TRAIN CERTIFY MAINTAIN
Family Medicine Musculoskeletal (FM MSK)
CURRICULUM
Advanced skills for certification
a. Probe
b. Knobology
i. Preset. MSK or small parts.
ii. Depth. Start at depth of 5 cm. Adjust as needed.
iii. Gain. Default. Adjust as needed.
c. Patient positioning.
d. Probe orientation
e. Probe grip
Pencil grip.
a. External landmark
b. Internal landmark
c. Relevant anatomy
d. Area of interest
BCT in 2 planes (transverse and sagittal).
e. Adequate view
Imaging of a round biceps tendon with its characteristic fibrillar structure and a well-defined (bright white, thin) humeral head cortex in short axis and long, linear, fibrillar and well-defined BCT in long axis.
a. Image generation
- i. Landmark
- BCT SAX:
- Start scan in transverse plane at anterior aspect of well-defined humeral head.
- End scan at myotendinous junction with biceps muscle.
- BCT LAX:
- Start scan in transverse plane at anterior aspect of well-defined humeral head.
- Rotate probe 90 degrees with probe marker towards patient’s head to scan in long axis (sagittal).
- End scan at myotendinous junction.
ii. Optimize image
- Adjust depth to centre image.
- Increase probe frequency to increase image resolution.
iii. Technique
- BCT SAX:
- Start scan in transverse plane at anterior aspect of humeral head.
- Slide cephalad to caudad and side to side to centre humeral cortex.
- Sweep probe to make humeral cortex appear well-defined (thin and bright white).
- Find internal landmark (bicipital groove) by sliding cephalad to caudad until U-shaped and side to side until centred.
- Rotate probe slightly aiming for patient’s neck might be needed. This is your HOME BASE.
- From this HOME BASE, slide cephalad and follow well-defined centred AOI until the rotator interval.
- Interrogate area to see subscapularis inserted over lesser tuberosity (medial) and supraspinatus over greater tuberosity (lateral) with BCT in the middle.
- Slide back caudally to your HOME BASE.
- Slide caudally and keep bicipital groove centred and well-defined on screen at all times.
- Follow centred BCT caudally until myotendinous junction is seen.
- Interrogate AOI at its myotendinous junction.
- BCT LAX:
- Go back to HOME BASE and rotate probe 90 degrees to sagittal plane (LAX).
- Slide probe side to side and sweep to keep BCT centred and rock probe to minimize anisotropy as you follow it caudally until myotendinous junction has been reached.
iv. Interrogate AOI
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. BCT fluid? (YES/NO).
ii. BCT rupture? (YES/NO).
a. A slight rotation aiming probe towards patient’s neck might be needed in most patients to centre bicipital groove on screen and appreciate its U-shaped appearance.
b. BCT SAX: sweep cephalad to caudad to prevent anisotropy. The distal BCT course commonly creates anisotropy and an artifactual hypoechoic appearance of the normal tendon.
c. BCT LAX: rock probe to bring biceps tendon perpendicular to the transducer beam to minimize anisotropy.
a. Technique
i. Failure to optimize image for anisotropy can create false pathology.
b. Image interpretation
i. Hypoechoic appearance of tendon secondary to anisotropy may be wrongly labeled as BCT rupture. Remember to sweep cephalad to caudad (SAX) or rock (LAX).
ii. Hypoechoic appearance of tendon secondary to anisotropy might also be wrongly labeled as fluid within the tendon.
c. Clinical integration
i. Fluid AROUND BCT mostly indicates presence of rotator cuff pathology and not specifically a BCT tear or tenosynovitis. Scrutiny of SSP is warranted to refine diagnosis.
ii. Fluid AROUND BCT can also be related to GHJ effusion.
iii. Isolated tenosynovitis of the BCT is rare. Clinical correlation is paramount in making the right diagnosis:
- Suspicious clinical presentation with localized fluid and localized pain favors tenosynovitis of BCT.
- Non-infectious causes with diffuse pain favor rotator cuff pathology or GHJ effusion.
iv. Up to 2 mm of fluid can be found around a normal BCT.
v. Any amount of fluid that surrounds the BCT completely is considered pathological (‘Swimming’ BCT).
vi. BCT tears can be a surgical entity and a timely orthopedic consult and having patient’s arm rested in a Stevenson sling are recommended until surgical consult.
a. If unable to find BCT in long axis find characteristic pyramid shape of lesser tuberosity and move transducer laterally from this point.
b. If unable to find BCT in long axis, return to HOME BASE in transverse. Optimize that view (U-shaped groove and centred with well-defined humeral bony cortex) and slowly rotate 90 degrees by using one hand to stabilize probe on patient and one hand to rotate.
c. NERD ALERT!!!! Rotator interval is a great place to inject corticosteroids to patients with chronic painful rotator cuff tendonitis! Real-time US-guidance procedure is recommended.
a. For a negative BCP SAX scan:
i. Must image a well-defined centred BCT from rotator interval to myotendinous junction.
ii. No tears or fluid found.
b. For a positive BCP SAX scan:
i. Must image a well-defined centred BCT from rotator interval to myotendinous junction.
ii. Presence of a tear or fluid is noted.
c. For a negative BCP LAX scan:
i. Must image a well-defined centred BCT from bicipital groove (HOME BASE) to myotendinous junction.
ii. No tears or fluid found.
d. For a positive BCP LAX scan:
i. Must image a well-defined centred BCT from bicipital groove (HOME BASE) to myotendinous junction.
ii. Presence of a tear or fluid is noted.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. BCT fluid + or –
b. BCT rupture + or –
c. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored BCT scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 10 shoulder BCT determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS BCT written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).
a. Probe
Linear probe or high frequency probe of choice (range of 12-15 MHz is ideal).
b. Knobology
i. Preset. MSK or small parts.
ii. Depth. Start at depth of 5 cm. Adjust as needed.
iii. Gain. Mid-range. Adjust as needed.
c. Patient positioning.
- Ideal – dorsal aspect of hand against back of patient.
- Acceptable – dorsal aspect of hand against contralateral hip or back pocket of patient.
ii. Modified Crass position.
iii. “Very modified” Crass position.
d. Probe orientation
e. Probe grip
Pencil grip.
a. External landmark
b. Internal landmark
c. Relevant anatomy
Acromion, greater tuberosity of humeral head, SSPT tendon, sub deltoid bursa, and deltoid muscle.
d. Area of interest
SSPT from its insertion point on the greater tuberosity to its myotendinous junction (LAX).
e. Adequate view
a. Image generation
i. Landmark
- Start scan at the insertion point of the SSPT on the greater tuberosity of the humeral head (Bird’s beak view).
- End scan at myotendinous junction (acromion rounded cortex seen medially and near field).
ii. Optimize image
- Adjust depth to centre image.
- Adjust gain as needed.
- Increase probe frequency to increase image resolution.
iii. Technique
- POSITION PATIENT PROPERLY!
- Place probe on rounded contour of humerus anteriorly with marker towards patient’s ear in LAX.
- Find greater tuberosity cortex by sliding side to side and cephalad to caudad.
- Sweep to make the greater tuberosity cortex appear well-defined (thin and bright white).
- Find SSPT at its insertion point on greater tuberosity.
- Gently rock probe to minimize anisotropy at insertion point.
- Slide side to side at SSPT insertion point to interrogate it anteriorly and posteriorly, scrutinizing the area for pathology.
- Anterior enough is when the intra-articular portion of the biceps tendon (BCT LAX) is visualized.
- Slide probe cephalad to image entire length of SSPT in LAX making sure to minimize anisotropy by rocking probe as needed and keeping SSPT centred at all times.
- Stop sliding cephalad when SSPT reaches its myotendinous junction. Acromion should be seen near field medially.
- End scan when myotendinous junction is interrogated completely.
iv. Interrogate AOI
- Interrogate AOI in 2 main areas of rupture:
- Insertion point on greater tuberosity: Sweep and slide over SSPT insertion on the greater tuberosity (imaging it from anterior to posterior) as it can be as wide as 2-2.5 cm in normal adults and most tears occur anteriorly at its insertion point.
- Myotendinous junction: Sweep and slide over area to image it completely.
- Note any other suspicious pathological findings like fluid in subdeltoid bursa.
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. SSPT tear? (YES/NO).
ii. Subdeltoid bursa fluid? (YES/NO).
iii. Tendinosis? (YES/NO) (not needed for certain courses
a. Use dynamic testing and ask patient to move supraspinatus during scan by ABDUCTING their shoulder to help localize proper tendon.
b. ANISOTROPY:
i. When evaluating an area of hypoechogenicity, use maneuvers to minimize anisotropy.
ii. Rock probe to redirect ultrasound beam perpendicular to tendon fibers.
iii. SSPT appears darker as it curves to insert on greater tuberosity: rock probe to minimize anisotropy at this level
a. Technique
i. To avoid missing a SSPT anterior tear, make sure to sweep until intra-articular portion of biceps tendon is identified as most tears occur in this area.
ii. Remember to position your patients properly in one of the Crass positions. When imaged with patient in a neutral position, proximal SSPT is hidden beneath acromion.
iii. Remember that “You’ll be cross if you don’t use Crass!”
b. Image interpretation
i. ANISOTROPY: anisotropy can wrongly be labeled as tendinosis or tendon tear. Rock the probe to minimize anisotropy!
ii. It can be arduous to distinguish between SSPT partial thickness tears and chronic tendinosis. The main differences between tears and tendinosis are:
- SSPT tears:
- Anechoic image disrupting the nice linear, fibrillar tendon fibers.
- Well circumscribed and defined.
- Homogenous.
- Thin tendon.
- Some degree of tendon retraction can be seen.
- Tendon volume loss.
- Loss of normal convex superior surface of tendon sometimes with deltoid muscle protrusion.
- Bone irregularity.
- Tendinosis:
- Hypoechoic aspect scattered among the tendon fibers.
- lll-defined.
- Heterogeneous.
- Increased thickness of tendon.
- Smoother bony cortex.
- Normal aspect of convex superior surface of SSPT.
iii. NERD ALERT!! Calcifications. Calcific tendinosis is a commonly found entity. Calcium deposits are echogenic in near field with shadowing in the far field. Thin areas of calcifications (without shadowing) can be difficult to distinguish from normal tendon fibers: heel the probe. The normal tendon fibers will become darker but the calcifications will remain echogenic. You can start training your eye for chronic tendinopathy findings and calcifications as these might be the first ‘pathological’ findings you will see in real-life patients!
c. Clinical integration
i. SSPT scan can be used in patients with acute or subacute shoulder pain as acute tears are less frequent and overuse tendonitis is frequent.
ii. Most rotator cuff tears involve SSPT even if fluid found elsewhere. SSPT LAX view is the most important because it allows for visualization of the 3 surface areas of the SSPT at its insertion point: articular, bursal and greater tuberosity.
iii. Failure to image all 3 areas will result in missing SSPT tears that can be clinically relevant. Remember that:
- 90% of rotator cuff tears occur in very close proximity to their insertion point.
- They usually result from chronic wear.
- Acute injury to SSPT is less frequent.
- Purely acute tears occur more proximally along tendon course and at its myotendinous junction.
iv. Failure to image SSPT AND sub deltoid bursa will miss clinically relevant pathology:
- Fluid collection in the subdeltoid bursa is pathological if greater than 2 mm.
- Differential for fluid in subdeltoid bursa: rotator cuff tear, infection, and bursitis.
v. Even in expert hands, shoulder ultrasound is not a perfect test. It is also less accurate for partial tears and tendinosis. If clinical suspicion remains high for SSPT pathology, refer patient for further diagnostic imaging. MRIs exist for that very reason.
a. Keep probe steady and anchored on patient as it may slide on the curved surface of the shoulder.
b. If needed, use other hand to keep probe from sliding off the patient.
c. If lost because of pathology or swelling, start analyzing image from bone (far field) to near field. Bone will always look like bone! What you will see is: bone, posterior tendon sheath, tendon, superior tendon sheath, subdeltoid bursa, deltoid muscle, subcutaneous layers.
a. For a negative scan:
i. Must image SSPT in long axis from insertion point on humeral head to myotendinous junction:
ii. Insertion point must be imaged from its anterior aspect (BCT LAX visualized) to its posterior aspect.
iii. Subdeltoid bursa must be scrutinized.
b. For a positive scan:
i. Must image SSPT in long axis from insertion point on humeral head to myotendinous junction:
ii. Insertion point must be imaged from its anterior aspect (BCT LAX visualized) to its posterior aspect.
iii. Subdeltoid bursa must be scrutinized.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. SSPT tear + or –
b. Subdeltoid bursa fluid collection + or –
c. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored SSPT scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 10 shoulder SSPT determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS SSPT written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).
a. Probe
Linear probe or high frequency probe of choice (10 MHz or more).
b. Knobology
i. Preset. MSK or small parts.
ii. Depth. Start at depth of 5 cm. Adjust as needed.
iii. Gain. Mid-range. Adjust as needed.
c. Patient positioning.
d. Probe orientation
e. Probe grip
Pencil grip.
a. External landmark
b. Internal landmark
c. Relevant anatomy
i. Quadriceps tendon (QUT): near field, fibrillar pattern, hyperechoic, under the subcutaneous fat. 3 distinct portions (trilaminar appearance):
- Rectus femoris (superficial).
- Vastus internalis and externalis.
- Vastus intermedius (deep).
ii. Myotendinous junction.
iii. Superior pole of patella.
iv. Suprapatellar fat pad: proximal to superior pole of patella, under quadriceps tendon.
d. Area of interest
e. Adequate view
a. Image generation
i. Landmark
- Scan starts in LAX anteriorly and midline on the distal femur, caudal extremity of the probe in contact with patella.
- Scan ends at the myotendinous junction of QUT and repeat scan in SAX.
ii. Optimize image
- Adjust depth to centre image.
- Adjust gain as needed.
- Increase probe frequency to increase image resolution.
iii. Technique
- Start scan by putting probe in LAX on anterior aspect of distal femur on the midline.
- Slide probe distally until caudad end of probe sits on the patella.
- Centre probe on midline by sliding probe side to side.
- Sweep probe to obtain a well-defined QUT (fibrillar, regular tendon fibers).
- Rock probe to minimize anisotropy of tendon fibers.
- Slide probe medial to lateral to assess the entire QUT at its insertion on patella.
- Slide probe cephalad and follow the well-defined centred QUT until myotendinous junction is reached.
- Sweep and slide the myotendinous junction scrutinizing area for tears.
- Turn probe In SAX and repeat process by sliding distally until QUT insertion on patella is reached.
iv. Interrogate AOI
- The area of interest is the quadricipital tendon.
- Scan in the sagittal plane (LAX) looking for a partial or a full thickness tear.
- Scan in transverse plane (SAX) to ensure a complete exam.
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. Evidence of partial or full thickness tear in the QUT? (YES/NO).
a. Make sure to see the superior pole of the patella well-defined (thin and bright white).
b. Make sure to optimize view to see the hyperechoic, fibrillar pattern characteristics of tendon anatomy.
c. Interrogate the AOI in both the sagittal and transverse planes.
d. Modify gain and depth if needed.
a. Technique
i. Not minimizing anisotropy can lead to false positives. Remember how to minimize anisotropy:
- Have patient bend their knee (30 degrees) to tense the extensor mechanism thus decreasing anisotropy (in full knee extension, natural anterior concavity in the area where quadriceps tendon inserts on patella can cause anisotropy).
- Rocking probe decreases anisotropy in LAX.
- Sweeping probe decreases anisotropy in SAX.
ii. Incomplete visualization of the quadriceps tendon may lead to false negatives. Make sure to scrutinize tendon carefully where most tears occur:
- Close to its insertion point on patella.
- At its myotendinous junction.
b. Image interpretation
i. ANISOTROPY: Anisotropy can be mistaken for tear or tendinosis if not careful to minimize its impact on screen.
ii. It can be difficult to differentiate between partial and complete tears. QUT tears can affect one or more of the 3 main layers. Differentiating between the different layers is useful for prognostication of severity of injury.
- Partial tears:
- Well-defined hypoechoic or anechoic clefts.
- Incomplete disruption of tendon fibers.
- Tendon sheath anteriorly or posteriorly can remain intact.
- Complete or full-thickness tears:
- Complete disruption of tendon architecture.
- Retraction of torn ends (shadowing artifact possible).
- Fluid flowing from the suprapatellar recess into the defect.
- Wavy appearance (instead of fibrillar) of the patellar tendon (patella distally displaced).
- Partial patellar avulsion.
iii. Patients are often unable to bear weight. If unsure if tear partial or full-thickness, using gentle dynamic testing can help with visualization and assessment of injury. If doubt remains, prompt referral and other diagnostic modalities are recommended.
c. Clinical integration
i. QUT tears are not that frequent but POCUS is an easy way to make diagnosis at bedside when patients complain of suprapatellar pain or knee pain with swelling.
ii. If clinical suspicion remains high and no pathology is seen on POCUS further diagnostic testing is warranted and recommended.
iii. Remember that areas of tears will depend on mechanism of injury and type of patient sustaining it (athlete vs sedentary individual): feeling a pop after landing from a jump, changing directions suddenly or forceful flexion of knee can present with QUT tears.
iv. If QUT injury found, immobilization of patient’s knee and prompt referral to orthopedics are recommended.
a. Although emphasis is put on assessing QUT in LAX (sagittal), a SAX (transverse) evaluation is also mandated for confirmation of findings and to avoid missing focal abnormalities.
a. For a negative scan:
i. Must image well-defined centred QUT from superior pole of patella to myotendinous junction in LAX and SAX.
ii. Must interrogate QUT by sliding medial to lateral at insertion point and myotendinous junction in both planes.
iii. No tear identified.
b. For a positive scan:
i. Must image well-defined centred QUT from superior pole of patella to myotendinous junction in LAX and SAX.
ii. Must interrogate QUT by sliding medial to lateral at insertion point and myotendinous junction in both planes.
iii. Tear identified.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. QUT tear + or –
b. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored QUT scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 5 knee QUT determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS QUT written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).
a. Probe
Linear probe or high frequency probe of choice (10 MHz or more).
b. Knobology
i. Preset. MSK or small parts.
ii. Depth. Start at depth of 5 cm. Adjust as needed.
iii. Gain. Mid-range. Adjust as needed.
c. Patient positioning.
d. Probe orientation
e. Probe grip
Pencil grip.
a. External landmark
b. Internal landmark
Inferior pole of the patella, anterior tibia and anterior tibial tuberosity (ATT).
c. Relevant anatomy
i. Patellar tendon (PAT): Uniform, fibrillar, hyperechoic.
ii. Inferior pole of patella.
iii. Anterior tibia and ATT.
iv. Infrapatellar (Hoffa) fat pad.
d. Area of interest
e. Adequate view
a. Image generation
i. Landmark
- Scan starts in LAX on the midline with cephalic probe extremity in contact with inferior pole of patella.
- Scan ends at the ATT.
ii. Optimize image
- Adjust depth to centre image.
- Adjust gain as needed.
- Increase probe frequency to increase image resolution.
iii. Technique
- Start scan in LAX with cephalic side of probe sitting on inferior pole of patella.
- Centre probe on midline by sliding side to side and finding the well-defined (thin, bright white) inferior patellar pole cortex.
- Sweep probe to obtain a well-defined (hyperechoic, fibrillar) tendon image.
- Rock probe to minimize anisotropy.
- Slide probe medial to lateral to scrutinize entire tendon insertion area.
- Slide distally keeping PAT well-defined until anterior tibial tuberosity reached.
- Rotate probe in SAX.
- Slide probe cephalad until insertion on patella reached.
- Slide medial to lateral to image entire tendon insertion area.
iv. Interrogate AOI
- The area of interest is the PAT.
- Scan in the sagittal plane (LAX) looking for a partial or a full thickness tear.
- Scan in transverse plane (SAX) to ensure a complete exam.
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. Evidence of partial or full thickness tear in the PAT? (YES/NO).
a. Inferior pole of the patella needs to be well-defined (thin and bright white) to start scan.
b. Care must be taken to image tendon with its well-defined characteristics: hyperechoic and fibrillar tendon fibers.
c. Interrogate the AOI in both the sagittal and transverse plane.
d. Modify gain and depth if needed.
a. Technique
i. Not minimizing anisotropy can lead to false positives. Remember how to minimize anisotropy:
- Have patient bend their knee (30 degrees) to tense the extensor mechanism thus decreasing anisotropy (in full knee extension, natural anterior concavity in the area where quadriceps tendon inserts on patella can cause anisotropy).
- Rocking probe decreases anisotropy in LAX.
- Sweeping probe decreases anisotropy in SAX.
b. Image interpretation
i. ANISOTROPY: Anisotropy can be mistaken for tear or tendinosis if not careful to minimize its impact on screen.
ii. Partial tears can be difficult to diagnose. Clinical judgment remains paramount in this situation.
iii. PAT is a common site for tendonitis. It can be difficult to differentiate partial tears from tendonitis. Characteristics suggesting a tear are:
- Hypoechoic or anechoic zone disrupting tendon.
- Retraction of torn ends in complete tears.
- Heterogenous aspect of hemorrhage.
- Jagged edges and refraction shadowing at the retracted torn tendon stumps.
- Neovascularity seen on color Doppler from chronic wear can be present in both entities.
- An effusion can be seen in superficial and deep infrapatellar bursae in case of a distal PAT tear.
iv. A small effusion seen in the deep infrapatellar bursa can be a non-pathological finding and deemed physiological.
v. When in doubt, remember that gentle dynamic testing of the PAT can help with diagnosis of tears with POCUS.
c. Clinical integration
i. If clinical suspicion remains high for a PAT tear and no pathology is seen on POCUS, further diagnostic testing is warranted and recommended.
ii. PAT tears are more frequent than QUT tears as the PAT is a common site for tendonitis. Patient will present with a history of sudden intense eccentric contraction of the quadriceps (after a person stumbles or after a powerful take-off maneuver). Patients can also report a recent history of corticosteroids injection.
iii. NERD ALERT! It is reported that up to 17% of volleyball players will present with symptoms of PAT tendonitis during their career!
a. Although emphasis is put on assessing PAT in LAX (sagittal), a SAX (transverse) evaluation is also mandated for confirmation of findings and to avoid missing focal abnormalities particularly in the proximal portion of PAT.
b. Use lots of gel to float the probe!
c. NERD ALERT! It is also possible to assess for patellar fracture, prepatellar bursitis and signs of Osgood-Schlatter disease.
a. For a negative scan:
i. Must image well-defined centred PAT from inferior pole of patella to anterior tibial tuberosity in LAX and SAX.
ii. No tear identified.
b. For a positive scan:
i. Must image well-defined centred PAT from inferior pole of patella to anterior tibial tuberosity in LAX and SAX.
ii. Tear identified.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. PAT tear + or –
b. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored PAT scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 5 knee PAT determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS PAT written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).
a. Probe
Linear probe or high frequency probe of choice (10 MHz or more).
b. Knobology
i. Preset. MSK small parts, or soft tissue.
ii. Depth. Start at depth of 5 cm. Adjust as needed.
iii. Gain. Default. Adjust as needed.
c. Patient positioning.
d. Probe orientation
e. Probe grip
Pencil grip.
a. External landmark
b. Internal landmark
c. Relevant anatomy
Calcaneus, Achilles tendon, retro-calcanea bursa, retro-Achilles bursa (seen only in pathologic states), Kager’s fat pad, planters tendon (if present), gastrocnemius muscles, soles muscle.
d. Area of interest
e. Adequate view
a. Image generation
i. Landmark
- Start the scan just at the calcaneus in the sagittal plane with probe marker towards patient’s head.
- End the scan when the tendon is no longer well-defined and becomes part of the muscle bellies underneath.
ii. Optimize image
- Adjust depth to centre image.
- Increase probe frequency to increase image resolution.
iii. Technique
- Start the scan just at the calcaneus in LAX on the midline with ankle dorsiflexed.
- Centre calcaneus on screen by sliding probe side to side.
- Sweep or rock probe to image a well-defined calcaneus cortex.
- Slide probe cephalad to image Achilles tendon.
- Rock probe to obtain fibrillar, well-defined image of Achilles tendon fibers.
- Slide side to side to interrogate AOI at its insertion point (2-6 cm cephalad from calcaneus).
- Slide proximally keeping tendon centred and well-defined until myotendinous junction is reached.
- Slide side to side to interrogate myotendinous junction.
- Rotate probe 90 degrees in SAX and repeat interrogation.
- Slide caudally until insertion is reached and AOI interrogated.
iv. Interrogate AOI
- Slide to interrogate well-defined centred tendon at 2 main sites of rupture in 2 planes.
- Insertion (2-6 cm from calcaneus).
- Myotendinous junction.
- Any area of discontinuity, loss of volume, swelling, hematoma or darkness within or around the tendon should prompt heightened scrutiny.
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. Evidence of Achilles tendon tear? (YES/NO).
a. Make sure to keep the tendon centred all throughout scanning.
b. Be prepared for anisotropy! Especially in and around the area close to the tendon insertion on the calcaneus.
c. Use dynamic testing to enhance tear detection.
d. Start scan at area of maximal tenderness if calf very swollen.
a. Technique
i. If ankle in plantar flexion, scanning the Achilles tendon will be very difficult. Dorsiflex patient’s ankle to 90 degrees as tolerated to flatten scanning surface.
b. Image interpretation
i.Tears can be filled with debris and be hard to assess. Dynamic testing of area by squeezing the calf (Thompson’s) or by flexing-dorsiflexing the ankle can help reveal partial and full thickness tears.
ii. Partial tears can be harder to diagnose than full-thickness tears.
- Remember that partial tears have:
- Well-defined hypoechoic or anechoic clefts.
- Incomplete disruption of tendon fibers.
- Tendon sheath anteriorly or posteriorly can remain intact.
- Full-thickness tears present with:
- Complete disruption of tendon architecture.
- Retraction of torn ends (shadowing artifact possible).
iii. It can be difficult to differentiate partial tears from tendonitis. Characteristics suggesting a tear are:
- Hypoechoic or anechoic zone disrupting tendon.
- Retraction of torn ends in complete tears.
- Heterogenous aspect of hemorrhage.
- Jagged edges and refraction shadowing at the retracted torn tendon stumps.
- Neovascularity seen on color Doppler from chronic wear can be present in both entities.
iv. Up to 3 mm of fluid can be seen in the retrocalcaneal bursa in a normal patient. When in doubt, compare with unaffected side.
v. Plantaris tendon can sometimes be seen far field in the presence of a complete Achilles tears (up to 20% of patients have a plantaris tendon).
vi. Retro-Achilles bursa (near field to Achilles tendon) is seen only in pathological states.
vii. Tendon AP diameter should only be measured in SAX.
- Normal is less than 2 cm in adults.
- Tendon thickening is found in chronic wear diseases.
viii. NERD ALERT! Size of tear. Once a full-thickness tear has been found, you can measure size of tear by measuring separation between the retracted ends with calipers in LAX. You can also measure cm from tear found to tendon insertion. Fluid in the bursas can be acute or chronic. Clinical correlation needed!
c. Clinical integration
i. Achilles tears found on POCUS warrant a rapid orthopedic consult and immobilization of patient’s leg according to local practice.
ii. Partial tears may be hard to detect even with ultrasound. Clinical judgment reigns supreme and diagnostic adjuncts are recommended when clinical suspicion remains high.
a. Put lots of US gel to ensure good probe contact and minimize applied pressure to tender areas.
b. Apply higher scrutiny to area of maximal tenderness.
c. Start scan at area of maximal tenderness if calf very swollen.
a. For a negative scan:
i. Must image a centred and well-defined Achilles tendon from its calcaneal insertion to its myotendinous junction in both long and short axis.
ii. Must interrogate AOI completely at 2 most frequent rupture points: 2-6 cm from insertion and myotendinous junction.
iii. No tendon tear identified.
b. For a positive scan:
i. Must image a centred and well-defined Achilles tendon from its calcaneal insertion to its myotendinous junction in both long and short axis.
ii. Must interrogate AOI completely at 2 most frequent rupture points: 2-6 cm from insertion and myotendinous junction.
iii. A tendon tear is identified.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. Achilles tendon tear + or –
b. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored Achilles scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 5-7 Achilles determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS Achilles written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).
a. Probe
Linear probe or high frequency probe of choice (10 MHz or more).
b. Knobology
i. Preset. Small parts or soft tissue.
ii. Depth. Minimal.
iii. Gain. Default. Adjust as needed.
c. Patient positioning
d. Probe orientation
e. Probe grip
Pencil grip or c-grip.
a. External landmark
b. Internal landmark
c. Relevant anatomy
Metacarpal, metacarpophalangeal joint
(MCPJ) space, proximal phalanx, medial phalanx, flexor tendon (FT), soft tissue.
d. Area of interest
e. Adequate view
a. Image generation
i. Landmark
- Start scan on metacarpal bone.
- Slide distally to proximal phalanx and again to medial phalanx.
- End scan when MCPJ space centred (MCPJ scan) or when FT centred on screen (FTS scan).
ii. Optimize image
- Use water bath to improve your view.
- Use minimal depth.
- Adjust probe frequency to its highest setting.
iii. Technique
- Start scan at metacarpal bone in long axis (probe marker towards patient’s head). Keep the bone cortex well-defined (bright white and thin) by sweeping or sliding side to side.
- Slide distally towards the proximal phalanx.
- Centre the MCPJ space on screen.
- Sweep to assess for effusion. Rotate probe 90 degrees into transverse to confirm impression.
- Re-centre and rotate probe back to sagittal
- Slide distally towards medial phalanx.
- Centre FT on screen.
- Assess for presence or absence of fluid surrounding the tendon by sweeping.
- Rotate probe 90 degrees to obtain transverse view and confirm impression.
- Compare with contralateral side or unaffected digit if unsure.
iv. Interrogate AOI
- Sweep MCPJ space looking for an effusion (MCPJ scan) in both axes.
- Sweep FT looking for fluid surrounding the tendon (FTS scan) in both axes.
b. Image interpretation
The following areas should be evaluated and a binary yes/no conclusion made:
i. Is there an effusion in the MCPJ space? (YES/NO).
ii. Is there fluid surrounding the FT? (YES/NO).
a. Use highest frequency possible.
b. Use water bath to improve visualization and alleviate the need to press on very tender areas.
a. Technique
i. Failure to centre joint can miss an effusion.
b. Image interpretation
i. Small amounts of fluid can be harder to detect. Compare to an unaffected digit.
ii. Cellulitis and cobblestone appearance of soft tissue can be mistaken for fluid around the FT. Remember your soft tissue layers.
c. Clinical integration
i. MCPJ scan:
- Impossible to distinguish on ultrasound between a septic or an aseptic effusion. Clinical correlation is paramount and tapping the joint recommended for final diagnosis if in doubt.
ii. FTS scan:
- FTS can also be non-infectious (ex: RA patient). Clinical correlation needed!
- Infectious FTS is a surgical emergency. Kanavel’s signs and clinical suspicion should guide your assessment. Call your hand surgeon early!
a. USE A WATER BATH to help with visualization.
b. Use gentle dynamic testing to locate FT. Can be used as Kanavel’s fifth sign!
c. Scrutinize area of maximal tenderness.
a. For a negative MCPJ scan:
i. MCPJ centred and swept in both axes and no effusion found.
b. For a positive MCPJ scan:
i. MCPJ centred and swept in both axes and effusion present.
c. For a negative FTS scan:
i. FT centred and swept in both axes and no fluid found around tendon.
d. For a positive FTS scan:
i. FT centred and swept in both axes and fluid around tendon present.
Document as per CPoCUS guidelines for positives and negatives according to clinical indications:
a. MCPJ space effusion + or –
b. FTS + or –
c. Indeterminate
Prerequisites
Appropriate didactic and practical introduction to technique that must include written materials covering all relevant ultrasound physics, anatomy and theory, a minimum of 30 minutes of live or on-line lectures, and at least 5 introductory proctored MCPJ/FTS scans.
The introductory scans do not count towards certification and do not need to be determinate.
Logged scan requirements
- 5 hand MCPJ/FTS determinate scans supervised directly by a CPoCUS MSK Track Instructor for the entirety of the scan.
- Determinate scans are defined in ‘Determinate scan requirements’.
- A minimum of x scans (to be determined) must be done ‘unassisted’.
- An unassisted scan is one in which the learner generates a determinate image and uses appropriate troubleshooting maneuvers without any assistance (verbal or physical) from the instructor.
- There is no requirement for a minimum number of positive scans.
- All scans must be recorded in a CPoCUS logbook.
Examinations
Pass mark on CPoCUS MCPJ/FTS written, practical, and visual examinations PLUS appropriate prerequisites AND logged scans as above.
Note: Prerequisites and/or logged scan requirements may be waived if a candidate is awarded a CPoCUS Exception to Certification (see website for application details).