musculoskeletal ultrasound in sports medicine fmf 2015
TRANSCRIPT
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Musculoskeletal Ultrasound in Sports Medicine
Family Medicine Forum Toronto, Ontario
November 12, 2015
Patrick Ling, MD, MPH, CCFP(EM), FCFP, Dip Sport Med, RMSK
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Disclosures • none
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions • On Field Assessment
• MSK US for Screening • Future Directions
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Case Presentation • basketball player • Ankle sprain during the game • MOI: ankle inversion, able to hop off court • Sent to locker room, ice, compression • Xray (Ottawa Ankle Rules) • RICE – POLICE • Rehabilitation/PT • ?MRI
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening • Future Directions
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History • 291% increase in utilization (Sharpe 2012)
• 717% increase in MSK US procedures
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MSK US Utilization in Olympics • US Olympic Training Center Sports Medicine Clinic
• Increased use of MSK US
• Incorporation into physical exam • Serial studies for monitoring healing processes
• Dynamic assessment
• MSK US 5x more use than MRI
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History • ARDMS – American Registry of Diagnostic
Medical Sonography • Introduced ‘RMSK’ designation in 2012 • First credential in musculoskeletal sonography
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History • AMSSM – Position Paper 2014
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History • AMSSM – Position Paper 2014
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape
• Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening • Future Directions
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Why Ultrasound • Quick • Easy • Accessible • Increased patient satisfaction
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Advantages of ultrasound • No radiation • Directed, real time examination • Dynamic (multi-planar, motion assessment)
• Contralateral comparison
• Colour Doppler evaluation • Sonopalpation for tenderness, fluctuance
• 3x better spatial resolution than MRI (150 vs 460 microns)
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Limitations • Operator dependent • Limited field of view
•Technically challenging • Limited view of intra-articular structures
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Ultrasound in the ER • FAST – Focused Assessment with Sonography in Trauma
• EDE 1, EDE 2, EDE 3 – Emergency Department Echo
• POCUS – Point of Care Ultrasound
• CPUS – Clinician Performed Ultrasound
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound?
• Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening • Future Directions
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Protocols • ARDMS – American Registry of Diagnostic
Medical Sonography • RMSK Musculoskeletal • RDMS Diagnostic Medical Sonographer • RDCS Diagnostic Cardiac Sonographer • RVT Vascular Technologist
• ESSR – European Society of Musculoskeletal
Radiology
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ARDMS Protocols • Elbow (medial, lateral, posterior, anterior)
• Wrist (dorsal, volar)
• Hip (anterior, lateral, posterior)
• Ankle - foot (anterior, medial, lateral, posterior)
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols
• Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening • Future Directions
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MSK US and Clinical Exam • Confirm clinical findings
• Tenderness • Provocative signs • Instability • Fluctuance • Clicking, snapping
• Correlated clinical findings with sono-pathology
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MSK US in Clinical Practice • Impact on decision making (Micu 2013)
• Change in management in 60% of patients
• Over 40% of clinical diagnoses were changed
following MSK US examination (Lynch 2008)
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Tenderness • Anterior Knee Pain
• DDX: patellofemoral pain syndrome, patellar tendinitis, Osgood Schlatter, pre-patellar bursitis, pes anserine bursitis, OA, meniscal tear
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Anterior Knee Pain • Prepatellar bursitis
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Anterior Knee Pain • Infrapatellar bursitis
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Anterior Knee Pain • Osgood Schlatter’s Disease
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Anterior Knee Pain • Patellofemoral pain syndrome
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Anterior Knee Pain • Patellar instability
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Common Areas of Tendinopathy • Common extensor tendon “Tennis Elbow” • Common flexor tendon “Golfer’s Elbow” • Supraspinatus • High Hamstring • Gluteus medius • Achilles tendon • Plantar fascia
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Tendinopathy
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Tendinosis • Mid portion Achilles tendinosis
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Assessment of Ligamentous Laxity • Anterior ACL drawer (Grzelak 2015)
• Ankle lateral ligaments (Gun 2013)
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Assessment of Ligamentous Laxity • knee Lateral collateral (Friedl 1991)
• Ulnar collateral ligament (Ciccotti 2014)
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Integrity • Tendinosis vs tear
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Myofascial Pain • Sonographic findings associated with trigger
points
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols
• Ultrasound in the hands of the clinician • Clinical Examination
• Guided interventions • On Field Assessment • Screening • Future Directions
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Ultrasound Guided Interventions • Ultrasound guided injection (USGI) more
accurate than Landmark guided injections (LMGI)
• USGI more cost effective than LMGI
• USGI more efficacious • Becoming the standard of practice of sports
medicine
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USG Interventions
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Knee Arthrocentesis
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Knee Arthrocentesis
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Knee Arthrocentesis
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening • Future Directions
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MSK US for On Field Assessment • Indications – similar to FAST, EDE examination • Clinical conditions
• Pneumothorax • Free fluid • Fracture • Tendon rupture • dislocation
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On Field Assessment • pneumothorax • Sliding lung sign
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On Field Assessment • Free Fluid in abdomen
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On Field Assessment • Fracture – loss of cortical margin, associated
periosteal hematoma • Detection of pediatric long bone fracture (Barata
2012)
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On Field Assessment • Calf injury – “Tennis Leg”
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On Field Assessment
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On Field Assessment • Shoulder posterior dislocation (Mackenzie 2013)
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On Field Assessment
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On Field Assessment • Acute knee – presence of hemarthrosis
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment
• Screening • Future Directions
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Limited Echo • To prevent sudden cardiac death in the young
(SCDY) • Controversial (?cost effectiveness)
• Consists of parasternal long-axis • Parasternal short axis • Apical 4 chamber • Apical 5 chamber
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Limited 2D Echo
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Limited Echo • Valvular abnormalities • Hypertrophic obstructive cardiomyopathy • Right ventricular dysplasia • Anomalous coronary artery
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US for Prediction of Injury • Achilles tendinopathy – power doppler predicts
symptomatic MPT (Hirschmuller 2012) • Patellar tendon findings predictor for jumper’s knee
(Cook 2000, Fredberg 2002) • ACL diameter predictor for injury (Mahajan 2015) • Transverse abdominus predictor for groin injury
(Jansen 2010) • Quadratus femoris weakness predictor for PFPS
(Doxey 1987)
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Abdominal Ultrasound • Splenomegaly in athletes with mono and return
to play decisions (O’Connor 2011)
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Case Presentation • MSK US evaluation of supportive ligaments • ATFL, CFL, peroneal tendons, syndesmosis, bony
avulsions • Prognostic value • interventions – PRP? • Return to play decision
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MSK Ultrasound in Sports Medicine • Outline
• History and Landscape • Why ultrasound? • Protocols • Ultrasound in the hands of the clinician
• Clinical Examination • Guided interventions
• On Field Assessment • Screening
• Future Directions
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Future Directions • Adding physiologic value to imaging
• Shear wave and elastography • Contrast enhanced ultrasound
• Clinical decision rule
• EDE – ATLS • Incorporating bedside imaging to decision making
and risk stratification
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Future Directions • Integration and development
• Current SEM practice • Educational standards • Professional standards • ?credentialing • Remuneration
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Acknowledgements • Physician Demonstrators:
• Dr. Constance Lebrun • Dr. Harpreet Sangha
• Models: • Dr. Sheila Parai, FMR2 • Dr. Chris Young, FMR1 • Dr. Rob Weitemeyer, FMR2
• Vendors: Zonare, Sonosite
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References • Johnson; How to Perform USG Knee Arthrocentesis: ACEPNow 2015 Aug 15 • Barata et al; Emergency US in the detection of pediatric long-bone fracture: Ped Emerg Care 2012 Nov 28(11):1154-7 • Bomberg; Acute hemarthrosis of the knee: indications for diagnostic arthroscopy: Arthroscopy 1990 6(3):221-5 • Ciccotti et al; Stress Sonography of the UCL of the elbow in Professional Baseball Pitchers. Am J Sports Med 2014 42(3):
544-551 • Cook et al; Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J
Ultrasound Med 2000 Jul 19(7): 473-9 • Doxey; Assessing Quadriceps Femoris muscle bulk with girth measurements in subjects with patellofemoral pain: J Ortho
and Sport Physical Therapy 1987; 9(5): 177-183 • Finnoff et al; American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports
medicine fellowships. BJSM 2014 0;1-6 • Finnoff et al; American Medical Society for Sports Medicine position states: interventional MSK US in sports medicine.
BJSM 2014; 0; 1-14 • Fredberg; Significance of US detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer
players: a longitudinal study. Am J Sports Med 2002 Jul-Aug 30(4):488-91 • Friedl Dynamic sonography in the diagnosis of ligament and meniscal injuries of the knee. Arch Orthop Trauma Surg
1991; 110(3):132-8 • Grzelak et al; Ultrasonographic test for complete ACL injuyr. Indian J Orthop 2015; 49:143-149 • Gun et al; Bedside US by EP for ATFL injury 2013 Jul-Sep 6(3): 195-198 • Hirschmuller et al; Prognostic value of Achilles tendon doppler sonography in asymptomatic runners: Med Sci Sports
Exerc 2012 Feb 44(2): 199-205 • Jansen et al; Resting thickness of TA is decreased in athletes with longstanding adduction-related groin pain. Man Ther
2010 Apr 15(2):200-5 • Lynch et al; Does MSK US change patient management in the clinic? 2008 American College of Rheumatology - Annual
Scientific Meeting • Mackenzie; Point of Care US facilitates diagnosing a posterior shoulder dislocation: J Emerg Med 2013 May 44(5): 97608 • Mahajan et al; Smaller ACL diameter is a predictor of subjects prone to ligament injuries: an ultrasound study. BioMed
Research International 2015 • Micu et al; Impact of MSK US in an Outpatient Rheumatology Clinic: Arthritis Care & Research 2013 Apr 65(4) 615-21 • O’Connor et al; Return to contact sports following IM: the role of serial US. Ear Nose Throat J 2011 Aug 90(8):E21-4 • Sharpe et al; Dramatically increase MSK US utilization from 2000-2009. J Am Coll Rad 2009 Feb 9(2); 141-146