Secondary Logo

Journal Logo

Special Communication

Ultrasound in Trauma and Other Acute Conditions in Sports, Part I

Hahn, Marlee MD1; Ray, Jeremiah MD2; Hall, Mederic M. MD3; Coe, Ian MD, MPH4; Situ-LaCasse, Elaine MD5; Waterbrook, Anna L. MD6

Author Information
Current Sports Medicine Reports: November 2020 - Volume 19 - Issue 11 - p 486-494
doi: 10.1249/JSR.0000000000000774



The use of point-of-care ultrasound (POCUS), portable ultrasound used at the bedside for a wide variety of indications, is becoming increasingly common across many medical specialties. Emergency physicians (EPs) have been using POCUS for more than two decades in the acute setting for evaluation of emergent and urgent traumatic conditions such as intra-abdominal injury, pneumothorax, pulmonary edema, cardiac ultrasound, fractures, globe rupture, retinal detachment, as well as other acute conditions, such as deep venous thrombosis, dehydration, and cutaneous abscess. These applications used by EPs also may be appropriate for use by sports medicine physicians in the acute setting.

The term sports ultrasound (US) was introduced in the 2014 American Medical Society for Sports Medicine sports ultrasound curriculum for sports medicine physicians (1) to incorporate both musculoskeletal (MSK) and non-MSK applications of sports US used by sports medicine physicians. Sports US training is a requirement of Accreditation Council for Graduate Medical Education-accredited sports medicine fellowships; however, this is often limited to MSK applications. It is now recognized that the utility of sports US extends beyond these MSK applications and includes evaluation for trauma and other acute conditions associated with sport and exercise. Sports US evaluations are most often performed to answer a specific clinical question, and there may be inherent limitations when performed in the field. The need for further imaging and involvement of other medical imaging experts should be considered.

This article is part 1 of a two-part series providing a review of the literature for assessment of traumatic injuries and other acute conditions which may be encountered in sports medicine. Part 1 will review the use of US for evaluation of intraabdominal injury, pneumothorax, hemothorax, pulmonary edema, limited cardiac assessment, dehydration, and fractures. Part 2 will review acute ocular injury, evaluation of elevated intracranial pressures, cellulitis, deep venous thrombosis, and lymphadenopathy.

I. Ultrasound for Abdominal Trauma

Focused Assessment with Sonography in Trauma (FAST) is a noninvasive US assessment to rapidly identify free pericardial, intraperitoneal, and pelvic free fluid (i.e., blood) after trauma. Blunt abdominal injury is a common concern for contact (football, rugby, lacrosse), airborne (gymnastics, diving, pole-vaulting, climbing), and high-impact (skiing, snowboarding, equestrian, rodeo or motorized sport) athletes. Patients may present with severe abdominal pain, with or without hypotension. The FAST examination may be applied in the sports medicine setting to quickly evaluate for intraabdominal bleeding after abdominal trauma and thus aid in medical decision making and disposition of the injured athlete. Earlier diagnosis enables prompt intervention, less complications, and better patient outcomes. Furthermore, the FAST protocol has been extended to include anterior thoracic evaluation for pneumothorax, termed the “E-FAST” examination. The use of sports US to detect pneumothorax, pericardial, and pleural effusion will be discussed in later sections.

FAST Examination Indications

  • - Blunt or penetrating thoracoabdominal trauma (2)
  • - Trauma in pregnancy
  • - Undifferentiated hypotension

FAST Examination Technique

Transducer: Curvilinear or Phased Array transducer

Patient Position: supine

Transducer Position: four standard views

  • - Right upper quadrant (RUQ), hepatorenal recess (Morison's pouch)
  • - Left upper quadrant (LUQ), perisplenic recess
  • - Suprapubic, retrovesicular (male) or retrouterine (female) pouch
  • - Subxiphoid, pericardial space

(See Figs. 1A–D here,,,

Key Findings: Absence or presence of free fluid.

(See Figs. 2A–D here,,,

Effectiveness of FAST Examination as a Screening Tool

There is a vast body of data on the efficacy of FAST examination in various clinical settings, patient injury severities, and performed by providers of various specialties and experience levels. This is summarized in Table 1. It is broadly accepted that FAST is an excellent screening tool in the hands of an experienced examiner and is a component of the Advanced Trauma Life Support (12) protocol as an adjunct to the primary survey (13). Overall, the use of US to detect intraperitoneal free fluid or pericardial effusion has a high specificity; however, a lower sensitivity. Data suggest that the examination is less reliable at low volumes of fluid, with a mean of 157 mL required in one study (14) and as high as 619 mL in another (15) for detection of intraperitoneal free fluid, depending on the region visualized. Serial FAST examinations have been shown to significantly increase the sensitivity of these studies (16), especially if the initial examination was completed early in the patient's presentation and prior to the accumulation of enough blood in the abdomen to be reliably detected. Thus, the FAST examination should be used as a screening assessment and not in place of a formal emergency department (ED) evaluation when indicated by clinical judgment.

Table 1 - Accuracy of FAST and E-FAST examinations for evaluation and detection of hemoperitoneum.
Year Author Examination Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Lee et al. (3) FAST 92 99 91 99
2019 Netherton et al. (4) EFAST 74 98
2018 Akoglu et al. (5) EFAST 43 98 71
2018 Samuel et al. (6) EFAST 90 99 95 98 98
2018 Waheed et al. (7) FAST 76 84 79
2017 Dammers et al. (8) FAST 67 99
2014 Verbeek et al. (9) FAST 64 94 84 83
2014 Arhami et al. (10) FAST 80 95 57 98 94
2010 Becker et al. (11) FAST 75 98 88 95 95
Boxes left blank were not reported in the study.
Sens, sensitivity; Spec, specificity; PPV, positive predictive value; NPV, negative predictive value.

RUSH Examination

More recently, critical care and emergency medicine literature has described the Rapid Ultrasound in Shock and Hypotension (RUSH) examination, a more extensive evaluation for the undifferentiated patient with hypotension and shock. It includes a more extensive cardiopulmonary assessment and volume status evaluation in addition to the screening test for pericardial effusion and hemoperitoneum from the FAST examination. The RUSH examination combines the standard images obtained in the FAST examination (discussed above) with additional images of the inferior vena cava (IVC), aorta, and thorax. Using IVC diameter to assess volume status will be discussed in further detail below. A common approach refers to “the pump” (heart), “the tank” (IVC/intravascular volume) and “the pipes” (arterial/venous vessels) as the major steps in the RUSH examination and evaluation of shock. The mnemonic “HI-MAP” (heart, IVC, Morison's pouch/splenorenal/bladder, aorta, pneumothorax) is utilized to facilitate performing the complete examination in consistent sequence. This entire examination can be completed in less than 2 min.

RUSH Examination Indications:

  • - Hypotension/shock of unclear etiology

RUSH Examination Technique:

Transducer: phased array, curvilinear, and option of linear transducer

Patient position: supine

Transducer choice and orientation varies with desired view:

Phased Array Transducer:

  • - heart: parasternal long, parasternal short, subxiphoid, apical four-chamber views
  • - IVC

Curvilinear Transducer:

  • - Morison's/FAST abdominal
  • - pelvic views with thorax/diaphragm views
  • - aorta

Linear High-Frequency Transducer:

  • - pneumothorax (lung windows)

(See Figs. 3A–F here,,,,,

Key Findings: cardiac motility/effusion, absence of lung slide, IVC diameter/respiratory variability, presence of free fluid

(See Figs. 4A–F here,,,,,

Effectiveness of the RUSH Examination as a Screening Tool

The RUSH technique is a newer protocol utilized by critical care and EPs, and the data of its efficacy are growing. The results, summarized in Table 2, outline the sensitivity and specificities of RUSH examination compared with computed tomography (CT) scan criterion standard for patients with shock. The RUSH protocol performs relatively well across all shock types.

Table 2 - Accuracy of RUSH examination for evaluation and diagnosis of shock.
Year Author Examination Type of Shock Sens (%) Spec (%) PPV (%) NPV (%)
2018 Elbaih et al. (17) RUSH Hypovolemic 92 92 95 87
Cardiogenic 100 99 91 100
Obstructive 93 98 87 99
Distributive 92 97 79 99
2015 Ghane et al. (18) RUSH Hypovolemic 100 96 89 100
Cardiogenic 90 98 95 97
Obstructive 91 98 91 98
Distributive 73 100 100 95
Mixed 64 98 88 93
2015 Bagheri-Hariri et al. (19) RUSH Hypovolemic 100 73 82 100
Cardiogenic 60 100 100 91
Obstructive 75 100 100 96
Distributive 100 100 100 100
Boxes left blank were not reported in the study.

II. Ultrasound for Thoracic Trauma and Acute Lung Illness

In the setting of thoracoabdominal trauma, bedside US is often used to evaluate for pneumothorax or hemothorax in conjunction with the traditional FAST examination and is called the extended FAST (E-FAST) examination (20). In fact, US has been shown to have higher sensitivity (21,22) than standard supine AP chest radiographs at detecting pneumothorax and may even be able to replace routine chest radiographs after blunt trauma (23). This can apply similarly to sports US evaluation for patients with dyspnea, chest pain, or hypoxia where specific concerns regarding pneumothorax, pulmonary edema, or hemothorax would be important to identify early. Sports US also can be used to evaluate for rib fractures in this scenario.

The Bedside Lung Ultrasound in Emergency (BLUE) Protocol has been described as a diagnostic tool in critically ill patients (24). There are several studies applying this to the ED setting to categorize and diagnose etiologies of dyspnea including pulmonary edema, pneumonia, obstructive airway disease, pulmonary embolism, and pneumothorax. On-site at athletic events, the most useful application of this protocol would be to identify pneumothorax, hemothorax, and pulmonary edema.

Thoracic US Indications:

  • - shortness of breath
  • - chest pain
  • - chest trauma
  • - undifferentiated shock

Pneumothorax US technique:

Transducer: high-frequency linear array transducer

Patient position: supine/semirecumbent

Transducer position:

  •  -Vertically oriented in a sagittal plane
  •  -Three intercostal spaces at the midclavicular line at the highest point along the thorax

See Figure 3G here

Key Findings: Absence or presence of lung sliding

See Figures 4E–F here,

The examiner may visually observe the absence or presence of the lung pleura sliding by noting the normal “comet tail” or “shimmering” appearance, which is absent with pneumothorax. Pneumothorax also may be detected using the M mode setting to visualize the “barcode” appearance which lacks the transition to aerated lung represented the normal “sandy beach” sign (25).

Hemothorax US Technique:

Transducer: high-frequency linear array transducer

Patient position: supine/semirecumbent

Transducer position: visualization of diaphragmatic recesses

  •  -RUQ view
  •  -LUQ view

Key Findings: intrathoracic free fluid (visually equivalent to pleural effusion) above diaphragm

The examiner should pay particular attention to the optimal visualization of the diaphragm and evaluation for peridiaphragmatic fluid in the pleural space, suggestive of effusion, or presumably blood in the acute traumatic setting.

Summarized below in Table 3 are the data for the recent studies elucidating the accuracy of bedside US for evaluation of hemothorax and pneumothorax.

Table 3 - Accuracy of ultrasound for evaluation and diagnosis of hemothorax and pneumothorax and other traumatic lung injury.
Year Author Pathology Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Bekgoz et al. (24) PTX 71 100
2019 Kozaci et al. (26) SubQ Emph 56 95
PTX 86 97
HTX 45 98
Pulm Cont 63 91
2019 Netherton et al. (4) PTX 69 99
2018 Akoglu et al. (5) PTX 75 99 87
Pl Eff 100 100 100
2018 Patel et al. (27) PTX/A profile 80 100 90
2016 Vafaei et al. (28) PTX 84 98 96 91
HTX 76 96 82 94
Pulm Cont 69 92 81 87
2015 Soult et al. (23) PTX 94 98 46 100
2008 Soldati et al. (29) PTX 92 99 96 99
2008 Lichtenstein and Mezière (30) PTX 88 100 100 99
2005 Blaivas et al. (21) PTX 98 99 98.1 99
PTX, pneumothorax; HTX, hemothorax; SubQ Emph, subcutaneous emphysema; Pl Eff, pleural effusion; Pulm Cont, pulmonary contusion.
Boxes left blank were not reported in the study.

Pulmonary Edema

There also is increasing data on the use of ultrasound for monitoring altitude effects and pulmonary edema in high altitude athletes. Pulmonary edema produces an ultrasound artifact known as B lines.

B lines are a type of ring down ultrasound artifact that are produced when there is enough perialveolar fluid to produce a tetrahedron between air and water molecules. Various “lung profiles” have been described in association with pulmonary pathologies in respiratory failure, and there is a strong correlation between the presence of bilateral B lines with associated lung slide in the diagnosis of pulmonary edema, known as “B Profile” (30).

Pulmonary Edema US Technique

Transducer: low-frequency curvilinear transducer or low-frequency phased array transducer

Patient position: supine/semirecumbent/upright

Transducer position:

  •  -anterior chest view
  •  -axillary view

(See Fig. 5 here

Key Findings: greater than three B lines per intercostal space. These can be seen as echogenic “comet tails” vertically oriented in intercostal spaces, in both anterior and lateral chest views

(See Fig. 6 here

When there are more than three B lines in a single intercostal space, this is consistent with increased interstitial pulmonary fluid and thus represents pulmonary edema. This could be extrapolated to the use of sports US at endurance events and other competitions at higher altitudes to identify exertional pulmonary edema. One study evaluated the incidence of subclinical pulmonary edema by serial arterial blood gases and comparative B line measurements on US in Himalaya trekkers. A total of 20 hikers ascended to 5160 m over 10 d and more than half developed increased B lines with altitude, which were negatively correlated with paO2s (31). Another study compared the use of US, CXR, and physical examination (moist rales on auscultation) in the detection of pulmonary edema and found lung US outperformed CXR and examination in sensitivity for pulmonary edema (as measured by presence of B lines) with US sensitivity of 98% compared to 93% and 81% for CXR and physical examination, respectively (32). Further, US detection of pulmonary edema has a combined sensitivity of 97% and specificity of 98% from a recent meta-analysis and systematic review (33).

It is worth highlighting that there is significant heterogeneity across the patient populations and conditions under which these data were obtained; however, the diagnostic utility of ultrasound in pulmonary edema applies across these populations, and similarly could be extrapolated to the athlete population.

Table 4 summarizes the primary data regarding US detection of pulmonary edema.

Table 4 - Accuracy of bedside US for evaluation and diagnosis of pulmonary edema.
Year Author Examination Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Bekgoz et al. (24) Pulmonary Edema 88 96
2019 Wooten et al. (34) B profile 96
2018 Koh et al. (35) BLUE protocol/B profile 71 81 73 80 77
2018 Patel et al. (27) BLUE protocol/B profile 92 100
2018 Wang et al. (33) B lines/all protocols 97 98
2018 Yang et al. (32) B lines/B score 98 91 98 91
2015 Dexheimer Neto et al. (36) BLUE protocol 85 87 80 91 84
2015 Pivetta et al. (37) B lines 97 97
2013 Baker et al. (38) Pulmonary edema 65 92 85
2011 Vitturi et al. (39) B lines 97 79 79 97 87
2008 Lichtenstein and Mezière (30) Pulmonary edema 97 95 87 99
Boxes left blank were not reported in the study.

III. Ultrasound for Cardiac Assessment

Another potential application of sports US is the performance of a limited cardiac ultrasound in the acute setting of an injured or collapsed athlete in extremis to rapidly answer several emergent questions regarding the hemodynamics, pathology and illness severity of a patient in real-time. While it is no substitute for a formal, comprehensive echocardiogram in the hands of a cardiologist, it may aid in evaluating gross cardiac function (40,41). The American College of Emergency Physicians’ consensus statement on focused cardiac US (FOCUS) emphasizes the importance of FOCUS as a preliminary diagnostic tool in the time-sensitive evaluation of symptomatic patients in the emergent setting and outlines the goals of FOCUS including (42):

Limited cardiac US Indications:

  • - presence of pericardial effusion,
  • - global cardiac systolic function,
  • - marked right ventricular and left ventricular enlargement,
  • - intravascular volume assessment.

Limited Cardiac US Technique:

Transducer: low-frequency phased-array transducer

Patient position: supine/left lateral decubitus

Transducer position: varies with each view

Four standard views:

  •  -parasternal long axis
  •  -parasternal short axis
  •  -apical four-chamber
  •  -subxiphoid (Four-chamber and short-axis views)

See Figures 3A–D here,,,

Key Findings

  • - pericardial effusion,
  • - hypokinesis,
  • - poor contractility,
  • - relative chamber size.

Pericardial Effusion

Evaluation of pericardial effusion in the acute traumatic and symptomatic patient is highly valuable in the emergent setting and early recognition can lead to lifesaving interventions. While recognition of tamponade is ultimately a clinical diagnosis (hypotension, tachycardia, pulsus paradoxus, and jugular venous distention), US is an important adjunct not only for diagnosis but also for treatment. It is important to remember that in a hemodynamically unstable trauma patient, the severity of hemodynamic compromise may be pronounced relative to a seemingly small-volume pericardial effusion or thrombus. Data summarized in Table 5 suggest that noncardiologist physicians can accurately assess for pericardial effusion, and ultrasound is the evaluation tool of choice in the acute setting.

Table 5 - Accuracy of US for evaluation and diagnosis of pericardial effusion.
Year Author Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Balderston et al. (43) 64 91 56 94
2019 Netherton et al. (4) 91 94
2017 Farsi et al. (44) 86 96 69 98 95
2005 Blaivas et al. (21) 73 44 30
2001 Mandavia et al. (45) 96 98 98
Boxes left blank were not reported in the study.

Global Systolic Function

To evaluate global cardiac function, it is important to evaluate multiple views, including parasternal, subxiphoid, and apical to assess cardiac contractility as a surrogate for cardiac output. Cardiac contractility is determined by the change in the volume of the left ventricle in systole and diastole. The goal of FOCUS is to assess global cardiac function qualitatively (normal, depressed, hyperdynamic, etc.) rather than quantitatively, with the overall goal of determining disposition and workup related to patient's symptoms or hemodynamics. In one prospective study by Moore et al. (40) in 2002 comparing EPs to primary cardiologists, it was found that qualitative evaluation of ejection fraction (normal, decreased, severely decreased) by EPs after undergoing a 10-h observatory training period was sufficiently accurate (R = 0.84). Table 6 below summarizes primary data regarding assessment of gross cardiac function.

Table 6 - Accuracy of limited cardiac ultrasound for evaluation of gross cardiac function.
Year Author Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Balderston et al. (43) 80 78 54 92
2017 Farsi et al. (44) 89–100 87–100 80–100 89–100 92–100
Boxes left blank were not reported in the study.

IV. Ultrasound for Volume Assessment

An athlete's hydration status is a critical component of health and performance. For example, cramping, heat exhaustion, and heat stroke may all be related to inadequate hydration and can be life-threatening, especially if not recognized early. The POCUS evaluation is regularly utilized in evaluation of undifferentiated shock, or to assess the intravascular volume and potential fluid responsiveness of a hypotensive patient in the ED setting. It also makes sense to apply this to the acute sideline assessment of an ill, collapsed, or injured athlete to evaluate their volume status to guide the diagnosis and treatment.

Commonly cited measurements that have been found to correlate with intravascular volume status include measurements of IVC diameter and respiratory collapsibility. Generally speaking, IVC diameter decreases with inspiration and increases with Valsalva, and while considerable heterogeneity exists regarding the exact relationship between right atrial pressure and the behavior of the IVC, an IVC diameter <1.5 cm suggests volume depletion and IVC > 2.5 cm suggests volume overload (2). There are a significant number of studies evaluating hydration status in correlation with IVC diameter variation, also known as the IVC collapsibility index or caval index: (Caval index = (IVCexpiration − IVCinspiration) / (IVCexpiration) × 100) (46). Unfortunately, there is significant heterogeneity in these studies, and the majority of this data are derived from critically ill patients. These studies provide potential support for IVC measurements as a marker for volume status and could be applied to athletes with suspected volume depletion in the appropriate clinical settings. A study by Waterbrook et al. (47) of preseason NCAA football players from 2015 evaluated the IVC diameter of players prepractice and postpractice and found statistically significant correlation with the players' percent weight loss during practice, suggesting correlation with hydration. Interestingly, Long et al's (48) systematic review and meta-analysis did not find respiratory variation of the IVC to reliably predict fluid responsiveness in critically ill patients, a subgroup analysis in this study did find IVC diameter to be a promising predictor, similar to the study previously performed in NCAA athletes. Inferior vena cava measurements are likely most useful when evaluating for the extremes: complete collapse may suggest that the athlete can benefit from hydration, and if there is no collapsibility or if the IVC is plump, the athlete may not need additional hydration. Inferior vena cava evaluation also may be performed as a part of the RUSH examination or in conjunction with limited cardiac US (see previous sections for further discussion of these examinations).

IVC Assessment Technique:

Transducer: low-frequency curvilinear or phased array transducer

Patient position: supine

Transducer position: subxiphoid (most optimal [49]) or subcostal view, sagittal plane

See Figure 3E here

Key finding:

  •  -Presence and degree of anterior-posterior collapse / variability of IVC diameter with respiration

See Figures 4C–D here,

The atria can be visualized and traced inferiorly, down to the perihepatic IVC where most reliable measurements can be made. When measured 3 cm to 5 cm inferior to the right atrium (1 cm to 2 cm below junction of hepatic vein) the normal IVC is approximately 1.5 cm to 2.5 cm in diameter.

Inferior vena cava measurement may be used as a tool to evaluate hydration status in athletes. Its accuracy, however, especially in well athletes, is still not fully known. Table 7 summarizes the current data on the accuracy of IVC collapsibility to predict fluid responsiveness. Clinical context should always be taken into consideration when using this technique of volume assessment and making treatment decisions.

Table 7 - Accuracy of IVC collapsibility to predict fluid responsiveness.
Year Author Sens (%) Spec (%) PPV (%) NPV (%)
2020 Orso et al. (46) 71 75
2018 Long et al. (50) 44 33
2017 Corl et al. (51) 87 81 82 86
2017 Long et al. (48) 63 73
2017 Preau et al. (52) 84 90
2016 Theerawit et al. (53) 75 77
2016 Zhao and Wang (54) 100 100
2014 Zhang et al. (55) 76 86
Boxes left blank were not reported in the study.

V. Ultrasound for Fracture Assessment

Ultrasound has been increasingly recognized as a reliable, safe, and rapid evaluation for fracture detection by identifying notable discontinuity of the hyperechoic bony cortex. Although MRI, CT, and radiographs are well established in the diagnosis of fractures, they are more expensive, may introduce radiation (CT and X-ray), and are not readily available on the sideline or in all training rooms. Furthermore, ultrasound has been shown superior to radiographs for detection of certain fractures, such as those of the ribs and sternum and for detection of radiographically occult fractures of the wrist (56–59). Sports US may be a safe and effective way to rapidly evaluate for fractures in appropriate clinical environments.

Fracture US Technique

Transducer: high frequency linear-array transducer

Patient position: position of comfort with affected limb at rest

Transducer position: over point of maximal bony tenderness

Key Views:

  •  - Affected bone should be visualized in long and short axes

Key Findings:

  •  - Cortical disruption/discontinuity
  •  - Soft tissue edema
  •  - Perifracture hematoma
  •  - Localized hyperemia on Doppler
  •  - Joint effusion

(See Fig. 7 here

As summarized in Table 8 above, data varies on use of US in fracture evaluation, depending on the body part and population. While sports US will not replace radiographs in the evaluation of fracture, it is a viable alternative when X-ray is not readily available or contraindicated.

Table 8 - Accuracy of US for evaluation and diagnosis of traumatic fractures.
Year Author Population Fracture Site Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Epema et al. (60) Pediatric Forearm 95 86 92 91 92
2019 Kozaci et al. (21) Adult Sternal 83 97
Clavicular 83 100
Rib 67 98
2019 Masaeli et al. (61) Pediatric Skull 92 96
2019 Ko et al. (62) Pediatric Forearm 97 100 100 94
2018 Parri et al. (63) Pediatric Skull 91 85
2017 Døssing et al. (64) Adult Extremity 92 94 85 97
2017 Hedelin et al. (65) Pediatric Wrist 97 84
2017 Pishbin et al. (57) Adult and Pediatric Rib 98 100 100 96
2017 Rowlands et al. (66) Pediatric Forearm 92 88
2016 Aksay et al. (67) Adult and pediatric Finger 79 90 72 93
2015 Dallaudière et al. (68) Adult Variable 98 98 100 95 99
2015 Herren et al. (56) Pediatric Forearm 100 100
2015 Kozaci et al. (69) Adult and Pediatric Forearm 98 96 98 96 98
2014 Atilla et al. (70) Adult Foot and Ankle 87 96
2013 Eckert et al. (71) Pediatric Elbow 98 95 98 95
2013 Waterbrook et al. (72) Adult and Pediatric Variable 90 96 90 96
2013 Bolandparvaz et al. (73) Adult Upper and lower limb 55–75 62–84 33–71 73–83
2013 Ekinci et al. (74) Pediatric Foot and Ankle 100 99 95 100
2013 Parri et al. (75) Pediatric Skull 100 95 97 100
2013 Rabiner et al. (76) Pediatric Elbow 98 70
2012 Barata et al. (77) Pediatric Long bone 95 86 84 96
2012 Beltrame et al. (78) Adult and Pediatric Variable, no intraarticular 94 92 94 91 93
2011 Chaar-Alvarez et al. (79) Pediatric Forearm 96 93 92 96 94
2011 Chien et al. (80) Pediatric Clavicle 90 90 95 81
2011 Sinha et al. (81) Pediatric Limb injuries 89 100 100 97
2010 Ackermann et al. (82) Pediatric Forearm 94 99
2010 Weinberg et al. (83) Pediatric Variable 73 92
2010 You et al. (58) Adult Sternal 100 100
Boxes left blank were not reported in the study.


The role of sports US in the assessment of acute traumatic injury is still being defined. Despite this, we encourage all sports medicine physicians to become comfortable and competent with basic ultrasound diagnostic techniques for acute conditions. As outlined above, there are multiple techniques for rapidly assessing a patients’ clinical status including but not limited to respiratory, cardiac, orthopedic, and hemodynamic evaluation. The literature supports these techniques as effective for first-line evaluation of these injuries. The RUSH and FAST ultrasound protocols provide rapid and comprehensive assessment for traumatic and acute injuries in more concerning patients which may assist sports medicine physicians in determining disposition and urgency of transport for athletes injured on the field of play. Regardless of primary specialty, sports medicine physicians should consider adding these additional sports US examinations for immediate evaluation of an athlete to their repertoire.

In part 2 of this review, we will discuss additional uses of ultrasound for evaluation of acute conditions in athletes, including evaluation for acute ocular injury, elevated intracranial pressures, cellulitis, deep venous thrombosis, and lymphadenopathy.

M.M.H.: MAB/Stock (Tenex Health); MAB/Stock (Sonex Health); Royalties (UpToDate, Inc.). The other authors declare no conflict of interest and do not have any financial disclosures.


1. Finnoff JT, Berkoff D, Brennan F, et al. American Medical Society for Sports Medicine (AMSSM) recommended sports ultrasound curriculum for sports medicine fellowships. PM R. 2015; 7:e1–11.
2. Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound. New York (NY): McGraw Hill Professional; 2008; 562 p.
3. Lee C, Balk D, Schafer J, et al. Accuracy of focused assessment with sonography for trauma (FAST) in disaster settings: a meta-analysis and systematic review. Disaster Med. Public Health Prep. 2019; 13:1059–64.
4. Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019; 21:727–38.
5. Akoglu H, Celik OF, Celik A, et al. Diagnostic accuracy of the extended focused abdominal sonography for trauma (E-FAST) performed by emergency physicians compared to CT. Am. J. Emerg. Med. 2018; 36:1014–7.
6. Samuel AE, Chakrapani A, Moideen F. Accuracy of extended focused assessment with sonography in trauma (e-FAST) performed by emergency medicine residents in a level one tertiary center of India. Adv. J. Emerg. Med. 2018; 2:e15.
7. Waheed KB, Baig AA, Raza A, et al. Diagnostic accuracy of focused assessment with sonography for trauma for blunt abdominal trauma in the eastern region of Saudi Arabia. Saudi Med. J. 2018; 39:598–602.
8. Dammers D, El Moumni M, Hoogland II, et al. Should we perform a FAST exam in haemodynamically stable patients presenting after blunt abdominal injury: a retrospective cohort study. Scand. J. Trauma Resusc. Emerg. Med. 2017; 25:1.
    9. Verbeek DO, Zijlstra IA, Van Der Leij C, et al. The utility of FAST for initial abdominal screening of major pelvic fracture patients. World J. Surg. 2014; 38:1719–25.
    10. Arhami Dolatabadi A, Amini A, Hatamabadi H, et al. Comparison of the accuracy and reproducibility of focused abdominal sonography for trauma performed by emergency medicine and radiology residents. Ultrasound Med. Biol. 2014; 40:1476–82.
    11. Becker A, Lin G, McKenney MG, et al. Is the FAST exam reliable in severely injured patients? Injury. 2010; 41:479–83.
    12. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS). 9th ed. Chicago (IL): American College of Surgeons; 2012.
    13. ATLS Subcommittee; American College of Surgeons' Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J. Trauma Acute Care Surg. 2013; 74:1363–6.
    14. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am. J. Emerg. Med. 2003; 21:476–8.
    15. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J. Trauma. 1995; 39:375–80.
    16. Blackbourne LH, Soffer D, McKenney M, et al. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J. Trauma. 2004; 57:934–8.
    17. Elbaih AH, Housseini AM, Khalifa MEM. Accuracy and outcome of rapid ultrasound in shock and hypotension (RUSH) in Egyptian polytrauma patients. Chin. J. Traumatol. 2018; 21:156–62.
    18. Ghane MR, Gharib MH, Ebrahimi A, et al. Accuracy of rapid ultrasound in shock (RUSH) exam for diagnosis of shock in critically ill patients. Trauma Mon. 2015; 20:e20095.
      19. Bagheri-Hariri S, Yekesadat M, Farahmand S, et al. The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg. Radiol. 2015; 22:517–20.
      20. Williams SR, Perera P, Gharahbaghian L. The FAST and E-FAST in 2013: trauma ultrasonography: overview, practical techniques, controversies, and new frontiers. Crit. Care Clin. 2013; 30:119–50.
      21. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad. Emerg. Med. 2005; 12:844–9.
      22. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad. Emerg. Med. 2010; 17:11–7.
      23. Soult MC, Weireter LJ, Britt RC, et al. Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination? Am. Surg. 2015; 81:336–40.
      24. Bekgoz B, Kilicaslan I, Bildik F, et al. BLUE protocol ultrasonography in emergency department patients presenting with acute dyspnea. Am. J. Emerg. Med. 2019; 37:2020–7.
      25. Husain LF, Hagopian L, Wayman D, et al. Sonographic diagnosis of pneumothorax. J. Emerg. Trauma Shock. 2012; 5:76–81.
      26. Kozaci N, Avcı M, Ararat E, et al. Comparison of ultrasonography and computed tomography in the determination of traumatic thoracic injuries. Am. J. Emerg. Med. 2019; 37:864–8.
      27. Patel CJ, Bhatt HB, Parikh SN, et al. Bedside lung ultrasound in emergency protocol as a diagnostic tool in patients of acute respiratory distress presenting to emergency department. J. Emerg. Trauma Shock. 2018; 11:125–9.
        28. Vafaei A, Hatamabadi HR, Heidary K, et al. Diagnostic accuracy of ultrasonography and radiography in initial evaluation of chest trauma patients. Emerg. (Tehran). 2016; 4:29–33.
          29. Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008; 133:204–11.
          30. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol. Chest. 2008; 134:117–25.
          31. Lim R, Ma IWY, Brutsaert TD, et al. Transthoracic sonographic assessment of B-line scores during ascent to altitude among healthy trekkers. Respir. Physiol. Neurobiol. 2019; 263:14–9.
          32. Yang W, Wang Y, Qiu Z, et al. Lung ultrasound is accurate for the diagnosis of high-altitude pulmonary edema: a prospective study. Can. Respir. J. 2018; 2018:1–9.
          33. Wang Y, Shen Z, Lu X, et al. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: a systematic review and meta-analysis. Med. Ultrason. 2018; 1:32–6.
          34. Wooten WM, Shaffer LET, Hamilton LA. Bedside ultrasound versus chest radiography for detection of pulmonary edema: a prospective cohort study. J. Ultrasound Med. 2019; 38:967–73.
          35. Koh Y, Chua MT, Ho WH, et al. Assessment of dyspneic patients in the emergency department using point-of-care lung and cardiac ultrasonography-a prospective observational study. J. Thorac. Dis. 2018; 10:6221–9.
          36. Dexheimer Neto FL, Stormovski De Andrade JM, Raupp Tabajara CA, et al. Diagnostic accuracy of the bedside lung ultrasound in emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients* and in the multidisciplinary intensive care unit prof. diagnostic accuracy of the bedside lung Ul. J. Bras. Pneumol. J. Bras. Pneumol. 2015; 4141:58–6458.
            37. Pivetta E, Goffi A, Lupia E, et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015; 148:202–10.
            38. Baker K, Mitchell G, Thompson AG, Stieler G. Comparison of a basic lung scanning protocol against formally reported chest x-ray in the diagnosis of pulmonary oedema. Australas J. Ultrasound Med. 2013; 16:183–9.
            39. Vitturi N, Soattin M, Allemand E, et al. Thoracic ultrasonography: a new method for the work-up of patients with dyspnea. J. Ultrasound. 2011; 14:147–51.
              40. Moore CL, Rose GA, Tayal VS, et al. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad. Emerg. Med. 2002; 9:186–93.
              41. Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad. Emerg. Med. 2003; 10:1054–8.
              42. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergency setting. Am. Coll. Emerg. Physicians. 2010; 1–10.
              43. Balderston JR, Gertz ZM, Brooks S, et al. Diagnostic yield and accuracy of bedside echocardiography in the emergency department in hemodynamically stable patients. J. Ultrasound Med. 2019; 38:2845–51.
              44. Farsi D, Hajsadeghi S, Hajighanbari MJ, et al. Focused cardiac ultrasound (FOCUS) by emergency medicine residents in patients with suspected cardiovascular diseases. J. Ultrasound. 2017; 20:133–8.
              45. Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann. Emerg. Med. 2001; 38:377–82.
              46. Orso D, Paoli I, Piani T, et al. Accuracy of ultrasonographic measurements of inferior vena cava to determine fluid responsiveness: a systematic review and meta-analysis. J. Intensive Care Med. 2020; 35:354–63.
              47. Waterbrook AL, Shah A, Jannicky E, et al. Sonographic inferior vena cava measurements to assess hydration status in college football players during preseason camp. J. Ultrasound Med. 2015; 34:239–45.
              48. Long E, Oakley E, Duke T, Babl FE. Does respiratory variation in inferior vena cava diameter predict fluid responsiveness: a systematic review and meta-analysis. Shock. 2017; 47:550–9.
              49. De Lorenzo RA, Morris MJ, Williams JB, et al. Does a simple bedside sonographic measurement of the inferior vena cava correlate to central venous pressure? J. Emerg. Med. 2012; 42:429–36.
              50. Long E, Duke T, Oakley E, et al. Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis. Emerg. Med. Australas. 2018; 30:556–63.
              51. Corl KA, George NR, Romanoff J, et al. Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients. J. Crit. Care. 2017; 41:130–7.
              52. Preau S, Bortolotti P, Colling D, et al. Diagnostic accuracy of the inferior vena cava collapsibility to predict fluid responsiveness in spontaneously breathing patients with sepsis and acute circulatory failure. Crit. Care Med. 2017; 45:e290–7.
              53. Theerawit P, Morasert T, Sutherasan Y. Inferior vena cava diameter variation compared with pulse pressure variation as predictors of fluid responsiveness in patients with sepsis. J. Crit. Care. 2016; 36:246–51.
              54. Zhao J, Wang G. Inferior vena cava collapsibility index is a valuable and non-invasive index for elevated general heart end-diastolic volume index estimation in septic shock patients. Med. Sci. Monit. 2016; 22:3843–8.
              55. Zhang Z, Xu X, Ye S, Xu L. Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound Med. Biol. 2014; 40:845–53.
              56. Herren C, Sobottke R, Ringe MJ, et al. Ultrasound-guided diagnosis of fractures of the distal forearm in children. Orthop. Traumatol. Surg. Res. 2015; 101:501–5.
              57. Pishbin E, Ahmadi K, Foogardi M, et al. Comparison of ultrasonography and radiography in diagnosis of rib fractures. Chin. J. Traumatol. 2017; 20:226–8.
              58. You JS, Chung YE, Kim D, et al. Role of sonography in the emergency room to diagnose sternal fractures. J. Clin. Ultrasound. 2010; 38:135–7.
              59. Williamson D. Ultrasound imaging of forearm fractures in children: a viable alternative? Emerg. Med. J. 2002; 17:22–4.
              60. Epema AC, Spanjer MJB, Ras L, et al. Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study. Emerg. Med. J. 2019; 36:613–6.
              61. Masaeli M, Chahardoli M, Azizi S, et al. Point of care ultrasound in detection of brain hemorrhage and skull fracture following pediatric head trauma; a diagnostic accuracy study. Arch. Acad. Emerg. Med. 2019; 7:e53.
                62. Ko C, Baird M, Close M, Cassas KJ. The diagnostic accuracy of ultrasound in detecting distal radius fractures in a pediatric population. Clin. J. Sport Med. 2019; 29:426–9.
                63. Parri N, Crosby BJ, Mills L, et al. Point-of-care ultrasound for the diagnosis of skull fractures in children younger than two years of age. J. Pediatr. 2018; 196:230–236.e2.
                64. Døssing K, Mechlenburg I, Hansen LB, et al. The use of ultrasound to exclude extremity fractures in adults. JBJS Open Access. 2017; 2:e0007.
                  65. Hedelin H, Tingström C, Hebelka H, Karlsson J. Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound. Crit. Ultrasound J. 2017; 9:11.
                    66. Rowlands R, Rippey J, Tie S, Flynn J. Bedside ultrasound vs x-ray for the diagnosis of forearm fractures in children. J. Emerg. Med. 2017; 52:208–15.
                    67. Aksay E, Kilic TY, Yesılaras M, et al. Accuracy of bedside ultrasonography for the diagnosis of finger fractures. Am. J. Emerg. Med. 2016; 34:809–12.
                    68. Dallaudière B, Larbi A, Lefere M, et al. Musculoskeletal injuries in a resource-constrained environment: comparing diagnostic accuracy of on-the-spot ultrasonography and conventional radiography for bone fracture screening during the Paris–Dakar rally raid. Acta. Radiol. Open. 2015; 4:2058460115577566.
                      69. Kozaci N, Ay MO, Akcimen M, et al. Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures. Am. J. Emerg. Med. 2015; 33:67–71.
                      70. Atilla OD, Yesilaras M, Kilic TY, et al. The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot. Acad. Emerg. Med. 2014; 21:1058–61.
                      71. Eckert K, Ackermann O, Schweiger B, et al. Ultrasound evaluation of elbow fractures in children. J. Med. Ultrason. 2013; 40:443–51.
                      72. Waterbrook AL, Adhikari S, Stolz U, Adrion C. The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED. Am. J. Emerg. Med. 2013; 31:1352–6.
                      73. Bolandparvaz S, Moharamzadeh P, Jamali K, et al. Comparing diagnostic accuracy of bedside ultrasound and radiography for bone fracture screening in multiple trauma patients at the ED. Am. J. Emerg. Med. 2013; 31:1583–5.
                      74. Ekinci S, Polat O, Günalp M, et al. The accuracy of ultrasound evaluation in foot and ankle trauma. Am. J. Emerg. Med. 2013; 31:1551–5.
                      75. Parri N, Crosby BJ, Glass C, et al. Ability of emergency ultrasonography to detect pediatric skull fractures: a prospective, observational study. J. Emerg. Med. 2013; 44:135–41.
                      76. Rabiner JE, Khine H, Avner JR, et al. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. Ann. Emerg. Med. 2013; 61:9–17.
                      77. Barata I, Spencer R, Suppiah A, et al. Emergency ultrasound in the detection of pediatric long-bone fractures. Pediatr. Emerg. Care. 2012; 28:1154–7.
                      78. Beltrame V, Stramare R, Rebellato N, et al. Sonographic evaluation of bone fractures: a reliable alternative in clinical practice? Clin. Imaging. 2012; 36:203–8.
                      79. Chaar-Alvarez FM, Warkentine F, Cross K, et al. Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. Pediatr. Emerg. Care. 2011; 27:1027–32.
                      80. Chien M, Bulloch B, Garcia-Filion P, et al. Bedside ultrasound in the diagnosis of pediatric clavicle fractures. Pediatr. Emerg. Care. 2011; 27:1038–41.
                      81. Sinha TP, Bhoi S, Kumar S, et al. Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients. J. Emerg. Trauma Shock. 2011; 4:443–5.
                        82. Ackermann O, Liedgens P, Eckert K, et al. Ultrasound diagnosis of juvenile forearm fractures. J. Med. Ultrason. 2010; 37:123–7.
                        83. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010; 41:862–8.

                        Supplemental Digital Content

                        Copyright © 2020 by the American College of Sports Medicine