A Future Career Path for the MSK Sonographer

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

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

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

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

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

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The Math

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

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

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

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

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

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

 

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

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

 

Ultrasound Set to Transform Occupational Medicine

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

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

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

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

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

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

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

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

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

Why I Attended AIUM’s MSK Course

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

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

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

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

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

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

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