michael scarpone, do / justin baker, dc perry pritchard ... · michael scarpone, do / justin baker,...

Use of Diagnostic Ultrasound in the Treatment and Rehabilitation of Upper Extremity : Multidisciplinary Case Review

Michael Scarpone, DO / Justin Baker, DC Perry Pritchard, PT, ATC

Progression of Diagnostic Ultrasound

Standard of Care-Direct

Visualization

•Tendionoplathy

•Intrinsic Changes

•Calcific Changes

Needle Placement

Dynamic Testing

•Impingement

•Bicep tendon subluxation

•Subluxation of glenoid labrum

Neovascularity Elastography

Is MSKUS Evidence Based?

Retrospective study of 1,012 patients treated by MSK and sports physicians over a 10-month period by Sivan et al. concluded that the use of clinic-based MSK US enables a one-stop approach, reduces repeated hospital appointments and improves quality of care.

Musculoskeletal Care. 2011;9(2):63-8

http://mgchiro.com/shoulder-and-arm-pain

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.sarasotasportsmed.com/physical-therapy/elbow-pain/&ei=Be0JVYfiCNCJNp61gPgC&bvm=bv.88528373,d.eXY&psig=AFQjCNE6F1r8VByKFqpjGoUIg_Od8L7oXA&ust=1426800257246606

Improved Outcomes

RCT by Sibbitt et al. in 148 painful joints were randomized.

US guided had 43% reduction (p<0.001) in procedural pain.

58% reduction (p<0.001) in absolute pain scores at the 2 wks outcome.

75% reduction (p<0.001) in significant pain and 62% reduction in non-responder rate.

Increased detection of effusion by 200% and volume of aspirated fluid by 337%.

Journal of Rheumatology. 2009: 36(9):1892-902

MSKUS vs. MRI In a prospective study of 124 patients, US and

MRI had comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears, with arthroscopic findings used as the standard.

J Bone Joint Surg Am. 2004; 86-A(4):708-16

Advantages of Ultrasound

No Radiation

Directed, real time

Patient Feedback is helpful

Dynamic

Multiplainer Capability

Dynamic Motion Assessment

Tendon Subluxation

Guided needle aspiration, injection

Contralateral Comparison

Not affected by implanted devices / metal

No Claustrophobia

Cost-effective

Color/Power Doppler sonography for vascularity

Non-radiopaque FB

Limitations of MSK US Limited Field of View

Detailed picture of relatively small area

Limited Penetration

Lower Resolution at greater depths

Unable to penetrate bone

Operator Dependent

Education (anatomy), scanning skills, and interpretation.

Requires Patient Cooperation

Body habitus dependent

> 5 cm deep hard to evaluate

When to Evaluate with Ultrasound ?

Shoulder Indications

Rotator Cuff Tears

Calcified tendinitis of the cuff

Subdeltoid-subacromial bursitis

Biceps tendinitis / tenosynovitis

Glenohumeral effusion

Impingement Syndrome

Acromiclavicular Joint

Suprascapular Ganglion Cyst

Ultrasound Accuracy for RTC Imaging

Difficult to differentiate

Partial-thickness articular vs tendinopathy

High-Grade partial vs full-thickness

With Modern Equipment

Full-Thickness

Sensitivity: 95 – 100 %

Specificity: 94 %

Partial-Thickness

Sensitivity: 93 %

Specificity: 87 %

Van Holsbeeck et al. Radiology 1995; 197: 443-446. Teefey et al. JBJS 2000; 82:498

Rotator Cuff :Partial Thickness Tear

Rotator Cuff Tear: Full Thickness

http://www.ultrasoundcases.info/files/Jpg/lbox_39941-Afbeelding3.jpg




Elbow

Ulnar collateral Ligament evaluation

Unknown accuracy vs MRI

Triceps / Biceps tendons

Epicondylosis

Olecranon Bursa

Effusion

US-Guided aspiration / injection

Ulnar Collateral Ligament

Elbow – Flexor Bundle

Elbow – Extensor Tendon

Use of Diagnostic Ultrasound in Rehabilitation

Inexpensive Can be used more frequently to monitor progress and

thus give feedback for continued rehabilitation and management

1. Multidiscipline Case Review – Elbow – UCL 2. Multidiscipline Case Review – Shoulder - RTC

Multidisciplinary Case Study : Right Elbow Jan. 2015

o 21 year old Male o Right Handed College Pitcher o History of various elbow,

shoulder complaints over the last two years.

o Completed traditional physical therapy for 4-6 weeks once year prior

o Was doing well until the beginning of this baseball pre-season

o Significantly frustrated since he was in a starting role for his team

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History

– Pre-Season Throwing

developed significant

elbow pain

Unable to throw or hold

on to the ball with

activities

Pain Level 6-8 out of 10

Complaints of tightness /

Swelling

Complaints of constant

achy pain even at rest.

Multidisciplinary Case Study : Right Elbow Jan. 21, 2015


Examination

Mild swelling medial

elbow

Normal pulses

(-) tinels

(+) tenderness medial

epicondyle and UCL

(+) ULC stress /

Bounce Test

(+) Wrist Resisted

Flexion

MRI Arthrogram Right Elbow

Mild Scarring of UCL w/o

Acute Tear

Thickening of UCL

Intermediate signal of UCL

attachment

Ulnar Nerve somewhat

prominent


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Plan of Care : Multidisciplinary Approach

to give him the best possibility to pitch

this season:

1. Diagnostic Ultrasound with Placental

Cell Injection into damaged tissues

2. Pre-Work Up for Outcomes

A. Quick Dash Questionnaire

B. Pain Level

C. Patient Rated Elbow Evaluation

3. Grip Strength / Goniometry / Scapula

Levels

4. Functional Movement Screen

5. Kinesotape Post injection

6. K-Laser 2-3 times a week



Quick Dash Sports 81.25

% Disability

Quick Dash Shoulder 28

% Disability

Patient Rated Elbow

Evaluation 70 %

Disability

Physical Therapist / ATC

Grip Strength : WNL –Avg 117 lbs

Shoulder Rom

1.Shoulder Arc (IR/ER = 180 : WNL)

2. Sleeper Rom- 56 deg – restriction noted

Scapula Position= WNL=dif of 1.1 cm –right

lower than left

Elbow Rom –lacking 2 degrees of extension


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Functional Movement Screen

o Identify individuals at risk, who are attempting to maintain / increase activity level

o Assist in program design by systematically using corrective exercises to improve fundamental movement patterns

o Systematic tool to monitor progress and movement pattern development in the presence of changing fitness goals

o Create a movement baseline – allowing – rating/ranking movement pattern

o Not used to diagnose, simply to identify or screen


Raw Score Final Score

Deep Squat 2 2

Hurdle Step 18 ½ L=2 R=3 2

InLine Lunge 2 2

Shoulder Mob 3 3

Active SLR 2 2

Trunk Stab push up

3 3

Rotatory Stab L=2 R=3 2

Total 16

Functional Movement Screen


FMS – Correction Hierarchy

# 1 =Address Mobility / Symmetry First before stability Mobility patterns will identify asymmetries thru shoulder

girdle, hip, core & spine, which can cause disruption thru the other patterns

Elbow Case- Addressed Active SLR correctives - Brettzel, Bridge single leg

#2 +Address Stability Second Stability is reflex driven and can’t be improved when mobility

is limited or impaired Elbow Case – Addressed Rotary Stability Correctives

Curl to press Half kneeling D1 flex/ext patterns

# 3 Address Functional Test Deficits – Lunge, Hurdle step, Deep

Squat


Diagnostic Ultrasound : Partial Cortical irregularity, mild tear of UCL at medial epicondyle

Pre-Injection

Pre-Injection

Pre-Injection

Pre-Injection

Injection of Placental Cells

Placental Injection


Post Treatment (next 5 days) - Ice - Active Rest - Avoid anti-inflammatores - K-Tape - K-Laser

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Multidisciplinary Case Study : Right Elbow Feb. 3, 2015

Patient is determined to pitch a few innings Feb 7 on their opener in the south. So he performed Light throwing in the Bull Pen Feb 1, 2015 against better judgment.

Reported he had mild pain and did not have good strength but that it felt much better than prior to the injection. He did decreased his number of pitches for the bull pen session and utilized ice x 20 min post

Today’s Treatment ( Local Concerns – Inflammation Management )

- Ice - K laser - Kinesio-Taping - Range of motion Exercises


Treatment A. Local Concerns

- Inflammation Management - Modalities - light strengthening – isometrics, TB shoulder - dynamic stabilization – Grip in throwing pattern

and body blade in three positions B. Global Concerns

- ART -Soft Tissue Correction - Core Activation - OMT – Cervical, Thoracic, Lumbar

C. K-Laser D. Kinesiotape


Warm-up at game Kinesiotape Pitched full game with K tape - 100 pitches—no sliders 0 @ 90 % - Gun speed 88 / 89 mph and finished 84 mph Won the game Reported he felt good during the

beginning and started to feel sore and loss strength toward the end. He admitted that it wasn’t a good idea to pitch

Use Ice post

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Patient Report - Pain level of a 4 out of 10 - Mild Swelling medial epicondyle - General soreness and stiffness of elbow

Local -Light cross friction, rom, grip, light theraband, web, body blade on air disk thru pitching motion -Closed Chain – Single arm weight shifts vibration plate -Ice,K-laser

Global - Hip Mobility /Squat

Circuit - Core –Quadruped, ham

Swiss ball curl FMS

-Brettzle Stretch -Dead lift Single leg bridge


Soft Tissue - ART

Manipulation-Cervical, Thoracic, Lumbar

Corrective Exercise – Thoracic Extension /

Rotation Quadraped

Laser

Thoracic Extension- each treatment is diagnostic

DNS / Voijta


Local-cross friction, putty,

therabar, dumbbell, body

blade, vibration plate,

Laser

FMS- Curl to press double

arm

P3 – Hip / Squat circuit and

Core activation.


Ultrasound US

Quick Dash = 28.33 % to 18.8 % disability

Quick Dash Sports = 81.25 % to 75.1 % Disability

Patient Report Elbow Evaluation = 70 % to 47.1 % Disability

Continued Multidisciplinary Rehab


2 week Post Injection

Pre- Injection

Comparison Views 3 Weeks


2 weeks Post Injection

Post Injection


Pre- Injection


Comparison Views 3 Weeks

Multidisciplinary Case Study : Right Elbow

Feb. 24, 2015

Progression cross

friction, general

strengthening,

dynamic stabilization

FMS –D1 patterns –

Tall kneeling , split

kneeling

Global-ART,

Manipulation,

Corrective exercise

Laser


March 3 , 2015

Quick Dash= 28.33 % to 18.88% to 11.37% Quick Dash Sports=81.25 % to 75.1% to 31.25 % Patient Reported Elbow Evaluation= 70 % to 47 % to 28 %

Local- Continued progression addressing elbow/shoulder K-Laser FMS –Curl to Press Single Arm from Single leg with one

DB Global-Corrective Exercise Core, hip, Thoracic Continue resistance in advanced positions



March 10 , 2015

6 Week Ultrasound Evaluation-


Pre- Injection

Multidisciplinary Case Study : Shoulder

75 yo man History of right rotator cuff

injury Previous PX 50 Placental

cell injection Followed by BMAC / AFG Previous specifics of case

presented in earlier matrices lecture

After the pain was becoming controlled this man was referred into the our multidisciplinary treatment protocol – local vs global

Injury

Local concern

Compensation

Global

concern

Dysfunction

Shoulder – 4 weeks post BMAC / AFG Physical Therapy : 4 weeks

Observations Forward head, Kyphotic posture Tight pectoralis / Lats Bilateral

Palpation Tenderness RC insertion and bicepital groove

ROM Flexion 135 Degrees ( painful arc 90-120) ABD 155 Degrees ER (POS) – 60 Degrees IR (POS)-64 Degrees

MMT – with pain complaints Flexion 4 /5 Abd 4 /5 ER 3+ / 5

Joint Mobility – Decreased inferior glide with pain

Spadi Score – 52 % disability


Treatment- address local concerns, scap stab, strength

Modalities of choice pre

ROM progression – AAROM, Pulleys, Flexband traction

GH Mobilization (inf / post)

Scap Lift – scap PNF

Strengthening Progression for RTC & Postural – isometric, Dumbbell, TB – PNF patterns

Proprioception progression – swiss ball on wall, rhythmic stab, body blade

K-Laser – used in conjunction with Physical therapy visits

YMCA – Last 5 visits – incorporating cybex circuit and Upper extremity cardio and general wellness program


Discharge Summary

Completed 12 visits of Physical Therapy

Completed 9 K-Laser treatments

Complete 3 sessions with Dr. Baker (1 x a wk in conjunction with Physical Therapy )

Pre Post

Pain Level 8 1

ROM -Flexion -abd - ER - IR

135 155 60 64

153 158 70 80

MMT-Flexion 4 /5 Abd 4 /5 ER 3+ / 5

4/5 4/5 3+/5

All 4 +/5

Spadi Questionaire 52 % disability 4 % Disability

Shoulder – 4 weeks post BMAC / AFG Dr. Baker –Sports Chiropractic Physician

Referred for scapular stabilization, manual techniques, and DNS post rehabilitation cellular therapy

Restricted ROM- flexion, abduction, IR

Moderate tenderness / spasm

Cervical paraspinals

Upper trap

Levator scap – bilateral

Right pec mnor

Stingy pain at 90 degrees of abduction

Inability to bear sustained pressure right supraspinatus

Joint mobility

Considerable decrease C5 into right lateral flexion

Functional Tests

Poor right scap stability

Right scalene inhibition

Positive tests – supraspinatus press test

Treatment Plan – Once a week for 3-4 weeks Muscle Energy –C5 into right flexion

ART / Myofascial Release to involved structures

Corrective Exercise – side scapular stability, neck strengthening

Plan – Once a week for 3-4 weeks

Shoulder – 4 weeks post BMAC / AFG Dr. Baker –Sports Chiropractic Physician

Functional Assessment Shoulder

Impingement

Environment Development

Impingement comes from two places

Postural Otogenesis Anatomy Genetics

Upper Thoracic

Eccentric Loss

Scalene Inhibition

Neurological

Inhibition

Movement

Dysfunction

Mechanical

Problem

Articular

Dysfunction

Compression

Reports he is doing well

Pain Scale is 0-1

No limitations at this point

Vague pain with full abduction

Taking no pain medications

Shoulder Quick Dash – 2.3 % Disability

Completed his physical therapy, K-Laser, and referral session with Dr. Baker

Exam- full ROM, Strength WNL, (-) impingement tests

US Findings

Mild tendinosis with resolution of hypoechoic areas previously noted

Some hyoechoic areas where the graft was placed

Small calcification in the supraspinatus @ 1.5 cm from the insertion

Dynamic Impingement Test – (-)

Treatment Plan

FU Ultrasound in 3 months

Shoulder : Placenta & BMAC/ AFG 16 week FU post BMAC / AFG

michael scarpone, do / justin baker, dc perry pritchard ... · michael scarpone, do / justin baker,...

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