“Sounds” Like A Great Idea!
By Dr. David Levi.
Over the last 10 years, ultrasound (US) has become an invaluable tool in making proper diagnoses and in providing greater accuracy in performing injections into joints, tendons, ligaments and nerves. The US image allows us to directly visualize anatomic structures in the office setting. Sound waves generated by the crystals contained in the US probe are placed and directed by holding the probe over a targeted area of the body. As these sound waves reach the different tissue planes or layers of tissues, echoes are produced. Using the same technology as sonar, the Ultrasound ‘s computer interprets the echoes and converts them into images that are a very accurate representation of the underlying tissue structures. We can really see everything including arteries, veins, nerves, tendons, bursa, joints, muscles, cysts and lastly, bone interfaces. Diagnostic Ultrasound used in settings like ours is referred to as MSK US. Needless to say , we use our US machines daily to help us determine the cause of someone’s pain, as well as to guide injections to alleviate their pain.
Studies performed over the last decade confirm that US guided injections are more accurate than what is commonly referred to as “blind injections.” These studies show the miss rate with “ blind” injections varying greatly between 10-75 %. Basically, blind injections rely solely on identification of surface anatomy and bony landmarks, which vary from patient to patient as well, as palpation, which varies from provider to provider. Certainly, this could explain why some patients don’t get better with “ blind” injections.
A typical case:
Recently, a gentleman in his 50s came to see us about his shoulder. He plays a great deal of golf and developed shoulder pain over the last few months, which he believes started after painting his grandson’s room. It was especially painful when he engaged in overhead activities. He had some improvement with physical therapy, but the pain continued to be an issue and affected his golf game. We performed a diagnostic ultrasound of his shoulder, which showed that his main shoulder tendons (rotator cuff), was not torn. During what we refer to as dynamic US testing, we were able to watch the tendons “live” with the ultrasound as he raised his arm. The ultrasound showed pinching (impingement) of one of his tendons as his arm elevated. It also showed an increased amount of fluid in a small sac above the tendon called the bursa. We diagnosed him with a shoulder bursitis caused by a tendon getting pinched or “impinged.” Injection options were discussed. We explained that a “blind “ injection (without ultrasound) can be only 60% accurate. This means that 40% of the time the needle is not within the bursa—and neither will be the delivered medication. In contrast, when the injection is performed with ultrasound guidance, studies show the needle position to be 100% accurate. We also explained to him that further research proved that, on average, patients obtain much better pain relief when physicians use ultrasound guidance. Additionally, because of the increased accuracy of delivery, we can use less volume and sometime less steroid. We chose to use ultrasound guidance for his injection. He did well and is back on the golf course.
At APM, we strive to provide the highest level of care to our patients. Ultrasound has become an invaluable tool, improving the accuracy and effectiveness of many of our treatments. In addition, the US has also expanded our ability to perform nerve blocks and other nerve related procedures which provide relief from neuromas and nerve entrapment syndromes, as well as nerve scarring from surgery and trauma, which can cause burning pain and numbness.
Lastly, with our growing interest in the use of biologic injections including PRP, fat derived stem cell grafts and bone marrow derived stem cells, we know that using the US machine allows us access to treat a greater array of conditions that were previously just outside of our reach.