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Past, Present, and Future Considerations for Musculoskeletal Ultrasound
P a s t , P re s e n t , a n d F u t u re Considerations for Musculoskeletal Ultrasound Scott J. Primack,
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KEYWORDS History Injection Intervention Musculoskeletal Neurologic Sonography Sports Ultrasound KEY POINTS Musculoskeletal ultrasound has been used since 1958, but its use has increased significantly in recent years. Training curricula, certifications, organizational guidelines, and position statements in recent years have helped formalize and standardize the practice of musculoskeletal ultrasound, particularly among nonradiologist musculoskeletal clinicians. Future developments in musculoskeletal ultrasound will be fostered by formal ultrasound education programs integrated into residency and fellowship programs.
Confucius stated, “study the past if you would define the future.” This clearly holds true for musculoskeletal ultrasound. Echolocation, the term used to detect objects and measure distances, was originally developed for nautical purposes. After the sinking of the Titanic, Reginald Fessenden patented the first sonar device capable of detecting an iceberg 2 miles away. By World War I, Paul Langevin and Constantin Chilowsky constructed an underwater sandwich sound generator using quartz and steel plates.1 The first recorded sinking of a German U-boat using a hydrophone was on April 23, 1916.2 Between World War I and World War II, ultrasound techniques were used as “reflectoscopes,” as a method of detecting flaws or defects in ships and aircraft. The application of echolocation was more widely applied during World War II. These technologies led to the development of the medical diagnostic use of ultrasound. Ultrasound as a medical diagnostic tool was first used by Dr Karl Dussik in 1942. He attempted to diagnose brain tumors and visualize the cerebral ventricles by measuring transmission of ultrasound beams through the head.3 The integration of ultrasound into clinical practice was established by Donald and colleagues.4 He was able to
Disclosures: The author has no commercial or financial conflicts of interest. Colorado Rehabilitation and Occupational Medicine, 1390 South Potomac Street, Suite 100, Aurora, CO 80012, USA E-mail address: [email protected] Phys Med Rehabil Clin N Am 27 (2016) 749–752 http://dx.doi.org/10.1016/j.pmr.2016.04.009 1047-9651/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
pmr.theclinics.com
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Primack
demonstrate the utility of ultrasound in differentiating between cystic and solid abdominal masses. The first report of musculoskeletal ultrasound was in 1958. Dussik and colleagues5 was able to describe and measure acoustic attenuation of articular and periarticular tissues. This work led to the first description of anisotropy and the effects of different articular injuries and diseases on ultrasound attenuation, thus laying down the foundation of diagnostic musculoskeletal ultrasound. In 1972, the first B-scan image of a human joint was reported. The clinicians were able to differentiate between a Baker cyst and thrombophlebitis.6 Just a few years later, Cooperberg and colleagues7 used ultrasound to demonstrate synovitis in rheumatoid arthritis patients. With improved technology, musculoskeletal ultrasound began to be increasingly used for detecting shoulder pathology. Crass and colleagues8 demonstrated the efficacy of ultrasound in the diagnosis of rotator cuff pathology, using surgical correlation as the gold standard. The first outcome-oriented study that used diagnostic ultrasound with a functional outcome measure was done by Harryman and colleagues.9 Their research demonstrated that a valid functional outcome measure, the Simple Shoulder Test questionnaire, correlated with the integrity of the repaired rotator cuff tendon complex at postsurgical follow-up. The recurrent rotator cuff defect was measured via specific criteria, as described by Mack and colleagues.10 At the same time, radiologists Fornage11 and Van Holsbeeck and Introcaso12 contributed significantly to ultrasound description of the musculoskeletal system. With advanced engineering in transducers, lower machine cost, and wider availability, there has been a larger trend for nonradiologists to integrate musculoskeletal ultrasound into the clinical assessment. Primack13 demonstrated that musculoskeletal ultrasound can be used as an extension of the clinical examination. Using ultrasound as the first-line modality for occupational shoulder injuries, it was shown that there was a 40% reduction in imaging cost without compromising quality or accuracy of diagnosis.14 Before the twenty-first century, European physicians used sonography as a primary diagnostic tool for neuromusculoskeletal imaging. Martinoli and colleagues15 were able to describe tendon and nerve sonology. They were able to demonstrate the utility of ultrasound in the detection of loose bodies in joints. One of the challenges of musculoskeletal ultrasound has been that it is operator dependent. Jacobson16 reviewed that the “non-operator-dependent” quality of MRI is complementary to musculoskeletal sonography. Nazarian17 pointed out 10 reasons why musculoskeletal ultrasound was an important imaging modality to complement MRI. It has been suggested that MRI is the gold standard for further musculoskeletal ultrasound studies. By the twenty-first century, musculoskeletal ultrasound was thought efficacious in the musculoskeletal clinician’s office. Given the unique ability to visualize soft tissue and bony landmarks accurately, ultrasound has been used for both diagnostic and therapeutic interventions in the outpatient clinical setting with increasing frequency. Given the increasing use of ultrasound as an adjunct in patient management, education has been an ongoing focus for many musculoskeletal clinicians. The American Academy of Physical Medicine and Rehabilitation, American Medical Society for Sports Medicine, American Osteopathic College of Physical Medicine and Rehabilitation, and American Institute of Ultrasound in Medicine, among other organizations, have instituted educational programs to support high demand from clinicians as well as create objectives for competency. A formal musculoskeletal sonography credential was initiated in 2012 by the American Registry for Diagnostic Medical Sonography.
Considerations for Musculoskeletal Ultrasound
The future is bright in musculoskeletal ultrasound, not only due to advancing technology but also, more importantly, because of the commitment to integrating this imaging modality into resident and fellow education. Coursework objectives have been developed and implemented in the physical medicine and rehabilitation residency program at the Rehabilitation Institute of Chicago since 2008, and other residencies have since followed suit. Finnoff and colleagues18 proposed a model musculoskeletal course for physical medicine and rehabilitation residents in 2008. In 2015, the American Medical Society for Sports Medicine published a recommended sports ultrasound curriculum for all sports medicine fellowships.19 The next decade, given the integration of musculoskeletal ultrasound into training curricula, will demonstrate further advances in musculoskeletal ultrasound for both diagnostic uses and therapeutic interventions by educating and training many future leaders in the field. REFERENCES
1. Hill CR. Medical ultrasonics: an historical review. Br J Radiol 1973;46:899–905. 2. Firestone FA. The supersonic reflectoscope, an instrument of inspecting the interior of solid parts by means of sound waves. J Acoust Soc Am 1945;17: 287–99. 3. Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiatr 1942;174:153–68. 4. Donald I, MacVicar J, Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet 1958;1:1188–95. 5. Dussik KT, Fritch DJ, Kyriazidou M, et al. Measurements of articular tissues with ultrasound. Am J Phys Med 1958;37:160–5. 6. McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker’s cyst and thrombophlebitis. Br J Radiol 1972;45:729–32. 7. Cooperberg PL, Tsang I, Truelove L, et al. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978;126:759–63. 8. Crass JR, Craig EV, Thompson RC, et al. Ultrasonography of the rotator cuff: surgical correlation. J Clin Ultrasound 1984;12(8):478–91. 9. Harryman DT II, Mack LA, Wang KY. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982. 10. Mack LA, Matsen FA III, Wang KY. Diagnostic ultrasound. St Louis (MO): Mosby; 1991. 11. Fornage BD. Musculoskeletal ultrasound. New York: Churchill Livingstone; 1995. 12. Van Holsbeeck M, Introcaso JH. Musculoskeletal ultrasound. St Louis (MO): Mosby; 1991. 13. Primack SJ. Musculoskeletal ultrasound: the clinician’s perspective. Radiol Clin North Am 1999;37:617–21. 14. Primack SJ, Bernton JT, Schauer LM. Diagnostic ultrasound of the shoulder: A cost-effective approach. Presented at the American Academy of Occupational & Evironmental Medicine. Las Vegas, April 28-May 5, 1995. 15. Martinoli C, Bianchi S, Derchi LE. Tendon and nerve sonography. Radiol Clin North Am 1999;37:691–711. 16. Jacobson JA. Musculoskeletal Sonography and M.R. Imaging: a role for both imaging methods. Radiol Clin North Am 1999;37:713–35. 17. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol 2008; 190:1621.
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18. Finnoff JT, Smith JF, Nutz DJ, et al. A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil 2010;1(89): 56–69. 19. Finnoff JT, Berkoff D, Brennan F, et al. American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Clin J Sport Med 2015;25(1):23–9.
DO
KEYWORDS History Injection Intervention Musculoskeletal Neurologic Sonography Sports Ultrasound KEY POINTS Musculoskeletal ultrasound has been used since 1958, but its use has increased significantly in recent years. Training curricula, certifications, organizational guidelines, and position statements in recent years have helped formalize and standardize the practice of musculoskeletal ultrasound, particularly among nonradiologist musculoskeletal clinicians. Future developments in musculoskeletal ultrasound will be fostered by formal ultrasound education programs integrated into residency and fellowship programs.
Confucius stated, “study the past if you would define the future.” This clearly holds true for musculoskeletal ultrasound. Echolocation, the term used to detect objects and measure distances, was originally developed for nautical purposes. After the sinking of the Titanic, Reginald Fessenden patented the first sonar device capable of detecting an iceberg 2 miles away. By World War I, Paul Langevin and Constantin Chilowsky constructed an underwater sandwich sound generator using quartz and steel plates.1 The first recorded sinking of a German U-boat using a hydrophone was on April 23, 1916.2 Between World War I and World War II, ultrasound techniques were used as “reflectoscopes,” as a method of detecting flaws or defects in ships and aircraft. The application of echolocation was more widely applied during World War II. These technologies led to the development of the medical diagnostic use of ultrasound. Ultrasound as a medical diagnostic tool was first used by Dr Karl Dussik in 1942. He attempted to diagnose brain tumors and visualize the cerebral ventricles by measuring transmission of ultrasound beams through the head.3 The integration of ultrasound into clinical practice was established by Donald and colleagues.4 He was able to
Disclosures: The author has no commercial or financial conflicts of interest. Colorado Rehabilitation and Occupational Medicine, 1390 South Potomac Street, Suite 100, Aurora, CO 80012, USA E-mail address: [email protected] Phys Med Rehabil Clin N Am 27 (2016) 749–752 http://dx.doi.org/10.1016/j.pmr.2016.04.009 1047-9651/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
pmr.theclinics.com
750
Primack
demonstrate the utility of ultrasound in differentiating between cystic and solid abdominal masses. The first report of musculoskeletal ultrasound was in 1958. Dussik and colleagues5 was able to describe and measure acoustic attenuation of articular and periarticular tissues. This work led to the first description of anisotropy and the effects of different articular injuries and diseases on ultrasound attenuation, thus laying down the foundation of diagnostic musculoskeletal ultrasound. In 1972, the first B-scan image of a human joint was reported. The clinicians were able to differentiate between a Baker cyst and thrombophlebitis.6 Just a few years later, Cooperberg and colleagues7 used ultrasound to demonstrate synovitis in rheumatoid arthritis patients. With improved technology, musculoskeletal ultrasound began to be increasingly used for detecting shoulder pathology. Crass and colleagues8 demonstrated the efficacy of ultrasound in the diagnosis of rotator cuff pathology, using surgical correlation as the gold standard. The first outcome-oriented study that used diagnostic ultrasound with a functional outcome measure was done by Harryman and colleagues.9 Their research demonstrated that a valid functional outcome measure, the Simple Shoulder Test questionnaire, correlated with the integrity of the repaired rotator cuff tendon complex at postsurgical follow-up. The recurrent rotator cuff defect was measured via specific criteria, as described by Mack and colleagues.10 At the same time, radiologists Fornage11 and Van Holsbeeck and Introcaso12 contributed significantly to ultrasound description of the musculoskeletal system. With advanced engineering in transducers, lower machine cost, and wider availability, there has been a larger trend for nonradiologists to integrate musculoskeletal ultrasound into the clinical assessment. Primack13 demonstrated that musculoskeletal ultrasound can be used as an extension of the clinical examination. Using ultrasound as the first-line modality for occupational shoulder injuries, it was shown that there was a 40% reduction in imaging cost without compromising quality or accuracy of diagnosis.14 Before the twenty-first century, European physicians used sonography as a primary diagnostic tool for neuromusculoskeletal imaging. Martinoli and colleagues15 were able to describe tendon and nerve sonology. They were able to demonstrate the utility of ultrasound in the detection of loose bodies in joints. One of the challenges of musculoskeletal ultrasound has been that it is operator dependent. Jacobson16 reviewed that the “non-operator-dependent” quality of MRI is complementary to musculoskeletal sonography. Nazarian17 pointed out 10 reasons why musculoskeletal ultrasound was an important imaging modality to complement MRI. It has been suggested that MRI is the gold standard for further musculoskeletal ultrasound studies. By the twenty-first century, musculoskeletal ultrasound was thought efficacious in the musculoskeletal clinician’s office. Given the unique ability to visualize soft tissue and bony landmarks accurately, ultrasound has been used for both diagnostic and therapeutic interventions in the outpatient clinical setting with increasing frequency. Given the increasing use of ultrasound as an adjunct in patient management, education has been an ongoing focus for many musculoskeletal clinicians. The American Academy of Physical Medicine and Rehabilitation, American Medical Society for Sports Medicine, American Osteopathic College of Physical Medicine and Rehabilitation, and American Institute of Ultrasound in Medicine, among other organizations, have instituted educational programs to support high demand from clinicians as well as create objectives for competency. A formal musculoskeletal sonography credential was initiated in 2012 by the American Registry for Diagnostic Medical Sonography.
Considerations for Musculoskeletal Ultrasound
The future is bright in musculoskeletal ultrasound, not only due to advancing technology but also, more importantly, because of the commitment to integrating this imaging modality into resident and fellow education. Coursework objectives have been developed and implemented in the physical medicine and rehabilitation residency program at the Rehabilitation Institute of Chicago since 2008, and other residencies have since followed suit. Finnoff and colleagues18 proposed a model musculoskeletal course for physical medicine and rehabilitation residents in 2008. In 2015, the American Medical Society for Sports Medicine published a recommended sports ultrasound curriculum for all sports medicine fellowships.19 The next decade, given the integration of musculoskeletal ultrasound into training curricula, will demonstrate further advances in musculoskeletal ultrasound for both diagnostic uses and therapeutic interventions by educating and training many future leaders in the field. REFERENCES
1. Hill CR. Medical ultrasonics: an historical review. Br J Radiol 1973;46:899–905. 2. Firestone FA. The supersonic reflectoscope, an instrument of inspecting the interior of solid parts by means of sound waves. J Acoust Soc Am 1945;17: 287–99. 3. Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiatr 1942;174:153–68. 4. Donald I, MacVicar J, Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet 1958;1:1188–95. 5. Dussik KT, Fritch DJ, Kyriazidou M, et al. Measurements of articular tissues with ultrasound. Am J Phys Med 1958;37:160–5. 6. McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker’s cyst and thrombophlebitis. Br J Radiol 1972;45:729–32. 7. Cooperberg PL, Tsang I, Truelove L, et al. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978;126:759–63. 8. Crass JR, Craig EV, Thompson RC, et al. Ultrasonography of the rotator cuff: surgical correlation. J Clin Ultrasound 1984;12(8):478–91. 9. Harryman DT II, Mack LA, Wang KY. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982. 10. Mack LA, Matsen FA III, Wang KY. Diagnostic ultrasound. St Louis (MO): Mosby; 1991. 11. Fornage BD. Musculoskeletal ultrasound. New York: Churchill Livingstone; 1995. 12. Van Holsbeeck M, Introcaso JH. Musculoskeletal ultrasound. St Louis (MO): Mosby; 1991. 13. Primack SJ. Musculoskeletal ultrasound: the clinician’s perspective. Radiol Clin North Am 1999;37:617–21. 14. Primack SJ, Bernton JT, Schauer LM. Diagnostic ultrasound of the shoulder: A cost-effective approach. Presented at the American Academy of Occupational & Evironmental Medicine. Las Vegas, April 28-May 5, 1995. 15. Martinoli C, Bianchi S, Derchi LE. Tendon and nerve sonography. Radiol Clin North Am 1999;37:691–711. 16. Jacobson JA. Musculoskeletal Sonography and M.R. Imaging: a role for both imaging methods. Radiol Clin North Am 1999;37:713–35. 17. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol 2008; 190:1621.
751
752
Primack
18. Finnoff JT, Smith JF, Nutz DJ, et al. A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil 2010;1(89): 56–69. 19. Finnoff JT, Berkoff D, Brennan F, et al. American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Clin J Sport Med 2015;25(1):23–9.