Tag Archives: MSK

Musculoskeletal Ultrasound: Improving Patient Care in Real-Time

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

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

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

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

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

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

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

The Potential of Elastography in MSK Ultrasound

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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.

What Rheumatologists Really Need for Ultrasound Is…

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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

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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.

References

  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.

A Future Career Path for the MSK Sonographer

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The sonographic community has the opportunity to take advantage of recent orthopedic surgeons’ interest in diagnostic ultrasound. Although much of the interest was prompted by the usefulness of guided injections, sonographers need to fully appreciate and understand the value of the information derived from an ultrasound study, which will ultimately lead the surgeon to better surgical decisions and better patient outcomes. Once you are a part of the orthopedic diagnostic team, you will be able to function as a specialist Physician Assistant member, adding a new dimension to the orthopedic practice and demonstrating the incredible value of diagnostic soft tissue imaging.

I am a Board-Certified Orthopedic Surgeon, with subspecialty in shoulder orthopedics including arthroscopy and open surgery. I incorporated diagnostic shoulder/MSK ultrasound as part of my office practice 20 years ago especially for evaluation of patients presenting with protracted shoulder pain (in addition to the traditional history and physical exam, and occasional MRI).

I have valued diagnostic shoulder imaging in my practice and determined that all Orthopedic Surgeons should be using ultrasound imaging as part of their usual diagnostic evaluation of patients (especially patients presenting with protracted painful shoulder problems affecting function). In addition, an ultrasound exam with normal findings may be more important than an ultrasound exam that finds some pathology.

I have concluded that the real-time ultrasound examination with comparison to the contralateral side available to the orthopedic surgeon, in most cases, is more valuable than the information obtained from the MRI (especially regarding soft tissue pathology, present or absent).

For example, compare the MRI detail of the supraspinatus with the ultrasound motion clip of the supraspinatus moving under the acromion (see the still MR image below and, at bottom of the page, the 1st video, which is the active ultrasound clip of the supraspinatus). MRI is accomplished with arms immobilized at one’s side, and does not benefit from the study being compared to the contralateral side. However, it produces a nice clear image. The ultrasound image in long axis can be a still image or a motion clip viewing the supraspinatus or infraspinatus moving under the acromion and the reaction causing impingement syndrome, spurs along the anterior lateral border of the acromion, dynamic sub acromial bursitis, or a rotator cuff tear, which may be attritional and similarly present on viewing the asymptomatic shoulder.

figure-1

The Math

The following statistics help to identify the future vital need for the sonographer to become part of the team working with the surgeon in an orthopedic office practice (Orthopaedic Surgeon Quick Facts, www.aaos.org; 10 Interesting Statistics and Facts About Orthopedic Practice, www.beckersspine.com; Am J Orthop 2016;45(2):66-67; 20 Things to Know About Orthopedics, www.beckershospitalreview.com).

There are approximately 28,000 (2012) orthopedic surgeons in the US, 75% of whom are in private practice, and many are in group practices of 2 or more. The general orthopedic surgeon sees an average of 70-90 patients per week, of which an estimated 12% or more have shoulder problems. This equates to 10 orthopedic shoulder evaluations per week for 1 solo general orthopedic practice, and 20 for a 2-man group (in the same office). Ten to 20 patients (minimum) per week would then benefit from ultrasound imaging information, assisting the surgeon in making a surgical decision.

The following image identifies how important the cross axis image is, as well as describes the degree of rotator cuff injury and approximates the relative number of rotator cuff muscle tendon units that have been rendered dysfunctional.

figure-2-a-to-c

Left, Close to the infraspinatus/supraspinatus interval and insertion site, many fibers are in harm’s way for tendon/fibril tearing. Center, The area for careful X-axis grid examination, looking for possible partial undersurface tearing, fibers losing their connection/attachment to the footplate. Right, Example of an X-axis grid examination of this full-thickness tendon tear, which should be accompanied by an x-axis measurement of the width/base of the triangular tear. Real time examination can help to identify the quality of the tissue, which may require repair. Usually, orthopedic surgeons pay more attention to the MRI reading and the coronal views (ultrasound long axis view). (See the 2nd video clip below for real-time imaging of the X-axis rotator cuff tear.) The X-axis view/measurement is the more important image. The wider the tear, the more tendon fibrils are affected and the more dysfunction to the rotator cuff area involved.

This need for diagnostic shoulder ultrasound information could be sufficient and important enough to support an entire career for an MSK sonographer. All the other valuable areas of MSK expertise that come with the MSK sonographer would be an extra bonus to the orthopedic office practice: helping with other ultrasound examinations, diagnosis, and surgical decisions.

Video clip 3 below is an MSK ultrasound examination for CTS identifying median nerve mobility or restriction within the tissue, questioning the presence of scar tissue restricting motion.

How have you used ultrasound in orthopedic surgery? What other areas of ultrasound are on the brink of emerging in a new field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Alan Solomon, MD, is a Board Certified Orthopedic Surgeon and Honorary Staff at the Metro West Medical Center, Natick/Framingham, MA.

Ultrasound Set to Transform Occupational Medicine

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There is no question that medical ultrasound is quickly becoming a valuable tool in musculoskeletal (MSK) medicine. Providers are realizing that this modality allows for quick evaluation in the office and even has a higher resolution than MRI. Research shows, for example, that scanning a shoulder to evaluate for a rotator cuff tear is faster, cheaper, and at least as sensitive and specific as ordering an MRI.

dr sayeedWhere using this modality for MSK medicine will have a huge impact is within occupational medicine.

In occupational medicine, we are tasked with providing quality care for patients while simultaneously enabling patients, institutions, corporations, and the overall health care system to save money. For practitioners, MSK ultrasound allows us to accomplish both of these goals. Widely utilized by our counterparts in European medical schools and hospitals, MSK ultrasound’s use in occupational medicine is still in its early stages in the United States. This means that occupational medicine is one specialty that stands to reap significant clinical benefits from its use.

But in order to understand the potential, and to position MSK ultrasound at the forefront of occupational medicine education, I conducted a little research.

Last year, I conducted a survey to learn how many occupational medicine program directors and residents were using MSK ultrasound and how many wanted to use it. The survey results confirmed that it was not widely used in occupational medicine residency programs. In fact, only a couple of programs use it and they do so cursorily.  The results also showed that most had a sincere interest in learning to use it, but there was not a program in place.

Since residency programs produce the field’s future physicians, I designed a multidisciplinary MSK ultrasound course to teach the basics to attendings and residents. Weekly sessions focused on specific anatomic regions to help provide a foundation for identifying pathology and improve interventional skills. This “how to” manuscript was recently published in the Journal of Occupational and Environmental Medicine.

Moving forward, I am presenting an introductory level lecture at the occupational medicine national conference (AOHC) to further demonstrate how MSK ultrasound could potentially be widely used in our field. I hope to introduce “hands-on” workshops over the course of the next few years to give the field a chance to learn this modality and implement it into practice. My goals are to see occupational medicine practitioners provide the highest standard of health care for this unique hardworking population of patients, while concurrently reducing costs for workers’ compensation claims.

What can AIUM provide occupational medicine to help further the use of ultrasound? What other areas are on the verge of being transformed by ultrasound? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Yusef Sayeed, MD, MPH, MEng, CPH, is an occupational medicine Chief Resident at West Virginia University in Morgantown, WV.

Why I Attended AIUM’s MSK Course

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In late 2014, I attended the AIUM MSK ultrasound course that was held at the USOC facilities in Colorado Springs. Why, you might ask? Well, here are four reasons I did.

  1. Focus—I do a lot of MSK ultrasound (I have my RMSK and my practice is AIUM accredited) but I do not see a lot of hand and wrist. Since the focus was going to be on upper extremity I felt that this would be a chance to get a good review of hand, wrist and elbow.
  2. USOCKiller faculty—Jay Smith, Lev Nazarian, Tony Bouffard and Jon Jacobson were all on the schedule. Combine them with a limited number of attendees and I knew I would get to interact with them on a more personal level.
  3. Great format—The way the content was structured really appealed to me. I like how we had a lecture, followed immediately by a live scan and then the ability to scan patients. It was excellent and really brought the lecture material right into practice.
  4. Location and price—I had never been to Colorado Springs, much less the Olympic training center. And when I looked at how focused the course was as well as the faculty, I felt the price was very reasonable—especially with the option of staying on site.

For me, the thing that stood out most at the course was getting an appreciation for scanning the scapholunate ligament (SLL). My scanning preceptor was very adept at showing us how to visualize the ligament and how to easily locate it. When I went back to the office and actually had an SLL injection, I was able to do it effectively and get my patient good relief.

I hope that if or when the AIUM does this course again, or another MSK course, they keep the number of participants limited and the topics varied. At some point, I think the course could become stratified so that whether you are at a beginner, intermediate or advanced level, you can participate and learn. Personally I’d like to see a course focusing on the hip and spine with injections.

All in all, given the hosts, the course faculty, the limited number of attendees and topic scope, the price and location, this was one of the best MSK ultrasound courses that I’ve attended.

What’s the best course you have attended? How can AIUM make its courses better? Have you heard about AIUM’s newest MSK Course? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Amadeus Mason, MD, is Assistant Professor of Orthopaedic Surgery and Family Medicine at Emory Sports Medicine Center in Atlanta.