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Abstract
The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.
- ultrasonography
- muscle
- skeletal
- sports medicine
- orthopedics
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Introduction
The use of ultrasound for diagnostic imaging and procedural guidance in musculoskeletal and sports medicine has increased dramatically and involves multiple disciplines and subspecialties. A lack of consensus regarding standardised terminology can lead to confusion when conveying information between colleagues for clinical and research purposes. Our learners often struggle as different terms are used to describe simple actions such as transducer movement and imaging planes. Furthermore, communication with our patients, third-party payers and the public also faces these same challenges.
The primary purpose of this consensus is to provide a clear and useable reference for anyone using musculoskeletal and sports ultrasound. We aim to improve the clarity of communication in clinical practice and improve consistency in the literature. While other terminology references are available, our focus was on clinically relevant topics in the context of musculoskeletal medicine, where we identified frequent variations in terminology used in everyday practice, scientific presentations and the literature. Our goal was to present a user-friendly reference of the most common terminology encountered in musculoskeletal and sports ultrasound.
Methods
Expert group selection and demographics
The project was approved by the board of directors of the American Institute of Ultrasound in Medicine (AIUM) and the American Medical Society for Sports Medicine (AMSSM) who served as the lead societies for this article. Members were invited to represent a diverse group of physicians with experience in the musculoskeletal and sports medicine applications of ultrasound. The AIUM and AMSSM reached out to multiple societies identified to be key stakeholders with the following societies contributing members: American Academy of Orthopaedic Surgeons, American Academy of Physical Medicine & Rehabilitation, American Orthopaedic Society for Sports Medicine, American Society of Regional Anaesthesia and Pain Medicine, European Society of Musculoskeletal Radiology, Society of Interventional Radiology and Society of Skeletal Radiology. Primary specialties represented include anaesthesia, emergency medicine, family medicine, physical medicine and rehabilitation, orthopaedic surgery and radiology.
Preliminary work
A list of general topics to be included was discussed among the group and organised as presented in box 1. Each section was then assigned to a small working group who was responsible for identifying key references and creating the initial list of terms to be defined. This was circulated among the group until agreement was reached on final terms to be included. Each small group was then responsible for drafting the working definitions. The list of terms, definitions and key references for each section was then made available to the group for review prior to the initiation of the Delphi procedure.
Musculoskeletal and sports ultrasound terms and definitions outline
General.
Equipment and tansducer manipulation.
Anatomical and descriptive.
Pathology.
Procedural.
Image labelling.
Documentation.
Delphi procedure
A Delphi method was used to reduce ‘group think’ bias by allowing anonymous voting and comments. The group leader (MMH) was responsible for developing and distributing all surveys and moderating discussion among the group. Qualtrics XM (Qualtrics, LLC, Provo, Utah, USA), an online survey and data collection tool, was used to create and conduct all surveys. We set a minimum requirement of >80% group participation for each round of surveys to be considered valid. Consensus was defined as group level agreement >80%. Questions not resulting in consensus were revised based on group feedback and incorporated into subsequent surveys until consensus was reached. Each section was addressed separately and carried through completion prior to beginning the next section.
Discussion
General
The term musculoskeletal ultrasound has been used extensively, but we were unable to identify a previously published formal definition. The term sports ultrasound has been more recently introduced by the AMSSM.1 2 Although this term has begun to appear more frequently in the literature, a formal definition has yet to be assigned. Table 1 presents our recommended definitions for each term.
General definitions
Equipment and transducer manipulation
When instructing or discussing ultrasound technique, consistency in terminology used to describe transducer movement and manipulation is critical to avoid confusion and to facilitate effective communication. Although prior authors have made recommendations, these have not been universally accepted.3 4 Furthermore, we identified ongoing confusion regarding cardinal movements as well as additional terms relevant to musculoskeletal and sports medicine practice as listed in table 2. Of note, we concluded that using a single term, ‘slide’, to describe moving the transducer from point A to point B was most clear. Further directional or anatomical descriptors may need to be added to provide clarity. These terms are discussed as follows and demonstrated in figure 1.
Equipment and transducer manipulation
(A) Slide, (B) heel–toe, (C) tilt, (D) compression, (E) rotation, (F) pivot, (G) stand-off and (H) oblique stand-off.
Anatomical and descriptive terminology
Table 3 lists recommended anatomical and descriptive terms. There was agreement with the imaging plane definitions presented in the AIUM Recommended Ultrasound Terminology document.5 When discussing body planes in relation to the anatomical region of interest, the group was unable to arrive at a consensus for a single term to describe parallel longitudinal planes. Either coronal/sagittal or longitudinal were proposed as appropriate terms. Similarly, when discussing axes of the target structure, we could not reach consensus on a single best term. Short axis and transverse can be used interchangeably as can long axis and longitudinal.
Anatomical and descriptive terms*
Pathology
Pathology terms have been divided into groups based on anatomical tissue type with consensus recommendations presented in table 4. Representative images demonstrating key terms can be found in figures 2–7. These terms are not meant to be prescriptive but rather represent the current best terms based on the literature and our expert opinion. We recognise that our understanding of pathophysiological processes is in constant evolution, and certain terms may require modifications based on future research. We focused on the accepted ultrasound appearance of common pathologies, recognising that pathognomonic ultrasound findings do not currently exist for all histopathological conditions. Furthermore, certain clinical conditions may be difficult to differentiate based on imaging features alone. Similarly, although Doppler flow is often considered a key imaging finding for some pathological conditions (eg, synovitis, tendinitis, etc), we agreed that, due to variability in both equipment and technique, the presence or absence of Doppler flow should not be an absolute requirement. Rather, we highlight when Doppler flow may be expected and further supports a specific diagnosis.
Pathology
(A) Tendinosis: long-axis image of midportion Achilles tendinosis. Note fusiform thickening (arrowheads) without fibre disruption. (B) Calcific tendinopathy: long-axis image of calcific tendinosis of the ACH insertion. The well-defined hyperechoic focus (arrow) demonstrates intermediate posterior acoustic shadowing. (C) Tenosynovitis: short-axis image of the AT demonstrating distension of the tendon sheath (asterisks) with increased Doppler flow. (D) Stenosing tenosynovitis: long-axis view of the first dorsal compartment of the wrist. The retinaculum (double arrow) is hypoechoic and significantly thickened with hyperaemia on Doppler. (E) Paratenonitis: short axis image of the ACH. There is focal hypoechoic thickening of the lateral aspect of the paratenon (open arrows) with hyperaemia on Doppler. (F) Tendon tear: long-axis extended field of view image of acute PT complete tear. There is loss of tension with a hypoechoic region of tendon fibre disruption (arrowhead). Edge shadowing artefact (arrows) is noted deep to the proximal tendon stump. ACH, Achilles tendon; APL, abductor pollicis longus tendon; AT, anterior tibialis tendon; CALC, calcaneus; PAT, patella; PT, patellar tendon; TIB, tibia.
(A) Muscle tear: (1) long-axis image of the RF demonstrating an acute disruption of the central aponeurosis and surrounding muscle (callipers); there is anechoic haemorrhagic fluid (asterisks) at the site of tear; (2) corresponding short-axis image. (B) Muscle contusion: long-axis extended field of view image of an acute quadriceps contusion. Muscle fibre disruption of the VI is noted with a large anechoic haematoma (asterisks) resulting in mass effect. (C) Myositis ossificans: long-axis image of the quadriceps. This follow-up image of the muscle contusion (B) demonstrates resolution of haematoma with formation of hyperechoic regions of myositis ossificans (arrows). (D) Muscle fatty infiltration: short-axis extended field of view image of the rotator cuff musculature in setting of chronic complete rotator cuff tear. The SS and IS are diffusely hyperechoic with loss of internal muscle fibre definition. FEM, femur; IS, infraspinatus; RF, rectus femoris; SS, supraspinatus; TM, teres minor; TRAP, trapezius; VI, vastus intermedius.
(A) Ligament tear: long-axis image of an acute UCL tear. A hyperechoic region of fibre disruption and haematoma (asterisks) is noted proximal. The distal attachment is intact but thickened (open arrows) and a hyperechoic linear density (solid arrow) overlying the joint space represents chronic calcific changes. Also note an associated muscle injury of the flexor/pronator group (arrowheads). (B) Ligament tear: long-axis image of acute anterior talofibular ligament (arrows) tear. Loss of tension results in an atypical contour of the ligament (open arrow). This can be further confirmed with dynamic stress imaging. FIB, fibula; HUM, humerus; UCL, ulnar collateral ligament; ULN, ulna; TAL, talus.
(A) Joint effusion: long-axis image of the suprapatellar recess with anechoic fluid distension (asterisk) representing a simple joint effusion. (B) Synovial proliferation: long-axis image of the anterior ankle with hypoechoic synovial tissue hypertrophy (arrows) without Doppler flow. (C) Synovitis: long-axis image of the dorsal wrist demonstrating hypoechoic synovial tissue with increased Doppler flow in the setting of rheumatoid arthritis. CAP, capitate; RAD, radius; PAT, patella; QT, quadriceps tendon; TAL, talus; TIB, tibia.
(A) Compression neuropathy: long-axis image of the median nerve (arrows) at the carpal tunnel. Significant swelling is noted proximal to the compression site (open arrow). (B) Nerve transection: long-axis image of complete ulnar nerve transection. Note discontinuity of nerve with retraction (callipers) and thickening at the ends representing stump neuromas (asterisks). (C) Neuroma: long-axis image of a partial transection of the lateral antebrachial cutaneous nerve (arrows). Focal hypoechoic enlargement (arrowhead) represents a neuroma at the site of injury. MN, median nerve; UN, ulnar nerve.
Fasciosis: long-axis image of the plantar fascia. Thickening of the origin is noted (double arrow) with focal hypoechoic regions (asterisks) representing degenerative changes. CALC, calcaneus; PF, plantar fascia.
Procedural
Like the pathology section, the procedural terms and definitions presented in table 5 attempt to reconcile the historic use of multiple similar terms in the absence of precise definitions. This has resulted in difficulties interpreting clinical outcomes and conveying procedural techniques both to colleagues and third-party payers. Our goal is for these core terms to be used with appropriate technical descriptors bringing more consistency to procedural reporting.
Procedural
Image labeling
There was consensus agreement that all ultrasound images should include labels identifying the target structure or region and laterality as appropriate. Other considerations which did not reach consensus but had majority agreement include (1) orientation of the image relative to the target structure or region (long axis, short axis, etc); (2) directional orientation (medial, lateral, proximal, distal, etc); (3) directional descriptors for cine loops (proximal to distal, medial to lateral, etc).
Documentation
The templates in boxes 2 and 3 include the key components which should be considered when documenting a diagnostic ultrasound or ultrasound-guided procedure. Notably, they are not meant to replace local institutional guidelines or policies regarding documentation of ultrasound-related services. These recommendations pertain to all billable ultrasound services performed in any setting. If studies are performed as a non-billable service (eg, in the athletic training room), then individual institutional guidelines and standards should be developed regarding documentation and image archiving. If any information populates the electronic medical record or images automatically, it does not need to be included separately in the report.
Template for documenting a diagnostic US examination*
Patient’s name and other identifying information.
Date and time of examination.
Ordering provider.
Location and contact information of facility in which the diagnostic US was performed.
Clinical history/indication.
Description of diagnostic US study performed.
Anatomical location.
Complete or limited exam.
Findings.
Impression/conclusion/summary.
*When reporting a diagnostic US, all structures evaluated should be specifically mentioned either in the ‘findings’ section or elsewhere in the report, even if within normal limits.
US, ultrasound.
Template for documenting a US-guided interventional procedure
Patient’s name and other identifying information.
Date and time of intervention.
Ordering provider.
Location and contact information of facility in which the US-guided procedure was performed.
Clinical history/indication.
Technical.
Device.
Medications or other administered substances, including lot number, if applicable.
Procedure performed (eg, knee joint aspiration, carpal tunnel release, etc).
Injection/aspiration/procedure details.
Informed consent and time-out statements.
Description of preinjection images.
Target images.
At-risk structures.
Description of procedure.
Conditions under which procedure was performed (sterile, aseptic, etc).
Type of anaesthesia.
Description of approach—in-plane/out-of-plane, long axis or short axis to the target, medial or lateral to the target.
Description of the procedure performed including names and amounts of medications or other substances used if applicable. Describe any devices used.
Specimen description, type and amount removed if applicable.
Blood loss (if applicable).
Complications.
How the procedure was tolerated
Disposition and follow-up plans.
Conclusion
The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine. This concise reference should improve clarity and consistency of communication and reporting.
Ethics statements
Patient consent for publication
Ethics approval
This study does not involve human participants.
Acknowledgments
We would like to thank Andrea Ceranic for her contributions to the artwork presented in Figure 1.
The following societies have endorsed this statement: American Institute of Ultrasound in Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Society of Regional Anesthesia and Pain Medicine, European Society of Musculoskeletal Radiology, Society of Interventional Radiology and Society of Skeletal Radiology. The American Academy of Physical Medicine and Rehabilitation has affirmed the value of the statement.
References
Footnotes
Twitter @jjacobsn
Presented at © 2022 BMJ Publishing Group Limited. All rights reserved. This article is being published concurrently in Journal of Ultrasound in Medicine and British Journal of Sports Medicine. The article is identical except for minor stylistic and spelling differences in keeping with each journal’s style. Citations from either of the two journals can be used when citing this article.
Correction notice This article has been corrected since it published Online First. The endorsed statement has been updated.
Contributors All authors were involved in the conception of the work, acquisition and interpretation of data, drafting and revising of the work, and final approval of the submitted version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MMH reports personal fees from Tenex Health and Sonex Health and other support from UpToDate, Inc, all outside the submitted work. GMA reports personnel fees from GE outside of the submitted work. PBD reports personal fees from Siemens Ultrasound, outside of the submitted work. JTF reports other support from DEMOS Publishing and Up to Date, and personal fees from COVR Medical, Sanofi and Aim Specialty Health, all outside the submitted work. DH reports personal fees from Sonex Health, outside of the submitted work. LN reports personal fees from Canon Medical Systems and Tenex Health, and other support from Samumed and SonoSim, all outside of the submitted work. JS reports other support from Sonex Health and Tenex Health, all outside the submitted work. LMS reports personal fees from Abiogen, Fidia Pharma Group, Pfizer, Novartis, Janssen Cilag, Esaote and Samsung Medison, and other support from Bracco Imaging Italia, all outside of the submitted work. All remaining authors have no competing interests to disclose.
Provenance and peer review Not commissioned; externally peer reviewed.