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The Emerging Role of Musculoskeletal Ultrasound in Occupational Medicine

Sayeed, Yusef MD, MPH, MEng, CPH; Sully, Keziah MD; Allen, Anna MD, MS, MPH; Werntz, Charles L. III DO, MPH

Journal of Occupational and Environmental Medicine: December 2014 - Volume 56 - Issue 12 - p e160
doi: 10.1097/JOM.0000000000000332
Letter to the Editor

Resident Physician, Department of Emergency Medicine, Division of Occupational Medicine, West Virginia University School of Medicine, Morgantown, Email: yasayeed@hsc.wvu.edu

Resident Physician, Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia

Assistant Professor, Clinical Emphasis, Department of Emergency Medicine, Division of Occupational Medicine, West Virginia University School of Medicine, Morgantown

Associate Professor, Clinical Emphasis, Department of Emergency Medicine, Division of Occupational Medicine, West Virginia University School of Medicine, Morgantown

Readers are invited to submit letters for publication in this department. Submit letters online at http://joem.edmgr.com. Choose “Submit New Manuscript.” A signed copyright assignment and financial disclosure form must be submitted with the letter. Form available at www.joem.org under Author and Reviewer information.

Disclosures: None declared.

No institutional funding or other funding required.

To the Editor:

Musculoskeletal (MSK) injuries are commonly seen by occupational medicine clinicians. Making evaluation and treatment more efficient is an important area for improvement in occupational medicine clinical care. Musculoskeletal injuries such as sprains, strains, and tears have the highest annual incidence rates in terms of work-related injury at 43 injuries per 10,000 full-time workers. The median days away from work being diagnosed with an MSK disorder was 12.1 Musculoskeletal disorders account for nearly 70 million physician office visits in the United States annually, and an estimated 130 million total health care encounters, including outpatient, hospital, and emergency department visits. According to Liberty Mutual, overexertion injuries—lifting, pushing, pulling, holding, carrying, or throwing an object—cost employers $13.4 billion every year.2

While MRI is often used as the primary mode of assessing MSK injuries, clinical based ultrasound (US) may be a more effective and less-expensive modality. MSK US can be used diagnostically to evaluate muscle, tendon, nerve, joint, bursopathy, and even some osseous diseases, like calcific tendinosis. MSK MRI has increased 353.6% reported from 1996 to 2005 by Parker et al.3 He also estimates that the substitution with MSK US, when appropriate, would lead to a saving of $6.9 billion.

In addition to being less expensive, MSK US is more patient-friendly. The claustrophobic patient who requires sedation will not be an issue when scanning with MSK US. MSK US is useful when there are contraindications to MRI such as metal implants. MSK US provides the clinician with the ability to focus on the relevant patient complaint or symptomology. Also, MSK US poses a unique advantage to MRI, diagnosis can be made very early after an injury. If used clinically, definitive visual diagnosis can be made in the first clinical visit. In addition, intervention can be performed during clinical evaluation under US guidance. For greater efficacy, US can be used to diagnose joint effusion and can also be used to provide real-time imaging for aspiration.

MSK US can incorporate both static and real-time scanning through a tendon or joints normal range of motion. Clinicians can visualize when and where the patient experiences symptoms: snapping tendons, catches in joints, or impingement can be assessed across the range of motion. This information can be clinically valuable to help direct treatment. Ultrasound also has the advantage of mobility. Many US machines today are small, the size of a computer laptop case, and portable. Many institutions have US devices available in a variety of settings and some medical schools have incorporated US into the curriculum. They can be easily moved to a clinic or an employer's worksite.

The main barrier to MSK US is that it is sonographer dependent and there is a learning curve. Diagnostic usefulness depends on technique, details, and thorough knowledge of appropriate MSK anatomy, neuromuscular anatomy, and the circulatory system. Once proficiency is obtained, clinical reimbursement may help offset the cost for the purchase of the device. Use of US in clinic may be time intensive but can provide valuable information for triaging injury at initial patient contact. As the sonographer becomes more proficient, this time may be reduced with experience.

Ultrasound is currently being taught as part of residency training programs for emergency medicine, OB/GYN, and PM&R. It is suspected that training in MSK US for occupational medicine residents and experienced physicians would be clinically useful.4 To our knowledge, no occupational medicine residency programs teach MSK US to their residents. We believe that MSK US can become common practice in most occupational medicine clinical settings. Residency training programs that teach MSK US can help train future clinicians as is common in other specialties to deal with a high volume of MSK disorders. In addition, per the ACOEM practice guidelines, there are recommendations for the use of MSK US for acute and subacute MSK injuries.5 In conclusion, we believe that MSK US can be extremely valuable to the occupational medicine physician in terms of diagnosis and intervention, allowing for more efficient treatment of patients, which should improve positive outcomes including return to work and reduce the cost of care. This could be a promising area of research over the coming years.

Yusef Sayeed, MD, MPH, MEng, CPH

Resident Physician

Department of Emergency Medicine

Division of Occupational Medicine

West Virginia University School of

Medicine

Morgantown

Email: yasayeed@hsc.wvu.edu

Keziah Sully, MD

Resident Physician

Department of Physical Medicine and

Rehabilitation

University of Pennsylvania

Philadelphia

Anna Allen, MD, MS, MPH

Assistant Professor, Clinical Emphasis

Department of Emergency Medicine

Division of Occupational Medicine

West Virginia University School of

Medicine

Morgantown

Charles L. Werntz III, DO, MPH

Associate Professor, Clinical Emphasis

Department of Emergency Medicine

Division of Occupational Medicine

West Virginia University School of

Medicine

Morgantown

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REFERENCES

1. Bureau of Labor Statistics; US Department of Labor. Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work. News Release. Available at http://www.bls.gov/iif/oshcdnew.htm. Published 2012.
2. National Research Council and the Institute of Medicine. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academies Press; 2001. Available at http://www.nap.edu/openbook.php?isbn=0309072840.
3. Parker L, Nazarian L, Carrino J, et al. Musculoskeletal imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5:182–188.
4. Finnoff JT, Smith J, Nutz DJ, Grogg BE. A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil. 2010;89:56–89.
5. ACOEM Practice Guidelines, American College of Occupational and Environmental Medicine. Available at http://apg-i.acoem.org/Browser/BrowseChapters.aspx. Published 2013.
Copyright © 2014 by the American College of Occupational and Environmental Medicine