Tag Archives: musculoskeletal ultrasound

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enhancing Diagnostic Accuracy With Musculoskeletal Ultrasound

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Season in the Life of a Tendon

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

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

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

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

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

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

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

Ultrasound as a Performance Barometer

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

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

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

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

Don’t Diagnose in a Vacuum

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

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

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

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

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

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

The 2025 AIUM Annual Convention: The Foremost Ultrasound Learning and Networking Opportunity

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Whether you are a seasoned clinician or new to the field of ultrasound, the 2025 AIUM Annual Convention, happening March 29 to April 1, 2025, offers something for everyone. Join us at the Signia by Hilton Orlando Bonnet Creek in Orlando, Florida, for the premier event for ultrasound professionals. This gathering offers a unique opportunity to connect with colleagues, learn from experts across various specialties, and explore cutting-edge advancements in ultrasound technology and its applications. 

The ultimate ultrasound learning and networking event starts off on March 29 with in-depth, professional Pre-Convention courses on critical ultrasound topics in musculoskeletal ultrasound, detailed first-trimester ultrasound, and dermatologic ultrasound. Then, the main convention begins on March 30, showcasing the latest technological breakthroughs, clinical applications, and the influence of artificial intelligence in diagnostic practices.

In addition to a plethora of educational sessions, the convention offers ample opportunities to network with other professionals and industry leaders. This event is the ultimate platform to exchange knowledge, explore the latest innovations, and collaborate with peers in the ultrasound field.

The 2025 convention features a lineup of keynote speakers presenting groundbreaking insights. Former NASA astronaut and International Space Station commander, Leroy Chiao, PhD, will share fascinating stories about spaceflight’s impact on human physiology, highlighting the connections between space medicine and healthcare innovations on Earth. Scott Dulchavsky, MD, PhD, a professor and NASA investigator, will delve into the use of ultrasound as a diagnostic tool in space, with lessons that have transformed care on Earth. Neuroscience pioneer Ali R. Rezai, MD, will present his work on using ultrasound to treat neurodegenerative conditions like Alzheimer’s, offering promising new therapeutic applications for the technology.

In the Exhibit Hall, a dynamic marketplace where prominent companies will display their latest innovative ultrasound products and services, attendees can get a firsthand look at new technologies and solutions.

The event also features supplemental interactive, hands-on learning labs that allow participants to practice skills in real time with expert guidance. Among the offerings are sessions on musculoskeletal (MSK) ultrasound, essential obstetric ultrasound techniques, gynecologic techniques, advanced echo imaging, and more. Additionally, participants can learn valuable procedures like ultrasound-guided nerve blocks and MSK interventions. These labs provide an invaluable opportunity to enhance practical skills under the supervision of skilled instructors, with a focus on improving clinical outcomes.

Don’t miss out on this exceptional opportunity to advance your skills and stay at the forefront of ultrasound innovation. Mark your calendar and register for the 2025 AIUM Annual Convention—the year’s most exciting ultrasound learning and networking event!

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

Musculoskeletal Ultrasound: Improving Patient Care in Real-Time

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

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

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

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

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

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

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

Understanding the Basics of Medical Ultrasound Safety in Musculoskeletal Ultrasound

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

ALARA Principle

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

Key Strategies to Apply ALARA:

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

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

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

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

Mechanical Index (MI)

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

Understanding MI Values:

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

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

Thermal Index (TI)

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

Categories of TI:

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

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

Essential MSK US Techniques

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

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

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

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

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

Conclusion

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

Join the POCUS Revolution: Unlock the Power of Point-of-Care Ultrasound

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A Hand-held ultrasound device scanning a patient

If you’re a fan of the AIUM (American Institute of Ultrasound in Medicine), then you already understand the importance of ultrasound technology in revolutionizing patient care. However, the emergence of Point-of-Care Ultrasound (POCUS) has taken this technology to new heights. POCUS is transforming the medical landscape, offering a sleek, affordable, and user-friendly solution that brings ultrasound imaging directly to the bedside. In this blog post, we’ll explore the advantages of POCUS over other imaging fields, share statistical data, discuss key POCUS techniques, and invite you to join us at the AIUM’s POCUS Course in Portland, Oregon, sponsored by AIUM and OHSU (Oregon Health & Science University), where you’ll discover the top 5 reasons to attend.

POCUS: Your Trusty Sidekick
POCUS is designed to be there for you when you need it the most, acting as a trusty sidekick to clinicians. With its ability to be performed at the bedside, POCUS delivers real-time answers, confirming diagnoses and guiding procedures without the need for additional appointments or waiting for results.

The Power of POCUS 

Let’s explore some statistical data that demonstrates the effectiveness and widespread adoption of POCUS:

  • Improved Diagnosis Accuracy
    According to a study published in a Royal College of Physicians journal, POCUS improved the accuracy of initial diagnoses compared to physical examination alone in various medical specialties, including emergency medicine, critical care, and primary care.
    Reduced Supplemental Exams
    A research article published in the Journal of Ultrasound in Medicine found that POCUS reduced the need for additional imaging studies and can reduce length of stay and imaging costs in various cases leading to significant cost savings and streamlined patient care pathways.
    Enhanced Patient Outcomes
    A systematic review and meta-analysis published in the Ultrasound Journal demonstrated that POCUS-guided interventions in cardiac patients resulted in improved outcomes, including reduced mortality rates and shorter hospital stays.

Key POCUS Techniques

POCUS encompasses various techniques that aid in diagnosing and guiding procedures. Some of the key techniques include:

  • Focused Cardiac Ultrasound (FOCUS)
    FOCUS allows clinicians to rapidly assess cardiac function, detect pericardial effusions, and evaluate for cardiac abnormalities such as wall motion abnormalities or valvular dysfunction.
  • Lung Ultrasound (LUS)
    LUS is valuable in the assessment of pulmonary conditions, including pneumothorax, pleural effusions, and pulmonary edema. It provides real-time visualization of lung sliding, B-lines, and consolidations.
  • Abdominal Ultrasound
    Abdominal POCUS aids in the evaluation of acute abdominal pain, gallbladder disease, kidney stones, and abdominal aortic aneurysms, among other conditions. It enables quick assessment and intervention in critical situations.
  • Musculoskeletal Ultrasound
    Musculoskeletal POCUS allows for an accurate evaluation of joint effusions, tendon injuries, muscle tears, and other soft tissue abnormalities. It assists in guiding interventions such as joint aspirations and injections.

POCUS is a game-changer, offering real-time answers that confirm diagnoses and guide procedures at the bedside. The statistical data highlights its effectiveness in improving diagnosis accuracy, reducing the need for supplemental exams, and enhancing patient outcomes. Don’t miss your chance to join the POCUS revolution and become a superhero in your own right. Register today for the AIUM’s POCUS Course in Portland, Oregon, and unlock the power of Point-of-Care Ultrasound. It’s time to level up your medical game and make a lasting impact on patient care. Sign up today!

Sources
Smallwood N, Dachsel M. Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine? Clin Med (Lond) 2018; 18(3):219–224. doi: 10.7861/clinmedicine.18-3-219. PMID: 29858431; PMCID: PMC6334078.

Amina Jaji, Rohit S. Loomba. Hocus POCUS! Parental quantification of left-ventricular ejection fraction using point of care ultrasound: Fiction or reality? [published online ahead of print December 30, 2022] Pediatr Cardiol. doi:10.1007/s00246-022-03090-w.

Kasmire KE and Davis J. Emergency department point-of-care ultrasonography can reduce length of stay in pediatric appendicitis: A retrospective review. J Ultrasound Med 2021; 40:2745–2750. https://doi.org/10.1002/jum.15675

Ávila-Reyes D, Acevedo-Cardona AO, Gómez-González JF, Echeverry-Piedrahita DR, Aguirre-Flórez M, Giraldo-Diaconeasa A. Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article. Ultrasound J 2021; 13(1):46. doi: 10.1186/s13089-021-00248-0. PMID: 34855015; PMCID: PMC8639882.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Musculotendinous Ultrasound Imaging Applications in Sports Medicine

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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.

References

  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:

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: