Ultrasound Guided Injections in a Sports Medicine Practice Edward W. Kelly, MD October 7, 2013 Annual Orthopedic Care Team Conference.

Ultrasound Guided Injections in a Sports Medicine Practice

Edward W. Kelly, MD

October 7, 2013

Annual Orthopedic Care Team Conference

Ultrasound Guided Injections in a Sports Medicine Practice

Nothing to disclose

Musculoskeletal Ultrasound

Goals

• Review Musculoskeletal Ultrasound

• Advantage and disadvantages of MSK US

• Demonstrate therapeutic US Guided Injections

Musculoskeletal Ultrasound

What is Ultrasound• High frequency sound wave• Audible sound 20 Hz – 20,000 Hz• Diagnostic US > 1,000,000 Hz (1MHz)

– Above human hearing

• Musculoskeletal Ultrasound – 7-18 MHz

Musculoskeletal Ultrasound

What is Ultrasound

• Sound waves travel through tissues at same speed

• How fast they return determines image

Musculoskeletal Ultrasound

What Can MSK Ultrasound Image

• Bone• Muscle• Tendon• Nerve• Subcutaneous Tissue• Fluid

Musculoskeletal Ultrasound

What Joints Can MSK Ultrasound Image

• Small joints- Foot/Ankle – Hand/Wrist• Knee• Hip

Musculoskeletal Ultrasound

What Joints Can MSK Ultrasound Image

Shoulder/Elbow

• Glenohumeral• Subacromial space• AC joint• Biceps• Lateral epicondylitis

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

The Rehabilitator

Fact or Fantasy?

https://www.youtube.com/watch?v=v1GGFR2mc9g

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

• Images muscle, soft tissue, and cortical bone surfaces

• No known long term side effects• Dynamic or “live” images

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

• Portable• No special room needed• High resolution – 1 mm• Accurate!

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

• 2009 Meta-analysis Am J Radiology• 65 studies

US as sensitive and specific as MRI to diagnose RC Tears

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

• Relatively inexpensive

Musculoskeletal Ultrasound

What Are Ultrasound Advantages

• MRI shoulder cost $ 750 Medicare• US diagnostic shoulder cost = $124 Medicare• US guided needle placement $208 Medicare

Musculoskeletal Ultrasound

What Are Ultrasound Disadvantages

• Can not see thru bone or gas• Relatively limited depth of penetration• Operator dependant• Steep learning curve – about 100 scans

Ultrasound Guided Intra-Articular Injections

Do you need guidance?

• Poor ability to get into desired joints blindly

– Glenohumeral 90% vs. 27%– Biceps 87% vs. 40%– Subacromial 90% vs. 30%– AC Joint 90% vs. 60%– Hip 90% vs. 30%

Ultrasound Guided Intra-Articular Injections

Do you need guidance?

• Better therapeutic response• Less pain for patient• Less likely to injure other structures

Ultrasound Guided Intra-Articular InjectionsExamples

Ultrasound Guided Intra-Articular Injections

Glenohumeral Joint

Ultrasound Guided Intra-Articular Injections

Glenohumeral Joint

Ultrasound Guided Intra-Articular Injections

Subacromial Space

Ultrasound Guided Intra-Articular Injections

Biceps Tendon Sheath

Ultrasound Guided Intra-Articular Injections

Biceps Tendon Sheath

Ultrasound Guided Intra-Articular Injections

AC Joint

Ultrasound Guided Intra-Articular Injections

AC Joint

Ultrasound Guided Intra-Articular Injections

AC Joint

AC joint injection

Ultrasound Guided Intra-Articular Injections

AC Joint

Small JointsElbow

• Lateral Epicondylitis

Small JointsElbow

• Lateral Epicondylitis

Small JointsElbow

• Lateral Epicondylitis• F.A.S.T procedure

– FOCUSED– ASPIRATION AND REMOVAL– SOFT– TISSUE

• http://www.fast-technique.com/

FAST for Patellar Tendonitis

FAST for Patellar Tendonitis

FAST for Patellar Tendonitis

FAST for Shoulder Calcific Tendonitis

FAST for Shoulder Calcific Tendonitis

FAST for Shoulder Calcific Tendonitis

Ultrasound Guided Injections in a Sports Medicine Practice

Summary

• Ultrasound provides reliable in office diagnosis• Lower cost• guided injections more effective• In-office procedure• Can be used for any joint• Steep learning curve