Musculoskeletal ultrasound is often a safer,1,2 more effective,3-5 economical,6-8 and accurate9-14 imaging modality compared to X-rays, MRIs and CT scans for diagnosing and treating acute and chronic neuromusculoskeletal conditions. Ultrasound-guided needling may also be a safer,15 more effective,16,17 and precise18,19 intervention for the treatment of some musculoskeletal conditions compared with manual palpation-guided needling interventions.
STATE PRACTICE ACTS AND THE USE OF MUSCULOSKELETAL ULTRASOUND IMAGING
Most physical therapy state practice acts include the use of sound, physical agents/modalities, but fail to mention language specifically related to the use of diagnostic ultrasound or musculoskeletal ultrasound for the purpose of real-time imaging scans. Notably, New Mexico does not exclude physical therapists from performing musculoskeletal ultrasound imaging.20 Arizona21 and Louisiana22 have explicitly included musculoskeletal ultrasound within the scope of physical therapy practice. New Mexico, New Hampshire, North Dakota, and Oregon have Medical Imaging Boards which may require physical therapists to take additional training to gain recognition on the imaging registry of their respective state.
EFFECTIVENESS OF ULTRASOUND-GUIDED DRY NEEDLING FOR MUSCULOSKELETAL CONDITIONS
Ultrasound-guided dry needling provides a cost effective and precise needle placement (i.e., insertion point, angulation, depth, target tissue) procedure for physical therapists; furthermore, this may increase the efficacy of treatment and minimize the risk of inadvertent injuries to neurovascular structures during dry needling.23,24 Ultrasound-guided dry needling has been found to be an effective therapeutic approach for the management of chronic pain,25 Achilles teninopathy,26 knee osteoartiritis,16 patellar tendinosis,27,28 supraspinatus tendinopathy,29 piriformis syndrome,23 lateral epicondylosis,30 chronic regional pain syndrome,31 myofascial trigger points,32 post mastectomy pain,33 and trigeminal neuralgia.34
NORTH CAROLINA BOARD OF PHYSICAL THERAPY OPPOSES USE OF MUSCULOSKELETAL ULTRASOUND FOR DIAGNOSIS OR FOR GUIDING NEEDLING PLACEMENT
In June 2023, the North Carolina Board of Physical Therapy Examiners (NCBPTE) issued a declaratory position statement claiming the use of musculoskeletal ultrasound for diagnostic purposes or for guiding needle placement during dry needling is not currently within the scope of physical therapy practice, and clients receiving this technique should not be advised or led to believe they are receiving physical therapy.35 It is almost certain that the NCBPTE will find themselves on the wrong side of history on this issue.
Notably, the 2023 position statement issued the NCBPTE is a reconsidered response from 2019 and is based on information from subject matter experts in North Carolina, CAPTE-accredited DPT programs, and scholarly sources on musculoskeletal ultrasound. Board Rule 21 NCAC 48C.0101 PERMITTED PRACTICE states (a) “Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.”35 In summary, research by the NCBPTE determined only one of the six CAPTE-accredited DPT programs in North Carolina that responded to the Board inquiry offer instruction beyond “introducing” or “mentioning” musculoskeletal ultrasound in their curriculum. However, none of the six DPT programs in North Carolina offer coursework or hands-on training in musculoskeletal ultrasound imaging.
FEDERATION OF STATE BOARDS OF PHYSICAL THERAPY REQUESTED ULTRASOUND IMAGING BE DELETED FROM NATIONAL PHYSICAL THERAPY EXAM CONTENT
Additionally, the Federation of State Boards of Physical Therapy (FSBPT) 2022 Practice Analysis Report from HumRRO concluded that ultrasound imaging of the musculoskeletal system (and other systems as well) be “selected for omission from the National Physical Therapy Exam content outline.” Results from the 2022 Practice Analysis Report were “very similar” to the 2016 report. Lastly, while musculoskeletal ultrasound imaging can be found in continuing education offerings, it is often not the primary subject matter taught.35 Notably, NCBPTE did state if new or additional information is provided to the Board regarding where musculoskeletal ultrasound imaging is taught in entry-level DPT programs or continuing education courses, and is “routinely” practiced by physical therapists, then the NCBPTE board will review the new information and make a determination.35
The decision made by the North Carolina Board of Physical Therapy Examiners and the content of the FSBPT 2022 Practice Analysis Report is contradictory to a 2009 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) position statement which states, “It is the position of the AAOMPT that ultrasound imaging is within the scope of physical therapist practice.”36 It is also contrary to a 2010 FSBPT Rehabilitative Ultrasound Imaging Resource Guide that concluded “there is a historical basis, available education and training as well as an education foundation in the CAPTE criteria, and supportive scientific evidence for including rehabilitative ultrasound imaging in the scope of practice of physical therapists.”37 Moreover, the position taken by the North Carolina Board of Physical Therapy is contrary to the 2016 APTA Orthopaedic Section imaging resource guide that noted, “Procedural ultrasound in PT practice encompasses many interventions that include but are not limited to patient biofeedback, neuromuscular re-education, monitoring real-time changes in morphology and movement during interventions, documenting change in clinical conditions, using ultrasound to localize target area for manual interventions and physical agents, and using ultrasound to guide needle placement in procedures such as dry needling and electroneuromyography.”38,39
PHYSICAL THERAPISTS ARE QUALIFIED TO USE & INTERPRET DIAGNOSTIC MUSCULOSKELETAL ULTRASOUND EXAMINATIONS
In November 2017, the American Institute of Ultrasound in Medicine (AIUM) and Alliance for Physician Certification & Advancement (APCA) added physical therapists to the list of healthcare professionals (MD, DO, DDS, DC, PT, NP, PA) who are qualified “evaluate and interpret diagnostic musculoskeletal ultrasound examinations.” Therefore, since 2017, physical therapists have been one of 7 healthcare professions that are permitted to earn the Registered Musculoskeletal Sonography Certification (RMSK).40
MUSCULOSKELETAL ULTRASOUND EDUCATION & RMSK CREDENTIALING
The American Institute of Ultrasound in Medicine (AIUM), Inteleos, and the American Physical Therapy Association (i.e., the Academy of Orthopaedic Physical Therapy & Imaging Special Interest Group) are working cooperatively to expand the expert utilization of diagnostic ultrasound in physical therapist practice. One facet of this initiative involves establishing an educational track aligned with the prerequisites for obtaining the RMSK credential. The outlined cooperative agreement, endorsed by all three organizations, highlights their joint commitment: “The APTA, AIUM, and Inteleos are committed to a collaborative effort to support the education, performance, certification, and accreditation of physical therapists and their practices in the field of musculoskeletal ultrasound. A structured pathway of education and training will provide physical therapists with opportunities to advance their proficiency. By successfully completing the pathway, they can earn the RMSK certification and improve their practice’s eligibility for AIUM practice accreditation. The combined effort of APTA, AIUM, and Inteleos will help bridge the gap for physical therapists in their pursuit of individual competency and practice accreditation.”41
Although the RMSK credential is not required for use of musculoskeletal ultrasound in clinical practice, physical therapists earning the RMSK credential will find it easier to get reimbursed by third-party payors with this credential.42
CONCLUSIONS
Musculoskeletal ultrasound imaging, once confined to radiology departments, has seamlessly integrated into the scope of practice for physical therapists, offering a non-invasive, radiation-free, and dynamic solution to enhance diagnostic accuracy and ensure patient safety. Physical therapists equipped with this skill are better positioned to integrate real-time imaging with the history and physical examination findings to more accurately diagnose acute and chronic musculoskeletal conditions, identify the precise location of tissue abnormality, quantify the level of tissue damage and healing over time, and provide more informed prognoses and precise intervention strategies for best practice.
AUTHORS
James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL
Casey Charlebois, PhD(c), DPT, MSc, FAAOMPT, Dip. Osteopractic
Director of Clinical Research, AAMT Fellowship in Orthopaedic Manual Physical Therapy
PhD Candidate, Nova Southeastern University, Fort Lauderdale, FL
Paul Bliton, DPT, OCS, SCS, FAAOMPT, Dip. Osteopractic
Associate Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
William S. Middleton Veterans Hospital, Madison, WI
Patrick Gorby, DPT, MPH, FAAOMPT, Dip. Osteopractic
Assistant Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Gorby Osteopractic Physiotherapy & Wellness, Colorado Springs, CO
James Escaloni, DPT, OCS, FAAOMPT, Dip. Osteopractic, RMSK
Senior Instructor, AAMT Fellowship in Musculoskeletal Sonography
Senior Instructor, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Wellward Regenerative Medicine, Lexington, KY
Ian Young, DSc, OCS, SCS, Dip Osteopractic, RMSK
Senior Instructor AAMT Fellowship in Musculoskeletal Sonography
Senior Instructor AAMT Fellowship in Orthopaedic Manual Physical Therapy
Tybee Osteopractic & Wellness, Tybee Island, GA
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OSTEOPRACTIC 