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RFS – Education and Training

Sports Ultrasound Training During a Pandemic

Developing a “Hands-on” Skill Through Distance Learning

Schroeder, Allison N. MD; Hall, Mederic M. MD; Kruse, Ryan C. MD

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American Journal of Physical Medicine & Rehabilitation: September 2020 - Volume 99 - Issue 9 - p 860-862
doi: 10.1097/PHM.0000000000001515
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Sports ultrasound (US) training is a required component of sports medicine fellowships.1 Historically, sports US has been taught through “in-person” formal didactics and mentored clinical experience as well as various self-directed supplementary learning methods. “In-person” didactic education occurs as part of a structured fellowship curriculum and at local, regional, or national US conferences. Self-directed learning uses textbooks and web-based videos (American Medical Society of Sports Ultrasound Curriculum, American Institute of Ultrasound in Medicine webinars, etc.) that are readily available. In addition, self-directed US scanning sessions should be performed using clinic-based US units outside of work hours or with portable US units at home. These sessions allow for “hands-on” practice with the opportunity to save normal images that an instructor can later review. However, in addition to these methods, mentored “in-person” US practice sessions are vital for developing proficiency in sports US.1 Barriers to “in-person” US scanning with direct mentorship do exist and include lack of access to skilled instructors, no formal didactic sessions at one’s training institution, and inability to attend US conferences because of cost or lack of time away from work.

Challenges of A Global Pandemic

Barriers to US learning are amplified during a global pandemic, where shortages of instructors due to quarantine restrictions, clinic closures, as well as cancellations of “in-person” US practice sessions and conferences negatively affect US learning. Although the self-directed learning methods described previously can continue to be used during times of social distancing and quarantine, “in-person” direct mentorship during “hands-on” didactic teaching sessions and conferences are limited or impossible. To continue US training during a pandemic, teaching methods must be adapted.

Use of Virtual Platforms

Sports US teaching can be conducted through various virtual meeting platforms (such as Skype, Zoom, FaceTime, Microsoft Teams, etc.) that can display real-time US images, providing an alternative teaching method that does not require in-person training sessions or live clinic patients.2,3 Picture-in-picture display of the transducer placement and the US screen can be obtained by connecting the US unit to a computer and then streaming it live on a virtual meeting platform (Fig. 1).4 A less costly option involves using two personal electronic devices (eg, phone camera and computer camera or webcam) to obtain separate images that are simultaneously streamed through a virtual meeting platform (Fig. 2). With these methods, the instructor can view both images, allowing them to verbally guide transducer manipulation (e.g. “translate, “rotate,” etc.), optimize images, and even quiz the learner in real time while providing immediate feedback. These methods are compared in Table 1.

Picture-in-picture method. A, Ultrasound machine is directly connected using machine-specific electronic cables and a video capture device (arrow) to a computer (triangle) to display the US screen while the computer camera or mounted webcam displays probe placement. This method uses only one camera. B, The image created with the picture-in-picture display.
Two camera method. A, One camera, in this image, a cell phone on a tripod (arrow), displays the ultrasound machine while another camera, in this image, a computer with a camera (triangle), is used to display probe placement. This method uses two separate cameras that are both separately connected to the virtual streaming platform. B, The image created using the two camera method.
Comparison of image capture techniques for virtual display

In addition, virtual platforms can be used to teach basic injection principles. Ballistics gel or other “home-made” injection models5–7 can be used to practice procedural skills including needle tracking and target acquisition. These procedural skills can be practiced individually or with an instructor virtually observing and offering real-time guidance and feedback.

Barriers to Virtual US Learning

Although the advantages of virtual US learning are described previously, barriers and disadvantages to this method of learning do exist and should be considered. These include lack of US access, inability of an instructor to physically reposition the transducer for image optimization during instructional sessions, and lack of technological capabilities. Nonetheless, these barriers can be overcome. If there is no access to a portable US unit, the use of an US in a less busy or closed clinic is possible. Transducer repositioning can be guided by verbal instruction using the methods described previously. The lack of technological capabilities could also be a barrier, but most basic virtual meeting platforms are free and the use of both a computer and phone camera circumvent the need for technological expertise and expensive equipment required to create a picture-in-picture image.4

Ultrasound Education Moving Forward

Despite difficulties with continuing US training during a pandemic, these virtual methods of teaching provide a way to overcome previous barriers to “in-person” US sessions. Virtual US teaching also increases access to mentorship by skilled instructors, allows for collaboration of didactic sessions across institutions, and enhances one’s ability to gain individualized US instruction without physically attending US conferences. In the future, these virtual opportunities should be considered complementary to traditional US teaching methods.


During a pandemic, there are unprecedented barriers to “in-person” sports US training with social distancing measures and clinic closures. However, diagnostic and interventional US training can continue through virtual methods that allow for real-time, individualized instruction. The addition of virtual US education to the current educational methods may positively change the way we offer US education in the future.


1. Finnoff JT, Berkoff D, Brennan F, et al.: American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Br J Sports Med 2015;49:145–50
2. Barbosa TBM: Zoom: an innovative solution for the live-online virtual classroom. HETS Online J 2019;9
3. Drake NTB: Best video conferencing software 2020: paid and free solutions for business. 2020. Available at: Accessed April 11, 2020
4. Rajasekaran S, Hall MM, Finnoff JT: An introduction to recording, editing, and streaming picture-in-picture ultrasound videos. PM R 2016;8:817–20
5. Bude RO, Adler RS: An easily made, low-cost, tissue-like ultrasound phantom material. J Clin Ultrasound 1995;23:271–3
6. Charnoff J, Naqvi U, Weaver M, et al.: Resident education of ultrasound-guided procedures: a homemade practice model pilot study. Am J Phys Med Rehabil 2019;98:e116–8
7. Farjad Sultan S, Shorten G, Iohom G: Simulators for training in ultrasound guided procedures. Med Ultrason 2013;15:125–31

Ultrasound; Sports Medicine; Virtual Education

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