SMUG Senior Lecturer in MSK Ultrasound - Mark Maybury

April 18, 2019

1. Where do you work?

Good Hope Hospital, Heart of England NHS foundation Trust Sutton Coldfield

2. What qualification do you have?

I have achieved a MSc Neuromusculoskeletal Health Care, BSc (Hons) Sports Science, BSc (Hons) Physiotherapy, PgD Biomechanics and Independent Prescriber. Specifically in MSK Ultrasound I have a Post Graduate Diploma.

3 When and why did you first get involved in diagnostic ultrasound?

I first got involved in MSK ultrasound in 2005, as I was interested in using it to accurately guide injections of hyaluronic acid for patients who were suffering from mild to moderate OA knee. At the time, I was involved with Orthopaedic Triage Clinics in secondary care and was seeing increasing numbers of patients with minor degenerative knee complaints, all keen to have arthroscopy who had not faired too well with physiotherapy. Injection of HA offered an alternative minimally invasive treatment aiming to reduce the burden on Orthopaedics Triage, but the product was best administered using fluoroscopy guidance.  The lead A & E consultant who was also a sports physician, suggested that using ultrasound may be a way of providing this service outside of a theatre environment, and in an OPD setting it was a simple and very easy procedure to carry out. I thought that's a good idea and when I looked into this further, ultrasound offered a cheap, free from radiation alternative. When I explained this idea to the radiology department (to their horror that a physiotherapist might actually do this) they suggested that I might want to learn how to do this properly and encouraged me to train in ultrasound. However, sadly, they were unable to offer any training with the then manager saying ‘over my dead body’.

4. How many years have you been scanning?

12 years and counting, and as for the radiology manager… I now scan for her!

5. What is your favourite machine and why?

I don't have a favourite machine as such, as I view US scanners as tools to do a job, and I pick the machine to use based on the job I need to do.  So, if I’m teaching or travelling between sites I use a portable system. If I’m at work in department I use a cart-based system.  I do like GE’s but I wasn't a great fan to start with preferring the Seimens Antares and Philips iU22. However, when I first saw and used a GE Logiq-e I changed my mind.  I am fortunate enough to use one of 2 GE S8’s in the Physiotherapy Department, and an E9 (or Toshiba Aplio 500 depending on the site I'm working at) in radiology when I work as a Sonographer. I like the workflow on the GE’s as they are easy to use, and this is standard across their range in the Logiq family. Nevertheless, there are many great scanners coming on to the market, and as time progresses so does the development of ultrasound technology. Ask me again in a few years!

6. What are the key features you look out for when choosing a machine?

Good resolution and a sensitive power Doppler, and if serious about MSK, then the must have feature I would have to have, would be extended field of view.  This is incredibly useful to show relationships of tears to other non-ultrasound savvy professionals.

7. What is the most technically challenging area to scan in MSK medicine and do you have any top tips to cope with it?

The technically challenging areas are the ones you don't scan frequently, and the areas that ultrasound has limitations based on the nature of the modality, for instance the deep rotators of the hip and deep structures of the knee. I also think that this is contextual and dependent on your level of experience, and what you get asked to scan. Top tips in learning to scan these regions for me has to be anatomy, anatomy, anatomy….oh and a good MR anatomy book!!

8. What are the common mistakes you see beginners making?

There are quite a few, how to hold a probe, not reducing cable length, pressing too hard, getting the image centered on the screen and maintaining a centered image, image falling off the edge of the screen, setting the depth control either two deep or not deep enough to get an adequate image, not getting the underlying bone as bright as possible or sharp as possible, being oblique on structures, and not purely transverse or longitudinal, not tilting the probe enough to maintain parallel orientation of probe to target tissue. All of these are correctable, but needs practice, so let me qualify this, its not just practice, its perfect practice.  If you repeat poor technique time and time again, its perfectly poor. What you want is to practice perfectly, and this takes time, and working with people who are exemplars of the technique.

9. Do you have any advise for those just starting out with ultrasound?

Be patient and do not be too hard on yourself, if you don't get it first time don't worry or panic as it's a motor skill and requires time and effort along with acquiring pattern recognition skill to develop in this fascinating and highly addictive discipline. Plan time to practice every day even if it's only a couple of minutes, it's better than nothing.

If you don't have a machine, beg or borrow until you get one. Get a supervisor, this is often a big stumbling block for all interested in MSK US (physiotherapists, Sonographers and sports physicians even some radiologists alike) and it's really difficult. The SMUG mentorship is a great solution to this problem. You can try and watch YouTube videos, read books, but there’s no real substitute for having someone sit on your shoulder saying “move your probe this way…” in the early days we would say on a course of 20-30 people the drop-out rate was quite high, now with more availability and the higher profile of ultrasound scanning, I would say never give up and think laterally to achieve your goal, as it can be done. I honestly could not go back to being a MSK practitioner without my ultrasound machine next to me.

10. Do you have any key books or online resources that you recommend?

Musculoskeletal ultrasound by Carlo Martinoli and Stefano Bianchi is my must have book, it's quite old now, and it's an imposing text book which will frighten beginners off (along with its price tag), but it's an incredible piece of work, and will take some beating. If the size of that book puts some people off, then the fundamentals of musculoskeletal ultrasound by Jon Jacobsen is a good start, and is less imposing. If you want to go cheap (free) well I don't think you can beat the ESSR guidelines on MSK ultrasound.

Mark regularly teaches on all of SMUG courses and is a real asset with a wealth of experience and knowledge.

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