Table 4.

key considerations regarding education and competency assessment

Educational elements	Relevance to scope of practice	Teaching and assessment considerations
1. Ultrasound image generation, includes: • Fundamental physics as applied to ultrasound • Artefacts and how to manage/interpret them	MSK USI PoCUS users require an awareness of: • Sonographic representation of different MSK tissues • Limitations of sonographic image generation	Assessment strategies should evidence the application of knowledge to musculoskeletal scenarios
2. Image optimisation, includes: • The function of ultrasound machine settings (relating back to fundamental physics principles) • ‘Knobology’ and application of image optimisations strategies in practical scenarios • Probe handling techniques	Image optimisation techniques are essential for high quality imaging practice and allows for adaptation to different ultrasound machines and clinical scenarios	Phantoms, simulators and healthy subjects may have a role in the initial teaching strategies
3. Safety and professional considerations, includes: • Ultrasound system’s quality assurance e.g., application of ALARA (As Low As Reasonably Achievable) principles • Infection prevention and control • Use of evidence based protocols; taking and labelling of standardised views • Documentation/reporting terminology • Secure storage of images and integration with electronic patient records • Awareness of benefits and limitations of USI and role of other imaging modalities • Indications for performing a scan; includes informed patient consent	Safety considerations include those generic in ultrasound imaging and others specific to MSK scanning Standardised image taking, recording and documentation allow for consistency with other ultrasound imagers As professionals without a pre-existing foundation in imaging, awareness of the indications for, and the role of imaging modalities is essential Establishing governance procedures e.g., methods of communicating with other clinicians and optimising service provision are required	Assessment may include knowledge-based approaches e.g., written coursework but evaluation of professionalism and safety must be components of clinical competency examination
4. Imaging of ‘normal’ anatomy, includes: • Standardised protocols to identify ‘normal’ anatomy • Implementation of patient specific adaptations in response to: o Patient habitus o Patient pain o Patient’s restricted mobility o Other clinical data e.g., patient’s functional problems, physical examination findings o Identification of tissue changes within MSK system	Awareness of the range of ‘normal’ presentations provides a reference for identifying deviations from normal Provides an opportunity to familiarise self with strategies for addressing sub-optimal imaging prior to moving onto imaging patients Incidental findings, normal variants, age appropriate MSK tissue changes must be identified	Initial learning on healthy subjects often provides opportunity to promote professional discussion e.g., the role of MSK USI can be debated when changes in MSK tissues are witnessed in peers who have no symptoms or symptoms have resolved Learning and assessment must develop to the clinical environment with symptomatic patients
5. Integration and relevance of USI into patient’s assessment and management • Awareness of the range of sonographic presentations associated with different pathologies/clinical scenarios. Where applicable, how to perform a differential sonographic diagnosis • Clinical relevance (or otherwise) of sonographic findings, including false + ve/-ve and symptomatic versus asymptomatic structural pathology • Integration of imaging into biopsychosocial framework	An awareness of how to interpret the imaging findings, implement them into clinical decision making/treatment should be underpinned by good knowledge of musculoskeletal presentations and typical management pathways The wider impact of the imaging modality includes considering communication to patients that will facilitate understanding of their condition, prevent catastrophisation through inappropriate language whilst optimising the therapeutic alliance	Learning and assessment in clinical environment needed. Requires a range of different pathologies/clinical presentations Essential requirements include availability of suitably qualified and experienced mentor, access to an appropriate patient mix and directly supervised scanning A clinician is not competent if tissue changes have been correctly identified from USI but the clinician is unable to frame them in the overall presentation