Economics of Musculoskeletal Ultrasound

The Radial Arc technique: A systematic ultrasound method to imaging the distal biceps brachii tendon from a medial approach with anatomical insights

Introduction

Distal biceps brachii tendon disorders predominantly result from repetitive use and eccentric loading. High-resolution ultrasound has emerged as a preferred diagnostic tool due to its dynamic imaging capabilities, accessibility, and cost-effectiveness.

Topic Description

This paper introduces the Radial arc technique, a didactic and systematic ultrasound scanning method from a medial approach designed to facilitate the identification of the distal biceps brachii tendon insertion in the long-axis view. The technique is a five-step sonographic approach navigating sonographers and clinicians through a series of landmarks to address the often-complex sonographic examination of the distal biceps brachii tendon insertion. The paper also provides detailed anatomical insights into the biceps brachii muscle and the distal tendinous complex, highlighting key morphological features critical for accurate ultrasound interpretation.

Discussion

The proposed approach is tailored to support the educational development of undergraduate and postgraduate students specialising in musculoskeletal sonography and enhance the practical skills of early-career and experienced sonographers and clinicians utilising point-of-care ultrasound. The anatomical framework provided offers a deeper understanding of the distal biceps brachii tendinous complex, supporting diagnostic accuracy for distal biceps brachii tendon-related conditions that are critical for guiding patient management.

Conclusion

The systematic nature of the Radial arc technique aims to standardise practices not only in clinical settings but also in the design and execution of research studies involving the assessment of the distal biceps brachii tendon integrity with ultrasound. Future research should focus on assessing the reproducibility of the Radial arc technique in diverse clinical settings and among different practitioners and operators, crucial for its adoption in sonographic diagnostics.

Diagnostic Performance of Articular Ultrasound Versus Magnetic Resonance Imaging in the Approach to Rotator Cuff Lesions at a Referral Hospital

Introduction Rotator cuff injury is a leading cause of musculoskeletal pain and the most common shoulder pathology. It is characterized by pain and limited mobility, particularly during overhead activities, and is associated with factors such as age, trauma, occupation, limb dominance, and cardiovascular risk. Diagnosis requires clinical evaluation and imaging, with ultrasound being a cost-effective and accessible option, whereas MRI is preferred for persistent or ambiguous cases. However, MRI access may be restricted by geographical and economic constraints. Methodology A retrospective census was conducted at a fourth-level hospital in Medellín, Antioquia (2015-2020), following research committee approval. Patients over 18 years old with suspected rotator cuff injury who underwent arthroscopy and had MRI and ultrasound reports within six months were included. Imaging and surgical data were retrieved from Xen RIS HIRUKO and Matrix systems. Ultrasound was performed using a General Electric Logiq S8 (15 MHz transducer) (General Electric Healthcare, Chicago, IL) and a Toshiba Aplio 400 (18 MHz transducer) (Toshiba Medical Systems Corporation, Tokyo, Japan). MRI was conducted on a Philips Achieva 1.5 T (Philips Healthcare, Eindhoven, Netherlands) with standard musculoskeletal protocols. Data were collected independently, processed in Excel (Microsoft Corporation, Redmond, WA), and analyzed using STATA 14 (StataCorp LLC, College Station, TX). Quantitative variables were reported as means and standard deviations, with normality assessed using the Kolmogorov-Smirnov test, while qualitative variables were expressed as frequencies. Results Twenty-four patients (62.4 ± 12.2 years) had 27 rotator cuff injuries; eight (33.3%) were traumatic (all men), and 16 (66.7%) were degenerative. Right-sided lesions occurred in 12 (50%), left-sided in nine (37.5%), and bilateral in three (12.5%). The most common arthroscopic finding was a complete supraspinatus rupture in 16 shoulders (59%), followed by subscapularis partial ruptures not exceeding 50% in 10 shoulders (37%) and supraspinatus partial ruptures exceeding 50% in seven shoulders (26%). For supraspinatus evaluation, ultrasound detected 79% of lesions and MRI detected 75%, both achieving 93.7% sensitivity for complete ruptures. For partial ruptures exceeding 50%, both modalities demonstrated good specificity and predictive values but low sensitivity (42.8%), with an area under the curve (AUC) of 0.78 for complete ruptures. Regarding the subscapularis, MRI detected 54.5% of lesions compared to 26.3% detected by ultrasound, demonstrating higher specificity. In the infraspinatus, both modalities detected only one of two complete ruptures, with several false positives. Agreement with arthroscopy was moderate for the supraspinatus (kappa: ultrasound = 0.59; MRI = 0.448) and low for the subscapularis (kappa: ultrasound = 0.25; MRI = 0.56), with ultrasound performing better in traumatic cases. Conclusions This study provides a direct comparison between ultrasound and MRI in the evaluation of rotator cuff injuries, with arthroscopy as the reference standard. While both modalities were effective in detecting complete supraspinatus tears, MRI demonstrated greater accuracy for subscapularis tendon assessment. These findings support the continued use of ultrasound as a practical and reliable tool, particularly in resource-limited settings.

Prospective Analysis of the Effectiveness of Targeted Botulinum Toxin Type A Injection Using an Ultrasound-Guided Single-Point Injection Technique for Lower Face Contouring

Background: Botulinum toxin type A (BoNT-A) injection is widely used for masseter hypertrophy. Traditional BoNT-A injection methods often incorporate landmark-guided blind injections, which approximate the shape of the masseter muscle inject across various points. Conversely, ultrasound (US)-guided injection techniques offer real-time visualization and dynamic monitoring, enhancing accuracy. Patients and Methods: 50 patients who underwent BoNT-A injections were included in this trial. One on the face side received a landmark-guided injection, and the other side was treated with a US-guided injection. Initial and post-procedure measurements of muscle thickness at the upper, middle, and lower regions were collected using ultrasound. Results: Both methods led to a significant reduction in muscle thickness one month after injection. In the upper area, the absolute difference in muscle thickness between the two methods was observed as a mean ± standard deviation (SD) value of 0.37 ± 0.0314 (p < 0.0001), indicating a superior effect with US-guided injection. Similarly, in the middle area, the mean ± SD difference was 0.41 ± 0.0608 (p < 0.0001) and in the lower area, the mean ± SD difference was 0.24 ± 0.0134 (p = 0.0004). Conclusions: This study demonstrated that the US-guided single-point injection technique is a more effective and accurate method for BoNT-A injection compared to the conventional method.

Sonographic evaluation of spondylolysis: technique description and feasibility study of diagnostic ultrasound for the detection of L5 pars interarticularis fractures

Objective

Technique description and verification of L5 pars interarticularis (L5PI) using diagnostic ultrasound (DUS).

Methods

Asymptomatic 10-year-old male subject was scanned with diagnostic ultrasound applying a linear array transducer (8-13 MHz) over L5/S1 facets; long-axis slide cephalad to capture both superior (SAP) and inferior articulating process (IAP) of L5. Contiguous hyperechoic cortex with deep acoustic shadowing between the SAP and IAP was assumed to be L5PI. To confirm in vivo technique representing L5PI, two spine models (plastic, human spine) were scanned to verify authors' assumption. Metallic paperclip was placed over L5PI then DUS image captured. Lastly, a subject with known spondylolysis was imaged and sonographic appearance of L5PI compared.

Results

The structures localized with the metal paperclip on L5PI models were equivalent to the in vivo DUS image. Spondylolysis demonstrates an abrupt step-off defect at L5PI.

Conclusion

We report the first technique description and verification of the L5PI using DUS.

The hidden cost of chronic pain: A narrative review of the environmental impact of outpatient spine and musculoskeletal care

Health care is a major driver of greenhouse gas emissions and is closely intertwined with industrial processes responsible for air, water, and soil pollution. Chronic pain - particularly as it relates to spine and musculoskeletal diagnoses - comprises a significant portion of health care utilization and affects millions of people worldwide. Despite the prevalence of chronic spine and musculoskeletal pain, there has been limited discussion of the environmental impacts of outpatient clinics and interventional processes as they relate to these conditions. This narrative review explores the environmental impact related to diagnostics, pharmacologics, and common nonoperative interventional procedures utilized in the management of patients with chronic musculoskeletal and spine pain. Topics explored include energy utilization, production and disposal of pharmaceuticals, and waste production from interventional procedures. This study aims to educate providers involved in spine and musculoskeletal disease management regarding the possible environmental consequences of their practices. The article also focuses on modifying approaches to patient care to those that are more sustainable as well as highlighting areas in need of further investigation.

The impact of a novel musculoskeletal consult service in an inpatient rehabilitation facility: A descriptive analysis

BACKGROUND

Musculoskeletal (MSK) pathologies significantly affect the rehabilitation course for patients admitted to an inpatient rehabilitation facility (IRF). The impact of a specialized inpatient MSK consult service has not been previously evaluated.

OBJECTIVE

To assess the demographics, pathologies, and impact on pain scores of patients who were evaluated by a specialized MSK consult service.

DESIGN

Retrospective descriptive analysis of patients at an IRF who were evaluated by the MSK consult service.

SETTING

Academic IRF.

PARTICIPANTS

230 patients evaluated by the MSK consult service over 4.5 years.

INTERVENTIONS

MSK consult service composed of sports medicine fellowship-trained physiatrists who use history, physical examination, point-of-care ultrasound, and specialized MSK knowledge to assess and address MSK barriers to functional improvement.

MAIN OUTCOME MEASURES

Primary rehabilitation diagnosis, length of stay, discharge destination, reason for consult, MSK diagnosis, need for injection, change in Numerical Pain Rating Scale (NPRS) pain scores, change in Functional Independence Measures (FIM).

RESULTS

A total of 230 consults met inclusion criteria for analysis. The most common symptoms were shoulder pain (47%), knee pain (30%), and hip/groin pain (10.4%). The MSK consult service made 82 different musculoskeletal and neuromuscular diagnoses. The most common primary rehabilitation diagnosis was stroke (28.3%). Injections were performed in 44.3% of consults, with an average reduction in NPRS pain score of 2.3 (SD 1.9) and a statistically significant reduction in average NPRS pain scores in patients who underwent injections compared to those who did not (p < .001).

CONCLUSIONS

This study is the first to examine the use of an innovative inpatient MSK physiatry consult service in an IRF. This promising consult service can play a pivotal role in patient care by reducing functionally limiting MSK pain to allow for better toleration of therapies and to optimize functional gains.

Influencing Physical Therapist's Self-efficacy for Musculoskeletal Ultrasound Through Blended Learning: A Mixed Methods Study

BACKGROUND AND PURPOSE

With the growing interest for physical therapists to incorporate musculoskeletal (MSK) ultrasound comes a need to understand how to organize training to promote the transfer of training to clinical practice. A common training strategy blends asynchronous learning through online modules and virtual simulations with synchronous practice on live simulated participants. However, few physical therapists who attend MSK ultrasound continuing education courses integrate ultrasound into clinical practice. Self-efficacy is a significant predictor of training transfer effectiveness. This study describes to what degree and how a blended learning strategy influenced participants' self-efficacy for MSK ultrasound and transfer of training to clinical practice.

SUBJECTS

Twenty-one outpatient physical therapists with no previous MSK ultrasound training.

METHODS

Twenty-one participants assessed their self-efficacy using a 26-item self-efficacy questionnaire at 3 intervals: before asynchronous, before synchronous training, and before returning to clinical practice. Participants were interviewed within 1 week of training using a semi-structured interview guide. Quantitative analysis included descriptive statistics and repeated-measures ANOVA. Thematic analysis was used to examine participants' experiences, and "following the thread" was used to integrate findings.

RESULTS

Self-efficacy questionnaire mean scores increased significantly across the 3- time points ( F [2, 40] = 172.7, P < .001, η 2 = 0.896). Thematic analysis indicated that asynchronous activities scaffolded participants' knowledge, enhanced their self-efficacy, and prepared them for synchronous learning; however, it did not replicate the challenges of MSK ultrasound. Synchronous activities further improved self-efficacy and helped participants better calibrate their self-judgments of their abilities and readiness to integrate MSK ultrasound training into clinical practice. Despite individual-level improvements in self-efficacy, interviewees recognized their limitations and a need for longitudinal training in a clinical environment.

DISCUSSION AND CONCLUSION

A blended learning approach positively affects participants' self-efficacy for MSK ultrasound; however, future training designs should provide learners with additional support during the transition phase.

Exploring the integration of diagnostic musculoskeletal ultrasound imaging into clinical practice by physical therapists

BACKGROUND

Musculoskeletal ultrasound (MSK-US) use for diagnostic purposes is expanding in physical therapy practice. Identifying and describing physical therapy-specific approaches to incorporating MSK-US into the evaluation process is needed. Musculoskeletal ultrasound extends the physical exam to allow clinicians to visualize anatomy and pathophysiology both statically and dynamically. Purpose: To document 1) weekly use of diagnostic MSK-US; and 2) clinical reasoning approach used in challenging patient cases by physical therapists (PTs) registered by Inteleos in musculoskeletal sonography (RMSK-certified).

METHODS

Longitudinal, observational, cohort study using mixed methods for data collection and analysis. All 23 currently RMSK-certified PTs using MSK-US in clinical practice across the United States were contacted, and 16 participated. Data were collected using an online survey created with the Research Electronic Data Capture System. Participants documented MSK-US clinical use and significant cases using weekly, reflective, online journals for three months. Demographic data were summarized using descriptive statistics. Case data were analyzed thematically.

RESULTS

Participating RMSK-certified PTs performed 1110 MSK-US examinations over 110 weeks. Clinicians averaged 7 (range 1-25) MSK-US examinations weekly, representing 28% of an average caseload. Examinations contributed significant anatomical/ pathological information 100% of the time. The most common joints scanned were the knee (n = 281), shoulder (n = 254), and wrist (n = 228). Case data revealed three themes: 1) augmenting the clinical evaluation to extend or narrow a diagnosis; 2) outcomes guiding action; and 3) lessons learned from clinical findings.

CONCLUSION

RMSK-certified PTs regularly used MSK-US to validate and refine their clinical diagnoses and treatment. Ultrasound imaging directly influenced patient care by informing the diagnostic process, guiding treatment, and appropriately identifying referrals.

Clinical and Ultrasonographic Characteristics of the Achilles Tendon in Hemodialysis Patients

Background and Objectives: The early recognition of tendon alterations in chronic hemodialysis (HD) patients, an awareness of the factors that influence the condition, and active intervention have considerable clinical relevance. The aim of this study was to investigate the musculoskeletal ultrasound (MSUS) features of the Achilles tendon in chronic HD patients and determine the factors associated with tendon abnormalities. Materials and Methods: This study was conducted on 46 HD patients and 24 sex- and age-matched controls. All participants were evaluated clinically for any signs of Achilles tendon abnormalities. Then, the Achilles tendon was scanned bilaterally using MSUS. Results: Among the 92 Achilles tendons in the HD patients, there was tenderness and swelling of only two (2.2%). Regarding MSUS features, there were statistically significant higher thicknesses in the proximal end (p < 0.001), midpoint (p < 0.001), and distal end (p < 0.001) of the Achilles tendons in the HD patients when compared with the healthy controls. Tendinosis was found in 12 (13%) of the HD patients' Achilles tendons, which was statistically significant in comparison to the healthy controls (p = 0.008). There were statistically significant higher scores of structural abnormalities (p = 0.005), bone erosions (p = 0.017), and calcifications (p = 0.015) in the HD patients when compared to the healthy controls. According to the results of a univariate regression analysis, age and male gender were predictive for US abnormalities in HD patients (p = 0.002 and 0.025, respectively). Conclusions: The Achilles tendon in subjects on chronic HD showed frequent US abnormalities. These abnormalities in HD patients appear to be more related to age and gender and may be asymptomatic.

Musculoskeletal ultrasound: a technical and historical perspective

During the past four decades, musculoskeletal ultrasound has become popular as an imaging modality due to its low cost, accessibility, and lack of ionizing radiation. The development of ultrasound technology was possible in large part due to concomitant advances in both solid-state electronics and signal processing. The invention of the transistor and digital computer in the late 1940s was integral in its development. Moore's prediction that the number of microprocessors on a chip would grow exponentially, resulting in progressive miniaturization in chip design and therefore increased computational power, added to these capabilities. The development of musculoskeletal ultrasound has paralleled technical advances in diagnostic ultrasound. The appearance of a large variety of transducer capabilities and rapid image processing along with the ability to assess vascularity and tissue properties has expanded and continues to expand the role of musculoskeletal ultrasound. It should also be noted that these developments have in large part been due to a number of individuals who had the insight to see the potential applications of this developing technology to a host of relevant clinical musculoskeletal problems. Exquisite high-resolution images of both deep and small superficial musculoskeletal anatomy, assessment of vascularity on a capillary level and tissue mechanical properties can be obtained. Ultrasound has also been recognized as the method of choice to perform a large variety of interventional procedures. A brief review of these technical developments, the timeline over which these improvements occurred, and the impact on musculoskeletal ultrasound is presented below.

The Role of Ultrasound in the Management of Ankle Sprains and a Clinically Relevant Geisinger Ankle Sprain Sports Ultrasound Protocol

ABSTRACT

Ankle sprains are the most common lower extremity injury in physically active individuals. These injuries are classified as lateral, medial, and/or syndesmotic. Treatment may include functional rehabilitation, bracing, weight-bearing restriction, medications, injections, and surgery. While most sprains heal rapidly, permanent disability and pain may arise. Diagnostic ultrasound has been demonstrated to be accurate in diagnosing ligamentous injuries, but it is often excluded from management algorithms that rely on physical examination alone to diagnose significant injuries. This article proposes a comprehensive, evidence-based diagnostic ankle ultrasound protocol to implement in conjunction with thorough history and physical examination. We also review the current literature to describe where this protocol most improves diagnostic accuracy compared with physical examination alone.

MSK Ultrasound - An IJSPT Perspective

MSK ultrasound is a valuable imaging technique which has become increasingly popular in recent years. This efficient technique proves beneficial in a variety of ways. MSK ultrasound effectively streamlines the process by enabling practitioners to securely and accurately image and assess structures all in one simple step. By allowing healthcare providers to access critical information quickly and conveniently, MSK ultrasound can help identify conditions early when interventions are most effective. Moreover, it may be able to shorten diagnostic times and reduce costs through more cost-effective use of resources such as imaging and laboratory testing. Furthermore, MSK ultrasound can provide additional insights into musculoskeletal anatomy and help improve patient care and outcomes. In addition, utilizing this method reduces exposure to radiation and provides enhanced patient comfort with its quick scan duration. MSK ultrasound has a high potential to provide quick and accurate diagnosis of MSK disturbances when used correctly. As clinicians become more comfortable and familiar with this technology, we will continue to see its use expand for various MSK assessments. In this commentary we'll explore how ultrasound can be used in physical therapy, specifically for musculoskeletal assessment. We'll also look at some of the potential benefits and limitations of using ultrasound in PT practice.

Diagnosis and Simultaneous Treatment of Musculoskeletal Injury Using H2O2-Triggered Echogenic Antioxidant Polymer Nanoparticles in a Rat Model of Contusion Injury

Ultrasound is clinically used for diagnosis and interventions for musculoskeletal injuries like muscle contusion, but contrast of ultrasonography still remains a challenge in the field of the musculoskeletal system. A level of hydrogen peroxide (H₂O₂) is known to be elevated during mechanical tissue damage and therefore H₂O₂ can be exploited as a diagnostic and therapeutic marker for mechanical injuries in the musculoskeletal system. We previously developed poly(vanillin-oxalate) (PVO) as an inflammation-responsive polymeric prodrug of vanillin, which is designed to rapidly respond to H₂O₂ and exert antioxidant and anti-inflammatory activities. The primary aim of this study is to verify whether PVO nanoparticles could serve as contrast agents as well as therapeutic agents for musculoskeletal injuries simultaneously. In a rat model of contusion-induced muscle injury, PVO nanoparticles generated CO₂ bubbles to enhance the ultrasound contrast in the injury site. A single intramuscular injection of PVO nanoparticles also suppressed contusion-induced muscle damages by inhibiting the expression of pro-inflammatory cytokines and inflammatory cell infiltration. We, therefore, anticipate that PVO nanoparticles have great translational potential as not only ultrasound imaging agents but also therapeutic agents for the musculoskeletal disorders such as contusion.

Mapping theme trends and recognizing research hot spots in the use of ultrasound in orthopaedics: a bibliometric analysis of global research

BACKGROUND

In the past decade, ultrasound has been increasingly used in the field of orthopaedics. The purpose of this study is to inspire future research in this field by analyzing the publications relating to ultrasound research in orthopaedics.

METHODS

All relevant articles published between 2009 and 2020 were retrieved from Web of Science. Statistical Package for Social Science and GraphPad Prism 8 software were used to generate and analyse diagrams. VOSviewer software and CiteSpace were employed to visualize the research trends based on co-occurring keywords. Finally, we obtained information about relevant clinical randomized controlled trials (http://clinicaltrials.gov.com/).

RESULTS

The United States had the most publications in this field and the most citations and the highest H-index. Furthermore, Skeletal Radiology published the most papers related to the use of ultrasound in orthopaedics, Ozcakar L published the most papers, and a study by Kwon, YM had the highest citation frequency. The keywords "MRI", "complication", "female" and "male" were identified as being indicative of emerging topics.

CONCLUSIONS

While the contribution of United States to publications in this field has been substantial, the future contributions of China cannot be ignored. Moreover, it is hypothesized that diagnostic and epidemiological aspects may become hotspots.

Trends in Utilization of Image Guidance for Hip Joint Injections

OBJECTIVE

This study aims to evaluate trends in utilization of image guidance for intraarticular hip injections and to compare the cost efficiency of ultrasound-, fluoroscopic-, and landmark-guided injections in the management of hip osteoarthritis (OA) and femoroacetabular impingement (FAI).

DESIGN

Retrospective descriptive epidemiology study.

SETTING

The information was collected from Humana private payer insurance claims database encompassing all practice settings.

PATIENTS OR PARTICIPANTS

A total of 302 855 patients for years 2007 to 2015.

INTERVENTIONS OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES

Primary diagnosis of hip OA or FAI.

MAIN OUTCOME MEASURES

Injection type [corticosteroid (CS) or hyaluronic acid (HA)], imaging modality (landmark, ultrasound, or fluoroscopic guidance), and costs.

RESULTS

Landmark-guided CS and HA injections for the management of hip OA decreased, whereas fluoroscopic and ultrasound guidance increased. Similar trends were demonstrated in the management of FAI using CS. In the management of FAI using HA, landmark- and ultrasound-guided injections decreased and fluoroscopic-guided injections increased. Cost analysis revealed lower reimbursement of landmark and ultrasound guidance compared with fluoroscopic guidance.

CONCLUSIONS

During the study period, there was an increase in the use of image guidance and decline in landmark guidance for the treatment of OA and FAI using CS and HA. Fluoroscopic guidance demonstrated increased reimbursement compared with landmark and fluoroscopic guidance. There is an opportunity to mitigate cost and reduce radiation exposure by using ultrasound-guided injections rather than fluoroscopic guidance.

The Evolving Roles of MRI and Ultrasound in First-Line Imaging of Rotator Cuff Injuries

Rotator cuff tears are the most likely source of shoulder pain in adults and may cause protracted disability. Management of rotator cuff tears is associated with considerable costs. Accurate diagnosis can guide surgical planning and help achieve a favorable clinical outcome. While radiographs remain the initial imaging test for shoulder injury, the roles of MRI and ultrasound (US) as first-line imaging after radiography are evolving. This review leverages current literature and the practical experience of subspecialty musculoskeletal radiologists from different institutions in describing a practical approach to imaging rotator cuff pathology. Both MRI and US are accurate for identifying rotator cuff tears, but each has advantages and shortcomings. As both modalities currently represent reasonable first-line approaches, considerable practice variation has evolved. Given the low cost of US, imagers should strive to optimize the quality of shoulder US examinations and to build referrer confidence in this modality. The roles of direct CT and MR angiography, as well as imaging evaluation of the postoperative rotator cuff, are also considered. Through careful selection among the available imaging modalities, as well as optimal performance and interpretation of such examinations, radiologists can positively contribute to the diagnosis and treatment of patients with rotator cuff injuries.

Exploring the use of musculoskeletal ultrasound imaging by podiatrists: an international survey

Background

Podiatrists, in musculoskeletal services, are demonstrating an expansion of their practice skills through the use of ultrasound imaging. There is an assumption that this practice is beneficial within the context of patient care and health systems. The aim of this research was to further investigate the use of musculoskeletal ultrasound (MSUS) by podiatrists within their clinical setting and gain additional insights into the impact that they perceive use of MSUS has on their approaches to management of musculoskeletal foot and ankle problems.

Method

An international study utilising a cross-sectional design and an internet-based platform was undertaken. The survey was developed and implemented through three phases: 1. survey development, 2. face validity agreement via questionnaire review, and 3. survey distribution and data collection. Twenty-two survey questions were developed and set as a two-step approach collecting quantitative data (part 1) and qualitative free text data (part 2). Data was exported from SurveyMonkey and analysed using Microsoft Excel software. Counts and frequencies were calculated for responses to all twenty closed questions. Responses to the two final open-ended questions were analysed using thematic analysis to search for patterns related to podiatrists’ perceptions of impact.

Results

Two hundred and thirty-two eligible participants consented to complete the survey. The majority (n = 159) of respondents were from the UK and Spain. Commonly MSUS has been used in practice for (i) diagnosing pathology, (ii) supporting rehabilitation, (iii) supporting interventions or (iv) research purposes. Most frequently, MSUS was used to assist in the diagnosis of injury/pathology (84%). A range of free text comments were received from the participants in response to the question relating to their thoughts on the impact of using MSUS imaging in their practice (n = 109) and on their perceptions of how the use of MSUS has influenced their approaches to management of their patients’ musculoskeletal foot and ankle problems (n = 108). Thematic analysis of the free text comments generated four themes: (i) diagnosis, (ii) delivery and access of care, (iii) patient education and engagement, and (iv) patient empowerment.

Conclusion

The perceived benefit podiatrists indicated in using MSUS as part of their practice is the perceived improvement in patient journeys through tighter, focused management plans and reduced waiting times. An additional novel finding was that MSUS provided the capacity for podiatrists to better inform patients of their diagnosis, which they believed led to improved engagement and consequent empowerment of patients in their treatment plans. We propose further investigation of patient experiences as well as testing of the model that embeds podiatrists’ use of MSUS as a key skill in musculoskeletal foot and ankle services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00478-4.

Present Status of Musculoskeletal Radiology in Europe: International Survey by the European Society of Musculoskeletal Radiology

No official data exist on the status of musculoskeletal (MSK) radiology in Europe. The Committee for National Societies conducted an international survey to understand the status of training, subspecialization, and local practice among the European Society of Musculoskeletal Radiology (ESSR) partner societies. This article reports the results of that survey. An online questionnaire was distributed to all 26 European national associations that act as official partner societies of the ESSR. The 24 questions were subdivided into six sections: society structure, relationship with the national radiological society, subspecialization, present radiology practice, MSK interventional procedures, and MSK ultrasound. The findings of our study show a lack of standardized training and/or accreditation methods in the field of MSK radiology at a national level. The European diploma in musculoskeletal radiology is directed to partly overcome this problem; however, this certification is still underrecognized. Using certification methods, a more homogeneous European landscape could be created in the future with a view to subspecialist training. MSK ultrasound and MSK interventional procedures should be performed by a health professional with a solid knowledge of the relevant imaging modalities and sufficient training in MSK radiology. Recognition of MSK radiology as an official subspecialty would make the field more attractive for younger colleagues as well as attracting the brightest and best, an important key to further development of both clinical and academic radiology. KEY POINTS: · Standardized training and/or accreditation methods in the field of MSK radiology is lacking at a national level.. · With certification methods, such as the European diploma in musculoskeletal radiology, a more homogeneous European landscape could be created in the future with a view to subspecialist training.. · Recognition of MSK radiology as an official subspecialty would make the field more attractive for younger colleagues as well as attracting the brightest and best, an important key to further development of both clinical and academic radiology..

Utility of sonoelastography for the evaluation of rotator cuff tendon and pertinent disorders: a systematic review and meta-analysis

OBJECTIVES

Sonoelastography has been increasingly used to investigate musculoskeletal disorders. The aim of this meta-analysis was to investigate the utility of sonoelastography in diagnosing rotator cuff tendon pathology and pertinent disorders.

METHODS

Searching through PubMed and Embase, we systemically reviewed clinical studies in which sonoelastography has been used for imaging rotator cuff tendon pathology and relevant disorders. The primary outcome was the standardized mean difference (SMD) of tendon elasticity between shoulders (or patients) with and without the designated pathological conditions.

RESULTS

A total of 11 cross-sectional studies were included in the meta-analysis. The supraspinatus and infraspinatus tendons assessed by shear wave sonoelastography were likely to be stiffer in shoulders with adhesive capsulitis, with a SMD of 2.103 (95% confidence interval (CI), - 0.151 to 4.357, p = 0.067) and a SMD of 1.548 (95% CI, - 0.032 to 3.127, p = 0.055), respectively. Regarding rotator cuff tendinopathy, there was no significant difference in the elasticity of supraspinatus tendons evaluated by shear wave velocity (SMD = - 0.107; 95% CI, - 0.524 to 0.310, p = 0.615) or strain ratios (SMD = 0.153, 95% CI, - 2.134 to 2.440, p = 0.896). Only one study used shear wave sonoelastography to investigate patients with rotator cuff tendon tears and found tendon that elasticity was similar between diseased and normal shoulders.

CONCLUSION

This meta-analysis revealed that supraspinatus and infraspinatus tendons tended to be stiffer in shoulders with adhesive capsulitis. Furthermore, no significant difference in tendon elasticity could be identified between shoulders with and without rotator cuff tendinopathy or tendon tears.

KEY POINTS

• Supraspinatus and infraspinatus tendons are likely to have decreased elasticity in shoulders with adhesive capsulitis, as assessed by shear wave sonoelastography. • There was no significant difference in tendon elasticity between shoulders with and without rotator cuff tendinopathy or tendon tears when evaluated by strain and shear wave sonoelastography.

Changes in Current Procedural Terminology Coding and Its Effect on Specialty-Level Utilization of Musculoskeletal Ultrasound

PURPOSE

Concerns regarding increasing utilization of non-vascular extremity ultrasound (US) imaging led to the Current Procedural Terminology (CPT) Editorial Panel separating a singular billing code into distinct comprehensive and focused examination codes with differential reimbursement. We explore this policy change's temporal association with utilization.

METHODS

Using Physician/Supplier Procedure Summary Master Files, we identified all nonvascular extremity US services billed for Medicare fee-for-service beneficiaries between 1994 and 2017. These included generic (CPT code 76880 from 1994 to 2010), complete (code 76881 from 2011 to 2017), and limited (code 76882 from 2011 to 2017) examinations. Annual utilization per 100,000 beneficiaries was computed and stratified by billing specialty. Compound annual growth rates were calculated.

RESULTS

Radiologists and podiatrists were the top 2 billing specialties for nonvascular extremity US examinations. From 1994 to 2010, radiologist services increased 6.1% annually. Following the 2011 code separation, radiologists' utilization increased 2.7% annually for complete and 12.3% for limited exams. Between 1994 and 2017, radiologists' market share decreased 72.8% to 40.4%. From 1994 to 2010, podiatrist services increased 87.1% annually. Following the code separation, podiatrists' annual utilization growth stabilized 0.4% for complete and 0.6% for limited exams. Podiatrists' market share was 9.1% in 2001, peaked at 31.3% in 2009, and declined to 14.3% in 2017.

CONCLUSIONS

Prior rapid growth in extremity nonvascular US for podiatrists slowed considerably following CPT code separation in 2011. Subsequent service growth has largely been related to less costly, focused examinations performed by radiologists. Further study may help better understand how CPT coding changes alter imaging utilization more broadly.

Detecting Rotator Cuff Tears: A Network Meta-analysis of 144 Diagnostic Studies

BACKGROUND

Many imaging techniques have been developed for the detection of rotator cuff tears (RCTs). Despite numerous quantitative diagnostic studies, their relative accuracy remains inconclusive.

PURPOSE

To determine which of 3 commonly used imaging modalities is optimal for the diagnosis of RCTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Studies evaluating the performance of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and ultrasound (US) used in the detection of RCTs were retrieved from the PubMed/MEDLINE and Embase databases. Diagnostic data were extracted from articles that met the inclusion/exclusion criteria. A network meta-analysis was performed using an arm-based model to pool the absolute sensitivity and specificity, relative sensitivity and specificity, and diagnostic odds ratio as well as the superiority index for ranking the probability of these techniques.

RESULTS

A total of 144 studies involving 14,059 patients (14,212 shoulders) were included in this network meta-analysis. For the detection of full-thickness (FT) tears, partial-thickness (PT) tears, or any tear, MRA had the highest sensitivity, specificity, and superiority index. For the detection of any tear, MRI had better performance than US (sensitivity: 0.84 vs 0.81, specificity: 0.86 vs 0.82, and superiority index: 0.98 vs 0.22, respectively). With regard to FT tears, MRI had a higher sensitivity and superiority index than US (0.91 vs 0.87 and 0.67 vs 0.28, respectively) and a similar specificity (0.88 vs 0.88, respectively). The results for PT tears were similar to the detection of FT tears. A sensitivity analysis was performed by removing studies involving only 1 arm for FT tears, PT tears, or any tear, and the results remained stable.

CONCLUSION

This network meta-analysis of diagnostic tests revealed that high-field MRA had the highest diagnostic value for detecting any tear, followed by low-field MRA, high-field MRI, high-frequency US, low-field MRI, and low-frequency US. These findings can help guide clinicians in deciding on the appropriate imaging modality.

Thresholds of ultrasound synovial abnormalities for knee osteoarthritis - a cross sectional study in the general population

OBJECTIVE

To establish "normal" ranges for synovial thickness and effusion detected by ultrasound (US) and to determine cut-offs associated with knee pain (KP) and radiographic knee osteoarthritis (RKOA) in the community.

METHODS

147 women and 152 men ≥40 years old were randomly selected from the Nottingham KP and Related Health in the Community (KPIC) cohort (n = 9506). The "normal" range was established using the percentile method in 163 participants who had no KP and no RKOA. Optimal (maximum sensitivity and specificity) and high specificity (90%) cut-offs were established using receiver operating characteristic (ROC) curve analysis in a comparison between people with both KP and RKOA and normal controls.

RESULTS

Effusion and synovial hypertrophy differed by gender but not by age or laterality, therefore gender-specific reference limits were estimated. However, the "normal" ranges between men and women were similar for effusion (0-10.3 mm vs 0-9.8 mm), but different for synovial hypertrophy (0-6.8 mm vs 0-5.4 mm). Power Doppler Signal (PDS) in the healthy controls was uncommon (1.2% in men and 0.0% in women). The optimal cut-off was 7.4 mm for men and 5.3 mm for women for effusion, and 3.7 and 1.6 for hypertrophy respectively. The high specificity cut-off was 8.9 for men and 7.8 for women for effusion, and 5.8 and 4.2 for hypertrophy respectively.

CONCLUSIONS

US effusion and synovial hypertrophy but not PDS are common, but differ by gender, in community-derived people without painful knee OA. Currently used cut-offs for abnormality need reappraisal.

US Assessment of Sports-related Hip Injuries

Traumatic and overuse hip injuries occur frequently in amateur and professional athletes. After clinical assessment, imaging plays an important role in diagnosis and in defining care management of these injuries. Ultrasonography (US) is being increasingly used in assessment of hip injuries because of the wide availability of US machines, the lower cost, and the unique real-time imaging capability, which allows both static and dynamic evaluation as well as guidance of point-of-care interventions such as fluid aspiration and steroid injection. Accurate diagnosis of hip injuries is often challenging, given the complex soft-tissue anatomy of the hip and the wide spectrum of injuries that can occur. To conduct a skillful US evaluation of hip injuries, physicians must have pertinent knowledge of the normal anatomy and should make judicious use of surface anatomy landmarks while using a compartmentalized diagnostic approach. In this article, common sports-related injuries of the anterior, lateral, and posterior hip compartments are discussed. This review includes assessment of joint effusion, acetabular labral tear, acute and chronic tendon injuries including tendinopathy, partial and full-thickness tears, snapping hip syndromes, relevant US-guided procedures, and some other conditions such as Morel-Lavallée lesion and perineal nodular induration. Principles of care management and current knowledge on imaging findings that may affect return to activity are also presented. Using an oriented US examination technique and having knowledge of the normal hip anatomy will help physicians characterize US findings of common sports-related hip injuries and make accurate diagnoses. Online supplemental material is available for this article. ^©RSNA, 2018.

Ultrasound-Guided Versus Landmark-Guided Local Corticosteroid Injection for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To review the literature and assess the comparative effectiveness of ultrasound-guided versus landmark-guided local corticosteroid injections in patients with carpal tunnel syndrome (CTS).

DATA SOURCES

Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), Embase (Ovid), and Web of Science (from inception to February 1, 2017).

STUDY SELECTION

Randomized controlled trials (RCTs) comparing ultrasound-guided injection with landmark-guided injection in patients with CTS were included.

DATA EXTRACTION

Two authors independently screened abstracts and full texts. The outcomes of interest were Symptom Severity Scale (SSS) and Functional Status Scale (FSS) scores of the Boston Carpal Tunnel Questionnaire and 4 electrodiagnostic parameters, including compound muscle action potential (CMAP), sensory nerve action potential (SNAP), distal motor latency (DML), and distal sensory latency (DSL).

DATA SYNTHESIS

Overall, 569 abstracts were retrieved and checked for eligibility; finally, 3 RCTs were included (181 injected hands). Pooled analysis showed that ultrasound-guided injection was more effective in SSS improvement (mean difference [MD], -.46; 95% confidence interval [CI], -.59 to -.32; P<.00001), whereas no significant difference was observed between the 2 methods in terms of the FSS (MD, -.25; 95% CI, -.56 to .05; P=.10). There were also no statistically significant differences in improvements of CMAP (MD, 1.54; 95% CI, 0.01 to 3.07; P=.05), SNAP (MD, -0.02; 95% CI, -6.27 to 6.23; P>.99), DML (MD, .05; 95% CI, -.30 to .39; P=.80), or DSL (MD, .00; 95% CI, -.65 to .65; P>.99).

CONCLUSIONS

This review suggested that ultrasound-guided injection was more effective than landmark-guided injection in symptom severity improvement in patients with CTS; however, no significant differences were observed in functional status or electrodiagnostic improvements between the 2 methods.