Radiologists who continue to neglect musculoskeletal ultrasound risk missing out on a growing and rewarding opportunity.

Levon N. Nazarian, MD, professor of radiology and vice chairman for education, Thomas Jefferson University Hospital

The image of the solitary radiologist—hunkered down in the dark deciphering films—is a pervasive stereotype. On the other end of the spectrum, radiologists who embrace musculoskeletal ultrasound are more likely to be interacting with patients.

For Levon N. Nazarian, MD, getting out of the viewing room is one of the numerous benefits of ultrasound, a modality that many radiologists are still largely ignoring. “Musculoskeletal ultrasound is a hands-on, patient-oriented procedure, and many people who chose to go into radiology may not be as comfortable in the patient care arena,” said Nazarian, professor of radiology and vice chairman for education at Thomas Jefferson University Hospital, Philadelphia. “Some radiologists would rather read high volumes of images, but not have to deal with patient care issues.”

High volume is usually associated with MRI studies, which are undeniably more lucrative. Nazarian acknowledges that the financial incentive to learn musculoskeletal ultrasound is weak, and many find it too time-consuming and prohibitively difficult. According to Medicare data, the average MRI scan reimburses about three to four times more than for ultrasound. Most radiologists can read about three MRIs in less time than it takes to do one ultrasound. Not surprisingly, says Nazarian, the rate of ultrasound growth among radiologists is much less than that of other specialties.

So why care about ultrasound? One reason is that MRI and CT are receiving ever more attention from cash-strapped payors. “I believe ultrasound reimbursement, and this type of interventional reimbursement, will stay the same, whereas other reimbursements are going to decrease—especially MRI and CT,” said George Flinn, MD, president and CEO of the Flinn Clinic, Memphis, Tenn. “Medicare and Medicaid have targeted these things, because they see the astronomical charges on these exams. They are looking for every way to cut medicine.”

New findings from a March 2009 study by the National Council on Radiation Protection and Measurement concluded that “doctors are ordering too many diagnostic tests, driving up the cost of health care in the United States, and potentially harming patients.” Widely reported by Reuters and elsewhere, the report goes on to accuse doctors of overusing tests for profit, and raising health risks for patients.

Particularly among nonradiologists, Flinn agrees that there is a tendency to overutilize. “If nonradiologists have their own MR machine in the office, they order at a much greater rate than what a radiologist would utilize,” Flinn said. “As radiologists, we need to embrace cost containment, not fight it. We need to do procedures and treatments that are efficient for the patient, because the whole system will go down if we don’t.”

For MRI-intensive radiologists who wish to incorporate more ultrasound into the practice, the two can coexist without problems. “I think it’s a misconception that ultrasound necessarily hurts your MR business,” said Ronald S. Adler, MD, PhD, a radiologist at the Hospital for Special Surgery, New York. “Even though we have experienced steady growth in the amount of ultrasound that we do—anywhere from 10% to 20% per year—it has not hurt our MR business at all. In fact, it has grown enormously. When I came, we had three MR scanners, and now we have eight scanners—we are doing well over 100 MR cases per day.”

Ultrasound is profitable at present, but Flinn is confident it will become more profitable in the future. If radiologists don’t seize the opportunity, sports medicine physicians, physiatrists, rheumatologists, orthopedic surgeons, and podiatrists will gladly seize it for them. Nazarian added, “There is so much potential in musculoskeletal ultrasound, not just for diagnosis, but many of us in the field foresee ultrasound as being a tool to guide minimally invasive surgery in the future.”

As another tool in the surgical evolution from open, to arthroscopic, to minimally invasive, Nazarian envisions a range of procedures that could be done under ultrasound guidance. “This is a huge potential market,” Nazarian said. “I am already seeing such patients in my clinic, and it is only going to grow. I do think radiologists will miss out by not jumping on the bandwagon of ultrasound-guided procedures.”

George Flinn, MD, president and CEO of the Flinn Clinic

Nazarian points out that certain anatomical features are particularly well suited to ultrasound-aided procedures and diagnoses, so clinicians do not have to worry about sacrificing quality. “It is clear from the literature now that MRI and ultrasound are equivalent for rotator cuff evaluation,” Nazarian said. “If payors eventually say we will no longer pay for MRI to rule out a rotator cuff tear, you better believe that is going to be a financial incentive for radiologists to learn ultrasound of the rotator cuff. There are other things for which ultrasound is equivalent to, if not better than, MRI, including Achilles tendon problems, Baker’s cysts, and Morton’s neuromas, to name a few.”

For patients with abdominal pain, Flinn says he often scans and finds muscle tears and/or areas of hematoma in the rectus muscle. From there, it is merely a matter of using ultrasound to guide the needle. “I’ll wind up injecting them with a combination of lidocaine and cortisone, or steroids, and it solves the problem,” Flinn said. “You get immediate relief of the pain if it is a muscle tear, and you get immediate feedback that you have done the right thing.”

Diagnoses of calf muscle tears are also possible, as is ruling out the potentially deadly condition of deep vein thrombosis. “Sometimes there is a large enough hematoma that is fluid filled, and we drain it right on the spot—and patients get instant relief,” Flinn said. “You get to see instant results, and you feel like you’ve done some good that day. The insurers are beginning to see that ultrasound is much more cost-efficient and patient-friendly. The ultrasound is sort of a one-stop shop. You get your exam, you find out what’s wrong, and you get treated.”

Ronald S. Adler, MD, PhD, Hospital for Special Surgery

This brand of interventional ultrasound stands in stark contrast to the faraway teleradiology readings used in so many hospitals these days. Nazarian believes a cultural shift toward more patient interaction is a good way to combat this outsourcing, and ultimately boost the value of radiology services for years to come.

“We must be wary of the commoditization of radiology,” Nazarian warned. “If you do an MRI of the knee, somebody in Australia can read that MRI in the information age. Radiologists must add value if they are going to thrive. One way to add value is patient interaction, and ultrasound is a perfect venue for this. You can’t outsource a hands-on ultrasound examination. You can’t outsource an ultrasound-guided injection, and you can’t outsource the ability to sit down with patients after the ultrasound and explain the findings.”

Spreading this message must ultimately fall on the medical schools and residency programs, but ultrasound training is by most accounts lacking in many places. “Radiology and musculoskeletal training programs as a whole have not been good at recognizing that the interventional part of radiology is a large part of what we do,” Adler said. “When I speak with Dr Nazarian, he has a similar level of frustration. He has been trying to get the major organizations to be more supportive of ultrasound training, but so far they have not shown the interest he had hoped for.”

For his part, Nazarian is realistic when it comes to the dominance of MRI, and he is careful not to force medical students to embrace ultrasound. “I’m not going to have my residents and fellows spend a lot of time and effort learning if I don’t think it will help them to be marketable in the future,” Nazarian said. “It’s not fair to them. Any resident can spend time with me by taking an elective, but I’m not going to shove musculoskeletal ultrasound down their throats if they don’t have an interest.”

Greg Thompson is a contributing writer for Axis Imaging News.

The Paradox

Musculoskeletal ultrasound is difficult to learn, although to some it seems pretty easy—such is the pesky paradox in the radiology community. Fortunately, wielding the probe with a measure of grace is well within the skill range of radiologists. “I sometimes think radiologists use the difficulty in learning as an excuse not to learn at all,” mused Levon N. Nazarian, MD, professor of radiology and vice chairman for education at Thomas Jefferson University Hospital, Philadelphia. “This is really no easier or harder than anything else we do. It is just that a lot of radiologists do not have the time and inclination to learn.”

Nazarian routinely trains sonographers, who have little prior knowledge of musculoskeletal anatomy, to be highly capable scanners in 3 to 6 months. If sonographers can do it, he reasons that musculoskeletal radiologists can also learn, and probably in less time.

Part of the challenge is that unlike an MRI scanner that spits out the image, radiologists must develop the image on their own, or with the help of a sonographer. “There is a lot of art, and there is skill,” Nazarian said. “The probe must be in the right place. The arm has to be in the right position, and you have to use the proper focal zone on your image. You actually may have to go in and produce the image yourself to make the diagnosis, and that is somewhat frightening to some radiologists.”

Conversely, ultrasound is also viewed as one of the easiest modalities by nonradiologists, because it is relatively simple to buy an inexpensive machine, put gel on the patient, and quickly have an image. “It is deceptively easy,” Nazarian said. “Many people who come to my courses are not cognizant of really how difficult ultrasound is. Those of us who do it make it look easy. The truth is in the middle. It’s not as hard as radiologists make it out to be, but it is not as easy as some nonradiologists think.”


By the Numbers

The American Institute of Ultrasound in Medicine (AIUM) boasts more than 7,000 members. A breakdown of membership interests (posted at reveals the following results.

54% Obstetric Ultrasound
29% General/Abdominal Ultrasound
18% Gynecologic Ultrasound
17% Sonography
15% Cardiovascular Ultrasound
12% Pediatric Ultrasound
11% Interventional/Intraoperative Ultrasound
11% Emergency Ultrasound
10% Musculoskeletal Ultrasound
13% Fetal Echocardiography
  8% Neurosonology
11% Basic Science and Instrumentation
  4% High Frequency Clinical and Preclinical Imaging