Ultrasound Obstet Gynecol 2006; 28: 204–206
Published online 5 July 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.2800
The hazards to practitioners of obstetric and gynecological
ultrasound
R. HACKMON*†, E. SHEINER‡, Y. BARNHARD†, R. BEER‡ and I. MEIZNER*
*Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tiqva and ‡Department of Obstetrics and Gynecology, Faculty
of Health Sciences, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel and †Department of
Obstetrics and Gynecology, Lenox Hill Hospital, NYC, NY, USA
K E Y W O R D S: back pain; hazards; joint pain; obstetrics and gynecology; ultrasound
ABSTRACT
Objectives To investigate the specific complaints of
physicians and technicians performing obstetric and
gynecological ultrasound.
Methods This was a cross-sectional retrospective survey.
Questionnaires were distributed to members of the Israeli
Society of Gynecological Ultrasound, including questions
on gender and profession, number and type of scans
performed, pain related to profession and any therapy
undergone. Statistical analysis included chi-square or
Fisher’s exact test, Student’s t-test, Pearson’s correlation
coefficient and logistic regression.
Results Joint pain was reported by 51.7% (30/58) of
the technicians compared with 25.3% (19/75) of the
physicians (P = 0.002). It was more common in females
than in males (P = 0.05) and it was more common
among those who performed transabdominal sonography
more frequently than they did transvaginal sonography
(P = 0.004). There was a significant association between
performing transabdominal ultrasound and back pain
(P = 0.05). Although females reported pain more fre-
quently, the rate of surgical procedures was higher among
males (P < 0.05).
Conclusions A technician is 3.5 times more likely to
report joint pain than is a physician. Transabdominal
sonography is a risk for both joint and back pain. There
may be gender differences in pain perception. Copyright
 2006 ISUOG. Published by John Wiley & Sons, Ltd.
INTRODUCTION
Sonography as a modality in modern medicine has
made an immense beneficial contribution as both a
Correspondence to: Dr R. Hackmon, Department of Obstetrics and Gynecology, Lenox Hill Hospital, 130E 77th St., New York,
NY 10021, USA (e-mail: rinatia@netvision.net.il)
Accepted: 19 October 2005
Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd.
diagnostic and a therapeutic tool. In the practice of
obstetrics and gynecology (Ob/Gyn), the ultrasound
examination has become so important and common that
frequently it is considered an integral part of the physical
examination1 – 5 . Its accessibility in the labor room,
gynecological wards, emergency rooms and physician’s
office contributes to its popularity. Thus it is used widely
by obstetric and gynecological practitioners from their
first year of residency, and by specialized technicians.
While performing the ultrasound examination, how-
ever, sonographers are obliged to perform repetitive
isometric maneuvers and may suffer misalignment of
body position6 , and various symptoms, such as myal-
gias and arthralgias, have been reported6 – 9 . In fact, these
symptoms are common in various workers whose jobs
require repetitive isometric maneuvers and/or continu-
ous misalignment of body positioning3 . Different types
of ultrasound examination require body positioning that
may expose the examiner to specific body strain. For
example, sonographic examination of the adult human
heart requires different body positioning and maneuvering
from that required for abdominal examination.
The Ob/Gyn ultrasound examination involves two
different technical approaches: transabdominal and
transvaginal. Each type of examination requires a different
size and shape of transducer as well as different
isometric maneuvers. The transabdominal approach is
more common in obstetrics, with the examiner usually
sitting or standing at the side of the patient, and using
an abdominal semilunar transducer. The transvaginal
approach is performed with the sonographer standing in
front of the woman or beside her, and using a longitudinal
transducer.
There have been few studies regarding the occupational
hazards of sonography, and most originated from the
cardiovascular field, with the main complaints reported
ORIGINAL PAPER
Hazards of obstetric ultrasound
being myalgia and arthralgia6 – 9 . We are aware of
a single report, published by our group10 , regarding
the occupational hazards of Ob/Gyn sonography. In
this small limited study we concluded that ultrasound
scanning in Ob/Gyn may pose an occupational risk
for doctors and technicians. The present study was
undertaken to investigate the specific health complaints
of physicians and technicians performing ultrasound
examinations in the field of obstetrics and gynecology.
We also evaluated specific physical symptoms associated
with the different technical approaches (transvaginal
vs. transabdominal), the influence of the frequency
of examinations performed, possible gender differences
among examiners and variations between physicians and
ultrasound technicians.
METHODS
This was a cross-sectional retrospective survey performed
between June 2002 and June 2003. Questionnaires were
distributed to active members of the Israeli Society
of Gynecological Ultrasound. These included questions
regarding gender, professional status, left- or right-
handedness, number of years of experience, number of
scans performed per day and percentage of types of ultra-
sound examination (abdominal/transvaginal) performed.
Respondents were also asked whether they had back, neck
or joint pain related to their profession, and which mode
of therapy, if any, they had undergone. Finally, they were
asked to suggest possible improvements.
Statistical analysis included chi-square or Fisher’s exact
test for comparison of proportions. For continuous
variables, Student’s t-test was used. Correlations were
calculated by Pearson’s correlation coefficient. Logistic
regression was used to assess the odds ratio (OR)
of joint pain as a function of the percentage of
transabdominal ultrasound examinations performed.
P ≤ 0.05 was considered statistically significant.
RESULTS
One hundred and thirty-three (66.5%) of the 200 surveys
distributed were returned. Sixty-eight respondents were
female and 65 were male (51.1% vs. 48.9%). Of
58 ultrasound technicians, 55 were female (94.8%),
compared with 13 of the 75 medical doctors (17.3%).
The majority of sonographers were right- rather than
left-handed (88.7%, 118/133 vs. 11.3%, 15/133). The
average number of examinations per day was 25.5 (range,
5–70); that for physicians was 20 compared with 29
for technicians, and that for females was 28 compared
with 20 for males. The percentages of transabdominal
and transvaginal examinations reported by physicians
and technicians were similar (46.2% vs. 45.2%, P = 0.93
for transabdominal examinations and 53.8% vs. 54.8%,
P = 1.0 for transvaginal examinations).
Joint pain, including of the wrist, elbow and shoulder,
was reported by 30 technicians compared with 19
Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd.
205
medical physicians (51.7% vs. 25.3%; OR, 3.16; 95%
CI, 1.4–7.0; P = 0.002). Joint pain complaints were
more frequent in females compared with males (44.1%,
30/68 vs. 27.7%, 18/65, P = 0.05).
All joint and back pain complaints were evaluated
according to the type of ultrasound examination per-
formed. Joint pain was significantly more common among
those who performed transabdominal examinations more
frequently than they did transvaginal ultrasound (mean,
21.9 ± 3.0 vs. 18.0 ± 2.0 complaints, P = 0.04). Like-
wise, there was a significant association between back
pain and the performance of transabdominal compared
with transvaginal examinations (20.9 ± 2.9 vs. 19.1 ± 2.1
complaints; P = 0.05).
Using a forward stepwise multivariate logistic regres-
sion model, the sonographer’s profession and type of
ultrasound examination performed were found to be inde-
pendent risk factors for joint pain (OR, 3.48; 95% CI,
1.6–7.5; P = 0.002, and OR, 1.031; 95% CI, 1.01–1.05;
P = 0.004, respectively); the risk for a technician of
reporting joint pain was 3.5-fold higher than that for
a physician, and the risk of transabdominal examinations
was greater than that of transvaginal examinations. The
model also included gender.
There were no significant differences regarding back
pain between technicians and physicians, or between
male and female operators, and there were no significant
differences in back and joint pain between right- and
left-handed practitioners.
Twenty-six sonographers reported ‘other damaged
organs related to ultrasound practice’ and five of these
(19.2%) described eye damage as the most common
complaint. Specifically, they reported deterioration of
visual acuity and the need for ocular eyeglass adjustments.
Other sporadic complaints such as tennis elbow, knee
injury and osteopathy were also reported.
Surgical procedures such as carpal tunnel release,
discectomy and rotator cuff surgery were performed
in eight of 65 males compared with two of 68
females. This difference was statistically significant
(12.3% vs. 2.9%, P = 0.034). There were no significant
differences in surgery undergone between technicians
and doctors (6.8% vs. 1.7%, P > 0.05) or between
right- and left-handed practitioners (3.4% vs. 13.3%,
P = 0.141).
The most frequent single therapy reported was
physiotherapy, which was required in 15% of the
respondents. Pain relief medication was used by 11.3%
of respondents, and 3.8% required both medical and
surgical intervention.
The last part of the questionnaire, answered by 45.1%
of those surveyed, consisted of suggestions for decreasing
the symptoms associated with performing sonography.
Responses included: 12.4% suggested improvement of the
position and mobility of the equipment, 4.2% suggested
lighter/supported transducers, 3% suggested a hand-
support system, and 0.8% suggested increased back
support during performance of the exam.
Ultrasound Obstet Gynecol 2006; 28: 204–206.
206
DISCUSSION
Our data indicate that joint pain among technicians is
significantly higher than it is among physicians. This
may be attributed to the higher number of examinations
performed by technicians. Although in our study 97.3%
of the technicians were female and joint pain was more
common in this group, female gender was not found to
be an independent risk factor for joint pain when assessed
by multivariate analysis.
Transabdominal ultrasound was found to be associated
with both joint and back pain. A possible explanation
might be that when performing the transabdominal
examination the practitioner stands or sits to the side
of the woman; this positioning requires an asymmetrical
alignment of the practitioner’s body. Another explanation
is that the average scan time in most cases is longer
during transabdominal compared with transvaginal
ultrasound examinations. Another possibility is that
during transabdominal scanning, which requires a
relatively heavy, semilunar transducer, there is more strain
on the joints of the arm and hand. In addition, when
performing transabdominal sonography, more spatial
maneuvers and movements of the joints are required
compared with during transvaginal sonography. All these
factors may act in concert, resulting in increased strain
during transabdominal scanning.
The likelihood for a technician to report joint pain
was 3.5-fold higher than that for a physician. As the
percentage of transabdominal examinations performed
increased, the frequency of joint pain reported increased;
for each increase of 1% in transabdominal ultrasound
performed there was a 1.03-fold increased risk of joint
pain. Despite the female predominance regarding joint
and back pain reported, males had significantly higher
rates of operative intervention. This difference was not
related to professional status (physicians or technicians).
It may perhaps be explained by different gender attitude
towards pain control; behavioral studies indicate that
women tend to access surgical care less frequently than
do men11 – 13 . Another explanation is that, while women
tend to express their feeling of pain more commonly,
men suffering from severe pain will more frequently
opt for surgical treatment7 . Visual deterioration was
the most common complaint reported by practitioners
responding to the question of specific symptoms related
to frequent ultrasound scanning. This unexpected finding
should be investigated further to determine whether it
is an incidental symptom, associated with aging, or
Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd.
Hackmon et al.
it is related to frequency of ultrasound examinations
performed.
It is our opinion that further studies are required to
improve the ergonomics and usability of ultrasound.
Specifically, more attention should be paid to the mobility,
angulations and weight of the various pieces of equipment.
We believe that such improvements are likely to reduce
musculoskeletal stress, thereby reducing injury during
ultrasound scanning in both sonographers and physicians.
Furthermore, these improvements can lead to an increase
in productivity, by reducing work-related injury expenses
and time lost due to disability. While reducing the hazards
of Ob/Gyn ultrasound scanning in medical practitioners,
these enhancements would also contribute to the overall
quality of medical care.
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