Real-Time Ultrasonography:

Seeing is Believing!

Anyone who has ever had an X-ray or MRI knows that the images from those procedures are still shots, taken while the patient is immobile. But the human body is a living moving organism, and pain often manifests during physical activity.

What if there was a way to see inside the body to observe the muscles and joints in motion, while simultaneously getting feedback from the patient?

Real-time ultrasound imaging (RUSI) offers just such technology. It is a valuable diagnostic tool for visually observing musculoskeletal structures, including muscles, tendons, ligaments, joints and bursae as they interact in real-time, in ways the patient would normally use them.

History of Ultrasonography

Ultrasonography has been in use for decades, and most mothers who have given birth since the 1980s have been exposed to it during pregnancy. As the technology advances, the images have become clearer and details more visible, enabling us to see the sex and facial features of unborn infants.

The roots of ultrasound go back as far as the late 19th Century, when Pierre Curie discovered piezoelectricity in 1877. The technology did not receive much attention until WWI, when the French government commissioned Paul Langevin, one of the Curie brothers’ students, to develop it to detect enemy submarines. His work formed the basis of sonar, which was widely used in WWII.

In the 1920s and 30s, ultrasound was used for physical therapy for members of European soccer teams, and in the 1940s it was used for everything from arthritic pains to gastric ulcers and eczema. As the technology advanced, uses for medical treatment grew, and the 1970s heralded a sonic boom as ultrasound was enhanced by Doppler to detect cardiac blood flow.

Advent of Real-Time Ultrasonography

Real-time ultrasound imaging (RUSI) started to appear in the early 1980s, and by the1990s, 3D and 4D images were clear enough for the public to interpret, and were enhanced by color. Early iterations of the technology required large scan heads and heavy cables, making the equipment cumbersome and immobile. Today, some ultrasound equipment is so compact that it can be carried to patients on a battlefield or used by astronauts in space.

Advantages of RUSI

Since the 1980s, the use of RUSI for diagnosis and treatment of musculoskeletal injuries has continued to grow, as real-time ultrasound has numerous advantages over other imaging technologies like X-ray, MRI and CT scan:

  • Non-invasive
  • No radiation exposure
  • Easy to use and control
  • Compact
  • Portable
  • Low cost
  • Safe
  • Shows real-time images in motion
  • Provides instant quantitative feedback

How does RUSI Work?

During a RUSI session, a water-based gel is applied to the area being examined. A small transducer, or probe, is placed directly on the skin and transmits high-frequency sound waves through the gel into the body’s tissues. Sound waves are then reflected off the tissues. Because different tissues have different densities, the sound waves reflect back at various rates, making it possible to distinguish one type of tissue from another.

The transducer collects the sounds that bounce back, and a computer then creates images that are displayed on a screen. Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s muscles, joints, internal organs, and even blood flowing through blood vessels.

Using RUSI, your therapist is able to observe the movements of your muscles as they occur and determine whether they are functioning correctly. The therapist can observe different layers of muscles contracting and relaxing, can look at the timing and size of muscle contractions, and can even see fatty tissue within your muscles.

RUSI is used in conjunction with an integrated total body assessment to diagnose muscle dysfunction. Feedback from RUSI can then be used to retrain muscles to perform optimal contractions. Images of a normal functional contraction can be compared to a patient’s dysfunctional muscle contraction so they are better able to understand the deficiency and how to correct it.

Who can benefit from real-time ultrasonography?

The vast applications of RUSI are growing daily, both for diagnosis and treatment. Patients with acute injuries, overuse syndromes, gait and performance deficiencies, and chronic diseases can all benefit from RUSI.

Physical therapists can use RUSI to provide quick diagnosis and perform muscle re-education through visual feedback in a variety of patients, including:

  • Athletes
  • Runners
  • Dancers
  • Fitness enthusiasts
  • Patients with pelvic instability
  • Sufferers of low back pain
  • Patients with heel pain
  • Patients with shoulder pain and stiffness
  • Older adults with balance and joint issues
  • Women recovering from C-section
  • Post-partum females with diastasis recti
  • Patients with rheumatoid arthritis

Virtually anyone who suffers from muscle and joint pain, dysfunction or instability can benefit from RUSI.

RUSI and Physical Therapy Treatment

RUSI allows your therapist to examine the function of specific muscles. It is often used to view the core muscles of the trunk that function to stabilize and protect your spine. RUSI is frequently used for pelvic floor rehabilitation to alleviate low back pain and correct its underlying causes. Retraining of deep trunk muscles improves their function, reducing low back pain and disability, and reducing the risk of recurrence.

Muscles can be difficult to reactivate after injury or surgery, especially those muscles that are deep, weak and small. RUSI allows the therapist to clearly display muscles on a screen, to show a patient how the muscles are working. RUSI feedback allows the patient to learn to control these muscles again in the most functional way.

Dynamic Ultrasound imaging enables physical therapist to quantify and qualify the patient’s motion potential. It thus facilitates treatment planning for the impaired motion. It can provide objective measurement of structures on clinical examination, to confirm or question the results of the usual clinical tests. Monitoring the progression of sonographic signs helps assess the effectiveness of physical therapy , ensuring a treatment plan optimally adjusted to the patient. Dynamic ultrasound imaging, associated to clinical tests, improves the choice of therapeutic strategy following initial work-up and helps guarantee the appropriateness of the treatment.


At NYDNRehab, we routinely incorporate RUSI into our diagnosis and treatment of a host of deficiencies and impairments. Used in conjunction with other cutting edge technologies like CAREN, our expert physical therapy team is able to accurately diagnose and effectively treat a broad range of conditions without surgery or other invasive procedures.

Our goal at NYDNRehab is to get to the source of your pain or disability and provide corrective strategies to restore optimal function. While many healthcare providers focus on treating your symptoms, we are dedicated to eliminating them by eliminating their underlying causes.

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