosis and careful management. Ultrasound is an indispensable tool in both the diagnosis and management of hydrops fetalis, offering detailed insights into the severity of the condition, the underlying causes, and the appropriate course of action. By utilizing ultrasound effectively, healthcare providers can improve the prognosis for affected fetuses, offering the best possible outcomes in challenging situations.

Gerald Walter Mosota is a Diagnostic Medical Sonographer in Mombasa, Kenya.

Gerald Walter Mosota

Diagnosing and Mapping Endometriosis With Ultrasound

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About four years ago, I felt like I had made a massive discovery akin to cracking cold fusion or inventing time travel. Although my revelation didn’t win me a Nobel Peace Prize, it forever changed the course of my medical training and gynecology practice. This discovery came through a podcast on Advanced Imaging for Endometriosis. Thus, my journey into the world of advanced gynecologic ultrasound (AGU) and endometriosis began.

The title and details of the mentioned podcast, "Advanced Imaging for Endometriosis" on the Gynecologic Surgeons Unscrubbed podcast dated Tuesday, Mar 23, 2021. The description states, "In this episode, Dr. Cara King speaks with Dr. Mathew Leonardi, an advanced gynecologic surgeon and sonologist (ultrasound specialist) at McMaster University Medical Centre in Hamilton, Canada. As March is Endometriosis awareness month, Mathew talks about advanced endometriosis imagery and how it impacts preoperative counseling, planning, and intraoperative surgical intervention. He also talks about how he created his own path to where he is today. Listen as he shares how to build skills in advance sonography and incorporate this into residency as well as fellowship education."

My years of medical school and residency training had never included this kind of diagnostic capability for endometriosis. The axiom that surgery was how endometriosis was diagnosed was firmly established in my mind. Furthermore, I was astonished that ultrasound, something so ubiquitous in obstetrics and gynecology, was the way to achieve this paradigm shift. I remember sitting in my car listening to Dr. Mathew Leonardi talk about the possibility of not just diagnosing endometriosis before surgery but specifically mapping out where the disease was present. My mind was blown. In my new-found passion for endometriosis diagnosis, I took to the internet.

After a brief exchange on Twitter, Dr. Leonardi graciously agreed to let me shadow his practice for a week. Fortunately for me, Hamilton, Ontario, where Dr. Leonardi worked, was just a short drive and a (sometimes) quick border crossing from where I was completing a residency in Buffalo, New York, so I could witness these transformative ultrasound techniques firsthand. What I experienced that week was a game-changing way to care for patients. Patients with pelvic pain and suspected endometriosis could visit the clinic, undergo a comprehensive pelvic ultrasound, and receive an informed management plan. It wasn’t a model of “let’s see what we find” or broad counseling about options. Patients received immediate information about the scan findings and knew what to expect in the management plan. Furthermore, the therapeutic benefit here cannot be understated. Many patients would tear up feeling validated as their experiences were finally reflected in tangible scan results.

Of course, I was impressed by the patient experience side of AGU. What hooked me even further was the amazing amount of information that one could garner from these ultrasound techniques. Cul-de-sac obliteration, deep endometriosis of the bowel, ureteral strictures, uterosacral ligament lesions, ovarian mobility, and the list goes on. With the wealth of information accessible through ultrasound and my sights set on a surgical practice, I had to learn this transformative skill. A few years later, while in my minimally invasive gynecologic surgery fellowship, I was fortunate to be able to travel to McMaster University and complete a month-long elective with Dr. Leonardi to develop my AGU skills. While this experience greatly advanced my ultrasound capabilities, I believe that anyone interested in AGU does not necessarily need a dedicated month of intensive scanning to bring this skill into practice. The journey starts with a single scan.

Mathew Leonardi and Daniel Nassar smiling and standing in front of the sign for the Department of Obstetrics and Gynecology at McMaster University
Mathew Leonardi, MD, and Daniel T. Nassar, DO, MPH

If you’re interested in starting this journey, enhancing your scanning techniques, or polishing your skills at The Ultrasound Event 2025 conference, I encourage you to sign up for the hands-on training session co-chaired by Dr. Leonardi and me: The UltraSolution Experience: Mastering Next-Gen Endometriosis Ultrasound. In this session, we, along with other experts in AGU, will guide you through simulated endometriosis ultrasounds using the Intelligent Ultrasound ScanTrainer® platform to focus on assessments of findings including bowel and bladder endometriosis. I hope you are as excited to join as we are to share the transformative capabilities of advanced gynecologic ultrasound with you all!

Please feel free to ask any questions about the course or share your journey with gynecologic ultrasound.

I hope to see you at the conference,

Daniel Nassar, DO, MPH
Minimally Invasive Gynecologic Surgery
Dept. of Obstetrics & Gynecology