Editorial

Br J Sports Med December 2010 Vol 44 No 16 1136

recognised this utility, and begun to use
laptop-sized US units which are able to
achieve an image quality that is satisfac-
tory for examining MSK systems as long
as high-frequency (1012 MHz) probes
are utilised. The more recent availabil-
ity of truly hand-held units has gener-
ated even greater interest in sonographic
augmentation of the physical examina-
tion, although currently these ultraport-
able machines are used mainly for basic
assessment of, for example, free uid in
the abdomen in trauma cases, and are not
designated by the vendors for MSK use.
Other advantages of US, such as a lack
of ionising radiation, ability to perform a
dynamic examination, high spatial reso-
lution and ability to guide intervention,
further exemplify this modalitys impor-
tant role in diagnosis and management of
MSK conditions.
education for sports medicine fellows.
1

It is also advantageous in that it is based
on the existing American Institute for
Ultrasound in Medicine (AIUM) curricu-
lum, as this agency has a wealth of experi-
ence in sports medicine.
As radiologists, we are acutely aware
of the great value of sonographic assess-
ment of musculoskeletal (MSK) injuries.
Non-radiologist clinicians have also
The paper by Finnoff et al (see page 1144)
is an important rst step in formalising a
detailed curriculum for ultrasound (US)
Musculoskeletal ultrasound:
changing times, changing
practice?
Bruce B Forster, Mark Cresswell
Department of Radiology, Vancouver General and
St Pauls Hospital, Vancouver, Canada
Correspondence to Bruce B Forster MD FRCPC,
Professor and Head, UBC Department of Radiology,
Room 3350-950 West 10th Avenue, Vancouver BC,
Canada V5Z 4E3;
bruce.forster@vch.ca
03_bjsports80796 & 80986.indd 1136 11/18/2010 7:45:56 PM
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Editorial
Br J Sports Med December 2010 Vol 44 No 16 1137
professional development credits per
2-year cycle to maintain competency in
US in emergency medicine. Other pro-
grammes such as monitoring of diag-
nostic accuracy compared with surgical
gold standards where appropriate, or
other imaging modalities, would also
ensure ongoing best practice.
Field-of-play/bedside US: these exam- 7.
inations, reported in the linked paper
by James et al (see page 1149), will in
the future involve ultra-portable units,
and raise additional questions, such as
image storage and reporting.
4
So, although the article by Finnoff et al
1

helps to establish some specic curricular
objectives, there do remain unresolved
details, which would be essential to ensure
quality performance and interpretation of
MSK US examinations. As multimodality
imaging experts, radiologists can assist our
colleagues in sports medicine in reaching
some of these important quality targets,
whether through performance of addi-
tional US examinations in difcult cases,
interpretation of other imaging modali-
ties such as CT or MRI to aid sonographic
diagnosis, curriculum design or through
suggestions to ensure competency. As
long as quality patient care is achieved,
we are all winners.
Competing interests None.
Provenance and peer review Not commissioned;
not externally peer reviewed.
Accepted 25 October 2010
Br J Sports Med 2010;44:11361137.
doi:10.1136/bjsm.2010.080986
REFERENCES
1. Finnoff JT, Lavallee ME, Smith J. Musculoskeletal
ultrasound education for sports medicine fellows:
a suggested/potential curriculum by the American
Medical Society for Sports Medicine. Br J Sports Med
2010;44:11441148.
2. Budoff MJ, Cohen MC, Garcia MJ, et al. ACCF/AHA
clinical competence statement on cardiac imaging
with computed tomography and magnetic resonance.
J Am Coll Cardiol 2005;46:383402.
3. American College of Emergency Physicians
Policy Statement on Emergency Ultrasound
Guidelines. Guidelines approved by ACEP Board
or Directors, October 2008. Page ranges: 138.
http://www.acep.org/WorkArea/DownloadAsset.
aspx?id=32878 (accessed Oct 20, 2010).
4. James P, Barbour T, Stone I. The match day use of
ultrasound during professional football nals matches.
Br J Sports Med 2010;44:11491152.
covered. Finnoff et al
1
propose that
fellows attempt to meet the AIUM
guidelines of 150 cases performed,
interpreted and reported, and 40 h
of category 1 American Medical
Associations Physicians Recognition
Award credits, unless within 2 years
of a fellowship which has accredited
US content. It would not be acceptable
to have a voluntary standard; all fel-
lows in such a programme should be
mandated to meet these requirements
in order to practise, and furthermore,
all fellows should be required to sub-
mit proof of their experience to their
facility prior to practising within the
modality. Ideally, such records would
be required by a credentialling body
such as the AIUM or the American
Medical Society of Sports Medicine,
which would then issue a certicate
of competence.
Requirement for hands-on experience: 3.
although many forms of sonographic
training exist, such as video, web-based
learning, DVDs etc, quality US train-
ing is distinguished by hands-on image
acquisition, for which there is no sub-
stitute. Radiologists in teaching insti-
tutions have extensive experience in
resident hands-on training and in ensur-
ing competence in US examination, and
would be an important resource for
development of programmes such as
that suggested by Finnoff et al.
1
Advanced levels of competence: com- 4.
petency criteria could be two-tiered,
with one level for purely diagnostic
studies, and a second tier for sono-
graphically guided intervention, the lat-
ter requiring added, mentored training.
Determination of competency: as well 5.
as proof of training and experience
as outlined above, competency could
be ascertained by observation of skill
in image acquisition, video review of
cases, over-reading of cases by experts,
simulator training or traditional exam-
ination, all of which are suggested as
reasonable methods by the American
College of Emergency Physicians
(ACEP) policy statement in their
Emergency Ultrasound Guidelines.
3
Ongoing quality assurance: the ACEP 6.
suggests at least 10 h of continuing
BENCHMARKING ESSENTIAL
HANDS-ON EXPERTISE
US requires hands-on expertise more than
any other imaging modality. Canadian
radiology residency programmes require a
minimum of 6 months of US experience,
albeit in all body systems, in order to prac-
tise in Canada. The MSK system is widely
considered to be one of the more difcult
body systems to master, and additional
training, over and above the 6 months of
residency experience, is often offered by
MSK imaging fellowship programmes.
However, there are too few radiologists
or US technologists to meet the needs of
our patients, whether at the eld-of-play,
in the hospital or in the ofce. Thus, in the
interest of optimising patient care, it is rea-
sonable for sports medicine physicians and
fellows to be offered training. However, in
order to ensure quality outcomes, several
benchmarks must be considered:
Collaboration with related special- 1.
ties: in a competence statement on
cardiac CT and MR
2
the American
College of Cardiology Foundation and
the American Heart Association con-
sulted with the American Society of
Echocardiography, American Society
of Nuclear Cardiology, Society for
Atherosclerotic Imaging, Society for
Cardiovascular Intervention and the
Society for Cardiovascular MR, all of
which include cardiology and imaging
specialist members. Such wide discus-
sion increases the likelihood of a com-
prehensive programme and improves
buy-in from multiple disciplines. The
scenario of cardiologists performing
coronary CT angiography, when the
vast majority had never formally been
involved in this modality before, is not
unlike the current scenario with sports
medicine clinicians and US.
Minimum education, training and 2.
experience, specied and veried: it
is vital that trainees undertake MSK
US training within programmes that
are accredited, and that a minimum
number of cases performed by the
candidate under expert supervision be
specied. Furthermore, if the intent is
for the candidate to perform general
MSK US, then all anatomical regions
within the MSK system should be
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doi: 10.1136/bjsm.2010.080986
2010 44: 1136-1137 Br J Sports Med
Bruce B Forster and Mark Cresswell
times, changing practice?
Musculoskeletal ultrasound: changing
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