[0:00] Narrator: This week on From Probe to Practice.
[0:03] Ryan Martin: I just think that there's this intimidation factor that nobody wants to admit, right? Like the elephant in the room is, I am not confident with reading them or doing them. Or I don't know somebody that is confident in reading them or doing them. Here, go get your MRI.
[0:24] Narrator: An advanced MSK Ultrasound Center podcast. From Probe to Practice. Hosted by Ryan Martin and Colin Rigney. Produced by Jason Kitza at NGG, NeedGreaters.com.
[0:39] Ryan Martin: Welcome, everybody. We want to hit two main topics today. I really want to talk about the $2,000 question. And I really want to talk about palpation theater. All right. So these are two topics that, you know, we could get relatively heated in the community that we've worked with on some of these topics. So Colin, with us here, you know, and I'm Ryan Martin. So Colin, let's take it away. Right.
[1:03] Colin Rigney: Yeah, man. So we got we got a couple of different things wanted to talk about. So the $2,000 coin flip, this is, you know, you and I talk with doctors all the time. And in training in residencies and fellowships, especially in certain, in most specialties, actually, you know, MRI is really the gold standard in those trainings. And so, you know, the adoption of ultrasound is met with some resistance in a lot of cases of, you know, because MRI is such a strongly used tool for imaging for a lot of different things, it can be difficult for certain doctors to adopt and adapt. And so we want to get into a bit of that today and maybe attack those objections head on and, you know, go back and forth on a couple things regarding, you know, you and I talk to people all the time about this stuff, and maybe we could talk about even a couple specific cases. But, you know, what are your thoughts when you talk to a doctor and, you know, they know they need to adopt ultrasound, they see their peers using it at the point of care, and there's a resistance when, you know, that's met with, oh, man, there's training involved, and why change if I can just continue doing what I'm doing? It seems to be working just fine.
[2:35] Ryan Martin: Now, and you know, it's, my feeling is this, I think these doctors know what best practice is. And I think these doctors, like, you know, behind closed doors, they secretly want to be using ultrasound, you know, but, there's that confidence level of using it and referring back to what you know, what you were taught in, you know, residency and fellowship, you know, and, you get set in your ways. I get that. I understand that. But I think, I think deep down inside a majority of these clinicians, physicians, you know, practitioners, they know what the standard of care is, and they know the power of ultrasound. I just think that there's this intimidation factor that nobody wants to admit, right? Like the elephant in the room is, I am not confident with reading them or doing them. Or I don't know somebody that is confident in reading them or doing them. Here, go get your MRI. So I think a lot of it comes down to awareness and education. I think a lot of it comes down to and I hate saying ego, but I think some of its ego is, you know, I've been doing this for so long, it's the right way. It's like that confirmation bias, right? So what I believe is what I believe in what I believe is true. So that's, I mean, and again, these are my opinions. But after sitting down with these physicians closed door, they'll openly admit, yeah, I know, I need to, I need to get better with ultrasound skills, or I need to, you know, bring ultrasound into my practice or find somebody in my local area that's doing ultrasound. I mean, these are the conversations that we tend to have, right?
[4:14] Colin Rigney: Yeah. and I get a little bit of imposter syndrome with it, too, of they don't want to start unless they're perfect. Oh.
[4:22] Ryan Martin: Oh.
[4:23] Colin Rigney: Yeah.
[4:23] Ryan Martin: Yeah.
[4:25] Colin Rigney: Or I don't want to charge for it until there's this mythical finish line of where they think they need to be before they can start doing it. And, you know, you've heard me say this, but the road to mastery goes through incompetency and you have to be willing to take some steps back in order to make multiple steps forward, you know, with respect to learning this new skill. and you know we've all been there with respect to imposter syndrome type A personality there's a there's a it's a it's a it's a feature not a bug with most health care professionals who are like really good at what they do and right we don't want to appear like we don't know something and sometimes having to right and we've all been there right we're not excluding ourselves from this as well. Right. So there's definitely that, psychological element to it. I encounter that. Yeah. I feel like that's an underlying, you know, thing quite frequently when we, when we have these conversations. Always, always. Yeah, for sure. Well, I think so. Yeah.
[5:39] Ryan Martin: I was gonna say, I think, you know, people listening to this, they're like, well, you know, which camp am I in? What am I, you know, do I believe in MRI? Do I believe in ultrasound? I think a few case studies, you know, it's always warranted, right? Because there's always going to be that case where MRI came in clean, no pathology or minimal pathology. And then under ultrasound you find something right. And so I think maybe we could talk maybe one or two cases of our history, you know, anecdotal discussion of, all right, well, what have I seen from an MRI that then turned into, Hey, there was actually something there.
[6:19] Colin Rigney: Yeah.
[6:22] Colin Rigney: There, are two areas that I'll, talk about and maybe I'll just focus on one And, you know, you and I did a webinar for TOBI Networks a few months ago. One of them was on the hip and specifically the superior anterior labrum. And, you know, I used to do, still do, but I used to do a lot of work out of an orthopedic surgeon's office and had the second set of eyes from the surgeon and what went on in the OR with respect to, you know, our findings and the decision-making that went through that process to necessitated to take them there. Right. And so there was this one gal in particular who, you know, very active mid forties had, you know, cam impingement and the MRIs, you know, with contrast. And then she had a second one, 3T without contrast that were both very inconclusive slash negative with respect to a labral signal and you know just her exam everything physically clinically history subjective all those things like all things pointed to the labrum and we did a dynamic ultrasound with her and we did a lot of stressing we did FADIR impingement tests and really compress the joints looking for if we can displace any labral material out of the out of the joint line and into the capsule. And we're quite confident that we were seeing what we were seeing and compare it to the other side. And we, saw, you know, we did see labral displacement and we did see what we, what we thought was cartilage cartilaginous material coming out of the joint with these maneuvers. And if you just kept them even dynamically in a neutral position, like it, you couldn't elicit it. You had to get into flexion, internal rotation and adduction in order to make it happen. And we saw that, and this was, you know, fairly early on in my kind of career. And so like, I, this is a novel case for me. the surgeon was like, you know what, this is cool. I really liked this. I clinically, it all makes sense. let's look at the other hip and sure enough, the other hip did not elicit the same signal. And you know, the OR findings were like, it was a classic, it was a classic tear in the labrum. And so that was a case where MRI missed it and dynamic ultrasound. Now, we had to really work for it if we just kept things static. So going back toward last week's episode of dynamics and the advantage of ultrasound, we still would have been left with the same questions. But that's one in particular I go back to. And then I'm sure you have plenty of others too, Ryan. And then there's a couple others that come to my mind specifically with the rotator cuff.
[9:14] Ryan Martin: Well, I mean, one that, one that always kind of like pops into my mind was a case of athletic pubalgia. And the MRI, he did a scan, said, all right, we're seeing some displays, but we're seeing some issues in here. But the person wanted an MRI. Like, okay, well, we can get an MRI. The MRI came out negative. And so now the patient was confused, right? They're saying, well, I thought you saw something. MRI came up clean, had a reread with another radiologist said they didn't see anything specific sent to a surgeon and the surgeon found it and ended up finding that the dysfunction was between the obliques and the rectus versus that lower portion of the adductor longus and rectus and so I think one thing is it wasn't checked dynamically and I think that was the only way that I could elicit this I said that just doesn't look right at that fascial plane something doesn't look right and then this person ended up I believe going under surgery and they found it and repaired it yeah.
[10:23] Colin Rigney: Yeah. Yeah. Yeah. Back to dynamics again, right?
[10:27] Ryan Martin: So I mean and again last week we talked about the other big topic which was you know operator dependent right so if I didn't understand how to elicit you know that motion it would have looked pretty normal right and the beauty of the patient saying it hurts right here and able to point and push and put right in that spot. And I could scan right in that area. You know, these were all like helpful in determining like, oh, OK, this is this is truly, you know, the area of contention. This is what it is. Oh, OK. Whoa, wait, what is that? OK, hey, let's do that maneuver again. But it's operator dependent. You have to, you know, you have to have the ability to understand the biomechanics and patho, you know, mechanics of what's going on before you can even put the probe on. And so I think that's a big thing is with static MR, they missed it. And maybe they weren't looking here. They're looking specific for athletic pubalgia down at the adductor longus, which did on ultrasound look unremarkable as well.
[11:29] Colin Rigney: An abdominal.
[11:30] Ryan Martin: So.
[11:30] Colin Rigney: Wall tear is very difficult to find on an MRI, especially at that level. I am not, granted, I haven't done a lot of them. I haven't looked at a lot of them, but unless there's a clear delamination with fluid, I'm not sure how that would even look on an MRI, especially statically, right?
[11:53] Ryan Martin: Got it. Yeah. And I don't know, you know, I don't read MRI. but I think you're right if it's not like massive or big enough creating fluid signal you may not see it but on ultrasound I was able to pick up some sort of dysfunction between the fascial layers I said is this where your pain is and when they said oh yeah that's exactly where it is okay let's have you do a little crunch let's do this okay we ruled out direct hernia indirect hernia we looked at you know Spigelian those kind of things and we're like okay, well, those don't fit, but there's something going on here. And then the surgeon, one of the best surgeons in the nation for this, picked it up, you know, first try.
[12:35] Colin Rigney: Yeah. Yeah. And I know who you're talking about. The, I mean, that's a, that's a high level exam too. And to be able to do it with ultrasound is really the most, in my opinion, the most reliable way to pick them up. Yes. If there are, you know, on the MRI, especially with the pubic symphysis, the adductor tubercle and the conjoined tendon, all those things, like that's a pretty easy find. If, there's, if there's something there on MRI, like you can see it for sure. But, the more like vague lower abdominal quadrant, it's usually unilateral, like that stuff, you know, where I'm suspecting a posterior wall tear or a, or a aponeurotic strain, you know, to just to use that term, that's something that really only you can see with dynamic ultrasound and confirm. A very experienced surgeon like the gentleman who you're talking about and a handful of others in the country are qualified to do that without any imaging tools because of just their experience under the skin there. But by and large for the medical community, 99%. That's a very difficult diagnosis to get to without knowing your way around with the ultrasound.
[14:01] Colin Rigney: The other one that comes up to me is, you know, the 2009 De Jesus study with rotator cuff. And this was, this one compares, you know, ultrasound for rotator cuff tears, sensitivity specificity for between MRI non contrast MRA with contrast and then ultrasound and the interesting part about it was the findings were very consistent for sensitivity and specificity for any type of tear between ultrasound and non-contrast MRI. The MRA was actually a very, was a bit better than both. Okay. But I think that was just for any tear. Now with, and that doesn't really tell you, an arthrogram doesn't tell you like the type of tear very well. It just says there's a leak of fluid here and there has to be a tear somewhere. And so it's just a signal that there is something, but with respect to ultrasound and the comparison with MRI in this particular study, you know, it was able to really differentiate the location and the type of tear versus non-contrast MRI, which I thought was very interesting with, you know, obviously the operators were all consistent and reliable and had a bunch of experience, but the ability to do This at the point of care, you know, if you have it, especially when compared to sending out for something that takes time, money, copay, it's just to get that image versus it takes 10 minutes in the office right there to get the same information, you know. So that's something that really resonates with people, that when you acquire the skills to do so, it can be very impactful for your practice and very impactful for your patients and your community. And not to mention, you're streamlining the whole plan of care, the whole plan of care with your decision making and what to do next about it, right? Right. So just it's just a you know, we want to just call attention to, you know, we're not we're not taking away from MRI by any means. We are adding to we're adding another tool to the set of options we have when it comes to how we get to a diagnosis. The MRI certainly has a place for a lot of things. MRI could certainly be used in cases where maybe your ultrasound is inconclusive. and, or the ultrasound just is not the right tool, right? So they're very, they can be complimentary to each other, but I would hesitate to be overly reliant on either one, to be honest, right? You have to know which tool to use and when, right, per given situation. And so, we teach our students, we teach our clients the ACR, the American College of Radiology Guidelines, and specifically how they're updated on a yearly basis and how ultrasound fits into a lot of that. So the ability for you, the doctor, you, the clinician, to discern when and why it's appropriate is probably the most important thing out of this whole topic, right? You know, let's say you do have the, you've acquired the skills to do ultrasound, right? And you're a Jedi master. And does that mean that this is going to be the answer for all your problems? No, right? It all comes down to why are you using it? What's your clinical reasoning? What is the cost-benefit ratio and what information are you, know, are you looking to either include or exclude with the findings? So, you know, I just, I was going on there for a bit, Ryan, as you were navigating there. So just getting into, yeah, just getting into, you know, the why behind everything with respect to how we're leveraging ultrasound. And it's not a panacea for all of our all of our issues. But I think given the right circumstances, man, it's such a dynamic tool. It's such a way to streamline just everything from the point of care to the plan of care, A to Z.
[18:54] Ryan Martin: Yeah, no, I have an Arizona problem. It is my phone overheated. So, yeah, you know, like what are the chances of that, right? So my phone overheated and shut me down. So I'm back. I'm back. And hopefully I have the air conditioning blowing on my phone right now. So hopefully that's not causing a lot of like, you know, extraneous sounds on this. So anyway, so I heard most of the conversation.
[19:24] Colin Rigney: And then I was just kind of ending on my piece on that. I didn't know if you had anything else to add with respect to cases, MRI versus ultrasound, and any other things that stood out to you with your you know specifically on the topic and anything that you've come on to and recently right.
[19:45] Ryan Martin: No, but you know, that leads me into the palpation topic, you know, like how many people are really focusing on their palpation skills, which is I mean, you know, your special tests and your palpation skills. they have a definitely have a place in medicine in physical medicine you know but to be heavily reliant and say that that's going to surpass you know imaging is I think that's the debate right now is okay is imaging better than palpation is it better than you know clinical you know testing that that's been one of the questions that really comes up that I hear a lot is well I've been doing this for 30 years I don't need ultrasound whether it's for diagnostic or for interventional I think that I think that's a topic that we should kind of brush because that's gonna heat up a couple people as well my.
[20:44] Colin Rigney: Yeah my hands are history enough, right?
[20:48] Ryan Martin: Hands are history enough yeah I've heard it before.
[20:51] Colin Rigney: Yeah.
[20:51] Colin Rigney: I heard it before or you know hey I stick scopes in the joints for a living like why do I need ultrasound guidance you know You know, so this is, yeah, it, yeah.
[21:07] Ryan Martin: You know, the experience. So.
[21:09] Colin Rigney: Yeah.
[21:11] Ryan Martin: Yeah anyway no.
[21:14] Colin Rigney: It's about precision. The, you know, as our friend Dr. Buford says all the time is, you know, I'm not aware of any studies that make anyone less accurate by using ultrasound with respect to needle guidance, right? And we're in the game of being as precise as possible. This is a, we're talking about needle-guided procedures, specifically in the orthobiologics area, arena, and precision is the most important lever in this whole thing. This is not like a surgery, right? When you compare it to a surgery, it's certainly more barbaric, right, in comparison, where you're demolitioning, you're violating a lot of tissue to get the job done, and you're sewing it up on the way out, and there's a whole healing cascade that's entirely different than being as precise as possible to violate as little tissue as possible with an orthobiologic and sometimes doing it through multiple needle punctures, right, if there's more than one structure you're trying to address, and avoiding collateral damage, if you will, with anything else, because again, you're looking to really address just two or three things as part of that treatment process, right? And in image guidance, whether, you know, ultrasound, obviously this is an ultrasound focused talk, so it's a big deal, right? And dynamically to be able to see what you're doing in real time while avoiding structures that you're trying to miss, like you're not trying to address, you know, that's something that you can really only do with ultrasound.
[23:01] Ryan Martin: I heavily agree with that heavily agree with that. So how do we, how do we create more awareness around that with physicians or clinicians, physical therapists, you know, that are heavily reliant on their special tests? How do we have the conversation with them to at least, you know, consider bringing in ultrasound? Like, how do we, how do we bring that up?
[23:29] Colin Rigney: Yeah. I mean, ultrasound, again, it goes back to, this is not the answer, guys. This is an extension of a clinical brain. This is a flashlight. You already know there's special tests. You already know how to palpate. You already know anatomy, right? This is just going to make you better. And it's going to allow you to see what's going on underneath the skin where you know where things are, right? And so why would you not want that information? That's my question. I would answer that question with a question as far as why would you not want that data? Whether or not you choose to do anything about it, right? Is that still like, is that not valuable, right? So some of the best, one of the best doctors I ever worked with was an orthopedic surgeon doing ultrasound. And to watch him use the machine, use the transducer, like he would use that transducer just like he would make a scalpel, like a cut with his scalpel. And like he knew exactly where the tissue was. He knew exactly the cut he was going to make. And he would literally just precisely put the transducer in that on the right, on the area where it was, if it was a UCL, if it was a common extensor, if it was a supraspinatus, whatever it was. And his offhand was always palpating and guiding his probe hand with how he would manipulate based on where he knew the anatomy was underneath the skin. And so he was getting all this information, assimilating all this data in real time with his clinical brain, because he's been underneath skin and scopes, and he knows it cold, but prior to making the decision, he's taken in all this data that's non-invasive and just allowing that to help him make the best decision in conjunction with the patient, right? So I think the awareness piece is, I think, coming back with the question again of why would you not want that information? And I think this is probably a good thing would be to bring on more people to with other kind of ways to explain it or give awareness you know on the show some of the doctors we work with and have them explain their perspective because everybody has a different journey that everybody took a different journey to get where they're at today some started with resistance some took time right and you know Sometimes that's the voice you need to hear when it comes to meeting people where they're at.
[26:15] Ryan Martin: Perfect. I love it. I think that's a good place to kind of simmer this one down shout out to Jason obviously shout out to you appreciate all of this is super fun yeah.
[26:27] Colin Rigney: Absolutely, yep. We're just getting started, man.
[26:30] Ryan Martin: Absolutely well I gotta head in got more patients to see I'll catch you all later.
[26:36] Summit ad: Ten years ago an ultrasound unit cost $20,000 or more now you can run one off your phone so the question isn't whether you'll scan it's what you'll do with it next. I'm Colin Rigney. I'm Ryan Martin. At AMSKU, we teach clinicians musculoskeletal ultrasound. On Saturday, December 5th, we're bringing the field together for the AMSKU Annual Global Summit. One day of MSK ultrasound and orthobiologics, fully online. No flights, no hotel, no closing your clinic. The whole day is built around four questions. Where does AI fit in ultrasound diagnosis. What's next in orthobiologics and regenerative medicine? Where does point-of-care ultrasound go from here? And what does the practice of the future look like? Dr. Don Buford, Dr. Scott A. Sigman, Dr. Marc Pietropaoli, Dr. Ariana DeMers, and many more. Three tracks, and every session has Q&A, so you can ask them yourself. Last year, clinicians joined us from five continents. Every session is recorded, so you keep it. The best moment in teaching is when the image clicks and you stop guessing. Train your eye, trust your hand. Tickets are at summit.amsku.com. Early bird tickets are available until October 24th. The next decade starts in your hands. AMSKU, AGS 2026.
[28:03] Narrator: An Advanced MSK Ultrasound Center podcast. From probe to practice. Hosted by Ryan Martin and Colin Rigney. Produced by Jason Kitza at NGG, needgraders.com. If you want to watch the playback from last year's annual global summit, or if you'd like to register for this year's annual global summit, visit summit.amsku.com.
