Musculoskeletal Ultrasound

Ultrasound has been used as a diagnostic imaging entity routinely for decades. Although it has been a common imaging option for musculoskeletal conditions in Europe, it is quickly gaining acceptance in the United States within the specialties of orthopaedics and sports medicine. Its “bedside” use in the office setting has allowed it to become the most practical imaging option in the orthopaedic setting. A few of the many advantages when compared to x-ray, MRI or CT include the ability to perform dynamic imaging; specifically viewing a ligament, tendon or joint during a range of motion or under applied stress; the ability to quickly image the contralateral side and make direct comparisons; the lack of ionizing radiation; its ease and comfort for the patient; allowing for a single clinician to take a history, examine the patient and interpret ultrasound images all during the same office visit; and finally, its cost effectiveness. In fact, the charge for a joint and soft-tissue ultrasound examination is typically only 15-25 percent of that of an MRI.

Many ask, “What conditions and structures may benefit from an ultrasound examination in the orthopaedic setting?” Rotator cuff tears, joint effusions, bursitis, trigger fingers, ganglion and popliteal cysts, knee and elbow ligament tears, lateral epicondylitis, plantar fasciitis, Achilles tendonopathy and tears, and patellar tendonopathy and tears are just a few of the conditions that can readily be visualized with ultrasound imaging. Nerves, such the median nerve at the carpal tunnel and the ulnar nerve at the cubital tunnel, can also be easily identified, measured and assessed for pathology. Finally, color and power Doppler imaging also for visualization of hyperemia to an area, suggesting inflammation, as well as vascular structures.

Using an ultrasound for injection guidance is another extremely useful application in the office setting. Ultrasound-guided injections allow for the solution to be delivered to the most precise location, and thus theoretically, resulting in the greatest amount of benefit from the injections. In addition, non-guided, or “blind,” injections result in an increased risk of injury to muscles, tendons, ligaments, bones or neurovascular structures. Aspirations may be more effectively and accurately performed, as well. Peer-reviewed journal entries and expert opinion have stated that blind injections are delivered to the precise and intended location far less frequently than expected by the physician performing the procedures.

Two studies in the last year have demonstrated improved patient outcomes with ultrasound-guided injections over blind injections in patients with shoulder pain. Recent cadaveric studies have demonstrated improved accuracy with guided versus blind injections in the tibiotalar joint, the sinus tarsi and the pes anserine bursa.

In fact, the pes anserine study demonstrated a 92 percent accuracy rate with the ultrasound-guided injections versus a 17 percent rate with blind injections.

Platelet-Rich Plasma Injections

Therapeutic injection options are quickly evolving in the world of orthopaedics. One of the newer options is platelet-rich plasma, or “PRP” injections. Venipuncture is performed in the office, followed the centrifugation (or a similar process, depending on the system used) of the patient’s blood. This separates the red blood cells from the plasma. This plasma is rich in platelets, which are rich in natural growth factors. Theoretically, these growth factors can greatly enhance the body’s ability to heal damaged tissue.

The plasma is then injected into the affected area. These are an excellent alternative to corticosteroid injections, which act as potent anti-inflammatories, but may have many adverse effects, including the risk of tendon rupture and degradation of an already degenerative joint. In addition, recent histological research has demonstrated that many chronic soft tissue orthopaedic conditions, such as tendonitis, are actually not inflammatory in nature, but instead, degenerative. Thus, injections that produce regeneration should be superior to those that simply reduce inflammation.

PRP injections first garnered significant attention in the sports lay media two years ago when a prominent receiver for an NFL team received PRP injections into the sprained medial collateral ligament of his knee two weeks prior to the Super Bowl, and then was able to compete with minimal limitations. Since that time, prominent athletes have been receiving PRP injections to regenerate partially torn ligaments and tendons on a relatively common basis. However, a patient doesn’t to have to be a star athlete to benefit from PRP. The mechanic with three months of tennis elbow; the homemaker with chronic plantar fasciitis; the high school running back with an acute MCL sprain; and the weekend-warrior basketball player with refractory patellar tendonopathy could all be ideal candidates for PRP injections.

The risks of the PRP are very low since the patient’s own blood is being utilized, and successful PRP injections may save a patient from having to undergo surgery. Prospective studies thus far have shown PRP injections to be efficacious in patients with lateral epicondylitis, Achilles and patellar tendonosis, muscle strains and degenerative cartilage lesions of the knee. Some studies have compared steroid injection to PRP, with those receiving PRP typically demonstrating greater long-term benefit.

A PRP injection under ultrasound-guidance results in an ideal combination of these two innovative techniques. Both PRP and the use of musculoskeletal ultrasound are cost-effective options, perhaps saving a patient from a much more expensive surgical procedure and/or a more expensive imaging study such as an MRI. All public and private insurance carriers in Tennessee currently reimburse for the ultrasound-guided portion of the procedure. Although ultrasound and PRP will never replace surgical intervention or the use of other imaging studies, they give patients very safe and potentially highly beneficial diagnostic and treatment options not offered in the office until recent years.

F. Clarke Holmes, M.D. is a board-certified sports medicine physician with Nashville Orthopaedic Specialists, PC. His practice is focused on the care of athletes and non-athletes, with an emphasis on non-surgical treatments. Nashville Orthopaedic Specialists is one of the few Middle Tennessee practices to offer the office-based procedures discussed in this article.

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