Updated training guidelines

Our 2010 training guidelines lacked specifics regarding diagnostic ultrasound and were challenging to implement for some fellowship programmes.3 Recognising the importance of establishing basic competency among all primary care sports medicine (PCSM) fellowship graduates, AMSSM established a Presidential task force to review and update the previous ultrasound curriculum and make recommendations regarding faculty development and additional educational tools to support programmes that are still building their ultrasound practices. The major updates to the curriculum were establishing core competencies for sports specific diagnostic ultrasound and revising the recommended interventional competencies. Completion of the curriculum fulfils the current American Institute of Ultrasound in Medicine (AIUM) training guidelines for MSK US (http://www.aium.org) and the American Registry for Diagnostic Medical Sonography's (ARDMS) Registered in Musculoskeletal (RMSK) sonography credential prerequisites (http://www.ardms.org). The task force hopes to facilitate the addition of sports ultrasound to the Accreditation Council for Graduate Medical Education's (ACGME) programme requirements for sports medicine fellowships.

Appropriate utilisation

Ultrasound-guided procedures (USGP) have been the focus of much discussion. This is in part due to the rapid increase in performing procedures among non-traditional users (ie, non-radiologists). This has led some third party payers to question the indications for ultrasound guidance. From 2004 to 2010, there was an increase in utilisation of USGP of greater than 100%.1 Over 70% of this growth was attributed to non-radiologists.1 While many clinical factors play into the decision to utilise ultrasound guidance for a procedure, it is important to critically review the available literature when making such decisions. In this edition of BJSM, AMSSM has released its position statement on Interventional MSK US in Sports Medicine. This represents an important advance in the debate regarding appropriate utilisation of ultrasound guidance.

During the formation of the position statement, several things became apparent. First, assessment of injection accuracy was highly variable. However, it was clear that ultrasound guidance improved accuracy, sometimes dramatically. Second, it was difficult to consider efficacy studies in the context of current musculoskeletal practice. Corticosteroid injections predominate the literature, while their usage continues to decline in the clinic due to lack of efficacy beyond short-term improvement and concern for their worsening long-term outcomes.4 ,5 Also, separating systemic from local effects of corticosteroid injections is challenging. Third and perhaps most importantly, was the lack of diagnostic specificity in many of the efficacy studies. It was unknown if even the image-guided injections were placed into the pain generating structure in most studies as there was no report of amelioration of pain with local anaesthetic. The potential cost savings associated with accurate identification of pain generators via diagnostic injections and avoidance of unnecessary treatments, which often carry risks for the patient as well, needs to be further evaluated in the literature.

What is often lost in the utilisation debate is the potential underutilisation of diagnostic ultrasound. Despite ultrasound being a first-line imaging recommendation for rotator cuff disorders, MRI continues to be the default among many providers.6 The potential cost savings as well as increased patient satisfaction with US versus MRI should be considered for those regions where sensitivity and specificity of diagnosis is equivalent, such as tendons, bursae, peripheral nerves, foreign bodies, etc.7

Sports ultrasound, more than just MSK

Ultrasound also provides valuable point-of-care information for the team physician outside of the MSK system. The Focused Assessment with Sonography in Trauma (FAST) exam has become standard of care in trauma patients and there are implications for on-site usage in sports-related trauma. Sports medicine physicians can obtain measurements consistent with cardiac sonographers for limited echocardiography.8 The implications for preparticipation screening are also intriguing. Thus, future iterations of the curriculum will likely include additional non-MSK applications.

Future direction of sports ultrasound

Ultrasound is becoming ubiquitous in sport medicine clinics and on-site at athletic events. Diagnostic applications will expand as technological advances yield higher resolution images and promise further tissue characterisation such as sonoelastography. We are now developing specialised tools to be used specifically with ultrasound guidance that have the potential to revolutionise outpatient sports medicine treatments. The future of sports ultrasound holds much potential and appropriate training, implementation and utilisation are crucial. AMSSM is committed to being in the forefront of ultrasound usage in sports medicine.