MRI After Ultrasound: Is It Really Necessary?

MRI After Ultrasound: Is It Really Necessary? Blog

Imaging technology for musculoskeletal injuries has been a game changer for practitioners whose treatment approaches depend on being able to see beneath the surface. Over the past several decades, MRI has been the imaging tool of choice due to its ability to provide clear still shots of ligaments, muscles, tendons and bones to reveal the locus and nature of damaged tissue.

Ultrasonography has been available for several decades as well, but early iterations of the technology provided unclear images that needed to be confirmed with MRI. However, recent advances in ultrasound technology have rendered it an accurate and in many cases preferable mode of soft tissue imaging.

Thanks to higher frequency transducers, significant increases in ultrasound image resolution make it possible to distinguish minute structures like individual nerve fascicles and tendon fibers. Power Doppler imaging allows for improved resolution of deeper structures.

Other advantages of ultrasonography over MRI include:

  • Small portable equipment
  • Ability to scan in real time while interacting with the patient
  • Higher special resolution than MRI
  • Enables dynamic examination of anatomic structures
  • Significantly less costly than MRI
  • Ultrasound can be used on patients with metal implants

Despite these distinct advantages, ultrasound should not be considered a competitor with MRI, but rather an imaging option that sometimes complements MRI. However, the question remains whether redundant imaging is in any way advantageous to the patient, or has any value in determining the clinical management of a musculoskeletal injury.

MRI After Ultrasound Studied

In a 2017 presentation at the American Institute of Ultrasound in Medicine (AIUM) Conference, Dr. Lulu He, a musculoskeletal radiology fellow at the Cleveland Clinic, revealed the findings of a retrospective review of 129 cases over a four-year period, where MRI was prescribed within 90 days after the patient had received an ultrasound scan. In only one case was an abnormality found on MRI that had not been detected by ultrasound.

The researchers noted that some practitioners routinely order MRI after ultrasound, even when it is not recommended by radiologists. In particular, orthopedists are most likely to prescribe MRI after ultrasound, with the foot and ankle being the most common body parts examined, followed by the shoulder, hip and knee respectively. In only 19 of the 129 cases studied did radiologists recommend ultrasound to clarify ambiguous imaging findings.

The researchers concluded that an MRI performed after an initial ultrasound for musculoskeletal injuries is almost always in concordance with the ultrasound results, and clinical management strategies are rarely changed after an MRI.

Given the advantages of ultrasound over MRI, the inconvenience of MRI, and the expense incurred by patients with redundant imaging, it stands to reason that MRI should only be prescribed subsequent to ultrasound in cases where the interpretation of ultrasound imaging is ambiguous.

Musculoskeletal Injury Diagnosis and Treatment in NYC

The sports medicine team at NYDNRehab prides itself on accurate diagnosis of musculoskeletal injuries. We use diagnostic ultrasound imaging interactively with our patients to visualize the area of injury in real time, enabling patients to participate in their own diagnosis and treatment. Our state-of-the-art technologies combined with the experience and dedication of our staff make NYDNRehab the best rehabilitation clinic in NYC.

 

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

image

Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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