Resident Accuracy of Musculoskeletal Palpation With Ultrasound Verification

Shoulder and Knee Arthroscopy Access Point: Prospective Comparison of Sonographic and Palpatory Detection - Which Method is Better for Novices?

Purpose  Arthroscopy is one of the most common interventions in orthopedics. Hence it is important to train users early in order to ensure the safest possible identification of access portals (AP). This prospective study aimed to compare a palpatory (PalpMethod) with a sonographic (SonoMethod) method for AP location in the shoulder and knee joints. Materials and Methods  The study included trainee doctors (n=68) attending workshops (lasting approx. 90 minutes). In these workshops a teaching video initially demonstrated the PalpMethod and SonoMethod of AP identification. An experienced operator first marked the access portals on the test subject with a UV pen (determined ideal point [DIP]). Adhesive film was then affixed to the puncture regions. Subsequently participants marked on shoulders and knees first the point determined by palpation, then the point determined by sonography. Analysis involved DIP visualization with a UV lamp and employed a coordinate system around the central DIP. In addition, participants completed an evaluation before and after the workshop. Results  The analysis included 324 measurements (n=163 shoulders and n= 161 knees). The majority of participants had not previously attended any courses on manual examination (87.9%) or musculoskeletal ultrasound (93.9%). Overall, the markings participants made on the shoulder using the SonoMethod were significantly closer to the DIP than those made by the PalpMethod (Palp 18.8mm ± 14.5mm vs. Sono 11.2mm ± 7.2mm; p<0.001). On the knee, however, the markings made by the PalpMethod were significantly closer to the DIP overall (Palp 8.0mm ± 3.2mm vs. Sono 12.8mm ± 5.2mm; p<0.001). Conclusion The results show that the SonoMethod produces more accurate markings on the shoulder, while the PalpMethod is superior for the knee.

Professional tennis players suffer high prevalence of shoulder alterations during the season: a possible tennis shoulder syndrome

PURPOSE

To analyze the shoulder alterations of professional tennis players during the competition season and to compare the differences between their dominant vs. non-dominant shoulders, as well as gender and age differences.

METHODS

Two-hundred and seventy shoulders of (78 men and 57 women) professional active tennis players were assessed during 3 ATP and WTA tournaments.

MAIN VARIABLES STUDIED

long head of biceps (LHB) tenderness and synovitis; glenohumeral internal rotation deficit (GIRD), total range of motion (TRM), external rotation (ER) and scapular dyskinesis (DK). Secondary variables: shoulder dominance, gender, age, training hours, ranking, type of backhand. LHB tenderness and synovitis were assessed by clinical and ultrasound examination, TRM with goniometer and DK by dynamic observation.

RESULTS

LHB tenderness of the dominant shoulder was present in 35% of all players, being more prevalent in women (47.4%) than men (26.9%) p = 0.023. LHB synovitis of the dominant shoulder was present in 20.2% of all players without difference between genders (n.s). High prevalence of GIRD was found in both dominant (87.4%) and non-dominant (56.3%) shoulders, being more prevalent in the dominant shoulder p = 0.00005. TRM was decreased in both dominant (144.5° ± 20.2°) and non-dominant shoulders (161.2° ± 18.9°) p = 0.00005. ER was normal in dominant (93.8° + /9.3°) and non-dominant shoulders (93.4° + /8.4°) (n.s). DK was present in 57.7% of dominant and 45.9% of non-dominant shoulders (n.s). The combination of LHB alterations, GIRD and DK in the dominant shoulder was present in 13.3% of the participants. There were no significant differences between younger (< 22 years) vs older players (≥ 22 years).

CONCLUSION

Professional tennis players actively playing suffer a high prevalence of LHB inflammation, GIRD, scapular dyskinesis and decreased TRM in their dominant and non-dominant shoulders. The LHB is a significant cause for anterior shoulder pain in this population. Women suffer more LHB tenderness than men. Young players are as affected as older players.

LEVEL OF EVIDENCE

Level IV.

Randomised controlled trial for evaluation of an ultrasound-guided palpation intervention for palpation skill training

Although there are increasing reports on the usefulness of sonopalpation with ultrasound imaging, many previous studies have reported interventions without a control group. This single-blind, parallel-group randomised controlled trial aimed to determine whether educational instruction with sonopalpation for physical therapy students has a more superior effect on skill improvement than traditional instruction without ultrasonography. Twenty-nine physical therapy students participated in the study and were randomised using block randomisation into an ultrasound imaging group (n = 15) and a control group (n = 14). Subsequently, they underwent three training sessions focusing on the shoulder joint. Participants underwent a scoring assessment of their palpation skills at pre-intervention, post-intervention, and follow-up 3 months after training. The raters were blinded to the subjects’ group. The Friedman and Mann–Whitney U tests were used for data analysis. The intervention group showed a significant increase in scores at post-intervention and the 3-month follow-up; the effect sizes were large (0.849 and 0.849, respectively). A comparison of the scores at different time points after the intervention at the 3-month follow-up revealed no significant difference between the groups. Education using ultrasound imaging may be non-inferior to education without it; nevertheless, further studies are needed to demonstrate superiority.

A Novel and Accurate Palpation Method for Identification of the L4 Spinous Process: A Preliminary Study of Accuracy

OBJECTIVE

The purpose of this study was to assess a novel method of lumbar spinous process (SP) palpation by using magnetic resonance imaging (MRI) high-signal marker reference standards for verification.

METHODS

Clinicians (doctors of chiropractic) in this study used either: (1) the standard/traditional method of identifying the L4 SP using the supracristal plane (n = 14) or (2) a novel method that manually induced sacral motion to identify the L5 and then the L4 SP (n = 54). The clinicians, blinded to the results of each other, used a grease pencil to mark the location identified as the L4 SP. An MRI high-signal marker then was taped across this location. The MRI scans were assessed by a radiologist, blinded to the palpation method, who extended a line posteriorly from the superior and inferior extent of the L4 SP and determined whether the high-signal marker was within the lines bordering the L4 SP (ie, "on-target").

RESULTS

Palpation using the traditional method showed a 35.7% accuracy, with 5 of 14 "on target" and all "off target" being too superior. Palpation using the novel method showed 77.8% accuracy, with 42 of 54 "on target" and 3 "off target" being too superior and 9 "off target" too inferior.

CONCLUSIONS

The novel method performed better than the traditional method. The novel method shows promise. Additional prospective research should be conducted to fully assess the accuracy of the novel method compared with traditional methods of palpation.

The Impact of an Ultrasound Curriculum on the Accuracy of Resident Joint Line Palpation

BACKGROUND

Ultrasound education has been used as a tool to help improve physical examination skills. However, its utility in increasing accuracy of joint line palpation has yet to be investigated.

OBJECTIVE

To evaluate the accuracy of resident palpation and identification of the lateral knee joint line before and after introducing a musculoskeletal ultrasound (MSUS) curriculum.

DESIGN

Cohort study.

SETTING

A physical medicine and rehabilitation (PM&R) residency program at an academic institution.

PARTICIPANTS

Seventeen PM&R residents.

INTERVENTIONS

Residents underwent a knee-focused MSUS workshop.

MAIN OUTCOME MEASURES

Distance from needle placement to joint line confirmed with ultrasound.

RESULTS

All residents demonstrated improved accuracy in lateral knee joint line palpation after completing a knee-focused MSUS workshop, with statistically significant (P < .05) improvement in postgraduate year (PGY) 2 (P = .02), PGY-3 (P = .04), and across all residents (P = .001).

CONCLUSIONS

MSUS education significantly improved lateral knee joint line palpation accuracy in resident physicians.

Identifying and Monitoring Deficiencies in Physical Examination of the Foot and Ankle With Diagnostic Ultrasound: Experience From a Physical Medicine and Rehabilitation Residency Training Program

Despite the high incidence of foot and ankle injuries and their biomechanical importance to more proximal joints, the foot and ankle are some of the most daunting and underemphasized musculoskeletal structures in medical training. This study used musculoskeletal ultrasound to identify a knowledge gap in physical medicine and rehabilitation residents in foot and ankle surface anatomy palpation and to determine whether senior residents had higher examination performance compared with more junior residents. Physical medicine and rehabilitation residents at different levels of training were tested cross-sectionally, and palpation accuracy was compared by class year. There was a trend of improvement across class years, with significant class differences in accuracy for the talonavicular joint, calcaneocuboidal joint, and posterior tibialis and peroneal tendons (P < 0.05). Despite this trend, the accuracy was not consistently higher among the senior residents considering the training they received. For all 30 residents assessed, accuracy within 1 cm was highest for the tibiotalar joint (93.3%), peroneal tendons (83.3%), posterior tibialis tendon (63.3%), and talonavicular joint (50%). It was lower for the calcaneocuboidal joint (26.7%) and the second (13.3%) and fourth for the tarsometatarsal joints (20%). Anatomical knowledge and palpation skills of the foot and ankle, particularly at the midfoot and forefoot, may be an area of improvement for physical medicine and rehabilitation resident training.

Identification and Analysis of Bacterial Contamination of Ultrasound Transducers and Multiuse Ultrasound Transmission Gel Bottle Tips Before and After the Aseptic Cleansing Technique

OBJECTIVES

To provide a descriptive analysis for species identification of culture and Gram stain results from ultrasound transducers and multiuse ultrasound transmission gel bottle tips in active clinical use and to compare bacterial cultures from ultrasound transducers before and after aseptic cleansing.

METHODS

A prospective blinded descriptive analytic study of 18 distinct clinical care sites within a single primary clinical institution was conducted. Before and after a disinfectant towel cleanse, transducers were pressed against tryptic soy agar contact plates. Plates were deidentified and submitted for blind incubation, Gram staining, and species identification with microsequencing. Results were classified as clinically relevant (CR) or non-clinically relevant. In total, 188 samples were analyzed: 80 from ultrasound transducers before and cleansing, 13 from multiuse gel bottle tips before and after cleansing, and 2 precleansing samples from the data collector's pen and badge.

RESULTS

Fifty-nine precleansing samples (73.8%) grew cultures with CR bacteria, and 21 samples (26.3%) did not. Staphylococcus simulans represented 31.0% of all positive culture samples. Thirteen postcleansing samples (16.3%) grew cultures with CR bacteria, equating to a 78.0% reduction of CR bacterial growth (likelihood ratio, 57.10; P < .001).

CONCLUSIONS

Ultrasound transducers have a notable CR bacterial burden and may serve as potential infective vectors. Aseptic cleansing effectively eliminates most of the bacterial load from ultrasound transducers, but some bacteria persist, presenting a risk of nosocomial infection with ultrasound-guided interventions. These findings support American Institute of Ultrasound in Medicine 2018 guidelines intended to ensure an appropriate level of transducer preparation based on the examination type while emphasizing rational infection control measures to minimize the risk of potential patient harm.

Design and Implementation of a Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents: Pilot Data on Improvement of Palpation Accuracy in Physical Examination

Studies have shown that physical medicine and rehabilitation residents have poor surface anatomy palpation accuracy, suggesting that new methods of teaching musculoskeletal (MSK) examination need to be found. This study describes the design of a novel MSK ultrasound course that integrated ultrasonography skills with palpation skills. Ultrasound was used to teach, validate, and refine physical medicine and rehabilitation residents' palpation of MSK structures. Surface anatomy palpation is intimately related to ultrasonography as clinicians should use palpation to guide their ultrasound examination rather than purely follow an algorithm. This study assessed whether the ultrasound course improved physical medicine and rehabilitation resident palpation accuracy at 12 upper limb structures. Palpation accuracy was tested at the beginning of their residency training and retested several weeks after completion of the ultrasound course's upper limb component, to assess retention of skill. There was significant improvement (P < 0.05) in 9 of 12 sites from pretesting to posttesting. Mean postcourse palpation accuracy was within 1 cm for 8 of 12 structures. This study demonstrates that an integrated MSK ultrasound and palpation curriculum improves palpation accuracy at multiple MSK structures and this improvement is retained. Physical medicine and rehabilitation residencies should consider integrating palpation skills into their ultrasound curriculum to improve the caliber of their trainees.

Brief Ultrasound-Aided Teaching to Improve the Accuracy and Confidence of Resident Musculoskeletal Palpation

BACKGROUND

Multiple studies demonstrate poor musculoskeletal palpation accuracy of physiatry residents. With the growing use of ultrasound clinically, it could serve as a powerful educational tool. However, there are no published studies examining the efficacy of ultrasound-aided education at the bedside, where much learning takes place during postgraduate training.

OBJECTIVE

To determine if brief ultrasound-aided teaching improves residents' accuracy and confidence of musculoskeletal palpation.

DESIGN

Before/After Trial.

SETTING

Academic Institution.

PARTICIPANTS

Ten physical medicine and rehabilitation residents were voluntary participants.

INTERVENTION

Each resident was given a survey to assess confidence in palpating the hook of the hamate and medial calcaneal tubercle. They then attempted to palpate and place a marker over these two structures in a model patient. Marker placement accuracy was verified by ultrasound. Faculty spent less than 1 minute per landmark, sonographically teaching its correct localization. The resident, after moving to a new model patient, was then re-tested on accurate marker placement for both landmarks. A repeat survey to assess confidence was administered.

MAIN OUTCOME MEASUREMENTS

Preintervention and postintervention accuracy and confidence of correct localization of both landmarks.

RESULTS

We used McNemar's and Wilcoxon's tests to determine whether the intervention improved the location accuracy and confidence of successful palpation, respectively. Confidence level of correct localization of two landmarks improved on average from 4.3 to 8.15 on a scale of 10 after intervention. Of 20 palpation attempts, 11 correctly placed the marker postintervention after an incorrect placement, 8 made no change, and one changed from correct to incorrect placement. The odds of improvement in accuracy was 11 (95% confidence interval [CI] 1.60-473.47, P < .01). Both tests showed significant improvements after the intervention at the significance level of .05.

CONCLUSIONS

Brief, ultrasound-aided teaching increases accuracy and confidence of residents' musculoskeletal palpation.