Margit Kooijman

MSU | 65 of the practices MSU was offered, mainly with the intention to improve diagnosis. Most practice owners seem content with their decision since nine out of ten would make the choice for MSU again. Data on this topic is scarce but research in Australia shows that requests by GPs for diagnostic shoulder ultrasonography are on the rise 15,16 . The participating MSU physiotherapists in the second part of the study indicate that by far, MSU is most frequently used in patients with shoulder complaints. The most frequently mentioned perceived advantage is that MSU helps them to make a better diagnosis. In new patients with shoulder complaints, MSU is more often used than in general patient population and ideally, many responding MSU physiotherapists think it should be used in all new shoulder patients. This finding supports our observation that in this specific group of patients, responding physiotherapists often seek assurance to improve their diagnosis and/or treatment by using MSU. Apparently, this applies to other clinicians as well since MSU physiotherapists receive relatively many requests from colleagues and GPs for these patients. A quarter of MSU physiotherapists did not examine these referred patients themselves by means of history and physical examination. It is not known to us what pre-existing information the responding MSU physiotherapists would have possessed among their patients, although research amongst Australian GPs indicates that around a third of the MSU requests did not contain any additional information for the radiologist 17 . Since supposed pathology in MSU findings may be asymptomatic, especially in patients over 60 years old, this lack of information could undermine the security that is looked for 18 . Even more so because it has been suggested that MSU is most effective when linked to history and clinical examination by the same clinician 15 . Radiologists do not examine patients themselves but MSU physiotherapists can, hence the profession could actually change this ‘problem’ to their advantage. Responding MSU physiotherapists themselves stated that dealing with inconsistent findings from MSU and physical examination is difficult. It is the biggest disadvantage from their point of view. This also shows in the diverse strategies they indicate they practice when it happens; some trust the results from MSU, others rely on clinical examination or discuss it with a colleague or GP. This might also explain why MSU physiotherapists more often and more specifically refer patients back to their GP. Whether this eventually leads to an increase or decrease in requests for care and associated costs is a legitimate question for further research. It is known that MSU is a valid and reliable method to identify full- and partial thickness tears of the tendon if performed by radiologists and/or orthopaedic surgeons, there is only limited evidence for tendinopathy, calcification and bursitis 1,19,20 . The first, small sample reliability study amongst physiotherapists in primary care indicates that there is slight to moderate agreement between MSU physiotherapists and radiologists and moderate to substantial agreement between MSU physiotherapists mutually, although both vary depending on pathology and experience 21 . It was also concluded that this was relatively low compared to reliability between radiologists. In their study on opinions on use of MSU in primary care, Scholten-Peeters et al. (2013) found that