Authors:

Levent Özçakar, MD
Murat Kara, MD Musculoskeletal Ultrasound
Ke-Vin Chang, MD
Alparslan Bayram ÇarlN, MD
Nuray Akkaya, MD
Fatih Tok, MD
Wen-Shiang Chen, MD, PhD
Tyng-Guey Wang, MD
LITERATURE REVIEW
Levent Tekin, MD
Alper Murat Ulas$ lN, MD
Carl P.C. Chen, MD, PhD
Erhan ÇapkNn, MD
Martine De Muynck, MD Nineteen Reasons Why Physiatrists
Affiliations: Should Do Musculoskeletal Ultrasound
From the Department of Physical and EURO-MUSCULUS/USPRM Recommendations
Rehabilitation Medicine, Hacettepe
University Medical School (LÖ); Ankara
Physical and Rehabilitation Medicine ABSTRACT
Training and Research Hospital,
Ankara, Turkey (MK); Department of Özçakar L, Kara M, Chang K-V, ÇarlN AB, Akkaya N, Tok F, Chen W-S, Wang T-G,
Physical and Rehabilitation Medicine, Tekin L, Ulas$ lN AM, Chen CPC, ÇapkNn E, De Muynck M: Nineteen reasons why
National Taiwan University Hospital,
physiatrists should do musculoskeletal ultrasound: EURO-MUSCULUS/USPRM
Taiwan (K-VC, W-SC, T-GW);
Department of Physical and recommendations. Am J Phys Med Rehabil 2014;00:00Y00.
Rehabilitation Medicine, Bursa Military This article is an eventual consensus of experts from the European Musculoskeletal
Hospital, Bursa (ABÇ); Department of
Physical and Rehabilitation Medicine, Ultrasound Study Group (EURO-MUSCULUS) and the Ultrasound Study Group
Pamukkale University Medical School, in Physical and Rehabilitation Medicine (USPRM) pertaining to the use of mus-
Denizli (NA); Physical and
Rehabilitation Medicine Clinic, culoskeletal ultrasound in physical and rehabilitation medicine. Nineteen important
İskenderun Military Hospital, reasons (as regards general advantages, specific conditions in physical and re-
İskenderun (FT); Physical and habilitation medicine, as well as comparisons with other imaging tools) have been
Rehabilitation Medicine Clinic,
Gülhane Military Academy Haydarpas$ a highlighted to consolidate the scenario of how/why the probe of ultrasound needs
Training Hospital, Istanbul (LT); to become the stethoscope, the extended hand, and the pen of physiatrists.
Department of Physical and
Rehabilitation Medicine, Afyon Key Words: Physical and Rehabilitation Medicine, Ultrasound, Physiatrist, EURO-
Kocatepe University Medical School, MUSCULUS, USPRM
Afyon, Turkey (AMU); Department of
Physical and Rehabilitation Medicine,
Chang Gung University, Chang Gung
Memorial Hospital and College of
Medicine, Taiwan (CPCC); Department
of Physical and Rehabilitation
Medicine, Karadeniz Technical
University Medical School, Trabzon,
Turkey (EÇ); and Department of
Physical and Rehabilitation Medicine,
B y and large, musculoskeletal ultrasound (US) has gained increasing impor-
tance in the field of physical and rehabilitation medicine (PRM) in the recent
Gent University Hospital, Gent,
Belgium (MDM). years. Of note, physiatrists, who are dealing with a wide spectrum of musculo-
skeletal diseases (pertaining to various tissues), still need awareness as regards the
Correspondence: potential utility of US in their daily practiceVnot only from the clinical but also
All correspondence and requests for
reprints should be addressed to:
from the research side of the story.1Y3
Levent Özçakar, MD, Hacettepe Since 2010, the European Musculoskeletal Ultrasound Study Group
Üniversitesi TNp Fakültesi Hastaneleri (EURO-MUSCULUS) has been working to raise attention concerning its use in
Zemin Kat FTR AD SNhhNye, PRM, to expedite European-wide the education process, and to standardize its
06100 Ankara, Turkey.
training/application.4 Similarly, the Ultrasound Study Group in Physical and
0894-9115/14/0000-0000 Rehabilitation Medicine (USPRM) was recently established within the umbrella of the
American Journal of Physical International Society of Physical and Rehabilitation MedicineYClinical Sciences
Medicine & Rehabilitation Committee. In this special report, with an attempt to make the aforementioned
Copyright * 2014 by Lippincott
issues more tangible/concrete, the authors have gathered experts from these two
Williams & Wilkins
working groups and summarized 19 reasons why physiatrists should use muscu-
DOI: 10.1097/PHM.0000000000000223
loskeletal US.

www.ajpmr.com Musculoskeletal Ultrasound in PRM 1

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Disclosures:
Financial disclosure statements have been obtained,
and no conflicts of interest have been reported by
the authors or by any individuals in control of the
content of this article.
GENERAL ADVANTAGES
Reason 1
US imaging is practical and convenient as well
as patient and physician friendly. Immediately after
medical history taking and physical examination,
the same physician can readily go on his/her as-
sessment by imaging. Herewith, it also shortens the
waiting period.5
Likewise, repeated evaluations for the same
patient/pathology are again quite easily performed,
and this feature is paramount for either diagnostic
confirmation or close follow-up during treatment.6
In addition, it is well tolerated by the patients. Of note,
US also allows interactive imaging in which patients
might be informed (and thus satisfied) regarding their
pathology and/or treatment outcome (i.e., a sort of
visual feedback). This reassurance significantly helps
to decrease patients’ anxiety.
Reason 2
US imaging is a noninvasive, radiation-free di-
agnostic test, and it does not have any contraindi-
cations. Accordingly, it can be used for patients at
any age (newborn, elderly, etc.)5 or for patients with
special conditions; for example, patients with metal
implants, cardiac pacemakers, and claustrophobia
as well as pregnant patients can all undergo US
imaging quite safely/comfortably.
Reason 3
US imaging is inexpensive; therefore, when
compared with other sophisticated imaging tools, it
can be widely available and provide cost-effectiveness
in physiatry clinics.5,7
Reason 4
US machines are portable. In this regard, bedside
imaging for any patient or, with smaller devices,
imaging in the sports field (even up the mountain)
can also be possible.8
Reason 5
US imaging provides simultaneous comparison
between multiple regions, and it is of great impor-
tance for prompt diagnosis. During daily practice,
2 Özçakar et al.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
this is usually performed via comparison with the
asymptomatic side of the patient, that is, in case of
unilateral disease. On the other hand, if the patient
has symmetric involvement, comparison can be done
with a healthy subject as well.9Y11
Reason 6
US imaging provides dynamic evaluation. Keeping
in mind the fact that the musculoskeletal system is
composed of moving units, evaluation of the pertinent
pathologies under dynamic imaging yields additional
(functional) information. This feature is indisputably
a unique superiority of US imaging in comparison
with other modalities whereby dynamic assessment
is either quite challenging or impossible.9,12
This issue also deserves special emphasis in
children. US imaging can be performed even if the
baby/child tends to move during the examination
(unwanted but likely). However, sedation needs to
be applied otherwise.13
Reason 7
Either with real-time or indirect guidance, US
imaging facilitates interventional procedures.11 In
simple words, if one can see a structure/pathology
under US scan, he/she can also have access to it.
Therefore, instead of using several landmarks, var-
ious interventional procedures can readily/better
be prompted by US imaging.14
Reason 8
Sonopalpation/Sonoauscultation
Placing the probe exactly on the location(s) in-
dicated by the patient as the painful area(s) is simply
referred to as sonopalpation/auscultation.15 Visuali-
zation of a relevant pathology with this technique
makes US imaging probably the most specific/sensitive
imaging modality. In addition, Bsono-Tinel[ is also
used for peripheral nerve entrapment syndromes.16
Reason 9
US images have high(er) resolution, andVunless
the structure to be visualized is inside the bone or
covered with a bony tissueVseveral pathologies of
the musculoskeletal system can be visualized signif-
icantly better with US.5 In this aspect, one can say
that, if the structure/pathology can be seen with US,
it seems to be superior; otherwise, in areas where
US beams cannot penetrate, the use of US might be
inconclusive.
Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2014
Reason 10
The vascularity (blood flow) within the tissues
can substantially be assessed by color/power Dopp-
ler US imaging. Especially, power Doppler imaging
allows a clear/sensitive depiction of even a mini-
mal blood flow change in various inflammatory con-
ditions (e.g., tenosynovitis, enthesitis, cellulitis) or
tumors.9,17 On the other hand, although quantifi-
cation would be difficult, semiquantitative grading
is commonly used.18
Reason 11
US imaging provides qualitative, semiquantitative,
and quantitative types of assessment.18Y21 Therefore,
in addition to an overall snapshot, various types of
data can be acquired and used for different research
and scholarly publishing, making it the Bstethoscope[
and the Bpen[ of physiatrists.1Y3
SPECIFIC CONDITIONS
Reason 12
Because it can be used to diagnose various forms
of tendinopathies (e.g., tendinosis, tears, tendinitis)
as well as articular, muscle, and ligament lesions, US
imaging provides an essential role in the manage-
ment of innumerous sport injuries (especially during
follow-up and decision making for return to play).
This pertains not only to diagnosis but also to several
interventionsVmuch more crucial for athletes.8,14
Reason 13
Similarly, being able to clearly demonstrate over-
use injuries, US imaging can readily be used for
different patients/pathologies commonplace in re-
habilitation medicine. The spectrum would definitely
encompass wheelchair users, stroke shoulder, het-
erotopic ossification, decubitus ulcers, and amputee
stump.2,8,15,22Y24
Reason 14
Because of the ease of scanning, US can readily
be used for peripheral nerve imaging throughout
(proximal to distal). In case of entrapment syn-
dromes, first, one can morphologically confirm the
pathology (i.e., nerve swelling); second, an underly-
ing cause (e.g., an adjacent ganglion cyst, a bony
spur, aberrant/accessory structures) might be un-
covered; third, an immediate intervention (e.g., as-
piration, injection, peripheral nerve block) can be
performed under US guidance; and fourth, naviga-
tion for an onward surgery to avoid iatrogenic in-
jury or follow-up (i.e., hematoma or scar tissue)
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thereafter can be provided.25,26 In addition, it can also
contribute in particular nerve entrapments in which
electrodiagnostic studies (technically) fail to clarify
the scenario (e.g., meralgia paresthetica, tarsal tun-
nel syndrome, Morton neuroma).27
Reason 15
Aside from peripheral nerve imaging, US can
also display changes regarding the muscle involve-
ment in various neuromuscular diseases.28,29 The
relevant findings comprise homogeneous increase
in muscle echogenicity with atrophy (as in neuro-
genic disorders) or inhomogeneous increase in mus-
cle echo intensity often with preserved muscle bulk (as
in myopathies).
Reason 16
US can assist in distinguishing between benign
and malignant soft tissue lesions. Either for a suspi-
cious mass lesion or during routine US evaluations,
the size, margins, and vascularity can be considered
for differential diagnosis. Yet, the spectrum of
lesionsVthat physiatrists might come acrossV
ranges from a simple lipoma/fibroma or nodular
fasciitis to a malignant soft tissue tumor.30
COMPARISON WITH OTHER
IMAGING MODALITIES
Reason 17
As far as radiation exposure is concerned, be-
yond dispute, US is superior to conventional x-rays.
However, US can simultaneously be applied to any/
every region, but cumulative radiation exposure
would definitely limit radiographic imaging espe-
cially in certain patient groups (i.e., children, malig-
nancies).9,31,32 Moreover, although early erosions
and calcifications or small bony lesions (i.e., fracture,
spur, and cortical irregularities) can hardly be visu-
alized with x-rays, with the help of sonopalpation,
such lesions can be better unmasked with US imag-
ing.9,13,33 On the other hand, radiographies might
be necessary in cases in which the general bony skel-
eton needs to be evaluated (particularly for intra-
osseous problems).
Reason 18
Likewise, radiation exposure seems to be the major
concern when comparing computed tomography
and US imaging.34 Besides, despite the lack of three-
dimensional orientation in US, relevant studies have
shown that US is not inferior to computed tomog-
raphy as regards the diagnosis of cortical lesions.31Y34
Musculoskeletal Ultrasound in PRM 3
 Reason 19
For soft tissue imaging, magnetic resonance
imaging is generally accepted to be a paramount
standard.35 On the other hand, because of its high
resolution, convenience, cost-effectiveness, and easy
dynamic real-time imaging features, in the hands
of clinicians, US becomes a great tool immediately
after physical examination.5 Further, various quanti-
fications regarding muscle architecture (e.g., pen-
nation angle, fascicle length) can be possible only with
US but not with magnetic resonance imaging.21 In this
sense, a general caveat would be to use US in case
both modalities can be used to see the structure/
pathology. On the contrary, if US is technically not
able to visualize the soft tissue structure/pathology,
magnetic resonance imaging may be considered as
the next/last resort.14
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