Musculoskeletal Ultrasound

The Future of Orthopedics is Here!JohnWatsonRD copy

By Dr. John Watson
Board Certified Physiatrist

Orthopedic and musculoskeletal (MSK) conditions continue to be the top reason people  see their doctor. We all have aches and pains, and some of us will suffer injuries that need to be surgically corrected. The important distinction between MSK conditions is whether or not the injury requires surgery or can be treated conservatively with cortisone injections or physical therapy. Wouldn’t it be nice if your physician had the technology to look inside your body on the day of your appointment to make that determination? That technology has arrived and it is called MSK ultrasound (MSK US).

The compact ultrasound equipment consists of a hand held transducer connected to a monitor the size of a laptop. The transducer gives off sound waves which bounce off the anatomical structures at different speeds, while an image is constructed and displayed on the monitor. This allows me to see live images beneath the surface of the skin and visualize things such as tearing or inflammation.

The ability to see dynamic images of someone’s anatomy in real time equates to a more rapid diagnosis with quicker treatments. Ultrasound technology has been around for decades, but the use in Orthopedics has rapidly evolved over the past 5-10 years.

Ultrasound has many advantages and just a few disadvantages to discuss. On the advantage side, US is very portable as the new machines are about the size of a laptop. The portability of the machine has allowed me to transport the machine to communities like Litchfield and Petersburg in order to help me quickly diagnose MSK conditions.

My patients really appreciate the examination since it is pain-free and there is no claustrophobia associated with the process. It is a very quick exam and the answers are immediately available without the usual interpretation lag time. It is also very safe without any significant contraindications. There is no radiation like in X-rays or CT scans, and therefore a patient can have multiple exams without any side effects or harm. US is often compared to MRI since they evaluate similar conditions.

However, the cost of US is 10-15% less than an MRI and this is very important in the current healthcare environment. Cost savings are vital to the system and US will help diminish some of the extra costs associated with more expensive testing options.

The other major difference between MRI and US is the dynamic evaluation that US can provide. Some patient have snapping or popping associated with their pain, and US can see these structures snapping real time in order to accurately diagnose the condition. This can been beneficial in conditions such as snapping hip syndrome, snapping nerves, and impingement syndromes of the shoulder. Some patients might benefit from an ultrasound if they are not able to have an MRI with metallic foreign bodies or severe claustrophobia.

With any new technology, there are certainly limitations that need to be respected. The ultrasound will not penetrate bone and has a difficult time with deeper structures, which limits the evaluation to certain structures. For instance, the ACL and

meniscus in the knee are better evaluated with an MRI since they are inadequately visualized with an ultrasound machine.

Mastering musculoskeletal ultrasound is also very time consuming and there is a steep learning curve. I have been utilizing US for eight years, and each year I learn new techniques and applications. Since it is a newer technology, there are very few experts, which means there are very few teachers available. This limits the options and opportunities available for learning, which is one of the main reasons for the slow integration of MSK US into American medicine.

dreamstime_l_22243797Uses and applications
Most of our anatomy that is superficial can easily be seen with ultrasound, and many deep structures are also available for evaluation. Therefore, tendons, nerves, muscles, ligaments, joints and cartilage are portions of our body readily accessible for evaluation.

In the shoulder, US is used to evaluate the rotator cuff which is a common cause of shoulder pain. The shoulder can be evaluated quickly to diagnose a rotator cuff tear, and whether or not surgery is needed. Most patients with shoulder pain will have non-surgical conditions such as impingement syndrome or bursitis which can usually be treated successfully with a cortisone injection and physical therapy.

In the wrist and elbow, you can evaluate the peripheral nerves to diagnose conditions such as carpal tunnel syndrome or cubital tunnel syndrome. Our muscles are also easily accessible for ultrasound to evaluate for mild or severe muscle tears that occur in sports such as soccer, tennis, and football. Tendons such as the biceps tendon, Achilles tendon and patellar tendon can easily be seen to determine if the patient has a partial thickness tear or a full thickness tear that would need surgical reattachment. Any type of cystic structure which is filled with fluid can be diagnosed such as a ganglion cyst of the wrist or a Baker’s Cyst which presents as pain and swelling behind the knee.

Another benefit of US is the ease of reproducibility and the option of evaluating the structures on a weekly and monthly basis to monitor the healing process. This type of information may someday help guide the physical therapy or surgical planning process.

Interventional Applications
The other valuable benefit to using US is the option of guiding your needle to its proper location. Most patients present with multiple musculoskeletal complaints and it is sometimes very difficult to determine the origin of the pain. Therefore, by guiding your needle to a specific location and numbing the structure, you will have your diagnostic information and will help the patient with their pain.

A common example of this comes up with pinched nerves in the back. Many patients with a pinched nerve in the back (or sciatica) will present with hip pain which can be confused with arthritis of the hip joint or bursitis around the lateral hip tendons. Utilizing an ultrasound guided injection into the hip joint, which is performed right in the office, will quickly help determine the cause of pain and will start providing pain relief in a matter of minutes.

I am also able to utilize ultrasound guided injections for joints including the knee, shoulder, foot and ankle. If a Baker’s cyst is diagnosed, this can be aspirated right in the office on the same visit which can be both time and cost effective for the patient.


Top: rotator cuff calcification.
Bottom: rotator cuff eight weeks after tenotomy.

New Procedures
One of the ultrasound procedures that has recently been developed is called a calcific tenotomy. This is a procedure that has historically been done surgically until recently. Ultrasound guided tenotomy has allowed for a more minimally invasive approach that patients usually prefer. Some patients have calcifications that develop on their tendons which are quite painful and cause significant functional and range of motion limitations. While using ultrasound, I can guide a needle directly to the calcification and carefully break up the calcium deposits. Once the calcium and tendon have been fenestrated, I am able to aspirate the tiny pieces of calcium and remove them for good. The best part of the procedure is that it’s very quick and is performed right in the office.

I recently performed this unique procedure on a rotator cuff tendon and the results were better than expected. The patient is now pain free and has complete range of motion. I have now performed this procedure on three more patients, all of which have had excellent results. The next step is to expand the procedure to areas such as the patellar tendon, the Achilles, and chronic injuries such as tennis elbow.

As you can see, MSK US can be a safe and effective alternative to X-rays, MRIs and CT scans. It has allowed me to diagnose and treat conditions on a patient’s first visit which make it a cost effective alternative as well. From an intervention standpoint, ultrasound injections are safe, less painful and more accurate which benefits both the patient and physician. The ability to diagnose a patient’s source of pain and guide an intervention safely on the same visit has completely changed my practice for the better, and the patients couldn’t be happier. It allows for more face time with my patients and they appreciate the opportunity to be involved with real time results and timely treatment recommendations.

In 2012 Dr. Watson achieved “Pioneer Member” status with the American Registry for Diagnostic Medical Sonography (ARDMS). There are fewer than 100 physicians in the US with this title and he is the only Illinois physician outside of Chicago to earn this distinction.

This article was published in the January-March 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.


OCI Employee of the Year


Congratulations to Jennifer Dickerson on her nomination for Employee of the Year! Ms.Dickerson works in accounts payable and has been with OCI for five years. She is pictured on the left with Dr. Tim VanFleet at the OCI Holiday Party on Dec. 13.

Did one of our staff members go above and beyond to make your experience at OCI a great one? You can nominate a staff member for employee of the month online or at our offices.

Physician Presentation: MAKOplasty and Partial Knee Replacements in Young Patients

RonRomanelli copyIs a past knee injury, surgery or arthritis keeping you from the activities you enjoy? Join Ron Romanelli, MD, to learn how
MAKOplasty and other partial knee replacement techniques can help young people regain active, healthy lifestyles.

Wednesday, Jan. 22, 2014
6:00 p.m. – 7:00 p.m.

Dove Conference Center, St. John’s Prairie Heart Institute
619 E. Mason, Springfield

Light refreshments will be served. To register for this free event,
please call (217) 814-4308

Avoid Injury When Clearing Snow

SnowShovelPic_1With heavy snowfall predicted this weekend for the Midwest, protect yourself with the tips provided below from the American Academy of Orthopaedic Surgeons.

According to the U.S. Consumer Products Safety Commission:

  • In 2011, more than 125,000 people were treated in hospital emergency rooms, doctors’ offices, clinics and other medical settings for injuries sustained while shoveling or otherwise removing ice and snow manually.
  • In that same year, more than 18,600 were injured using snow throwers or blowers.Types of injuries can include sprains and strains, particularly in the back and shoulders, as well as lacerations and finger amputations.

Recommendations to help you stay safe while clearing snow:

  • Check with your doctor. Because this activity places high stress on the heart, speak with your physician first. If you have a medical condition or do not exercise regularly, consider hiring someone to remove the snow.
  • Dress appropriately. Light, layered, water-repellent clothing provides both ventilation and insulation. It is also important to wear the appropriate hat, as well as mittens or gloves and thick, warm socks. Take a break if you feel yourself getting too hot or too cold.
  • See what you are shoveling/snow blowing. Make sure that your hat or scarf does not block your vision. Expect icy patches and uneven surfaces. Avoid falls by wearing shoes or boots that have slip-resistant soles.
  • Clear snow early and often. Begin when a light covering of snow is on the ground to avoid trying to clear packed, heavy snow. If the snow is wet, lift smaller, lighter amounts with each shovel load.


  • Pace yourself. Take frequent breaks and replenish fluids to prevent dehydration. If you experience chest pain, shortness of breath or other signs of a heart attack, seek emergency care, such as by calling 9-1-1.
  • Use a shovel that is comfortable for your height and strength. Do not use a shovel that is too heavy or too long for you. Consider buying a shovel that is specially designed to prevent too much stooping. Space your hands on the tool grip to increase your leverage.
  • Push the snow instead of lifting it,as much as you can. If you must lift, take small amounts of snow, and lift it with your legs: Squat with your legs apart, knees bent and back straight. Lift by straightening your legs, without bending at the waist. Then walk to where you want to dump the snow; holding a shovelful of snow with your arms outstretched puts too much weight on your spine.
  • Do not throw the snow over your shoulder or to the side.This requires a twisting motion that stresses your back.

Snow blowing:

  • Never stick your hands or feet in the snow blower!If snow becomes impacted, stop the engine and wait at least five seconds. Use a solid object to clear wet snow or debris from the chute. Beware of the recoil of the motor and blades after the machine has been turned off.
  • Do not leave the snow blower unattended when it is running. Shut off the engine if you must walk away from the machine.
  • Watch the snow blower cord. If you are operating an electric snow blower, be aware of where the power cord is at all times, so you do not trip and fall.
  • Add fuel before starting the snow blower. Never add fuel when the engine is running or hot. Do not operate the machine in an enclosed area.
  • Read the instruction manual. Prior to using a snow blower, read the instruction manual for specific safety hazards, unfamiliar features, and whenever attempting to repair or maintain the snow blower.