Five Top Tips for beginning musculoskeletal ultrasound

  1. Basics first

Begin learning normal ultrasound appearances of soft tissue layers; muscles, tendons, ligaments and nerves.  Once you are comfortable with normal appearances, progress on to common conditions such as tendon tears, bursal effusions and the stages of tendinopathy.

  1. Anatomy

Those wonderful anatomy textbooks make it look simple with their colour coding and clear labelling! With ultrasound however, those structures are going to look very similar. Learn each body region methodically - each tendon origin and attachment site. Use origin and attachment sites to allow tracking one bony landmark to another. Draw your own diagrams to reinforce learning. Consider the names and their meaning to help remember and locate the structures using bony landmarks. For example, the supraspinatus muscle sits on top of the superior aspect of the scapula (the supraspinous fossa) seen in a lateral scapula or Y-view radiograph.

  1. Anisotropy artefact

Practice causing and then correcting anisotropy on common areas for it to occur. Try a transverse section of the long head of biceps tendon in the bicipital groove of the humerus and the tibialis posterior tendon at the level of the medial malleolus.

  1. All may not be as it seems

It’s not unusual for lumps and bumps to appear on musculoskeletal lists due to similar symptoms or misinterpretation of differential diagnoses from the referrer. Research superficial pathology such as epidermal inclusions cysts, lipomata and normal versus pathological lymph nodes.

  1. Patient positioning and dynamic assessment

Master which patient positions will aid visualisation for each structure and integrate these into a smooth and repeatable routine. The subscapularis tendon is best visualised with external rotation of the arm. Dorsiflexion while scanning will help assess the integrity of the calcaneo-fibular ligament. Scan techniques will vary between colleagues. For instance, shoulders can be scanned from either in front or behind the patient. Learn which suits you ergonomically to avoid developing musculoskeletal repetition injury.

Author: Alex Boxall, Musculoskeletal Interventional Sonographer. Royal Surrey NHS Foundation Hospital, UK