Our centers in Florida and Illinois are utilizing musculoskeletal ultrasound to allow us to effectively visualize and diagnose various musculoskeletal conditions and efficiently treat one joint or multiple joints with Prolotherapy immediately thereafter in cases that warrant this type of technology.
Concomitantly diagnosing and treating injured and degenerated joints is an added bonus in particular aspects of patient care. The use of ultrasound at Caring Medical will not replace palpation of the painful joint and the clinical examination, but will be used as a tool to compliment the expertise at hand. Ultrasound guidance can be used before treatment to assess and diagnose, during treatment to inject directly into the injured joint structures, and after treatments-once repair has occurred- to document the successful healing outcomes.
We are using the SonoSite ultrasound system, a lightweight, portable point-of-care ultrasound machine, originally created in 1980 for the Department of Defense, as a durable and efficient battlefield unit. The use of ultrasound imaging began in the 1950’s, and was first applied in musculoskeletal medicine in 1972.1 Ultrasound imaging of musculoskeletal structures has continued to advance. The portable high-resolution ultrasound machines, compared to the rather large and cumbersome conventional machines, have allowed for wide access for use in various types of clinics, beyond the traditional context of hospitals and radiology centers. The progress of ultrasound technology includes increased image quality in these laptop-sized machines, as well as lowered pricing for affordability for the average practitioner.With these advances, the ultrasound machine can be brought directly to the patient!
What is Ultrasound?
Ultrasonography is an imaging modality that uses high frequency sound waves, which normally cannot be heard by human beings, to visualize internal structures of the body. “Ultrasound travels as sound waves, and images are generated when pulses of ultrasound from the transducer produce echoes at tissue or organ boundaries. Between pulse transmissions, the transducer serves as a detector of echoes, which are processed to form an anatomic image.”2 The waves are recorded and made into images, allowing us to visualize structures such as tendons, muscles, ligaments, and more. “Interpretation of the ultrasound images depends on the echogenicity: the brightness of the image, depending on the degree of reflection in the ultrasound waves. The images are also described in terms of the plane on which the sonogram is viewed, which is usually longitudinal or transverse in relation to the structure scanned.”2
Ultrasound is attractive to patients because of its safety! It is non-invasive, painless, convenient, cost-effective, and free of radiation! Other benefits include:
Potential to show documented improvement in soft tissue injuries and track patient objective outcomes from Prolotherapy treatments utilizing before and after images.
Documents musculoskeletal pathology. Studies suggest that ultrasound is the primary imaging technique for soft tissue injuries.2
Sensitivity in diagnosing rotator cuff injuries.
“Rotator cuff disease is common and is one of the most common reasons for using ultrasound. Many studies report excellent sensitivity and specificity of ultrasound in diagnosing rotator cuff tears.”2
Ultrasound diagnosis and treatment aid in Tendon degeneration and tears.
Tendon degeneration on ultrasound is seen as irregularities of fibrillar appearance, such as thickening and fragmentation, focal hypoechoic areas, and calcifications.
“Dynamic imaging deserves special emphasis because it is useful in differentiating full-thickness from partial-thickness tendon tears, muscle tears, and tendon and nerve subluxations or dislocations.”3
Accurately visualize and diagnose tendon tears of the upper and lower extremities.
For example, studies reported an accuracy of 94% when ultrasound was used to diagnose tendon tears of the ankle.3
Reveals altered anatomy after surgery. In many post-surgical cases, a patient’s anatomy may be altered slightly. Ultrasound is effective for evaluation of soft tissue near metal hardware, which may include metal screws, plates, etc.
In certain instances, anatomy is relocated, such as in the case of the ulnar nerve in the elbow, which may be relocated as part of the surgery. Ultrasound can help visualize the altered anatomy so as to avoid transposed nerves or metal structures. “Ultrasound applications are not limited to, but include evaluation of peripheral nerves, evaluation for soft-tissue foreign bodies, evaluation of soft-tissue abnormalities adjacent to hardware.”3
Monitor needle positioning during the injection procedure. For example, injections into joints such as the hip, as well as soft tissue injections into the tendons, ligaments and other joint structures.
Ultrasound can demonstrate joint instability better than MRI. Unlike an MRI, ultrasound can be performed on a patient while joints are in motion. In cases of shoulder impingement, for example, a patient may only have pain with certain motions and none at rest. Ultrasound can help visualize what happens with the tissue during motion. “The main advantages are its ability to perform dynamic examinations and to conduct side-to-side comparisons on the spot, allowing clinicians to correlate their patients’ symptoms directly with anatomic visualization.”3“Studies have shown ultrasound to be accurate in the diagnosis of conditions that require joint movement or positioning to display the abnormality, such as peroneal tendon subluxation in the ankle (100% positive predictive value). Such diagnoses are not possible or are difficult with routine MRI.”3
In our office, we can check the motion of the “bad” joint versus the “good” joint and clearly document joint instability because the joint motion can be analyzed in real-time. This is excellent for many extremities, including knees where a meniscal tear is suspected, or even smaller joints like fingers and toes.
Assists in performing hydro-dissection of nerves. Rarely, a patient presents with a chronic pain condition that relates solely to nerves. However, in such cases, ultrasound allows practitioners to hydro-dissect affected nerves (this involves administering small amounts of fluid around a nerve to help free it up from surrounding tissue) to help ease chronic pain.“Ultrasound evaluation for peripheral nerve abnormalities, such as nerve entrapment disorders and nerve dislocation, is now common at many institutions as part of musculoskeletal imaging.” 3
Are there any disadvantages to using Ultrasound?
The main disadvantages are operator dependence. The same holds true for MRI, X-ray and any other diagnostic tool. Ultrasound must be used as an adjunct to treatment. Palpation, physical exam, patient history and practitioner experience are paramount.
Ultrasound-guided joint injections
Ultrasound allows us to visualize musculoskeletal tissue. We can visualize the injured tissue right in the office without having to wait for an MRI. During treatment, we can inject the injured structures and maintain continued needle visualization of the targeted areas.
Ultrasound-guided treatment is not used on every patient. Caring Medical has been a practicing Prolotherapy clinic for over 50 years without the use of image guidance for injections. Dr. George Hackett used and taught the palpation guided technique included in his textbook in 1956 until the latest publication in 1991.4
The Prolotherapists at Caring Medical, along with many other physicians have been using this same treatment method. During this time, thousands and thousands of patients have had their pain levels improve dramatically without the addition of ultrasound. At Caring Medical, our success rate in using the palpation guided technique is about 88-92%.
The many benefits of ultrasound are noted above; however, we try to keep our Prolotherapy -related costs as low as possible. Any added cost can be a financial burden to patients, especially those who require many treatments or those who have multiple joints treated. In addition, patients not receiving insurance coverage for their treatments will have this added expense.
The decision to use ultrasound guidance is based on the needs of the individual patient and is not a rule for all.
As one of the largest Prolotherapy clinics in the world, we see a lot of the more complicated cases. People come to us in pain! They have frequently seen numerous physicians, received numerous procedures, tried multiple medications and have been subjected to one or multiple surgeries. Upon arrival to Caring Medical, these patients are oftentimes in worse condition than when they started their quest for pain relief. If their anatomy has been changed due to surgery, with ultrasound we can safely localize the altered anatomy, implants, screws and rods, and then treat the injured or degenerated joint(s).
Ultrasound allows visualization of pathology during motion. This means that we can watch the ligaments and tendons around the joint through ultrasound as you move. Take a ballplayer for example. They may only feel discomfort when they throw the ball or with overhead movements, but have no pain at rest. With ultrasound, the patient can perform the motion that elicits the pain, while we visualize the joint and joint structures. This allows us to see directly and immediately, any changes that occur in the anatomy during the motion that exhibits pain. We can then treat the visualized musculoskeletal condition with Prolotherapy.
As you know, the Prolotherapists at Caring Medical do not rely on MRIs or other imaging. However, in certain cases imaging may be deemed necessary. Some patients may not be able to get an MRI due to metal implants in their body. If someone has a metal implant from a previous surgery, we can still perform an ultrasound to help visualize the pathology without risk of dislodging the implant. Also, in complicated cases, imaging may be advantageous. Having the availability of ultrasound is a valuable option.
How does ultrasound compare to MRI?
Ultrasound has significant advantages over MRI, including hundreds to thousands less money than an MRI. Ultrasound is also preferable to MRI for it’s ability to perform dynamic imaging, or imaging while the joint is in motion. For example, we can evaluate external rotation in the shoulder to diagnose a tendon dislocation or arm elevation to diagnose an impingement or adhesive capsulitis. The elbow can be flexed to diagnose snapping triceps syndrome. Visualization of movement in the hip can diagnose snapping hip syndrome. Ultrasound imaging of the ankle can aid in diagnosing a tendon subluxation or tear.
- Various studies have found comparable accuracy of diagnostic ultrasound and magnetic resonance imaging for diagnosis and measurement of rotator cuff tears.2,3
- “One limitation of ultrasound is the inability of the ultrasound beam to penetrate beyond bone cortex. Although ultrasound can evaluate some aspects of joint cartilage, MRI offers a more comprehensive evaluation of those structures. Nonetheless, much of the musculoskeletal system can be evaluated with ultrasound.”3
- As in any field, there are variables with equipment, training, and experience. High accuracy can be obtained with proper training and use of appropriate equipment. The ultrasound professional must understand anatomy. Prolotherapists, who have been palpating painful joint for years, understand anatomy as well as referral patterns. The Prolotherapist trained in ultrasound technology can also adequately evaluate structures in a standardized imaging plane, recognize artifacts and correct for them, recognize abnormalities in the image, and finally interpret the imaging findings. When comparing to MRI, the MRI technologist must be properly trained as well. A possible benefit of MRI over ultrasound is the use of intra-articular contrast material to boost reporting accuracy for tears while using MR arthrography.3“Ultrasound is an ideal and inexpensive alternative for imaging structures, such as tendons, ligaments, and peripheral nerves of the distal extremities as well as for evaluation for soft-tissue foreign bodies. Compared with ultrasound, MRI offers a more comprehensive evaluation that includes intra-articular structures, bone marrow, and deep soft tissues.”3
In summary, ultrasound is a simple and safe, radiation-free modality that offers the convenience of musculoskeletal assessment right in the doctor’s office. The physician can palpate the injured area, utilize ultrasound to link the imaged area with the patient’s subjective symptoms and pathology, and then treat the visually confirmed musculoskeletal condition with Prolotherapy, Stem Cell Prolotherapy, or PRP Prolotherapy. As treatment progresses, ultrasound offers the ability to document clinical changes, repair and healing of the treated structures.
1.Kane D, Balint PV, Sturrock R, Grassi W. Musculoskeletal ultrasound—a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology. Rheumatology. 2004; 43 (7): 823-828.
2.Lew HL, Chen CPC, Wang T-G, Chew KTL. Introduction to musculoskeletal diagnostic ultrasound: examination of the upper limb. Am J Phys Med Rehabil. 2007;86:310–321.
3.Jacobson JA. Musculoskeletal Ultrasound:Focused Impact on MRI.AJR 2009; 193:619–627.
4.Linetsky F, Torres F. An assessment on the ultrasound guided dextrose prolotherapy for persistent coccygeal pain: A case series and review of literature. Altern Integ Med. 2014; 3 (2): 155. doi:10.4172/2327-5162.1000155