Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.1 These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.2 For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.3

The following are some of the critical factors that can lead to the development of WRMSDs:

  • Poor ergonomics, including poor posture and machines with poor ergonomic design.3
  • Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.3
  • Lengthy exams with an increasing workload and number of exams to be performed during the workday.4
  • Inadequate breaks between examinations in addition to an increasing workload.5
  • Psychological stress and psychosocial factors in the workplace.6
  • Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.7

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.10 Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

  1. At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.11 Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
  2. The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.11,12
  3. The operator’s neck should be straight, and neck extension should be avoided.6
  4. The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
  5. A “wearable transducer cable support device,”13 such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.11,12
  6. A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
  7. Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
  8. The ultrasound machine keyboard should be easy to move and adjust.
  9. Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
  10. With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.14

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

  • Ergonomic education for employees
  • Safety and resource utilization
  • Equipment updates
  • The numbers and types of reported symptoms and/or injuries, and
  • Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”13 to include safety practices for all health care professionals who utilize ultrasound.


  1. Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists. A representative sample. J Diagn Med Sonog 2009; 25:287– 299.
  2. Wareluk P, Jakubowski W. Evaluation of musculoskeletal symptoms among physicians performing ultrasound. J Ultrason 2017; 17:154– 159.
  3. Bowles D, Quinton A. The incidence and distribution of musculoskeletal disorders in final-year Australian sonography students on clinical placement. Sonography 2019; 6:157– 163.
  4. Gibbs V, Young P. A study of the experiences of participants following attendance at a workshop on methods to prevent or reduce work-related musculoskeletal disorders amongst sonographers. Radiography 2011; 17:223– 229.
  5. Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013; 32:1363– 1375.
  6. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: can you reduce risk? Ultrasound 2015; 23:224– 230.
  7. Chari R, Chang CC, Sauter SL, et al. Expanding the paradigm of occupational safety and health: a new framework for worker well-being. J Occup Environ Med 2018; 60:589– 593.
  8. United States Department of Labor, Occupational Safety and Health Administration. Ergonomics website. Accessed November 12, 2021.
  9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. Accessed November 12, 2021.
  10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. Accessed November 12, 2021.
  11. Rousseau T, Mottet N, Mace G, Franceschini C, Sagot P. Practice guidelines for prevention of musculoskeletal disorders in obstetric sonography. J Ultrasound Med 2013; 32:157–164.
  12. BP Bernard (ed). Musculoskeletal Disorders and Workplace Factors; A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. U.S. Department of Health and Human Services July; 1997 DHHS (NIOSH) Publication No. 97B141.
  13. Industry standards for the prevention of work related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2017; 33:370–391.
  14. AIUM practice principles for work-related musculoskeletal disorder [published online ahead of print January 24, 2023]. J Ultrasound Med.

Sonography and Work-Related Musculoskeletal Disorders

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

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

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

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

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

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

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

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

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

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

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

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

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


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

* The WRMSD Grand Challenge Alliance of Organizations:

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

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