Sports ultrasound (US) has traditionally been used in the evaluation of musculoskeletal conditions, and its use is rapidly expanding. Sports US also can be used for evaluation of nonmusculoskeletal injuries, such as abdominal trauma (1–3), retinal detachment (4,5), vocal cord dysfunction (2,6), and peripheral nerve injuries. In addition, sports US can be used to guide procedures and has been shown to improve accuracy, efficacy, and safety of most peripheral joint and soft tissue injections (7–18). The use of sports US for diagnostic and interventional purposes is becoming an expected skill of sports medicine clinicians and is now a required component of sports medicine fellowship training (2).
It is well established that sports US is an operator-dependent skill and developing competence in the use of sports US requires extensive training in image optimization, acquisition, and interpretation (19–22). Instructors recognize that sports US education is of greater importance now than it was in the past, and many resources have been created for sports US education (2,23). Historically, sports US has been taught through self-directed learning, formal didactic sessions, and in-person, “hands-on” scanning sessions. Real-time feedback from experts during scanning sessions is critical in efficiently developing competence and confidence as an ultrasonographer and is typically obtained through mentored experiences during a 1-year sports medicine fellowship (2) or at local and national conferences. Instructor-guided US training has been shown to be superior to self-guided US training (24–26) and conferences that offer “hands-on” US training in addition to formal didactics are thought to be particularly beneficial by the conference attendees (27–30). This further highlights the importance of real-time feedback during “hands-on” education for developing and mastering US scanning and procedural skills. However, obtaining real-time, in-person feedback can be difficult if one lacks the time or funding to attend these conferences.
With the emergence of COVID-19 and the development of a global pandemic, typical barriers to US education have been amplified and the lack of access to expert instructors and inability to travel to conferences are more evident than they have ever been. Many in-person sports US sessions and local, national, and international conferences have been canceled or postponed, and their future is uncertain. Without in-person conferences, self-directed learning and webinars can continue, but opportunities to receive real-time instructor feedback are limited. In light of the barriers created by the COVID-19 pandemic, a surrogate for in-person US teaching is critical to continue to develop competent sports medicine ultrasonographers. We propose various virtual US teaching methods, described in this article which can be used not only for self-directed learning but also to allow expert instructors the ability to directly observe a learner performing an US scan while providing them real-time feedback.
Virtual Sports Ultrasound Education
Just as many lecture/didactic based conferences have moved to virtual meeting platforms (31,32), sports US education also must adapt. While prerecorded videos, webinars, and live demonstrations aid self-directed learning, these learning methods do not provide an opportunity for “hands-on” scanning with real-time feedback from an expert ultrasonographer. This “hands-on” component of sports US education is critical and is directly impacted by the cancellation of conferences and in-person teaching. However, using virtual platforms, the “hands-on” portion of sports US education can continue, utilizing user-friendly methods, which allow an instructor to directly observe a learner performing sports US scanning and provide real-time feedback. These virtual educational sessions may augment or replace in-person educational sessions that have been canceled or postponed and also may offer an opportunity to expand the reach of sports US education and collaboration.
Methods of Virtual Sports Ultrasound Education
There are two primary methods of virtual sports US education that should be mentioned: (A) observational methods and (B) live, “hands-on” methods. Online or virtual sports US didactics have typically been taught using prerecorded videos or live demonstration scans that allow learners to observe scanning sessions and ask questions of the instructor. These methods allow for passive, observational learning only. However, using some of the same technology used for these teaching sessions, such as virtual meeting platforms, an instructor has the ability to provide real-time feedback to a learner performing a live scan on their own. This virtually recreates an in-person, “hands-on” educational experience. The methods to create both types of virtual learning environments are described below.
Observational virtual education methods
Learners can watch prerecorded lectures or live demonstration scans via various platforms, such as (A) the American Medical Society for Sports Medicine's US curriculum for sports medicine fellowships, (B) the American Institute of Ultrasound in Medicine webinars, and (C) US scanning techniques published in the American Journal of Roentgenology. Watching prerecorded or live US videos can be beneficial as they often include US scanning demonstrations with concurrent display of transducer placement. These are easily accessible online and can be viewed at the convenience of the learner. Furthermore, the learner can then practice the US scanning protocols on his or her own time. While these methods are a beneficial mode of indirect learning, they do not allow for mentored, “hands-on” scanning opportunities, which, as stated previously, are critical in becoming proficient in sports US.
Live, real-time virtual education methods with direct feedback
Direct, real-time feedback while performing an US scan can be conducted virtually using an Internet connection and streaming devices with cameras. Various online virtual meeting platforms can be used to display real-time US images while allowing for auditory and visual interaction between the instructor and the learners (31,32). This method of live virtual display of both the transducer placement and the US screen can allow an instructor to give direct, real-time feedback to a learner as they are scanning, similar to what is done during an in-person, “hands-on” scanning session. For real-time feedback to be possible, both the instructor and the learner must have access to an US machine and access to the same virtual meeting platform. There are two main methods in which a virtual, real-time sports US scanning session can be achieved: (A) picture-in-picture method, and (B) two-camera method (Table).
Comparison of virtual US display methods.
||Two Camera Method
||–US machine connected to computer with machine-specific electronic cables and video capture device.
–Computer camera (or webcam) used for image transducer placement.
–Computer connected to virtual platform through an internet connection and streaming both US images and transducer position (2).
|–One device (i.e., smartphone) connected to virtual platform through an Internet connection and streaming US screen.
–Second device (i.e., computer with camera or webcam) also is connected to virtual platform and streaming transducer position.
–Device with best image quality should be used to view US screen.
–1 computer with camera or webcam
–Video capture software
–Cable to connect US machine to VCD
–Cable to connect VCD to computer
–2 devices with cameras
|US image quality:
||Depends on US machine quality
||Depends on US machine and camera quality
VCD, video capture device.
The picture-in-picture method, as described by Rajasekaran, Hall, and Finnoff, creates a small image of transducer position within a larger image showing the US screen (Fig. 1) (33). In addition to an US machine and internet access to enter a virtual streaming platform, this setup requires a computer with video capabilities (or webcam), a video capture device (with an aspect ratio matching that of the US machine), video capture software, and the appropriate connecting cables. The US machine is connected to the computer using the video capture device and cables, and the US image is transmitted directly to the computer screen. The computer camera or webcam is used to view the position of the transducer. The instructor can then use the virtual meeting platform to share their screen, allowing for visualization of the US image and transducer placement. This technique creates high-definition picture-in-picture US videos but comes at a higher cost because of the hardware, software, and connecting cables.
An alternative method uses two devices with cameras (i.e., smartphone camera and laptop camera or webcam) that can separately connect to the virtual streaming platform through an internet connection (Fig. 2). One device (with the higher quality camera) is used to display the screen of the US machine while the other device is used to display the position of the transducer. By streaming thorough two devices simultaneously while using a virtual meeting platform, a side by side image of the US machine screen and transducer position is created. Since many learners and clinicians own a smartphone and laptop with camera, this method is relatively low cost. Purchasing a small tripod to hold a smartphone for optimal view of the US machine is recommended and is inexpensive. With a typical smartphone, the streamed image is of adequate quality to identify the structures being scanned and to interpret the US images.
Using these virtual methods, an instructor can essentially recreate a live, “in-person” teaching session. The instructor can observe the learner performing a live US examination while at the same time provide real-time feedback on image optimization, transducer manipulation, and image interpretation. The instructor also can demonstrate transducer placement and the ideal US image on their US machine that the learner can observe in real-time. Additionally, the instructor can observe needle tracking techniques of the learner (who can use a home-made injection model ([24,25,34]) and provide real-time feedback, allowing for procedural skills education. One limitation of virtual US education is the inability of an instructor to directly reposition the learner’s transducer to optimize the image. However, the use of virtual US education, using verbal instruction, is likely better than no formal instruction. Despite limitations, these methods may become a routine part of sports US education in the future, and may expand the availability of “hands-on” teaching.
Additional Applications of Virtual Sports Ultrasound Education
As previously described, these methods for virtual US education allow for real-time display of high-quality US images and transducer placement with audiovisual interaction between instructors and learners. By using these methods, “hands-on” US education can continue remotely, offering an alternative to in-person educational sessions at conferences, which is important during times of restricted travel because of the COVID-19 pandemic. Additionally, virtual US may enhance sports US education and collaboration around the world by allowing for both expansion of sports US education to rural areas and easier global exchange of ideas, without the barriers of cost and travel time.
Virtual sports ultrasound as an alternative to in-person educational sessions
These virtual educational methods also can be used as a way to allow large conferences to continue during a pandemic. A virtual sports US conference can be structured similarly to a “typical” in-person conference, with a combination of didactic lectures and “hands-on” scanning. Following a group didactic session and scanning demonstration, learners and instructors can break-out into small “virtual rooms” with a few learners and one instructor per room. Using these methods, the instructor and the learner have the ability to visualize each other's transducer position and US machine screen. This allows for real-time instruction and recreates a live, “hands-on” educational session. In addition to this live feedback option, a learner could record their scanning session, including both the transducer positioning and live images, which could be reviewed and critiqued by an instructor at a later date. This is a valuable alternative if live sessions are not possible.
Although virtual sports US conferences will likely never fully replace in-person conferences, they may offer some advantages and can augment in-person teaching sessions. With virtual sports US, learners who may not have previously had the opportunity to travel to conferences will be able to participate. Virtual sports US also may allow for the possibility of more frequent sports US educational opportunities, bypassing the costs of travel and lodging associated with formal conferences. Additionally, virtual sports US may improve access to expert instructors from around the world who may otherwise not be able to travel internationally to conferences. This may enhance the educational experience through exposure to instructors with varied teaching methods, skill sets, and/or perspectives. Finally, recording of the virtual sports US sessions would allow for subsequent review of the material or distribution of the material to a broader audience.
Virtual sports ultrasound and the global expansion of sports ultrasound teaching
Virtual sports US educational sessions may help circumvent some of the barriers to clinicians in rural areas acquiring and retaining US skills. In rural areas, even those within the United States, clinicians lack access to expert instructors, lack training and funding, and have difficulty maintaining their US skills because of infrequent educational sessions (26). Although sports US education sessions of <1 wk duration in rural areas may have some educational benefits (35–37), they are costly. It has been shown that ongoing refresher/retraining sessions are needed to improve sports US scanning competence (36), but these in-person educational opportunities may not be practical in rural areas because of the cost of travel and time away from work. However, virtual educational methods may offer an alternative. These methods would broaden the reach of sports US education, ultimately allowing clinicians in rural areas (that historically may have had poor access to advanced imaging modalities) the opportunity to develop competency in sports US, a skill that requires “hands-on” training.
Virtual sports ultrasound as an opportunity to enhance collaboration
Lastly, virtual sports US education methods may provide an opportunity to enhance collaboration between experts in the field. Historically, exchange of ideas between experts required trips to an expert's home institution or ad hoc discussion of ideas at conferences. Virtual sports US educational methods allow for both international and interdisciplinary collaboration and discussion of novel sports US techniques used by other clinicians or researchers. A short demonstration that includes virtual display of novel sports US scanning protocols, newly discovered structures, or unique US-guided procedures could occur among experts who are hundreds or thousands of miles away. This would allow for easy and possibly more frequent sharing of ideas, facilitating collaboration. As new US technology, scanning protocols, and procedural techniques are constantly being developed, the educational infrastructure must keep pace to continue to advance the field of sports US.
Sports US requires live, “hands-on” training to gain competence and virtual sports US education provides an alternative to in-person teaching sessions, while still allowing for real-time, direct feedback from instructors. Additionally, these virtual methods allow for expansion of sports US to areas that may not have readily available sports US educational sessions and also provides the opportunity for immediate sharing of ideas and new procedures among experts throughout the world. These virtual teaching methods are particularly relevant during a global pandemic but may ultimately become complimentary to in-person educational sessions in the future.
The authors declare no conflict of interest and do not have any financial disclosures.
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