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.
Uses 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.
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.
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.