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What a Physical Therapist and an Athletic Trainer Have to Say About a Diagnostic Tool Called MSK Ultrasound

Jeannine Noble

As a physical therapist (PT), I’ve been deeply impressed by the power of technology to revolutionize the field of physical therapy. Along with PTs, athletic trainers (ATs) ATs are highly respected, well-trained professionals who serve as valuable members of a healthcare team. With our level of education, ATs can provide many services, including primary care, injury rehabilitation and prevention, and examination and clinical diagnosis. What if a tool were available to increase diagnostic accuracy, potentially decreasing rehab time and overall healthcare costs? Fortunately, something like this is available now, called Diagnostic Musculoskeletal Ultrasound (MSK Ultrasound).

Therapeutic Ultrasound v. Diagnostic Musculoskeletal Ultrasound (MSKUS)

When referring to ultrasound it’s important to distinguish between therapeutic ultrasound and diagnostic ultrasound. Although both utilize sound waves, therapeutic ultrasound uses high frequency waves to modify or destroy tissue while diagnostic ultrasound uses those same waves to image structures within the body, helping to diagnose medical issues.

Diagnostic musculoskeletal ultrasound is relatively new to the athletic training world. When I first started performing MSK ultrasound in 2000, there were only a handful of resources available to assist in learning this amazing new skill. Fortunately, I was lucky enough to work with a handful of forward-thinking physicians who were as excited about this new modality as I was. I would sit in their offices with an ultrasound machine and a bag full of anatomy books and scan patients. It was challenging, but extremely rewarding to see muscles, tendons, and other soft tissue move in real time and provide the objective visualization that the physicians needed to make a diagnosis.

Very few physicians accepted this new technology in 2000, but the patients loved it. And over the years MSK ultrasound has gained respect as a valuable diagnostic tool.


What are the Benefits of Diagnostic Musculoskeletal Ultrasound?

As a diagnostic tool, musculoskeletal ultrasound is invaluable. When properly trained, athletic trainers can visualize many pathologies and therefore make more accurate diagnoses and treatment plans. Common areas that are scanned with MSK ultrasound include shoulder, elbow, hand/wrist, knee, hip and foot/ankle.

There are some limitations in each of these: exFor example, the anterior labrum in the shoulder, the anterior cruciate ligament and intraarticular abnormalities are not clearly visualized with MSKUS. But overall, soft tissues that are superficial to bone can be accurately scanned to an incredible degree.

There are a wide variety of benefits from incorporating MSK ultrasound into a practice:

  1. Accuracy: First and foremost, is the ability to diagnose and treat patients more accurately. Musculoskeletal ultrasound can be an extension of your objective exam, taking your clinical skills to the next level.
  2. Competitive Advantage: Having diagnostic ultrasound available for your patients will set you apart from almost every other practitioner.
  3. Patient Buy-In: Diagnostic ultrasound serves as a powerful patient education tool. When you can demonstrate to a patient in real time what is a likely cause of their pain, the percentage of compliance to your treatment increases.
  4. Safety: For athletic trainers who are licensed to perform dry needling, ultrasound can improve accuracy and safety when needling.

What Equipment Is Needed for Diagnostic MSK Ultrasound?

As you might have guessed, performing diagnostic MSK ultrasound requires an ultrasound machine, gel, and plenty of paper towels. There are a variety of ultrasound machines available. The units most familiar to us are the “workhorse” machines seen in hospitals and imaging centers that are used for OB/GYN, abdominal and cardiac scans.

In the early 2000s, ultrasound manufacturers began producing portable ultrasound units. Along with a significant decrease in size, there was also a huge drop in price, making these “laptop” machines affordable to more practices throughout the world. Physicians now had the ability to perform ultrasound scans and guided injections in the office setting.

But it didn’t stop there. With advances in technology, “handheld” ultrasound machines are now available at an affordable price. These pocket-sized scanners use a cell phone or tablet for the screen and allow access to ultrasound literally anywhere.

Is Learning to Use MSK Ultrasound Difficult?

Like any other valuable skill, there is a learning curve in the beginning that is pretty steep. But the key to becoming an expert is to learn how to scan correctly from the start and then practice, practice, practice! Friends, family, and patients all have extremities for you to scan. They’ll love it and you’ll become proficient with a modality that will benefit you and your practice.

How is Diagnostic MSK Ultrasound Used Specifically in Athletic Training?

One of our star learners, Kit Vreeland, is an Athletic Trainer in Vermont. When asked about the role MSK Ultrasound plays in her career, here’s what she had to say:

I have been a certified athletic trainer for 18 years, primarily as a faculty member at a University with a 30% clinical appointment. I can confidently say one of the most stimulating moments of my career was watching our Varsity Team Physician demonstrate visualization in vivo of the biceps tendon and rotator cuff muscles using a musculoskeletal ultrasound unit. At the time, MSK ultrasound was too costly and bulky of a machine to be feasibly used in my practice.

The pandemic shut down practices and games nation-wide, which offered me a lot more time to pursue professional development opportunities to enhance and learn new skills and strategies. I started seeing handheld MSK ultrasound units, and one of my colleagues was able to show off her new battery-powered, Bluetooth capable unit. We even used it outside due to social-distancing, which mimicked the conditions I would use it during my clinical practice as I only provide sideline care. No electric outlet needed, only the unit, gel, and a smart phone! The incredible potential to enhance my clinical practice and teaching inspired and motivated me to pursue training.

After taking the remote-guided courses from Aeyr, I was able to secure a grant for the handheld unit called the Butterfly IQ+. This is a great starter unit to learn and practice scanning, recognition of the structures, and visualization of the tissues during active and passive movement. I have since used it primarily in the classroom for functional anatomy and biomechanics demonstrations: looking at muscular architecture, cross-sectional area, fibular patterns of tendons, recognition of the muscle-tendon junction, slide-and-glide of healthy tissues during movement, and so much more. My students and I are fervently engaged and stimulated by the ability to have this type of real-time visualization of tissue in the palm of our hands.

I’ve continued to develop my skills and knowledge for clinical purposes, learning how to recognize irregularities in tendon, such as loss of fibular pattern, collagen matrix disorganization, and  ground substance proliferation, which are all indicators of a tendinopathy. If your scope of practice and training includes dry needling, the MSK ultrasound is a fantastic tool for direct visualization of the needle to ensure treatment of the correct tissue. The MSK ultrasound can be helpful in complementing clinical diagnoses of ligament injury by visualizing the joint in real-time as a stress test is performed. Some athletic trainers have reported using it to measure muscle cross-sectional area for baseline and progression of muscular hypertrophy, a way to motivate patients during preseason muscular development or post-injury/surgery to monitor atrophy.

The above outlines just a few examples of the benefits that MSK ultrasound can provide the practicing athletic trainer, or educational program for ATs. Depending on your state’s practice act and your own personal training, ultrasound imaging can be used for diagnostic, rehabilitative, interventional, and research purposes.

Ultimately, adding diagnostic musculoskeletal ultrasound to my professional development has been an excellent, high-quality, and stimulating pursuit of my professional career – and I think it could be for any AT.

Jeannine Noble PT, MS, RMSK