ultrasound is an extension of your clinical brain my mentor Wayne Smith said scan everything with a linear probe until you cannot and and I think you summed it up succinctly here is is the higher the frequency the better the resolution if you're not optimizing the gain you're shortchanging yourself and more importantly you're not getting the best view possible for your patient understand your why which is you know the old Simon Sinek kind of thing is know your why and then from that point set it up the right way and the decision making should first fall into what's the clinical situation an advanced msk ultrasound center podcast From Probe to Practice hosted by Ryan Martin and colin rickney produced by Jason Kitza at NGG, needgreaters.com welcome everybody i'm Ryan Martin physical therapist and msk ultrasound sonographer we are going to be starting our our inaugural podcast here. I'm here with Dr. Colin Rigney. Hey, Colin, how you doing? Hey, Ryan.
Doing well, doing well. This is really fun. This is going to be a great time. Yeah. So this is something we'd envisioned for many years.
And we've done podcasts. We've done guest podcasts. We've done a lot of things with social media. But now we're going to get serious and do podcasts that really go from probe to practice. So in this initial scanning or this initial podcast, what we really want to cover are some basics that we have a lot of questions that come in and they say, okay, well, why would I use a linear versus a curvilinear?
What the heck is frequency differences? And what are some of the first things that we do before we even start a scan? So Colin, let's go into some basics here. Let's actually start with the last one first. And so let's let's chat a little bit about like what what things or what's going through your mind.
What's one of the first things that you're doing before you even get the probe to the patient? Man, I think the biggest thing is we had a webinar last night. I always I'm always quick to emphasize that ultrasound is an extension of your clinical brain. And the decision-making should first fall into what's the clinical situation in terms of their mechanism history, location of injury, any prior imaging. If so, when assimilating all those data points really, really will help drive your scan, what you're looking for, and potentially, you know, what recommendation may come after that.
But I think, you know, really, it's it's about your clinical decision making skills. That's the first thing. Why are you doing it? What's the what's the intent? You know, that's that's the first thing I think about.
So how about you? Well, I mean, clinical decision making, critical thinking. Those are all super, super important. But the question comes down to is like, OK, we teach physicians, physical therapists, PAs, nurse practitioners, sonographers, athletic trainers. I mean, the list goes on, right?
And everybody's scope of practice is a little bit different. And maybe not all of the sonographers or some of the other practitioners have the same in-depth clinical reasoning skills as, say, like biomechanics or, you know, pathognomonic type of scenarios. scenarios. So at that point, it's like, yeah, you have to have your critical skills. You have to have all that kind of stuff, especially in the case that like you and I sit in, because we are essentially physician extenders, right?
And so the physicians that we work with rely heavily on what we come up with prior to them even walking in the room, right? And so for us, I would say, so, and I think it's clinician dependent, but in our situation, I think the first and foremost thing before I even bring the machine out into the conversation is why am I doing it? Exactly what you said. It's intention-based, right? Does this warrant medical necessity?
Is this something that is going to change the outcome? Why am I doing it, right? And that's the first and foremost thing, right? But then I think we get into a little bit of like semantics here. It's like, all right, what do we start with?
I would talk about optimization. And now everybody, if they follow me on social media, they know that I'm kind of a physics nerd. I'm a kind of an optimization nerd. I teach a lot of the introductory type of stuff. I would say one of the first things that I'm doing is once I kind of understand what I'm looking at and what the purpose is of this scan, you know, like what body part and everything, then I look at my machine and I think of optimization.
So I would go in that route. And I mean, I think this will kind of tail into some of our other topics for today, but I would talk a little bit, you know, if people are wondering like, all right, what's the first thing you do is you look at your machine and you say to yourself, hey, does this make sense for what I'm about to look at? You know, is this the correct probe? Is this the correct frequency? Is this the correct depth?
So on and so forth. So before I even do that stuff, I start gathering that data in my mind, like, all right, this is my patient. This is their habitus. This is the body part. This is the pathology.
How would I optimize this to the best way possible before I even put the probe on them. But I think you're absolutely right. I think the first thing is that critical thinking is, why am I even doing this, right? So why am I even doing this? But let's move a little bit forward then.
Okay, so if it's an optimization thing, right, and you've got your machine all set up and it's ready to rock and roll, let's talk a little bit about probe selection, right? Let's talk about probe selection and and why it matters like why would you use a hockey stick versus a curvilinear versus a linear and then we have to kind of think about well what is that based on you know is it based on shape size frequency you know what what parameters does it change when i change my probe so i'm gonna i'm gonna pose that question to you is what the heck is the difference between linear curvilinear and like a hockey stick well i'm not going to come at this from a physics perspective i'm going going to leave that to you um but in terms of in terms of like probe selection right so um i'm actually pretty rudimentary with this i would say if i'm going to try to get away with scanning anything i possibly can just for the pure purpose to visualize it in the highest resolution possible is just to use a linear probe whenever you can okay meaning um if you want the highest yield If you're doing this exam, let's just say you're doing the exam for a diagnostic purpose. As much as possible, you want to use a linear probe. Okay, so we'll just start with that. And then from there, it's like, okay, linear probe, but what frequency, right?
You know, a lot of machines now have like a mid, deep, or superficial setting under, you know, like a 15 megahertz probe or something like that. that. And when you have that, that's like a really nice setting on your machine, but not all machines have that. You know, some people, you know, some manufacturers have like an 11 megahertz and a 15 megahertz. Some people want both.
I understand for, you know, a linear probe, like 11 megahertz, it's like really nice for kind of deeper injections, like facets. I know a lot of our interventionalists like that. But purely from an image acquisition process and the highest resolution possible, use a linear whenever you can. And then if that's not possible, the curvilinear probe, so the lower the frequency, the more depth of penetration. And the higher the frequency, the less depth of penetration we sacrifice.
You sacrifice depth for For quality and inversely with the curvilinear, you're sacrificing resolution quality for depth. And, you know, on some cases where if you're going into this exam, you have a larger habitus person, and you've got to look at the hip joint. You know, in some cases, the curvilinear is your only option, you know, and you do the best you can with it. But, you know, for everything else, extra-articular and even, you know, large joints, if you can, use the linear just because you can pick up the details such as, you know, the hip flexor tendons, I'm going with the hip, the overlying capsule, the labrum with a much better, with a much higher quality. quality um so you know uh curious curious on your thoughts i know you probably have a more kind of nuanced and detailed way from uh the mechanical side of things as far as like what your what your choice would be here right well and and again my mentor wayne smith said scan everything with a linear probe until you cannot and and i think you summed it up succinctly here here is the higher the frequency, the better the resolution, right?
And the linear probes have a higher frequency just by and large. And so if you're aiming for the best resolution possible, yeah, then always shoot for the linear first. Now I'm going to give a quick story. And it's funny that we talk about this. It was just this morning, I had a patient that had to come back to a clinic because the clinic I'm in only had a linear probe.
This patient happened to be here last week and with the linear probe i just could not see anterior hip now granted this patient is pure muscle and i would say thigh circumference is about 32 inches right i mean that's like a waist and so i ended up being about 11 almost 12 centimeters to get the femoral head and neck junction so in that case there was no way i was going to use a linear probe right to your point before. So each machine, I'm going to have like my own little personal cutoff. Like, Hey, if this gets past seven or eight centimeters, I'm probably going to go back to the curvilinear. Um, and so that was just a case that happened today. So the patient came back today.
I had a curvilinear. We were able to see the joint space, but again, we have to compromise a little bit resolution. Okay. Um, but we were able to get the pictures. We were able to make a diagnosis and it actually made a difference in how the physical therapy and medical team are going to handle this.
So it was great to have that option. Now, not everybody has that option. And especially with people who have like a handheld machine that has one setting on it, that's where we kind of get into some, you know, it gets a little bit more difficult, you know, to find some of these deeper structures. And you never want to put any patient off because you don't have the right equipment. So that's the first thing.
But if we're talking linear versus curvilinear, sometimes people like the curvilinear during interventional or injection base because of the shape of it. In fact, crazy, I should have one right about here. And so a lot of people like using the curvilinear during injections because it's easier to get through this lip here. And so versus if we were to look at the linear probe here, you have this almost 90 degree angle. And so getting a needle through that area is sometimes a little bit more difficult versus when I use a curvilinear and we have the physicians, it's just easier to slide through that area.
But one significant caveat or something that I would mention is the physics, and I'm not going to go in depth here, but the physics of the linear versus the curvilinear is huge. And so manipulating this curvilinear in a way to get the correct view is a little bit more challenging. So I would say that when using a curvilinear probe is understand the physics a little bit, because sometimes you can make a straight bone look curved or the overall shape of the anatomy might look a little distorted. So if you're going to be using a curvilinear, do your practice, practice with the linear curvilinear and understand how to manipulate that. But yeah, that's really my best, my big take on using linear versus is curvilinear.
Use this guy all the time if you can. And remember, Ryan's point there was important because the linear arrays, they all come off of the transducer in parallel with each other. The curvilinears crisscross. And if you're not angling exactly 90 degrees and accounting for those arrays you can make you can get really squirrely pretty fast so there's only a handful of um i shouldn't say that it's in in some ways it's easier to account for the angle of incidence with a um with a curve linear in your needle i'm described i'm specifically talking about um than it is with the linear transducer however you have to be a little bit craftier with your your, um, sono anatomy and probe skills using, using the curvilinear in, in many cases. Okay.
Specifically, like if you're doing like a, a challenging interarticular hip, that's a lot of depth, um, with a long needle and, and, and, um, like maybe a deep hip rotator, um, injection or a sciatic nerve injection back there where the anatomy is challenging number one number two is depth and they're very dynamic structures and and i think we should something we should talk about this too and this kind of is overlapped with our first our first point of the decision making in in the probe selection is patient position because patient position how they're um how their position and and to what degree um are there is the targets you know um on um on stretch on tension on slack like what what does it look like there that has a lot to do with the way uh your image turns out uh would you agree 100 i i always say this is um the way that you position your patient is going to ultimately set up the success of the total like of the image right but i i would i would feel remiss if i didn't bring up the idea because i mean we're biomechanists we work on ergonomics we're physical therapists by education i would say practitioner positioning is is very important as well yeah um you know how you position yourself the the position of your arm your wrist you know where is your machine located so if i'm scanning somebody here and you see my machine back here. If I have to do this, you know, every time I'm looking, that's not appropriate. So room setup, patient position, practitioner position, those are all imperative. And I always tell people that if you are doing injections and you do a scout prior to, to kind of get a lay of the land, if you don't know it already, always scout in the position that you're going to do the intervention. Because there's been countless times where they'll scout a shoulder in a seated position and they lay the patient down and sometimes people get a little backwards, you know, and sometimes it can be a little bit harder.
So one thing I can't stress enough, going back to our first point of, you know, what are some of the things that I would do before I, you know, actually put the probe on is patient, practitioner, machine positioning and make sure that it all makes sense in an ergonomic and practical way. And yeah, that's where I stand on it. Yeah, yeah, yeah. Yeah. No, I think we covered a lot with the, with those two things, you know, but just, I really want to reinforce the first topic.
The first decision is it's kind of cheesy, but start with why, like why, why, what, what's your intent? Why are you doing this? What's the, you know, what's the outcome, you know, is what, why is this thing going to help lead to a better outcome in this particular case? And then everything after that are, you know, the things we, We just described, you know, patient position, probe position, probe selection, anatomic depth, tissue type, all those things factor into, you know, as Ryan was talking about, the optimization of your equipment, you know, and optimization kind of is this catch-all term where we're talking about, you know, the frequency with the transducers, the gain on the, you know, we'll probably do a separate episode on that. But all the things that you're, all the tools on the equipment, lateral focus, gain, depth, that you adjust and optimize to get the best possible resolution on your diagnostic or your procedure.
Yeah. End of point is if you're not optimizing the gain, you're shortchanging yourself. And more importantly, you're not getting the best view possible for your patient. And so that can skew your outcome. come.
So yeah, I believe that a hundred percent, but understand your why, which is, you know, the old Simon Sinek kind of thing is know your why. And then from that point, set it up the right way. Right. Know that the nuanced details. And if anybody has questions, comments, or concerns about how do I optimize my machine?
Hey, why don't you go to amsku.com, find our contact information and reach out. Morten happy to explain that to you. Yeah. And I mean, our introduction to MSK ultrasound ryan you did a whole course on this right i did and and funny story is i may have written a physics book so um if there's questions about it please reach out to me yeah i think that's good um we left a lot on the table but i think that's a lot on the table is going to be left for the next time so i i got some ideas on you know um how this next set of things can go And really, we hope to kind of build on on each on each episode, each topic, each subject every time we every time we catch up. Yeah.
Well, the hard one's always the first one, right? It's just kind of getting that initial information out there. See if anyone bites on it. And hey, let's build from here. So, Colin Rigney, I want to thank you so much for helping put this together.
We have our engineer and an audio visual and expert in digital on the back line. Jason Kitza, thank you so much for putting this together for us. And I am looking forward to continuing this and helping anybody and everybody that we can progress in MSK Ultrasound. Thank you. Yep.
See you next time guys. People say I don't have time. You have time. Everybody has time. It's just how do you prioritize it?
Don't forget what got you here. Like this is just a tool. It's not replacing, it's not replacing like your clinical, your clinical skills and background. I know the grass is greener over there, but I just don't want to make the effort to climb over the fence. And diagnostic musculoskeletal ultrasound really is the next generation.
And if you are not embracing it, you are going to be left behind, period. And it's an extension of your physical exam. An advanced MSK Ultrasound Center podcast. From probe to practice. Hosted by Ryan Martin and Colin Rigney.
me. Produced by Jason Kitza at NGG. needgreaters.com. If you have any questions about today's episode or are curious to know more about AMSKU, visit amsku.com or check the links in the show notes.
