Break the cycle of pain and MSDs in sonography

Awkward postures lead to MSDs

Standing in an awkward posture, reaching across a patient, pressing on a transducer, twisting to look at a monitor — the daily tasks of sonographers put them at risk of musculoskeletal injury.

In fact, some 84% of sonographers suffer from pain, according to a 1995 survey of 3,000 sonographers in the United States conducted by the Health Care Benefit Trust of Vancouver/British Columbia.1 Although sonographers represent a small portion of the health care work force, the potential for costly, career-ending injury is high. Hospitals are now trying to address these injuries with changes in equipment, training, and scheduling.

"These people have years of pain and discomfort while they're scanning," says Joan Baker, MSR, RDMS, RDCS, FSDMS, a former sonographer and director of global marketing for Sound Ergonomics, a consulting firm based in Kenmore, WA. "They ignore it until it gets to the point where they cannot ignore it — for example, when the hand will no longer hold on to the transducer and the pain is excruciating."

For an individual hospital, musculoskeletal disorder (MSD) injuries may mean the loss of valuable employees. At Baystate Health in Springfield, MA, safety director John Murray, CHMM, CSP, CIH, became alarmed when seven sonographers suffered significant injuries in 2003.

"Sonographers are very, very difficult employees to recruit," he says. "We need to keep the ones we've got healthy."

Meanwhile, the length of time for each scan has been decreasing, a trend influenced by financial pressures and improved technology. This often means more scanning and fewer breaks for sonographers, says Baker, "often causing more pain and discomfort, which may eventually leat to a career-ending injury."

Look for multifaceted solution

There's no single answer to the ergonomic issues of sonographers, no one piece of equipment or change in practice that will eliminate the risk. Rather, hospitals need to evaluate the work environment and seek individualized solutions, says Baker.

For example, the sonographer's arm should not be more than 30 degrees abducted from the body. However, during scans, sonographers are often 70 to 90 degrees abducted. The strain and fatigue from maintaining that position can lead to shoulder and neck injuries, Baker says.

Overreaching and exerting pressure while in a static posture also can lead to pain, strain, and injuries. "If you have a multifaceted problem, you're going to have a multifaceted solution," she says.

At Baystate, Murray worked with Sound Ergonomics to implement changes in technique, as well as to adjust equipment. For example, the hospital purchased arm rests and repositioned equipment as much as possible. Ergonomists helped the sonographers adopt a better posture while scanning. As the ultrasound equipment is updated, the hospital will seek adjustable units that have ergonomic features, he says.

Ideally, the sonographer should have an adjustable chair and the patient should be on an adjustable exam table, says Baker. An office-style chair isn't suitable; the chair should be high enough so the sonographer can keep his or her arm by his or her side. Adjustable ultrasound equipment also is available, with a separate monitor and keyboard that can be situated for ease of use. Lighter, balanced transducers also reduce the risk of repetitive wrist strain, Baker says.

"One of our big interventions was the almost complete elimination of bedside sonography," says Murray. The hospital beds were typically too wide or too low for the sonographer to achieve a comfortable position. Now, those bedside exams are used only when there is "an end-of-life issue or a person who is substantially encumbered with traction equipment," he says.

With the changes, Baystate experienced just one sonography injury in 2005 and one so far in 2006.

Redesigning the schedule

Schedule changes provided important relief as part of an injury prevention program at Kaiser Permanente/Colorado in Denver. Through a labor management partnership, employees and supervisors worked with a facilitator to conduct a root-cause analysis of the sonography injuries and brainstorm solutions.

One finding: Sonographers were skipping breaks to extend their lunch period. Sonographers also said they sometimes didn't have enough time to complete the exam as well as paperwork and other assigned tasks.

"We decided to redesign the master schedule," says radiology director Don Rueschhoff, MA, RT. "I talked to them about how much time they needed. We came up with a schedule with one less patient but more break times.

"We had to add additional sonographers and one more machine to make up for the difference. We were willing to do that because it keeps everybody on the job longer," he says.

Wrist and shoulder injuries were most prevalent among the sonographers, Rueschhoff says. By videotaping the sonographers at work, ergonomists helped them adjust their posture and add support cushions.

Giving them more time

Longer exam times give sonographers time for stretching in between patients. And a supervising sonographer manages the schedule and observes sonographers to maintain a focus on safety.

Buy-in from employees and a trusting environment helped lead to lower injury rates, says Rueschhoff. Last year, there was just one injury among the 14 sonographers.

"Were trying to influence a very open and honest environment," he says. "[We tell them,] 'Let us know if you're in pain.'"

It's important to address the pain and discomfort, Murray agrees. "Don't wait. When these issues start to crop up, you have to act on them rapidly."

(Editor's note: More information on ergonomics and sonography is available on the Sound Ergonomics web site,


1. Pike I, Russo A, Berkowitz J, et al. The prevalence of musculoskeletal disorders and related work and personal factors among diagnostic medical sonographers. Journal of Diagnostic Medical Sonography 1997; 13:219-227.

Best practices to reduce MSD injuries

The Plano, TX-based Society for Diagnostic Medical Sonography developed industry standards, including these best practices for sonographers, at a consensus conference in May 2003. The standards are available at

1. Minimize sustained bending, twisting, reaching, lifting, pressure, and awkward postures; alternate sitting and standing and vary scanning techniques and transducer grips.
2. Adjust all equipment to suit user's size and have accessories on hand before beginning to scan.
3. Use measures to reduce arm abduction and forward and backward reach to include: instructing the patient to move as close to the user as possible, adjust the table and chair, and use arm supports.
4. Relax muscles periodically throughout the day:
    a. Stretch hand, wrist, shoulder muscles, and spine.
    b. Take mini breaks during the procedure.
    c. Take meal breaks separate from work-related tasks.
    d. Refocus eyes on distant objects.
    e. Vary procedures, tasks, and skills as much as reasonably possible.
5. Use correct body mechanics when moving patients, wheelchairs, beds, stretchers, and ultrasound equipment.
    a. Correct body mechanic guidelines are available from employers or regulatory bodies.
6. Report and document any persistent pain to employer and seek competent medical advice.
7. Maintain a good level of physical fitness in order to perform the demanding work tasks required.
8. Collaborate with employers on staffing solutions that allow sufficient time away from work.