Musculoskeletal Ultrasound

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It would be nice if athletic injuries were simple, clean and easy to diagnose. However, most athletic injuries occur during play, involving large force loads at high velocities, often resulting in complex injuries to multiple structures.

Traditionally, X-Ray and MRI have been used to assess and diagnose sports injuries. However, those methods have several limitations, and results can take hours or even days while the images are read and interpreted. Meanwhile, athletes and coaches are left guessing about the extent and severity of an injury, and treatment is delayed.

Advantages of Ultrasound Imaging

Musculoskeletal Ultrasound (MSUS) delivers high frequency sound waves to the injured area, which bounce back as images that can be viewed on a computer monitor. Soft tissue damage precedes hard tissue changes, and MSUS is all about soft tissues. MSUS provides pictures of muscles, tendons, ligaments, joints, internal organs, neural bodies and blood vessels in real time. Moreover, MSUS can detect stress fractures to bones earlier than X-ray or MRI.

Unlike X-ray or MRI, MSUS equipment is lightweight and portable, enabling accurate diagnosis to be done within minutes after the injury occurs. Moreover, the images can be viewed in real time by both clinician and patient, enabling the patient to participate in the diagnostic process.

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Advantages of MSUS over X-Ray, CT and MRI include:

Ultrasound is safe and can be used on anyone. Because X-ray and CT scan emit radiation, the amount of exposure per year is limited, and those methods cannot be used on pregnant females, and in certain other cases. MRI does not emit radiation, and it can provide details of soft tissues, but because it uses large magnets, it cannot be used on patients with metal implants or pacemakers, during pregnancy, or in other less common cases. Because of its safety, MSUS can be used repeatedly over a short period of time.

A high-end MSUS transducer can provide more details than other imaging methods, providing a clearer view of abnormalities like tendon tears. MSUS’s higher resolution makes it more effective for detecting small calcifications and tiny foreign bodies.

MSUS provides an extended field of view. Due to the elastic nature of soft tissue, sonoelastography can assess the response of tissue to stress (pressure), to visualize stiffness that can indicate tissue damage or pathology. Elastography can be used to predict recovery time following treatment, and to help assess a patient’s readiness to return to activity, based on a normal tendon elastogram. Doppler imaging can detect inflammatory changes earlier than blood work or MRI.

Dynamic real time MSUS imaging is interactive, enabling the examination to be directed to the exact location of a patient’s pain or discomfort. During interactive examination, the patient is able to produce movements that cause pain, giving the examiner greater insight into the nature and location of injury. Movement can reveal joint abnormalities and impaired movement in tendons, bursa, muscles and joints.

MSUS is more comfortable for the patient, who is not subjected to prolonged immobilization in a claustrophobic tunnel as with MRI.

The patient is able to provide valuable feedback during MSUS in response to palpation and movement. When a painful area is detected, associated abnormalities can often be seen on the monitor, confirming diagnosis. The patient’s feedback can provide vital information that may reveal tendon or joint subluxation, or ligament incompetence.

Rapid results: Since MSUS diagnosis is performed in real time, both patient and clinician can receive immediate results and begin to devise a treatment strategy in the same session.

Ultrasound waves provide high resolution images of tendon tissue, which is hyperechoic, 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.

Guided aspirations: Ultrasound provides a useful tool for performing accurate real-time guided injections or aspirations.

Blood flow: MSUS can detect changes in blood flow that can help the clinician pinpoint an injured area.

Bilateral imaging: With MSUS, the clinician can quickly and easily view images of both sides of the body during the same session, to compare the patient’s injured structures to bilateral “normal” structures.

MSUS allows for a dynamic view of the entire length of a structure. The transducer can follow the entire pathway of a nerve to identify the specific point at which it is compressed. It can follow a long muscle like a hamstring from origin to insertion to pinpoint the precise location and nature of an injury.

MSUS can detect the presence and behavior of cystic masses.

Both MRI and MSUS provide superior imaging over X-ray, and they are similar in sensitivity and specificity. However, in addition to the advantages listed above, the cost of MSUS is a small fraction of MRI, and the equipment requires very little space compared to MRI.

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A Case in Point

Physical therapy and rehab can be time consuming, and a faulty diagnosis can make treatment a total waste of time. Failure to accurately diagnose a condition in its early stages can lead to chronic problems and sometimes devastating results.

Diagnostic musculoskeletal sonography (MSUS) provides the perfect tool for the rehab practitioner. Yet many doctors and physical therapists have no experience with MSUS, are unaware of its advantages, and have no idea how to use it as a diagnostic tool.

Below is a prime example of how ultrasound can take the guesswork out of diagnosis.

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.

Ultrasound Imaging for Diagnosis and Treatment of Athletic Injuries

For athletes, early and accurate diagnosis and treatment means sooner return to play. Not only does MSUS allow for diagnosis within minutes of injury, but it provides an important tool for assessing the progress of rehabilitation, and for determining whether an athletic injury has healed sufficiently for the athlete to safely return to play.

Conditions diagnostic ultrasonography is commonly used for:

MSUS at NYCSPT

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Dr. Lev Kalika, founder of NYCSPT, 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 to Dynamic Functional Ultrasonography. Dr. Kalika is also in process of organizing a post graduate education school for physiotherapists, sports medicine physicians and chiropractors.

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

130 West 42 Street Suite 1055, New York NY 10036

Research at NYDNRehab

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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)

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Complete tear of rectus femoris
with large hematoma (blood)

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

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