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A Musculoskeletal Ultrasound Course for Physical Medicine and Rehabilitation Residents

Finnoff, Jonathan T. DO; Smith, Jay MD; Nutz, David J. MD; Grogg, Brian E. MD

American Journal of Physical Medicine & Rehabilitation: January 2010 - Volume 89 - Issue 1 - pp 56-69
doi: 10.1097/PHM.0b013e3181c1ee69
Education & Administration: Ultrasound

Musculoskeletal ultrasound is an imaging modality that can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures. A growing proportion of physiatrists are interested in musculoskeletal ultrasound as demonstrated by the increasing number of musculoskeletal ultrasound articles published in physical medicine and rehabilitation journals and quantity of musculoskeletal ultrasound courses and workshops at physical medicine and rehabilitation conferences. The Mayo Clinic (Rochester, MN) Physical Medicine and Rehabilitation residency program developed a musculoskeletal ultrasound course for their physical medicine and rehabilitation residents, which was implemented in 2008. A detailed description of the course is provided in this article. In addition, results from a premusculoskeletal ultrasound course and postmusculoskeletal ultrasound course practical and written test are presented, and the results of a postmusculoskeletal ultrasound course resident survey are discussed. This information can be used by other physical medicine and rehabilitation residency programs to assist in the creation of their own musculoskeletal ultrasound course.

From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.

All correspondence and requests for reprints should be addressed to Jonathan T. Finnoff, DO, Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individual in control of the content of this article. This information has not been presented previously. No funding or grants were received for this project.

Physiatrists have a long history in the field of ultrasound medicine, which has been demonstrated by their founding of the American Institute for Ultrasound in Medicine in 1954. Although their initial interest may have been related to ultrasound's therapeutic use as a deep heating modality, the recent introduction of affordable, real-time high-frequency ultrasonographic imaging has led many physiatrists to explore its clinical utility as an imaging modality for musculoskeletal conditions. The interest of physiatrists in musculoskeletal ultrasound (MSUS) is reflected by an escalating number of articles published on this subject in physical medicine and rehabilitation (PM&R) journals over the past 5 yrs,1–38 particularly when compared with the number of articles published in PM&R journals from 1996 to 1999.39–46 MSUS is a safe, inexpensive, noninvasive, easily accessible imaging modality that provides real-time imaging during dynamic maneuvers.47 Ultrasound can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures.21

Because the integration of MSUS into the practice of PM&R is in its infancy, many practicing physiatrists have not received formal training in MSUS. A recent survey of 225 AAPM&R members reported that nearly 75% of the respondents had participated in 5 hrs or less of continuing medical education related to MSUS (unpublished data, American Academy of Physical Medicine & Rehabilitation (AAPM&R), Chicago, IL). In addition, 85% of those who were currently not trained in MSUS expressed a strong interest in obtaining training and incorporating MSUS into their practices within the next 4 yrs (personal communication with the AAPM&R). Based on these findings, the AAPM&R's Medical Education Committee is currently developing multiple MSUS-related educational products to meet this need.

Much of the education physiatrists receive is during their PM&R residency. Therefore, it is logical that topics relevant to the practice of PM&R should be taught during residency. Although the Accreditation Council for Graduate Medical Education currently does not require the inclusion of MSUS training as part of an accredited PM&R residency program, the faculty and residents of the Mayo Clinic (Rochester, MN) PM&R residency program perceived a need to initiate MSUS training into PM&R residency education. A formal MSUS course was subsequently developed. Although there have been a few papers on MSUS education, to our knowledge, there are no previous publications within the medical literature outlining a formal MSUS curriculum with respect to PM&R residency.47–50 Therefore, the purpose of this article is to present the PM&R residency's MSUS course, the objective measures of PM&R resident MSUS knowledge and practical MSUS skills before and after the course, and the subjective opinions of the PM&R residents regarding the MSUS course and MSUS in general. Our hope is to provide other PM&R residency program directors with information that may assist them in the development of an MSUS course.

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The PM&R Residency MSUS course was developed over a period of 9 mos (October 2007–June 2008) and implemented in July 2008. The previous literature regarding MSUS education was reviewed, and the senior author's (J.S.) previous experience as course director for a successful multiday MSUS course was considered.47–50 The MSUS course was incorporated into the existing PM&R Residency Musculoskeletal Education course. The Musculoskeletal Education course was divided into modules, each of which focused on a specific joint and/or anatomic region. During each module, the residents spent 2 hrs in the anatomy lab dissecting and reviewing the pertinent anatomy, attended a 2 hrs hands-on physical examination workshop, and received a 2 hrs lecture discussing common injuries, conditions, and treatments. Therefore, the MSUS course was divided into similar modules, and the MSUS didactic sessions were scheduled at the end of each relevant module of the Musculoskeletal Education course. Five physicians served as faculty for the MSUS course. The faculty were staff physicians of the Department of PM&R, who had attended formal training in MSUS at national and regional courses, received mentorship and education in MSUS from other staff members, and had applied MSUS in clinical practice for a minimum of 2 yrs. Five ultrasound units were used for the MSUS course. The ultrasound units came from several different departments within our institution.

Before beginning the MSUS course, the residents were given a written test containing 25 multiple choice questions and a 20-question practical test. The written test questions related to basic ultrasound concepts such as ultrasound physics, common artifacts, and image optimization through manipulation of the various ultrasound machine functions (commonly referred to as knobology or instrumentation). The practical test included questions on image acquisition of specific anatomic structures, and optimization of a specific image through instrumentation. The practical test was scored using a 0- to 2-point ordinal scale in which 0 indicated that the resident was unable to perform the requested action, 1 indicated that the resident was able to partially perform the requested action, and 2 indicated that the resident was able to correctly perform the requested action.

The curriculum and learning objectives for the MSUS course are presented in Appendix 1. Before the first didactic session, the PM&R residents were required to complete a 30-mins online ultrasound physics course created by the Radiology department, which was adapted from a larger scale ultrasound physics course provided to radiology residents. This online course included annotated post-test questions for self-study. In addition, the residents were given reading assignments, which they were expected to complete before each didactic session. Each didactic session lasted 2 hrs. There was approximately 1–5 wks between MSUS course didactic sessions because of its incorporation into the existing PM&R Residency Musculoskeletal Education course.

The first four MSUS didactic sessions focused on specific joint(s). During the first didactic session, approximately 30 mins were spent discussing basic ultrasound concepts including instrumentation (orientation to position and function of U.S. machine controls), transducer selection, image optimization, and common U.S. artifacts. All MSUS joint examination didactic sessions included more than one joint with the exception of the shoulder MSUS didactic session. Because the shoulder is the most complex joint to image using an ultrasound device, we decided to dedicate an entire MSUS didactic session to shoulder MSUS.

The MSUS joint examination didactic sessions began with a course faculty member performing live MSUS joint examination(s) using the MSUS scanning protocol created for the course (Appendix 2). The MSUS scanning protocols were developed by the senior investigator (JS) based on his extensive MSUS experience and multiple resources such as the American Institute for Ultrasound in Medicine Practice Guideline for the Performance of the MSUS Examination ( and the European Society of Skeletal Radiology protocols ( Proper MSUS imaging of all the required (bold print) structures listed in the MSUS scanning protocol of the course were demonstrated by the faculty member. The residents were then divided into groups of approximately five residents per one faculty member and practiced performing the same MSUS examination(s) demonstrated by the faculty member. Between didactic sessions, the residents were encouraged to establish study groups and practice MSUS imaging to reinforce what they had learned in the didactic session.

The final two didactic sessions of the MSUS course involved instruction on the performance of MSUS-guided procedures. In the first didactic session, faculty members provided lectures discussing MSUS-guided procedure techniques, indications, contraindications, potential complications, commonly used medications and their therapeutic benefits, and potential side effects. The lectures were followed by a hands-on session in which residents practiced visualizing and guiding needles in a turkey breast using MSUS. During the next didactic session, the residents received direct instruction in the performance of upper limb and lower limb MSUS-guided procedures by the faculty members of the course. The residents practiced performing the procedures on unembalmed cadaveric upper (including the shoulder) and lower (including the hip) limb specimens.

After completion of the MSUS course, the residents were given the same written and practical examinations they had taken before the course, although the question order was rearranged. The difference between the pre-MSUS course written and practical test scores and post-MSUS written and practical test scores were compared using descriptive statistics.

The residents were also asked to fill out a post-MSUS course survey. The survey collected the following information:

1. Postgraduate year

2. Amount of pre-MSUS course exposure to MSUS

3. Level of MSUS interest

4. Adequacy of didactic session lengths and time duration between didactic sessions

5. Most difficult and easiest joint(s) to scan

6. Sufficiency of supplemental resources (i.e.: text book, American Institute for Ultrasound in Medicine online resources, MSUS course scanning protocols, and online physics course)

7. Level of MSUS knowledge before and after the MSUS course

8. Ability to operate a U.S. machine before and after the MSUS course

9. Capacity to optimally image musculoskeletal structures using MSUS before and after the MSUS course

10. Overall rating of the MSUS course

11. Whether the presence of the MSUS course would have influenced their decision regarding where to complete their PM&R residency

12. Whether the presence of the MSUS course would influence their recommendation of the PM&R residency when discussing PM&R residency programs with medical students interested in PM&R

The information from the pre- and post-MSUS course written and practical tests, and the post-MSUS course survey were analyzed using descriptive statistics.

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All 24 PM&R residents completed the pre-MSUS course written and practical tests, and 21 of the 24 residents (88%) completed the post-MSUS course written and practical tests. The three residents who were unable to complete the post-MSUS tests were participating in out-of-state clinical rotations at the time of the post-MSUS tests. The pre- and post-MSUS course written and practical test results are presented in Table 1. The average increases in pre-MSUS course to post-MSUS course written and practical test scores were 6.4 and 20.6, respectively, representing a 62% and 237% improvement, respectively.

All 24 PM&R residents completed the post-MSUS course survey, eight from each postgraduate year. The survey results are listed in Table 2. After the MSUS course, all PM&R residents demonstrated increased MSUS knowledge, ability to operate a U.S. machine, and ability to optimally image musculoskeletal structures. Twelve residents (50%) indicated that the shoulder session was the most difficult, while five residents (21%) reported the elbow-wrist-hand session to be the most difficult, two residents (8%) reported the hip-knee session was the most difficult, two residents (8%) reported the ankle-foot session to be the most difficult, and three residents did not provide a response to this question (13%). Thirteen residents (54%) indicated the hip-knee session was the easiest session, while five residents reported that the elbow-wrist hand session (21%) was the easiest session, four residents (16%) indicated that the ankle-foot section was the least difficult session, and four residents did not answer the question (16%). None of the residents indicated that the shoulder was the easiest session.

Before the course, 30% of the residents reported no previous exposure to MSUS, 38% had only observed MSUS, 25% had performed 25 or less MSUS scans and/or procedures, and 8% had performed more than 25 MSUS scans and/or procedures. All of the residents indicated that the faculty/US machine to resident ratio (i.e., 1:5) was appropriate. Eighty-two percent of residents felt there was adequate time during the didactic sessions, and 88% indicated that there was sufficient time to study between didactic sessions. Eighty percent of residents were satisfied with the resources provided for the course (i.e., course syllabus, textbook, online physics course, scanning protocol, and the American Institute for Ultrasound in Medicine online resources). The remaining 20% suggested additional resources such as the European League Against Rheumatism Ultrasound Website ( or more MSUS reference books.

An open-ended question at the end of the survey asked the residents whether they had any suggestions that may improve the MSUS course. Three residents indicated that additional time should be spent on MSUS-guided injections. In addition, because the shoulder was found to be the most difficult joint to evaluate with MSUS, two residents suggested moving the shoulder MSUS didactic session to a later date within the course. Three residents also indicated that more time should also be spent on ultrasound physics and the basic principles of MSUS at the beginning of the course.

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To the authors' knowledge, this is the first published article describing a formal diagnostic and interventional MSUS course as part of a PM&R residency program. The purpose of developing the PM&R resident MSUS course was to provide our residents with a basic understanding of MSUS principles and a practical introduction to MSUS-guided interventional procedures and joint scanning techniques. Each section of the PM&R resident MSUS course was designed to instruct the PM&R resident on specific MSUS-related topics (e.g., physics, image optimization, etc.), joint scanning techniques, or MSUS-guided interventional procedures. The majority of the PM&R residents (92%) had limited or no MSUS before the MSUS course. Most residents were satisfied with the resources provided for the course, number of faculty and ultrasound machines, duration of time for each didactic session, and time period between each didactic session. The resident's pre and post-MSUS course written and practical test results demonstrated a significant increase in the resident's MSUS knowledge and the ability to operate an ultrasound machine and perform a diagnostic MSUS examination after the MSUS course. These findings suggest that PM&R residents were satisfied with the structure and content of the MSUS course and that the MSUS course was an effective means to teach basic diagnostic and interventional MSUS to PM&R residents. While the success of an MSUS course is dependent upon sufficient didactic time, the presence of adequately trained faculty and access to multiple ultrasound machines and cadaveric specimens, it seems reasonable to assume that our results should be reproducible at other residency programs. Further research to replicate our findings is required.

It was not surprising that the PM&R residents indicated that the most difficult session was the shoulder session. It is well known that the shoulder is difficult to evaluate with MSUS for a number of reasons including susceptibility to specific types of MSUS artifacts (e.g., anisotropy), depth of the joint, and the presence of multiple potential pain generators with overlapping pain patterns, thus necessitating a complete MSUS examination rather than a focused examination. The hip-knee session was the least difficult session for the PM&R residents, probably because of the focused nature of MSUS in these joints, the limited number of sonographically relevant structures, and the relative ease of imaging these structures.

On the basis of the MSUS course feedback from residents and faculty, several changes to the curriculum were implemented for 2009 including an additional didactic session dedicated to basic ultrasound concepts, moving the shoulder MSUS session to the last joint-scanning session and the hip-knee session to the first joint-scanning session, and adding an additional didactic session to the MSUS-guided procedures portion of the course, such that the content of the first day remains the same, but the second day is dedicated to upper limb MSUS-guided procedures, and the 3rd day is dedicated to lower limb MSUS-guided procedures. An additional MSUS reference text with a compact disk containing multiple ultrasonographic images was also purchased for the PM&R residency library.

An interesting finding of our study was the perceived importance of the MSUS course to the PM&R residents. This was demonstrated by the resident's high level of interest in MSUS, the rating of the MSUS course (particularly in relationship to their other residency courses), and the 100% affirmative reply to the questions regarding whether the MSUS course would positively influence their choice of where to complete their PM&R residency and whether they would recommend the PM&R residency to applicants because of the MSUS course. Therefore, it may be beneficial for PM&R residency programs to consider adding an MSUS course to their curriculum to attract future residents and increase the satisfaction of their current residents.

The strengths of our PM&R resident MSUS course included providing the PM&R residents with a thorough, well-structured exposure to the basic principles of MSUS, practical experience performing MSUS scanning of common joints, and hands-on experience performing basic MSUS-guided interventional procedures on unembalmed cadaveric specimens. The course can also be used by other specialties as a template when developing resident MSUS courses relevant to their field and for subspecialized MSUS courses within PM&R (e.g., spasticity management). A limitation of the course was its limited exposure to sonographically apparent pathology. However, the PM&R resident MSUS course was not meant to establish competence in diagnostic and interventional MSUS after its completion. It is only the first step in MSUS education. To obtain competence, significant additional MSUS training is required including attendance of additional, more advanced MSUS courses, and participation in a substantial number of mentored clinical experiences performing diagnostic MSUS evaluations and MSUS-guided interventional procedures on patients with pathology. More advanced MSUS courses may be developed by the PM&R residency program, although the PM&R resident certainly could attend one of the many available continuing medical education conferences devoted to MSUS. The mentored clinical experiences may be incorporated into the PM&R residency's current core musculoskeletal clinical rotations or made available to the residents on an elective basis.

There are several reasons why PM&R residency directors may consider the inclusion of a MSUS course as part of their curriculum. The purpose of PM&R residency is to prepare residents to practice PM&R. Evaluating and treating patients with neurologic and/or musculoskeletal injuries is integral to the practice of PM&R. Frequently, after the completion of a comprehensive history and physical examination of patients with neuromusculoskeletal ailments, diagnostic imaging is warranted. A physiatrist trained in diagnostic MSUS can perform a diagnostic MSUS examination, thus enabling rapid, accurate diagnosis of the patient's pathology. When indicated, ultrasound-guided interventions can also be performed. Therefore, the ability to perform diagnostic and intervention MSUS is a practical skill for physiatrists that will enhance patient care. Despite the fact that the introductory MSUS course described in this article does not establish competence in MSUS, we feel it provides a good initial exposure of PM&R residents to MSUS, informs them of the potential uses of MSUS within a physiatric practice, hopefully instills an interest in MSUS within PM&R residents, and provides them with a basic foundation of MSUS knowledge on which they can build if they choose to pursue further MSUS training.

There are many challenges that PM&R residency directors may face when creating an MSUS course. An MSUS course requires faculty adequately trained in MSUS and access to a sufficient number of ultrasonography units. In institutions where a PM&R department does not currently contain adequate numbers of faculty members trained in MSUS, interested faculty members can be trained in MSUS by sending them to MSUS courses and setting-up mentorship programs with local medical professionals who are competent in diagnostic and interventional MSUS. In addition to PM&R, medical professionals from other specialties such as radiology, rheumatology, or orthopedics may be able to serve a mentorship role.

Another challenge may be the acquisition of an adequate number of ultrasonography units. As described in the methods section of this study, the ultrasonography units for the MSUS course came from many different locations within our institution. It is very likely that a PM&R residency housed within an institution with multiple specialties will have a number of ultrasonography units on site that may be accessible to the residency programs during nonclinical times. In addition, portable units are not prohibitively expensive for many programs and can be used clinically, thus recouping the initial investment in a relatively short period. We found that a ratio of one ultrasonography unit and one faculty member per five residents was sufficient. Therefore, for many PM&R residencies, only two or three ultrasonography units and faculty members would be required for an MSUS course. Through access to PM&R faculty members and/or other medical professionals with MSUS training and ultrasonography units within the PM&R Department and/or other departments within your institution, the creation of a successful PM&R resident MSUS course is a realistic goal.

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In conclusion, MSUS is a safe, inexpensive, noninvasive, easily accessible imaging modality for the evaluation of nerve, tendon, muscle, ligament, and joint disorders and the guidance of therapeutic procedures. The findings of our study suggest that our PM&R resident MSUS course effectively teaches basic diagnostic and interventional MSUS to PM&R residents. Residents and practicing physiatrists alike recognize the diagnostic and interventional utility of MSUS and are interested in receiving MSUS training. Because the primary aim of a PM&R residency is to prepare residents to practice physiatry upon completion of their residency, and because MSUS is a highly desirable and practical skill for physiatrists, residency program directors may want to consider incorporating an MSUS course into their PM&R residency curriculum.

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Ultrasonography; Education; Diagnostic Imaging; Internship and Residency

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