Challenges to address prior to considering performing musculoskeletal point-of-care ultrasound
-
Steven B. Soliman
To the Editor,
I commend the efforts of McGillicuddy and Haus [1] on their publication entitled, “Rotator cuff injuries: improving identification with bedside ultrasound.” They highlight the role of musculoskeletal (MSK) ultrasound (US) and especially point-of-care ultrasound (POCUS) as a valuable and accurate tool in the evaluation of rotator cuff pathology.
The use of MSK US has significantly increased over the past few decades because of its ease of accessibility, portability, ability to perform dynamic imaging while interacting directly with the patient, and ability to compare with the contralateral side [2], [3], [4]. There are also many recent and exciting advancements in MSK US including ultra-high-frequency imaging, microvascular imaging, and elastography [4]. Furthermore, POCUS use has significantly increased, and POCUS has been coined the “stethoscope of the future” [5].
However, there are a few issues on which I would like to comment. Being at an institution that performs a substantial volume of MSK US, I can attest to how challenging MSK US is, and this is even true among fellowship-trained MSK radiologists. MSK US is challenging in the sense of image interpretation as well as image acquisition. Therefore, the need for proper training in MSK US is vital. Hospitals may even want to consider requiring certification (R.M.S.K.) in MSK US before anyone attempting to perform it and especially if it is being utilized for US-guided procedures.
Moreover, when MSK POCUS is performed, especially in the inpatient or emergency room setting, images that are labeled high-quality should be obtained and saved. The labels should include the body part and whether the images were obtained in the short-axis (transverse) or long-axis (longitudinal) axis. These images should also be saved in the electronic medical record and radiology system. They should also be available for review and comparison. This is important because when an additional study such as an MRI or a follow-up US is ordered, the radiologist must be able to compare the images to evaluate the changes in rotator cuff tear sizes, muscles quality changes, and so on. These parameters are critical for determining surgical eligibility and management.
In the US in Figure 1B [1], the arrow is not pointing to an absent tendon but rather to deep subcutaneous fat with a partially visualized underlying hyperechoic deltoid muscle that can be seen in those with type 2 diabetes [6, 7]. There is no rotator cuff or humeral head/greater tuberosity in this image to identify a rotator cuff tear. Additionally, the arrow in Figure 1C [1] (MRI) is pointing to the axillary recess and inferior glenohumeral ligament with a joint effusion. There is no arrow pointing to the torn and retracted supraspinatus tendon, which is more superior.
These issues highlight the need for proper training in image interpretation, performing MSK US, US physics, optimizing US images, and MSK anatomy, before performing POCUS and more importantly before MSK US use is attempted by anyone, especially those who are not MSK radiologists trained in MSK US.
-
Research ethics: Institutional review board protocol review was exempt per our institutional review board policies for this type of manuscript.
-
Informed consent: Not applicable.
-
Author contributions: The author provided substantial contribution to conception and design if this manuscript; the author drafted the article and revised it critically for important intellectual content; the author gave final approval of the version of the article to be published; and the author agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
-
Competing interests: None declared.
-
Research funding: None declared.
-
Data availability: Not applicable.
References
1. McGillicuddy, C, Haus, D. Rotator cuff injuries: improving identification with bedside ultrasound. J Osteopath Med 2023;123:411–12. https://doi.org/10.1515/jom-2022-0227.Search in Google Scholar PubMed
2. Soliman, SB, Davis, JJ, Muh, SJ, Vohra, ST, Patel, A, van Holsbeeck, MT. Ultrasound evaluations and guided procedures of the painful joint arthroplasty. Skeletal Radiol 2022;51:2105–20. https://doi.org/10.1007/s00256-022-04080-y.Search in Google Scholar PubMed
3. Laucis, NC, Rosen, KA, Thodge, A, Leschied, JR, Klochko, CL, Soliman, SB. Sonographic evaluation of the association between calcific tendinopathy and rotator cuff tear: a case-controlled comparison. Clin Rheumatol 2021;40:2897–905. https://doi.org/10.1007/s10067-021-05597-8.Search in Google Scholar PubMed
4. van Holsbeeck, M, Soliman, S, Van Kerkhove, F, Craig, J. Advanced musculoskeletal ultrasound techniques: what are the applications? AJR Am J Roentgenol 2021;216:436–45. https://doi.org/10.2214/ajr.20.22840.Search in Google Scholar PubMed
5. Andersen, CA, Holden, S, Vela, J, Rathleff, MS, Jensen, MB. Point-of-care ultrasound in general practice: a systematic review. Ann Fam Med 2019;17:61–9. https://doi.org/10.1370/afm.2330.Search in Google Scholar PubMed PubMed Central
6. Soliman, SB, Rosen, KA, Williams, PC, Spicer, PJ, Williams, LK, Rao, SD, et al.. The hyperechoic appearance of the deltoid muscle on shoulder ultrasound imaging as a predictor of diabetes and prediabetes. J Ultrasound Med 2020;39:323–9. https://doi.org/10.1002/jum.15110.Search in Google Scholar PubMed
7. Rosen, KA, Thodge, A, Tang, A, Franz, BM, Klochko, CL, Soliman, SB. The sonographic quantitative assessment of the deltoid muscle to detect type 2 diabetes mellitus: a potential noninvasive and sensitive screening method? BMC Endocr Disord 2022;22:193. https://doi.org/10.1186/s12902-022-01107-2.Search in Google Scholar PubMed PubMed Central
© 2023 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Articles in the same Issue
- Frontmatter
- Cardiopulmonary Medicine
- Review Article
- The role of aspirin, statins, colchicine, and IL-1 inhibitors in prevention of cardiovascular events: a systematic integrative review
- Medical Education
- Original Article
- Teaching ultrasound in osteopathic medical schools
- Brief Report
- Expansion of osteopathic medicine practitioner education on substance use disorders
- Musculoskeletal Medicine and Pain
- Original Article
- Increased circulating microRNA-21 level as a potential indicator for predicting a higher risk of incident fragility fractures
- Public Health and Primary Care
- Commentary
- The evolution of type 2 diabetes management: glycemic control and beyond with SGLT-2 inhibitors and GLP-1 receptor agonists
- Clinical Image
- Green nail syndrome in a teenager
- Letter to the Editor
- Challenges to address prior to considering performing musculoskeletal point-of-care ultrasound
Articles in the same Issue
- Frontmatter
- Cardiopulmonary Medicine
- Review Article
- The role of aspirin, statins, colchicine, and IL-1 inhibitors in prevention of cardiovascular events: a systematic integrative review
- Medical Education
- Original Article
- Teaching ultrasound in osteopathic medical schools
- Brief Report
- Expansion of osteopathic medicine practitioner education on substance use disorders
- Musculoskeletal Medicine and Pain
- Original Article
- Increased circulating microRNA-21 level as a potential indicator for predicting a higher risk of incident fragility fractures
- Public Health and Primary Care
- Commentary
- The evolution of type 2 diabetes management: glycemic control and beyond with SGLT-2 inhibitors and GLP-1 receptor agonists
- Clinical Image
- Green nail syndrome in a teenager
- Letter to the Editor
- Challenges to address prior to considering performing musculoskeletal point-of-care ultrasound
