Q&A Time: Realtime Ultrasound in the Clinic? | Modern Manual Therapy Blog

Q&A Time: Realtime Ultrasound in the Clinic?

"Based on this, I can conclude..... we still need to do movement testing"

This Q&A Time regarding realtime US is from a commentary on the last Guest Post Top 5 Fridays from last week. The response from the author, Dennis was so good, I thought I would post it here, since it also echoes my thoughts.

"As a current PT student this was very interesting and relevant for me. I recently went to a lecture on diagnostic ultrasound and the possibility of PTs using it. I actually brought up the same point you did about how diagnostic tests can be useless and often do more harm than good. But I was wondering about your thoughts on the possibility of PTs doing them.

The benefits I see is PTs could control the message and perhaps allay some of the fears patients have when they receive a diagnosis. It also could add legitimacy as well. There is something about seeing seeing a clinician use a piece of equipment like that that could change the perception of patients.

First, I have only heard a few lectures on diagnostic ultrasound, so I most definitely don't consider myself an expert on the topic, but I seemed to have gotten enough info to see its potential clinical applications.

So the quote I was talking about (from Dr. Perry Nickelston) is "Pain only tells you there is a problem, it does not tell you what it is." If a patient complains of pain over a certain area, it doesn't necessarily mean that that area is the source of pain (and most likely it isn't). Therefore, ultrasounding that area to see what that structure looks like wouldn't provide you with info that you could then use to develop your treatment plan. It doesn't give you the "why," it just tells you what that structure looks like. And as therapists, we want to treat the "why."

Even if a patient gets a placebo effect from you using a cool medical machine (and I am fully aware that happens), is it worth your time to set everything up, image multiple structures (because you know patients complaints tend to be vague), and then just tell them, everything looks ok (even if it doesn't, because you don't want your potential placebo effect to become a nocebo effect)!?

You talked about adding legitimacy to our evaluation and I get where you are coming from, but rather than just use a cool-looking machine I think you can go a different route to get it. I feel the best way to capture a patient (and I do realize it's not the only possible way, but I think it applies to the majority of patients) is through pre-test, treament, post-test (and subsequent education). If you can get the patient to feel or move better then you are on the right track. I guess if a patient feels better after your treatment you could do an ultrasound to show them how structures are moving differently (which would also require a before ultrasound of however many movement patterns you have the patient perform), but you are going to waste a lot of time doing this. Many times in the medical communitty we are the first ones who actually treat the patient, and while this is unfortunate for the patient (and a sad fact of the medical community), it tends to make us look like a hero at times. So in my opinion, the best way to add legitimacy is, simply, to get people better.

With all that being said, I do think diagnostic ultrasound will continue to have a bigger and bigger role in the medical community - just not necessarily ours. I think it will take the place of MRIs in some diagnoses as it is cheaper, less time-consuming, and gives you similar info (all music to insurance companies' ears). I also think it should be used by the orthopedic community when giving injections. The research on doctors' efficiency of putting an injection in a particular area is eye-opening (they are not nearly accurate as they think) and real-time ultrasound makes that essentially fool-proof. Another use is the breaking up of calcific deposits - the clinicians who do this seem to get good results. The PTs that will probably use ultrasound the most are those in the research world as it is relatively cheap, quick, and provides images of how structures are moving As a very recent example, the Rocktape course had some really cool and powerful ultrasound videos.

Hopefully this helped, if not, just let me know.

Thanks again to Dr. Dennis Treubig, PT, DPT, SCS, SFMA, CSCS! These thoughts really echo my own when it comes to this in the clinic. For research, I think it's pretty fascinating, for the clinic, the ROI plus chances of nocebo outweigh the benefits. I think it would reverse streamline your efficiency in the clinic, or we would end up having PTAs or a entirely new sort of tech would do it so we can focus on evaluation and treatment. In the end, it is most likely not needed in a  majority of cases. Remember your leash, if a patient has zero improvement in 4 weeks, refer out.

Keeping it Eclectic...


  1. Echoes.....I see what you did there.

  2. Lol! No pun intended literally! Maybe my subconscious is wittier than my conscious.

  3. Completely agree with everything you said - thanks for the response.

    Only thing I'd like to add though, is given the current state of PT/medicine patients usually go to their primary physician first (and many PT practices won't take a patient until they have a prescription from their doctor for fear of getting denied payment by insurance companies). That primary physician will almost always call for some diagnostic test, whether it be X-rays or an MRI.

    So until our field gets to the point where patients are actually coming directly to us, why not take over the diagnostics to control the message? And it doesn't hurt that it's actually one of the things insurance companies are willing to reimburse.

  4. My patients come directly to me and before I went cash based all HMOS reimbursed for their visit. Over 70 percent was direct access.

  5. In NYC I called multiple PT establishments and most wouldn't see me without a prescription.

  6. You're calling the wrong places then. That's old school mentality

  7. Fantastic to hear that my experiences aren't the norm. Some places seem to have the mentality that they don't need your business and so they won't accept you without that referral. And unfortunately some of those places come with very high regard. Many that are part of large hospitals require that referral and the conspiracy theorist in me wonders if it's so you go to their doctors for an extra revenue bump.

    Big fan of the blog and look forward to continue to supplement my learning from sources like this.

  8. I didn't say it was not the norm, I just said you were calling the wrong places. Many places have an old school mentality, see 4 or more patients per hour per PT and practice little to no evidence based care. There is a bell curve in most businesses and few are to the right of the curve. I can refer you to several great clinicians in NYC.

  9. I'd be interested in a couple recommendations - more for the potential for the possibility of a clinical affiliation in a couple years than for PT treatment.

    I had what I believe is/was a UCL tear and went to an MD for treatment to get a prescription for PT. She really wanted to do an X-ray but I didn't see the point and got the prescription. I've done a lot of strengthening of my own (especially in the shoulder complex) and it's feeling much better. Just another example of diagnostic test being a bit superfluous.

    Appreciate how engaged you are with your readers. It's clear you have great passion and compassion.

  10. In the future if it's bothering you, you may want something like a FMS or SFMA to look at you. The last "UCL" I saw on a javellin thrower was a loss of contralateral hip, tibial, and ankle ROM. Cleared that up and all his medial elbow pain went away with throwing. Sometimes it's local, sometimes it's not.