Jeffrey Cusmariu, MD shows a patient the real-time view of her shoulder using the muscular-skeletal ultrasound.
Recent advances in ultrasound technology mean orthopedists can now treat with pinpoint accuracy and diagnose injuries that previously had to be left in a “wait and see” scenario.
“For instance, we were limited by technology in how to find the cause of heel pain. We had to do some guessing,” says Francisco Caycedo, MD, an orthopedist with OrthoSports Associates. Patients had to wait and see if their injury improved to determine whether it was a partial rupture needing only rest or a full rupture that required surgery.
But now, the muscular-skeletal ultrasound offers an unprecedented look at body joints and limbs. “With the ultrasound, we can now see whether the Achilles tendon has a partial rupture or full rupture right in our office, without having to wait or do surgery,” Caycedo says.
The same situation applies to the shoulder where a strain mimics a tear, so rotator cuffs fell in the wait-and-see category as well. “The ultrasound helps at the front end, so we don’t have to send everyone for MRIs or wait three weeks to see if therapy works,” says Jeffrey Cusmariu, MD, another orthopedic surgeon at OrthoSports Associates, where the new ultrasound was installed six months ago.
“The ultrasound is not a replacement tool, it’s an adjunct,” Cusmariu says. “But it is a lot less expensive than MRIs, and we can do it in the office.”
The technological difference in the muscular-skeletal ultrasound rests with transducer and software advances. “The penetration is deeper and more detailed, so when it hits bone or tendon, it gives you a particular image,” Caycedo says. “It’s an amazing quality of picture.”
But there’s a learning curve to using and reading the ultrasounds, says Cusmariu. “It’s hard learning the anatomy again on ultrasound versus other modalities, because we’re looking at tissues in a whole different manner,” Cusmariu says. “And we’re learning the technical part, the application, and we’re being the interpreter too.”
The ultrasound does trump the MRI when it comes to metal, a common treatment tool in orthopedics. “When we look post-op, metal anchors can start obscuring the MRI. But metal doesn’t affect ultrasound, so post op we can assess the rotator cuff more clearly,” Cusmariu says.
The greatest benefit with the new ultrasound comes from the real-time view of a joint or limb in motion. “It’s a dynamic image,” Caycedo says. “With this kind of technology, we can see new formations of vessels, watch fluid collections in the fascia or tendons, see how the tendons are moving, almost everything. And it’s in color. You don’t get any of that with an MRI or x-ray.”
For the first time, orthopedists have an accurate internal, dynamic view as they give injections. “If you have inflammation around the tendon, you need to put the injection where it is inflamed, or it doesn’t help,” Caycedo says. “It used to be the only way to see exactly where the injection was needed was to do open surgery, but now we can see with ultrasound, even if the patient moves while we do the injection.”
Before the ultrasound, the only non-invasive guide for injections was by landmarks and by feel. “To give you an idea of the difference the ultrasound makes, studies show that in the knee, which is a very accessible joint, getting injections into the joint occurred 70 percent of the time, even with an experienced surgeon,” Cusmariu says. “Now try getting it in the hip, especially with overweight people. Even under fluoroscopic guidance, it’s very difficult to get into a shoulder or hip joint.”
Caycedo, who specializes in the heel, stresses the ultrasound’s ability to spot entrapped nerves. “With the ultrasound, we can see the shape of the nerve, even as it’s surrounded by tendons and the sheath of the fascia,” Caycedo says. “There’s a lot of live information given to us with these devices.”
Cusmariu says that the savings in pain and costs with the ultrasound’s accuracy and real-time viewing have made a big a difference to patients. “With injuries like rotator cuffs, we had to give it a few weeks and do therapy. But these days, patients don’t have the luxury to spend a couple of hundred dollars trying therapy for a few weeks,” Cusmariu says. “With the ultrasound, we know right away if they have a tear, so we save them the money and the discomfort, and they can use all their insurance-limited therapy sessions post-surgical.”