Treatment Methods: Musculoskeletal Ultrasound

About Ultrasonography

Anyone who has ever had an X-ray or MRI knows that the images from those procedures are still shots, taken while the patient is immobile. But the human body is a living moving organism, and pain often manifests during physical activity. What if there was a way to see inside the body to observe the muscles and joints in motion, while simultaneously getting feedback from the patient?

Real-time ultrasound imaging (RUSI) offers just such technology. It is a valuable diagnostic tool for visually observing musculoskeletal structures, including muscles, tendons, ligaments, joints and bursae as they interact in real-time, in ways the patient would normally use them.

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Dr. Lev Kalika
Dr. Lev Kalika

Clinical director & DC RMSK

About Knee Pain Specialist Dr. Lev Kalika

Dr. Lev Kalika, founder of NYDNRehab, has personally studied with some of the world’s most prestigious experts in diagnostic ultrasonography, including Carlo Martinolli MD,PhD , Alexander Kinzersky MD PhD , Thomas Clark DC, RMSK, Anna Vovchenko MD, and Rostislav Bubnov MD, PhD. Over the past seven years, Dr. Kaika has attended MUSOC, EFSUMB, AIUM and Gulfcoast Ultrasound Institute. He is an active member of the American Institute of Ultrasound in Medicine (AIUM), and is currently developing his own unique approach tors.

Dr. Kalika’s services are frequently sought out by elite athletes for rehabilitation and performance enhancement.

Practical Applications Of RUSI In Physical
Therapy And Rehabilitation At NYDNRehab

We use RUSI to successfully evaluate:

  • Morphologic characteristics of muscles and tendons (thickness, CSA, and volume)
  • Muscle activation patterns
  • Outcomes of rehabilitation or exercise interventions
  • Pathologic conditions
  • Muscle and tendon stiffness using sonoelastography
  • Biofeedback for muscle retraining

How Does Msk Ultrasound Work?

During a RUSI session, a water-based gel is applied to the area being examined. A small transducer, or probe, is placed directly on the skin and transmits high-frequency sound waves through the gel into the body’s tissues. Sound waves are then reflected off the tissues. Because different tissues have different densities, the sound waves reflect back at various rates, making it possible to distinguish one type of tissue from another.

The transducer collects the sounds that bounce back, and a computer then creates images that are displayed on a screen. Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s muscles, joints, internal organs, and even blood flowing through blood vessels.

Using RUSI, your therapist is able to observe the movements of your muscles as they occur and determine whether they are functioning correctly. The therapist can observe different layers of muscles contracting and relaxing, can look at the timing and size of muscle contractions, and can even see fatty tissue within your muscles.

RUSI is used in conjunction with an integrated total body assessment to diagnose muscle dysfunction. Feedback from RUSI can then be used to retrain muscles to perform optimal contractions. Images of a normal functional contraction can be compared to a patient’s dysfunctional muscle contraction so they are better able to understand the deficiency and how to correct it.

Advantage Of Real-Time Ultrasonography

Real-time ultrasound imaging (RUSI) started to appear in the early 1980s, and by the1990s, 3D and 4D images were clear enough for the public to interpret, and were enhanced by color. Early iterations of the technology required large scan heads and heavy cables, making the equipment cumbersome and immobile. Today, some ultrasound equipment is so compact that it can be carried to patients on a battlefield or used by astronauts in space.

Advantage Of Real Time Ultrasound Imaging

Since the 1980s, the use of RUSI for diagnosis and treatment of musculoskeletal injuries has continued to grow, as real-time ultrasound has numerous advantages over other imaging technologies like X-ray, MRI and CT scan:

  • Non-invasive
  • No radiation exposure
  • Easy to use and control
  • Compact and Portable
  • Low cost
  • Safe
  • Shows real-time images in motion
  • Provides instant quantitative feedback

As a case in point, isokinetic dynamometry is a tool commonly used to test peak muscle torque in research and rehabilitation. However, the method yields a relatively crude estimation of forces, and is unable to isolate individual muscles within a muscle group. For example, the quadriceps is a group of four distinct muscles that work together to produce movement. Isokinetic testing is not able to distinguish between the individual muscles, and only tests forces produced by the group as a whole. Yet when diagnosing and treating knee injuries such as ACL and meniscus tears, patelafemoral dysfunction, jumper’s knee and other injuries, it is important to isolate and test the function of individual muscles in the quadriceps. Real-time ultrasound imaging enables us to view and measure the strength and function of each muscle with the knee in multiple positions, something that is not possible with isokinetic testing.

Who Can Benefit From Real-Time Ultrasonography?

The vast applications of RUSI are growing daily, both for diagnosis and treatment. Patients with acute injuries, overuse syndromes, gait and performance deficiencies, and chronic diseases can all benefit from RUSI.

Physical therapists can use RUSI to provide quick diagnosis and perform muscle re-education through visual feedback in a variety of patients, including:
  • Athletes
  • Runners
  • Dancers
  • Fitness enthusiasts
  • Patients with pelvic instability
  • Sufferers of low back pain
  • Patients with heel pain
  • Patients with shoulder pain and stiffness
  • Older adults with balance and joint issues
  • Women recovering from C-section
  • Post-partum females with diastasis recti
  • Patients with rheumatoid arthritis

Virtually anyone who suffers from muscle and joint pain, dysfunction or instability can benefit from RUSI.

Treatment Methods: Musculoskeletal

It would be nice if athletic injuries were simple, clean and easy to multiple structures. Traditionally, X-Ray and MRI have been used to be read and interpreted. Meanwhile, athletes and coaches are left guessing about the extent and severity of an injury, and treatment is delayed.

RUSI for Core Stability and Pelvic Floor Dysfunction

When it comes to view with the patient in a static supine posture.

During movement, the deep core muscles play a crucial role in mediating load transfer between the lower and upper body. When the core muscles are weakened, the pelvis becomes less stable, increasing the risk of injuries, low back pain and herniated discs. Real time ultrasonography has been shown in multiple clinical trials to collaborate in the diagnostic process, with the body in motion.

Advantages of Ultrasound Imaging

Musculoskeletal Ultrasound (MSUS) delivers high frequency sound waves to be done within minutes after the injury occurs. Moreover, the images can be viewed in real time by both clinician and patient.

Advantages of MSUS over X-Ray and MRI include:
  • Ultrasound can be used on anyone. Because X-ray emits radiation, the amount of exposure per year is limited, and it cannot be used on pregnant females, and in certain other cases. MRI does not emit radiation, and it provides more detail of soft tissues, muscles, tendons, and cartilage. However, because it uses large magnets, it cannot be used on patients with metal implants or pacemakers, during pregnancy, and in other less common cases.
  • A high-end MSUS transducer can provide more details that X-ray or MRI, in real time
  • MRI and X-ray produce a static image, and the patient must remain very still. During MSUS, dynamic real-time images enable the patient to the nature and location of injury. Movement can reveal joint abnormalities that cannot be detected with a static image
  • Because tendons are hyperechoic relative to muscle, ultrasound waves provide high resolution images of tendon tissue, making MSUS the method of choice for distinguishing between partial- and full-thickness tendon tears. It is also useful for depicting tendon subluxation and calcific tendonitis, and for evaluating tendons of the feet and ankles.
  • Ultrasound provides a useful tool for performing accurate real-time guided injections or aspirations.
  • The patient is able tor, confirming diagnosis.
  • MSUS can detect changes in blood flow that can help the clinician pinpoint the injured area.
  • With MSUS, the clinician can quickly and easily view images of both sides of the body during the same session, to bilateral “normal” structures.
  • X-ray and MRI images only depict segments of long structures like muscles and nerves. MSUS allows for a dynamic view of the entire length of a structure. The transducer can follow the entire pathway of a nerve to pinpoint the precise location and nature of an injury.
Both MRI and MSUS provide superior imaging over X-ray, and they are similar in sensitivity and specificity. However, in addition to MRI.

Ultrasound Imaging for Diagnosis and
Treatment of Athletic Injuries

For athletes, early and accurate diagnosis and treatment means sooner return to play. Some common athletic injuries and pathologies for which MSUS provides superior imaging include:

  • Injuries rotator cuff
  • Ankle and Achilles tendon injuries
  • Carpal tunnel syndrome
  • Foot pain and plantar fasciitis
  • Knee pain and injuries, including ACL and meniscal tears, IT band syndrome, Baker’s cyst and patellar tendonitis
  • Ligament sprains and cartilage disorders

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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)


    Complete tear of rectus femoris
    with large hematoma (blood)


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

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