by Laura Currie, B.S., RT(R), RDMS, RVT, RMSKS

As a sonography student in 1986, the subject of my graduation project was “Ultrasound Evaluation of the Rotator Cuff”.  The procedure was in its infancy on the West Coast but beginning to see increased use in some regions of the country.  The scans were performed by Radiologists with a particular interest in sonography and a willingness to accept the challenge.

I was fortunate to have worked with one of those Radiologist, Dr. Charles Pope, in Raleigh, NC from 1988 – 2005.  Dr. Pope had a great working relationship with many of the Orthopedic Physicians in the capital city and they referred patients for shoulder ultrasounds first to rule out rotator cuff tears.   Two days per week were reserved for shoulder patients and we averaged 16-20 rotator cuff scans per week.  As ultrasound technology advanced, we were increasingly confident in diagnosing partial thickness tears, avulsion fractures and tendon calcifications in addition to complete tears.  MRI procedures were seldom required for these patients.

In 2005 I relocated to Wilmington and began teaching in the CFCC Medical sonography program.  I was surprised to find that ultrasound was not being used to diagnose rotator cuff tears in my new community.  For the past 15 years, I have followed the growing MSK Sonography modality and watched from afar as it expanded to include scans of all upper and lower extremity joints.  Yet after 15 years of continued growth in the MSK sonography field, my community remains underserved in this modality.  While it is being used for guided therapeutics and surveillance of rheumatoid arthritis treatments, the use of ultrasound to diagnose joint/tendon injuries and pathologies has been quite slow to catch on here.

One reason for this delay is that MSK sonography is very operator dependent and our community lacks experienced MSK sonography practitioners.  As with any new medical technique or procedure, appropriate training and practice is necessary.  Some Radiologists have ultrasound scanning experience, but may not be comfortable in their ability to acquire MSK images. Orthopedic Physicians may also have been exposed to ultrasound use in their residencies and fellowships but the learning curve is steep and requires consistent exposure and practice.

Diagnostic Medical Sonographers already possess the foundation needed to learn MSK sonography and thus are able to hone the required skills at a faster pace.  CFCC sought the opinion of the sonographers in our community and found sufficient levels of interest and desire to learn MSK sonography.  In response to this interest, CFCC offered our first MSK Sonography Program in the spring of 2020.   Our curriculum includes instruction in anatomy, scan techniques, protocols and pathologies of all upper and lower extremity joints.  Students also learn the dynamic techniques that can be performed while scanning, which gives ultrasound an advantage over MRI scans.

Our first class of students included sonographers, Physical Therapists and Physicians Assistants from North Carolina, Virginia and California.  Two sonographers in Wilmington completed the first MSK course and are ready to scan shoulders, elbows, wrists, hands, hips, knees, ankles and feet.  Our Medical Sonography program plans to continue training additional sonographers and Physicians each year with the next MSK sonography course starting on January 7, 2021.

Education and training are essential to the availability of these cost-effective and convenient MSK sonography procedures in our community.  Now that this training is available, what else needs to be done before MSK sonography can move forward in Wilmington?  Is there an established dialogue between local Orthopedic Physicians and Radiologists to discuss interest in referring patients for MSK Sonography procedures and the procedures that are available?  I look forward to hearing about MSK Sonography progress in the near future.

 

Laura Currie is a North Carolina native and a graduate of Greensboro College, Moses Cone Radiologic Technology Program and the UNC-CH Medical Sonography Program.   She has worked as a staff sonographer at Duke University Medical Center and as a Supervisor and sonographer at Wake Radiology Diagnostic Imaging in Raleigh, NC.  

Laura is registered through the American Registry of Diagnostic Medical Sonographers holding RDMS credentials in Abdomen, OB-GYN and Neonatal Neurosonography specialties.  She also holds the RVT credentials for vascular technology and most recently earned the new RMSKS credential for musculoskeletal sonography.  In addition, Laura is a registered Radiologic Technologist. 

Laura is the Clinical Coordinator for the Medical Sonography Program at Cape Fear Community College and teaches sonographic physics, vascular sonography, obstetrical sonography and musculoskeletal sonography.  She is a past president of the North Carolina Ultrasound Society and has worked with the Society as a member of the Board of Directors and an Administrator to bring quality continuing education to sonographers throughout the Carolinas.

by Richard J. Nasca M.D., FAAOS

Nearly half a million people are affected with rotator cuff tears each year. Most, but not all, patients with rotator cuff tears give a history of injury to the shoulder at the onset of their pain, decreased range of motion with altered function and persistent night pain that interferes with their sleep.

The examiner will find weakness of the torn rotator cuff muscles during manual muscle testing, a disconnect in scapulohumeral rhythm and poor control of the unsupported, abducted upper extremity.

A reliable, non-radiographic method for confirming the diagnosis would be welcomed by patients and providers. Several studies comparing, Ultrasonography and magnetic resonance imaging (MRI) have demonstrated ultrasound to be as reliable and accurate in confirming full thickness rotator cuff tears as MRI. (1,2,3,4)

Ultrasound is readily available during an office visit, more cost effective than MRI and can be used when metal artifact would be an issue with MRI. Unlike MRI, ultrasound can be done without delay bypassing the difficulty in getting insurance approval and scheduling MRI, all of which can sidetrack definitive treatment.

Considering that ultrasound has been found to be reliable and accurate in confirming full thickness rotator cuff tears when performed by experienced operators using high-quality units, why is there still the need to order MRI which may not be readily available, very expensive and sometimes an uncomfortable experience for a claustrophobic patient to undergo?

Other than concerns about the quality of the unit and experience of the operator, I can see no reason that if a tear is seen on ultrasound and the history and physical examination also support the diagnosis, the surgeon should feel compelled to order an MRI. Rather it would seem prudent and reasonable for him or her to perform surgical repair with confidence.

References:

1. Diagnostic Accuracy of Ultrasound in Rotator Cuff Tears, Okoroba KR, Fidal MS, Tramer JS, Davis KD. Ultrasonography; Nov 2018, 38(3),1-15.
2. Effect of surgeon -sonographer interaction on ultrasound diagnosis of rotator cuff tears: a five -year cohort study in 775 shoulders. Kurz AZ, Kelly MJ Hackett L, Murrell GA. J Shoulder Elbow Surg 2016;25:1385-1394.
3. Diagnostic accuracy of ultrasound for rotator cuff tears in adults: A systemic review and meta-analysis. Smith TO, Back T, Toms AP, Hing CB. Clinical Radiology 2011; 66: 1036-1048
4. Accuracy of MRI, MR arthrography and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. De Jesus JO, Parker L, Frangos AJ, Nazarian LN. AJR Am J Roentgenol 2009,192:1701-1707
5. Detection and measurements of rotator cuff tears with sonography: analysis of diagnostic errors. Teefey SA, Middelton WD, Payne WT, Yamaguchi K. AMJ Am JRotengen 2005;184:1768-1773.

Dr. Nasca was born in Elmira NY and is a graduate of Georgetown College and Georgetown Medical School. He completed his internship at the Hospital of the University of Pennsylvania and post graduate training in Surgery and Orthopaedics at Duke University Medical Center and Affiliated Hospitals. Dr. Nasca served as Chief of the Amputee and Hand Services at the Philadelphia Naval Hospital caring for Vietnam casualties.

Dr. Nasca held teaching appointments in orthopaedic surgery at the University of Arkansas School of Medicine and the University of Alabama School of Medicine.  During his time in practice he specialized in caring for patients with spine deformities, injuries and disorders.