Sonographers and Contrast-Enhanced Ultrasound

Now that contrast-enhanced ultrasound (CEUS) has been approved in the United States for several abdominal applications in adults and pediatrics, I decided to take a deeper look into the sonographer’s role in CEUS. Traditionally, sonographers perform ultrasound examinations based on a protocol, construct a preliminary ultrasound findings worksheet, and perhaps discuss the findings with a radiologist. And now CEUS has transformed traditional ultrasound and gives physicians and sonographers additional diagnostic information related to the presence and patterns of contrast enhancement.DSC00125

Based on sonographers’ traditional scope of practice, some questions came to mind. What is the training process for sonographers to learn CEUS? How should CEUS images be obtained and stored? How should CEUS findings be communicated?

I envision CEUS training for sonographers broken down into stages, where they begin by learning the basics and eventually transition to where they can perform and record the studies independently. The first stage for sonographers is the ‘CEUS learning curve.’ In this stage, sonographers become familiar with basic CEUS concepts, eg, understanding physics of contrast agents and contrast-specific image acquisition modes, CEUS protocols, and typical patterns of contrast enhancement seen in various organs. In addition, an important part of the training is recognizing contrast reactions, and learning IV placement, documentation and billing related to CEUS.

The next stage involves sonographers performing more patient care and gaining scanning responsibilities. Sonographers place the IV and prepare the contrast agent. The scope of sonographer responsibilities does not generally include contrast injection (although it is reasonable since CT, MR, nuclear medicine, and echocardiography technologists routinely place IV lines and inject contrast). It should be noted that CEUS examination usually requires an additional person (physician, nurse, or another sonographer) to assist with contrast injection while the sonographer performs the ultrasound examination. In the beginning of sonographer training, it is very beneficial to have a radiologist present in the room to guide scanning and appropriate image recording.

In the third stage, a well-trained sonographer is more independent. At the completion of the examination, the sonographer will either send clips or still images to a physician to document the CEUS findings and discuss the procedure. Ideally, a worksheet is filled out, comparable to what is done today with “regular” ultrasound.

The majority of CEUS examinations are performed based on pre-determined protocols, usually requiring a 30–60-sec cineloop to document contrast wash-in and arterial phase enhancement. After that continuous scanning should be terminated and replaced with intermittent acquisition of short 5–10-sec cineloops obtained every 30–60 sec to document late phase contrast enhancement. These short clips have the advantage of limiting stored data while providing the interpreting physician with real-time imaging information. Detailed information on liver imaging CEUS protocols could be found in the recently published technical guidelines of the ACR CEUS LI-RADS committee.[i] Some new users might acquire long 2–3-minute cineloops instead, producing massive amounts of CEUS data. As a result, studies can slow down a PACS system if departments are not equipped to deal with large amounts of data. In addition, prolonged continuous insonation of large areas of vascular tissue could result in significant ultrasound contrast agent degradation limiting our ability to detect late wash-out, a critical diagnostic parameter required to diagnose well-differentiated HCC. Any solution requires identifying and capturing critical moments, which will be determined by a sonographer’s expertise. Exactly how sonographers can ensure CEUS will successfully capture the most important images is a critical question that must be answered and standardized.

Ideally, leading academic institutions should provide CEUS training for physicians and sonographers. I have seen and attended CEUS continuing medical education courses and they are a great way for physicians and sonographers to learn CEUS imaging. CEUS is a step forward for sonographers and will potentially transform our scope of practice. The technology will advance the importance of sonographers and diagnostic ultrasound, and importantly it will improve the care of our patients.

Acknowledgements:
Dr. Laurence Needleman, MD
Dr. Andrej Lyshchik, MD
Dr. John Eisenbrey, PhD
Joanna Imle, RDMS, RVT

[i] Lyshchik A, Kono Y, Dietrich CF, Jang HJ, Kim TK, Piscaglia F, Vezeridis A, Willmann JK, Wilson SR. Contrast-enhanced ultrasound of the liver: technical and lexicon recommendations from the ACR CEUS LI-RADS working group. Abdom Radiol (NY). 2017 Nov 18. doi: 10.1007/s00261-017-1392-0. [Epub ahead of print]

Has CEUS helped your sonography career? How do you envision CEUS being incorporated in your work? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Corinne Wessner BS, RDMS, RVT is the Research Sonographer for Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. Corinne has an interest in contrast-enhanced ultrasound, ultrasound research, medical education, and sonographer advocacy.

Bigger and Better in the Big Apple

Last week a near-record 1,500 physicians, sonographers, scientists, students, and educators from across the country and around the world gathered in New York City to network, share, and learn. It was, by all accounts, one of the biggest and best AIUM Conventions yet!

What it made so great? A variety of educational opportunities covering a wide range of topics addressing at least 19 different specialties is just the start. More interaction across disciplines to share techniques, more hands-on learning labs, new product releases, and collaborative learning events added to the excitement and collegiality.

If you were in New York City, we hope you shared your feedback in the follow-up surveys. If you were unable to make it this year, here are a few of the highlights:

New Offerings—As if putting on the AIUM Convention weren’t enough, we decided to make a host of changes. We doubled the number of hands-on learning labs (most sold out), we added the more intimate Meet-the-Professor sessions (again, most sold out), we enhanced networking by adding exhibit hall receptions, we brought back the mobile app to make navigating the event easier, and we invited our corporate partners to host Industry Symposia, which included education, networking, and food. Whew!

New Offerings

SonoSlam—In its third year, a record number of medical schools (21) sent teams to compete for the coveted Peter Arger Cup. This year’s winning team, F.A.S.T. and Furious, is from the University of Connecticut. They competed last year and had so much fun they returned and were triumphant! Save the date for next year—April 6. Big thanks to headline sponsor CoapTech.

SonoSlam 2018

Global Plenary—AIUM President Brian Coley, MD, hosted the Plenary session that featured a lecture on global health from John Lawrence, MD, President of the Board of Directors for Doctors Without Borders-USA. This was followed by Roberto Romero, MD DMedSci, who presented the William J. Fry Memorial Lecture on ultrasound imaging and computational methods to improve the diagnosis and care of pregnant women and their unborn children. The entire Plenary Session is available on the AIUM Facebook Page.

Social Media—This year was the most active social media convention ever for the AIUM. StatsFrom streaming live videos on Facebook to more than 754 individuals participating and sharing on Twitter (a 50% increase over last year), the social media scene was active and engaging.

Fun Activities—Not only was #AIUM18 educational, it was also fun. This year attendees could participate in a morning jog through Central Park; do a scavenger hunt with the AIUM app (Congrats to Offir Ben-David, RDMS, from Stamford, CT, and Jefferson Svengsouk, MD, MBA, RDMS, from Rochester, NY, for winning prizes by completing the scavenger hunt); network during 3 different AIUM receptions and the new Industry Symposia; and win prizes at the AIUM booth (Congrats to Jenna Rothblat who won a free 2019 AIUM Convention registration).

Fun Activities

Sold-out Exhibit Hall—This year’s exhibit hall was the most exciting and active it has ever been. At least 3 companies unveiled new ultrasound machines and several others shared their insights with live video feeds. Combine that with networking receptions and New York street fare at lunchtime, and the exhibit hall was always the place to be.

Award Winners—AIUM was proud to recognize the following award winners (look for upcoming blog posts and videos from some of these individuals):

Wesley Lee, MD, FAIUM—Joseph H. Holmes Clinical Pioneer Award

William D. Middleton, MD—Joseph H. Holmes Clinical Pioneer Award

Thomas R. Yellen-Nelson, PhD, FAAPM, FAIUM—Joseph H. Holmes Basic Science Pioneer Award

Tracy Anton, BS, RDMS, RDCS, FAIUM—Distinguished Sonographer Award

Alfred Abuhamad, MD, FAIUM—Peter H. Arger, MD Excellence in Medical Student Education Award

Creagh Boulger—Carmine M. Valente Distinguished Service Award

Rachel Liu—Carmine M. Valente Distinguished Service Award

Lexie Cowger—Carmine M. Valente Distinguished Service Award

Adriana Suely de Oliveira Melo, MD, PhD—AIUM Honorary Fellow

Simcha Yagel, MD, FAIUM—AIUM Honorary Fellow

E-poster winners—Every year, the AIUM supports an e-poster program. This year, a record number of abstracts were submitted and the AIUM recognized the following e-poster winners:

  • First place, Basic Science: Construction and Characterization of an Economical PVDF Membrane Hydrophone for Medical Ultrasound, presented by Yunbo Liu, PhD, from the FDA, Silver Spring, MD.
  • First place, Education: Investigation into the Role of Novel Anthropomorphic Breast Ultrasound Phantoms in Radiology Resident Education, presented by Donald Tradup, RDMS, RT, from Mayo Clinic-Department of Radiology, University of Pittsburgh Medical Center-Department of Radiology, Dublin Institute of Technology, Ireland.
  • First place, Clinical Science: Sonography of Pediatric Superficial Lumps and Bumps: Illustrative Examples from Head to Toe presented by Anmol Bansal, MD, Mount Sinai Hospital, Icahn School of Medicine.
  • Second place, Basic Science: Strain Rate Imaging for Visualization of Mechanical Contraction, presented by Martin V. Andersen, MS, from Duke University.
  • Second place, Education: Tommy HeyneSonography in Internal Medicine, Baseline Assessment (MGH SIMBA Study), presented by Tommy Heyne, MD, MSt, Massachusetts General Hospital-Department of Internal Medicine and Department of Emergency Medicine.
  • Second place, Clinical Science: Serial Cervical Consistency Index Measurements and Prediction of Preterm Birth < 34 Weeks in Twin Pregnancies, presented by Vasilica Stratulat, CRGS, ARDMS, MD, Sunnybrook Health Sciences.

Up and Comers—In addition to our national awards and our eposter winners, the AIUM also recognizes its New Investigators, which this year were sponsored by Canon.

Nonclinical
Winner— Ivan M. Rosado-Mendez, PhD, for “Quantitative Ultrasound Assessment of Neurotoxicity of Anesthetics in the Young Rhesus Macaque Brain.”

Clinical Ultrasound
Winner— Ping Gong, PhD, for “Ultra-Sensitive Microvessel Imaging for Breast Tumors:  Initial Experiences.”

Honorable Mentions
Juvenal Ormachea, MS,
for “Reverberant Shear Wave Elastography: Implementation and Feasibility Studies.”

Kathryn Lupez, MD, for “Goal Directed Echo and Cardiac Biomarker Prediction of 5-Day Clinical Deterioration in Pulmonary Embolism.”

2019

Life Hacks for the 2018 AIUM Annual Convention

Plan
View the full program online and, to keep on top of all things #AIUM18, download the eventScribe app now from the Apple store or Google Play store and search for AIUM 2018. imageBefore and during the convention, use the app to plan your schedule, read about sessions, take notes, learn about exhibitors, and engage with other attendees.

Learn all about the app by checking out these videos on using the app: Quick Navigation Guide, Browsing Style, Taking and Sending Notes, E-mailed Notes, Messages, and Events.

Go
Travel to the convention via plane, train, or automobile. The hotel, New York Hilton Midtown, is located on Avenue of the Americas (6th Ave) between West 53rd and West 54th Streets. To get to the hotel from 1 of the 3 nearby airports, or Grand Central Station, Penn Station, or Port Authority, which are all within approximately 20 minutes of the hotel, you can take a taxi or rideshare service. To get around the city, walk or take the subway, a taxi, or a rideshare.

Follow
Stay in the know by following the AIUM and the Convention on Twitter (#AIUM18), Instagram (AIUMultrasound), vimeo, LinkedIn, and Facebook as we share news and events, as well as photos and videos.

Learn and Network

  • Two preconvention postgraduate courses will be offered on Saturday, March 24. Additional fees apply.
  • We doubled the number of hands-on Learning Labs. Our Learning Labs provide an up-close and personal learning experience while earning CME credit.
  • Learn from leading ultrasound experts in small group settings in Meet-the-Professor sessions. There are a dozen Meet-the-Professor events to choose from. Each comes with lunch. Separate registration fee is required. If you haven’t registered, act quickly because more than half the sessions are sold out.
  • The AIUM has added 2 networking receptions to the Convention schedule. Plan to meet up with colleagues, explore the latest technology, and ask questions you may have during these cocktail and hors-d’oeuvre events on the Exhibit Hall floor.
  • The AIUM received a record number of research abstracts for the 2018 AIUM Convention. This research will be shared by AIUM’s new investigators, abstract presenters, and e-poster submitters throughout the event.
  • Community and Interest Group Meetings: Meet with other ultrasound professionals who share your interests, plan future AIUM educational programs, and discuss the issues in your specialty.

Exercise
Start your day off with some exercise: join your colleagues and AIUM staff each morning from 6:30–7:15 am for a 3-mile run/walk around New York City’s Central Park. You’ll meet up in the Main Lobby at 6:30.

Hunt
Join the Scavenger Hunt at the convention: download the eventScribe app (search AIUM18) to get started on your chance to win one of several prizes that will be awarded upon completion of the game. A grand prize winner will be announced Tuesday afternoon.

Earn

CME      Earn up to 6.5 CME credits during the Preconvention and 29.5 CME credits during the Convention.

ARRT    Earn up to 6.5 ARRT credits during the Preconvention and 29.5 ARRT credits during the Convention.

SAMs     The American Board of Radiology (ABR) has approved 7 Self-Assessment Modules (SAMs) activities from our upcoming 2018 Convention.

UGRA    One session at the Preconvention and 8 sessions at the Convention have been added to the UGRA Portfolio program’s course offerings.

Please note that although the AIUM provides CME certificates to those who have participated in an AIUM educational activity, the AIUM does not submit credits to regulating bodies or certifying organizations on behalf of the participant. It is the participant’s responsibility to submit proof of credits on his or her own behalf.

Explore

Lid5nyGET

When you’re not attending the convention, check out some of what New York has to offer. Here is a short list of just a small portion of what is out there, including museums, parks, iconic buildings, and more. And, don’t forget to check out minus5° in the hotel’s lobby, where everything in the bar is made of ice, including the glasses.

The Expeditious Evolution of Emergency Ultrasound Fellowships

RJG Photo 2

Access to the internet was dial up through AOL, Bill Clinton was President, and ultrasound machines were big, clunky, and new to the emergency department. It was 1999 and I was in Long Island as a resident. As a resident, I saw the ultrasound machine lurking around the emergency department, but very few faculty seemed to know how to use it. A search of fellowships in emergency ultrasound found a single listed fellowship in Chicago, so I organized a rotation to see what ultrasound was all about.

Emergency ultrasound fellowships in the early 2000s were disconnected, isolated, and in many ways under the radar. As the ultrasound interest group president in SAEM (soon to become the Academy of Emergency Ultrasound) I heard firsthand how difficult it was for fellows to find ultrasound fellowships and how difficult it was for fellowship directors to find applicants. Partnered with Pat Hunt, we started EUSFellowships.com as a platform for fellows and programs to meet. Ultrasound became more mainstream as ACEP, SAEM, and CORD fought to have ultrasound integrated into residency training and general emergency medicine.

Eventually EUSFellowships.com evolved into the Society of Clinical Ultrasound Fellowships as a more robust organization focused on advanced training for bedside ultrasound. The first couple of emergency ultrasound fellowships started around 1997. Within 5 years there were 12 fellowships, and within 10 years there were 27. Today there are over 100 emergency ultrasound fellowships graduating more than 70 fellows each year. There are more ultrasound fellows graduating each year than in toxicology and EMS combined.

Emergency ultrasound fellows today join a large vibrant group of specialists across the United States and the world. Physicians use ultrasound to diagnose, monitor, and guide procedures everywhere from the African savannah to the neighborhoods in New York City. The initial meetings in the 1990s involved small groups getting together to discuss cutting-edge research and new applications. Now ultrasound meetings in emergency medicine involve hundreds of people discussing topics such as board certification or ultrasound program management. Research has evolved from single “we can do it too” projects to multi-center collaboratives. The change in ultrasound over the last 20 years is mind blowing.

When I interview medical students now, I ask them why they went into medicine. What do they want to achieve? One of the best answers I hear is that they want to make a difference in medicine and improve care for all patients. I feel that I have been lucky enough to witness the birth of a new subspecialty that will improve how patients are cared for in the future.

What was your initial experience with ultrasound education? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Romolo Gaspari, MSc, MD, PhD, FACEP, is the Executive Vice Chairman of the Department of Emergency Medicine at UMASS Memorial Medical Center. He has also served as the president of a number of Emergency Ultrasound Societies including what is now the Academy of Emergency Ultrasound and the Society of Clinical Ultrasound Fellowships.

Flying Samaritans, the Seed to Pediatric Point-of-Care Ultrasound

There are some experiences in life that seem to have a tremendous impact on the person you become, and the career path you decide to take. When I started working with the Flying Samaritans in medical school, little did I know that it would change the trajectory of my career.

Kids from El Testerazo Mexico

The kids I fell in love with in El Testerazo, holding the pictures I had taken and shared with them. They came by even if they weren’t sick. Of note, they are now in their 20s with families of their own.

Since the UC Irvine School of Medicine was so close to the USA-Mexico border, the UC Irvine Flying Samaritans chapter was actually a driving chapter. Each month we drove down to El Testerazo, Mexico, to give medical care and medications to an underserved community. I immediately fell in love with the community and the children of El Testerazo, Mexico. They would all laugh at my then broken high school-level Spanish but would appreciate my trying. There was also something about the group of undergraduates (who ran the clinic), medical students, residents, and attending physicians who volunteered their time there that brought back the humanity to medicine. The experience was challenging and rewarding at the same time—to work with limited resources, but to become a trusted member of their community was priceless. Each time I went to the “Flying Sams” clinic, I remembered why I went into medicine in the first place.

During my time with the “Flying Sams,” I worked with a then Emergency Medicine resident, Chris Fox. When he told me he was going to Chicago to do a 1-year Emergency Ultrasound fellowship, I thought he was crazy.

Old ultrasound machine

The ancient beast of an ultrasound machine that we had in the “Flying Sams” clinic.

Not only was he leaving sunny Southern California, but he was going to spend a year looking at ultrasounds? When I looked at ultrasounds, I could barely make out structures; images looked like the old tube TVs from the 1980s. When Fox returned, he said, “Steph, the next big thing will be pediatric ultrasound.” Again, I thought he was crazy. But slowly, by seeing how ultrasound impacted the management of our patients in El Testerazo, I realized the brilliance in this craziness. Chris Fox’s enthusiasm and “sonoevangelism” was infectious. I think nearly everyone in the “Flying Sams” ended up eventually doing an ultrasound fellowship. Even though the ultrasound machine in the clinic was old, and images were of limited quality, we were still able to impact the medical care of this community that became near and dear to my heart.

And so it began…my passion for emergency ultrasound (now referred to as point-of-care ultrasound) and for Global Health. My initial goal was to become good at performing ultrasounds. As I quickly realized, I was one of the only people who had experience in pediatric point-of-care ultrasound. I felt a tremendous responsibility to become as knowledgeable and skilled as possible if I were going to teach others this powerful tool. After 4 years of undergraduate education, 4 years of medical school, 3 years of a Pediatrics residency, and 3 years of a Pediatric Emergency Medicine fellowship, I decided to do an additional 1-year fellowship in Emergency Ultrasound. With medical school loans looming and so many years without a “real job,” I was reluctant to do this. This California girl moved from sunny Southern California to Manhattan to embark on a 1-year Emergency Ultrasound fellowship. This was a move far outside of my comfort zone for so many reasons. And that was one of the reasons why it ended up being one of the best decisions I’ve ever made. It has been a privilege to be a part of this growing community… to take better care of the most vulnerable of patients… and to give this tool to other doctors around the world. I certainly would have never had these experiences or opportunities if it weren’t for the “Flying Sams” and Chris Fox; to both, I am forever grateful.

 Are you involved in global medical education? If so, what led to your decision to go into the field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie J. Doniger, MD, RDMS, FAAP, FACEP is the Editor of the first pediatric point-of-care ultrasound textbook “Pediatric Emergency and Critical Care Ultrasound,” and is currently practicing Pediatric Emergency Medicine and Point-of-Care Ultrasound in New York. She has additional training in Tropical Medicine and is in charge of Pediatric POCUS education for WINFOCUS Latinamerica.

To My Fellow Sonographers

Dear fellow sonographers,

I am proud to say that I have worked as a sonographer since 1983 and have been on an incredible journey for 34 years. I started out at the Washington Hospital Center in Washington, DC, as a radiologic technologist and had the privilege to work on the job as a sonographer. I have evolved, grown, and through my profession, I have continued to educate myself. When I passed the ARDMS certification in 1984, I decided that I would continue to set goals for myself and keep my career in ultrasound exciting and challenging.

Over the next 33 years, I worked in a Radiology office, in private practice, and in maternal-fetal medicine. Now, I am honored to be part of the American Institute of Ultrasound (AIUM). So, why am I saying all this? Because I now want to encourage all of you to use my experiences to take your profession to the next level.

My personal goal is to educate sonographers. To encourage sonographers to love their jobs and be the best. Times have changed, especially in the ultrasound world. Doing an OB exam and showing only a 4-chamber heart is no longer enough. Now, we are expected to do outflow tracts, aorta, ductus, and sometimes the infamous 3-vessel trachea view.

If you are asking what is the 3-vessel trachea view? Well, let me just tell you about this amazing cardiac image. If you can acquire and document a normal 3-vessel trachea you can rule out Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), and Right-sided Aortic Arch. You can also be the hero of the office when you go to your doctor at your practice and say “Hey, the 3-vessel trachea view looks abnormal, what do you think?” Not only will you impress them and possibly save a life, but you will earn respect and, hopefully, you are reminded as to why you wanted to be a sonographer in the first place.

I have always loved my job and continue to learn every day. There is a whole world of ultrasound information out there. I challenge you to go beyond what you know to get the job done, be the best, and always treat your patient as your best friend, whoever that might be. My challenge for you is to read about the 3-vessel trachea view and, if it is not a part of your daily OB routine, add it.

Please join me and expand your education!

Haylea Weiss, RDMS (AB FE OB/GYN)
American Institute of Ultrasound in Medicine

Apply for AIUM’s new Sonographer Scholarship Grant, a program that provides $500 and free registration to an AIUM post-graduate event. Applications due March 1, 2018.

Ultrasound-Guided Musculoskeletal Injections

I began using Musculoskeletal (MSK) ultrasound (US) in 2010. It has been incredibly exciting to observe the growth of applications of this amazing technology for both myself personally as well as for the entire MSK US practicing community. MSK US has become an integral part of my Sports Medicine practice and I certainly anticipate its’ role to continue to expand and be able to provide cutting-edge medical care to my patients.IMG_8265

There is great variability with which MSK US is used among practitioners. Some providers do complete diagnostic scans of the shoulder, for example, to evaluate the extent of a potential rotator cuff tear to guide with potential surgical decision making, while others perform selective nerve blocks and finally, some practitioners simply use it to assist with the accuracy of various MSK joint and soft tissue injections. I would like to illustrate to all of you the applications for which I most commonly use MSK US to improve patient care.

Probably the most common application for which I use MSK US is to assist with the accuracy of joint and soft tissue injections. It has been clearly documented that MSK US improves the accuracy of certain MSK injections. While I do not use MSK US for all injections, ie, simple knee intra-articular and shoulder sub-acromial injection, I routinely employ MSK US to assist with certain injections. Common joints and soft tissue areas for which I employ MSK US for either cortisone or pro-inflammatory injections like Platelet Rich Plasma (PRP) are:

Shoulder: Glenohumeral and acromioclavicular joint and long head biceps tendon sheath

Hip: Femoroacetabular, hamstring origin (tendon or bursa), mid-portion hamstring, pubic symphysis, gluteal tendons and bursa, iliopsoas bursa and tendon

Knee: Pes anserine and iliotibial bursae, patella and quadriceps tendons, Baker’s cyst aspiration

Wrist: Triangular fibro cartilage complex (TFCC), various wrist extensor and flexor tendons, aspirate ganglion cysts, numerous hand and wrist joints

Elbow: Lateral and medial epicondyle area, triceps insertion, olecranon bursitis, distal biceps and intra articular

Ankle: Achilles, tibialis posterior, peroneal tendons, numerous foot and ankle joints, plantar fascia

Back: Sacroiliac joint

I would also like to illustrate some interesting recent cases supporting the utility of MSK US in a Sports Medicine practice.

I am consulted numerous times a week by my orthopedic surgeon colleagues for diagnostic joint injections. Oftentimes, a patient’s hip pain may be multifactorial or difficult to specifically isolate. I will perform an intra-articular injection to see if it alleviates that patient’s pain, thus identifying that the area in which I placed the injection as the pain generating location. Correct identification of the pain generating source will help to assist with treatment considerations.

I also recently had a patient with greater than 1 year of hip pain. He had seen 8 different providers and had an extensive workup with imaging and injections only to have continued pain. He had hip joint and hamstring origin injections and felt no improvement. I was able to use the US to identify and isolate the obturator internus as the source of his pain by providing a diagnostic injection. This injection helped to make the appropriate diagnosis and ultimately influenced treatment.

Last month, an orthopedic surgeon asked me to evaluate a patient for refractory symptoms from a Baker’s cyst. The cyst persisted despite multiple intra articular-injections. I evaluated the cyst with US and noted that it was multilobulated. I was able to specifically aspirate each of the loculations and the patient has remained symptom-free.

I was also asked to see one of our varsity basketball players for refractory lateral knee pain. His athletic trainer was treating him with rehabilitation and multiple modalities but the pain persisted and was affecting the athletes’ ability to play. I was able to identify an inflamed Iliotibial band bursa with the US and subsequently inject it. He became pain-free and was able to play in that weeks’ game as well as the rest of the season.

Another exciting application of MSK US that has piqued my interest recently is the use of the US to assist with appropriately identifying the compartments of the lower extremity for chronic exertional compartment testing. I can employ the US to guarantee that I am in the appropriate anatomic compartment for testing.

With any new technology, the application and utility of MSK US can be user-dependent and it can be affected by a somewhat steep learning curve. MSK US curriculums are frequently being added to Sports Medicine fellowships to train some of the future leaders of medicine. I certainly anticipate that this technology with continue to evolve and its’ treatment applications will continue to expand.

How do you use MSK US? How has it improved your practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Bryant Walrod, MD, CAQSM, is Assistant Professor: Clinical at Ohio State University, is Team Physician for the Ohio State Athletics, and practices at The Ohio State University Wexner Medical Center.