Ultrasound - Guided Musculoskeletal Interventions - SD

Introduction

Hi, I am Lev Nazarian.

I'm professor of radiology and Vice Chairman for education at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.

And I'll be speaking on interventional procedures in musculoskeletal ultrasound.

Musculoskeletal ultrasound has grown rapidly in recent years in terms of its diagnostic capability, and with the increase in diagnostic capability comes the greater ability to guide musculoskeletal interventions.

Real-time ultrasound imaging allows interventions that are otherwise difficult or impossible without it.

And these interventions can be diagnostic, they can be therapeutic, or they can be a combination of both.

General Procedure Details

There are certain procedure details that we need to go over.

The procedures that we do under musculoskeletal ultrasound guidance are generally done under aseptic conditions.

We use a chlorhexidine scrub and we use sterile drapes to prepare the patient.

And we also use a sterile probe cover over the ultrasound transducer.

Most of our procedures are done under local anesthetic using 1% lidocaine, and we use a freehand technique.

There are guides available that clip on the side of transducers that can be used to guide these procedures, but we find that freehand technique allows us to use an infinite number of planes and therefore gives us more flexibility in our approach to these procedures.

This is a picture of a typical procedure that we do under ultrasound guidance.

Note how the transducer is placed on the skin with a probe cover on it.

We wear gloves and we have the needle directed along the long axis of the probe.

By directing the needle in the long axis of the probe, we're able to see more of the needle throughout its course and therefore are better able to hit our target.

Biopsy of Superficial Masses

The first intervention that I'll be speaking of is biopsy of superficial masses.

For this, we use a 20 or 22 gauge hypodermic or spinal needle, depending on the depth of the mass, we confirm the needle tip is within the lesion by ultrasound, and then we do 10 to 15 excursions of up to one centimeter with the needle back and forth through the lesion.

We then take the aspirated material and submit it for cytologic evaluation.

If the cytology is equivocal, we perform an 18 gauge core biopsy and send that for surgical pathology.

The reason we need to do biopsies of soft tissue masses is their ultrasound appearance is often nonspecific.

This is a man who presented with a mass on his thigh, and what we see is a hypoechoic mass with abundant power doppler flow within it.

But really, besides knowing that this is a solid mass, we have no way of having a specific diagnosis.

We guided a needle into the mass shown here, and the aspirated material showed malignant lymphocytes, and this turned out to be a non-Hodgkin's lymphoma presenting within the subcutaneous tissues.

Diagnostic Aspiration of Fluid Collections

We also do diagnostic aspiration of fluid collections.

We start with an 18 gauge needle because the fluid is often more viscous than it appears.

So if you go with a smaller needle, you may not be successful in removing the fluid.

You usually aim for the most anechoic area because that's the area that's most likely to be aspirable.

You confirm the needle is within the collection and then you aspirate with the syringe.

If there's no return, you can reposition the needle.

If there's still no return of fluid, you can agitate the needle within the collection and pull out a few drops because if the question is whether the collection is infected, then you can pull out a few drops for culture and that will be plenty.

Muscular Hematoma Case

Here's a typical case of a patient who presented with a muscular hematoma.

He was anticoagulated and developed a hemorrhage within the gluteus medius muscle shown here on CT.

And then here is our needle within the hematoma and ultrasound.

Now, if you notice, a hematoma often has abundant internal echoes and is more like gelatin in its consistency rather than fluid.

So we weren't able right away to get fluid from this collection, but by agitating the needle, we were able to coax out a few drops of blood that we sent for culture, and this turned out to be a non-infected hematoma.

Calcaneal Osteomyelitis Case

Now, here's a case of a patient who is known on MRI and bone scan to have a calcaneal osteomyelitis, but on ultrasound, we're able to help by finding the actual organism responsible.

So the C here represents the calcaneal echo and there was fluid next to the calcaneus with some inflammation around it.

Here's a black and white picture of the color Doppler image that shows abundant flow around this fluid.

We were able to guide a needle into this fluid and confirm staph aureus as the cause of the patient's osteomyelitis.

Crystal Arthropathies Case

Here's another type of diagnosis we could make in patients that have crystal arthropathies.

Here's a 53-year-old man with foot pain.

Here's his MRI, which was done first and shows the achilles tendon coming down, and then there was intermediate signal intensity material at the distal attachment of the Achilles with some erosion of the adjacent bone.

My colleagues in MRI diagnosed this as either rheumatoid arthritis or perhaps gouty deposition at the calcaneal insertion of the Achilles.

And so with that differential diagnosis in mind, we brought the patient up to ultrasound, and here I've turned the ultrasound image to be in the same plane as the MRI.

And as we follow the achilles tendon down here, we can see that this circled area is the same area circled on the MRI and showed some hyperechoic material which looked crystal in nature.

So now our next goal was to try to prove the etiology of this.

So we performed an aspiration with an 18 gauge needle.

We took the needle and placed it on a syringe with some local anesthetic and we lavaged and broke up this crystalline material.

Here's the needle tip seen within the crystal.

It's a little bit hard to see because the crystals are hyperechoic, but in any event, we took the aspirated material and we submitted to the pathology lab who made the diagnosis of monosodium urate crystals.

So here not only was the diagnosis suggested on the MRI, but we were able to bring the patient up to ultrasound and make a specific diagnosis all within one patient visit to the imaging center.

Pre- and Infrapatellar Bursitis Case

Now, here's a patient who had severe pre and infrapatella bursitis.

This is the infrapatella tendon, and this patient had a large collection in front of it and the story was that his wife was actually an internal medicine physician, and every four weeks or so would stick a needle into this collection and remove about a hundred ccs of bloody fluid.

It never grew out anything in culture and it also never showed anything on crystalline analysis.

So the question is why was this recurring and what was the problem here?

Here's an extended field of view image showing the patella.

Here's the quadriceps tendon, the infrapatella tendon, and there's this very large collection both in the prepatella space and in the superficial infrapatella space.

One of my astute sonographers realized that there were this small little crystals on top of the patella, and these were actually the key to the diagnosis because these crystals were felt to be causing an irritation that was creating this bursitis.

The fluid never yielded any crystals on any of the aspirations, and therefore the feeling was that we had to actually get down to these crystals in order to make the diagnosis.

So we got a needle into the crystals, we took it to the pathology lab, and they were able to make a diagnosis of calcium hydroxyapatite deposition disease.

So the good news was that the removal of these calcifications for the laboratory actually was able to be therapeutic for this patient because after this procedure, he no longer reaccumulated the fluid and he essentially was cured by simply needling these crystals.

Conversion to Therapeutic Procedures

Now, when you do a diagnostic aspiration of fluid collections, at any time you can convert the diagnostic to a therapeutic procedure.

You can either complete the needle aspiration and basically suck the collection dry, or you can convert to a catheter drainage for more definitive drainage of the collection.

So this is an AIDS patient with muscle pain and fever, and he had a hypoechoic collection in his rectus femoris muscle.

Power Doppler really confirmed that this was very inflammatory, this fluid collection, but it's not going to tell you exactly what the cause is, so you really do have to aspirate it.

We saw a relatively avascular area, which seemed like a good place to stick a needle and get material.

And when we did, we got pus out of this and then we were then able to convert the aspiration into placement of a catheter for definitive drainage of this muscular abscess.

Muscular Hematoma Decompression Case

Now, here's a pro football player who took a knee during practice and developed a heterogeneous hematoma within his vastus lateralis muscle.

We were asked in this case not to make a diagnosis because that was clear, but rather to see if we could help this individual by decompressing the hematoma and making it easier for him to return to play.

This is one case where I actually used a guide, which you see here on the side because I felt that in order to get into this and actually remove any of this fluid, I needed a 14 gauge needle.

I thought anything smaller would not be effective.

So I used a guide, made one pass in with a 14 gauge needle and took out about nine ccs of hemorrhagic fluid, which was enough to give him some relief and he was able to be back on the field in about two weeks.

Joint Aspiration

Joint aspiration is often referred to ultrasound guidance after a so-called dry tap.

Typical would be that the patient would have several bandaids where clinicians had tried without imaging guidance to remove fluid from the joint, but were unsuccessful.

When we do tap a joint, we're often asked to send it for crystals and culture and sensitivity.

Even the decompression alone may alleviate the symptoms.

This is a shoulder joint seen posteriorly.

We see the humeral head and the glenoid, and this is an effusion posteriorly lifting up the joint capsule from a posterior approach.

We get a needle into the collection.

You can see already from this image that the fluid has been aspirated and there is the needle tip.

Ganglion Cysts in the Shoulder

Now, fluid can be also seen in the spinoglenoid notch, the so-called ganglion cyst, which occurs when there is a partial tear within the glenoid labrum and fluid leaks out of the shoulder joint into the spinoglenoid notch, which is shown here.

These ganglion cysts can be very painful and can cause atrophy of the overlying infraspinatus muscle due to compression on local nerves and aspiration really provides immediate relief.

So here is a post aspiration image of the same patient showing that the ganglion cyst has decompressed and usually with immediate relief of symptoms.

Elbow Joint Aspiration Case

Now here's a quandary of an elbow patient, a patient with rheumatoid arthritis with elbow pain, and the question was where to tap the joint.

And this is one of the patients who had a few bandaids when it came down to our department.

And the reason was that there was a very palpable swelling in the elbow that the clinicians guided a needle into, but that was not where the fluid was.

We can see that where that palpable swelling was, there was a lot of power doppler flow showing that this in fact was solid tissue related to rheumatoid pannus and wasn't fluid at all.

Scanning around showed that in fact there was an anechoic area of fluid that we were able to then access under ultrasound guidance.

So here's the echoic fluid with flow around it, and here's ultrasound guiding a successful aspiration with the needle within the fluid.

Septic Arthritis Emphasis

Now I show this slide to emphasize the fact that there's nothing about a collection that tells you whether it's infected or not.

In other words, if you are suspecting septic arthritis, you absolutely have to aspirate the joint no matter what the fluid looks like.

This is a patient where there was a hip effusion, fever and severe hip pain.

And even though there was nothing specific about the effusion shown here, it was felt that we had to aspirate this and we did, and we got staph aureus out of this collection as well.

So it's really important to when in doubt aspirate and send the fluid for culture.

This is another patient who had hip pain and osteoarthritis, and the clinician wanted us to aspirate the fluid for two reasons.

One, potentially to give therapeutic relief, but also to make sure the collection wasn't infected.

Here's the femur.

Here is the femoral neck with the fluid pre and post aspiration.

Notice the marked thickening of the joint capsule that goes along with the diagnosis of chronic osteoarthritis.

Ganglion Cysts General

Ganglion cysts are occasionally sent for aspiration.

Now the problem with ganglion cysts is that they have a high tendency to recur because they are often fed by an underlying joint or tendon sheath.

But still, if a patient is very symptomatic, they may or be willing to take the chance that this collection may reoccur and want this ganglion to be aspirated.

So here's an example of a bilobed ganglion cyst seen on MRI an ultrasound.

These often look anechoic, but they can also look hypoechoic, iso, even hyperechoic.

There's really a wide range of ultrasound appearances for ganglion cysts, but what they almost all have in common is that their contents are much thicker than they appear on ultrasound.

They tend to be very mucoid and can be very hard to aspirate.

Here's an example of this foot ganglion cyst with a needle within it.

So MRI and ultrasound both are able to make this diagnosis, but of course, only ultrasound is able to guide the aspiration in real time.

Here's another ganglion cyst seen very well on MRI.

We see a large ganglion cyst rising from the anterior cruciate ligament and you can see it's multiloculated on this axial view.

Again, ultrasound's not the primary way to image the anterior cruciate ligament, however, is an excellent way to guide aspiration of ACL ganglion cysts.

Here's the distal femur with articular cartilage on it.

Here is the tibia, here is the patella with the infrapatella tendon.

Here's the ganglion cyst.

There's a needle within the ganglion cyst on this image and we're able to aspirate the bulk of this.

Once you aspirate a ganglion cyst, you may or may not then go ahead and do a corticosteroid injection.

And here is a posterior cruciate ligament ganglion cyst.

Again, seen very well on MRI.

Here's the posterior cruciate ligament and the ganglion and on ultrasound posterior cruciate ligament and the ganglion, and we can guide aspiration of this as well.

Baker's Cysts Case

Now here's a case that taught me quite a bit about baker's cysts.

So baker's cysts, if you are familiar with the anatomy occur between the medial head of the gastrocnemius and the semimembranosus tendon, and most of them communicate with the underlying joint so that they form this mushroom shape on ultrasound.

This patient was bothered by her ganglion cyst.

It was quite swollen behind her knee.

So I went ahead and I stuck a needle in it and I removed it.

Patient sat up and said, wait a minute, doc, you didn't do anything.

The cyst is there.

And I showed her the syringe of 20 ccs of fluid.

She said, but the cyst is still there.

So I laid her down and sure enough the cyst was still there, so I'm thinking, wait a minute, what's going on here?

So I aspirated it again, it went away again and she sat up again and said, it's still there.

So I'm saying, what's going on?

And then I remembered that these cysts often communicate with the knee joint.

So I said, let's turn you around and look at your anterior knee joint.

And she had a very, very large knee effusion with adjacent synovial thickening.

And what was happening was every time I was removing this baker cyst, it was filling up immediately from all the fluid within the knee joint.

So in this case, what I did was I placed a tourniquet over the suprapatellar space, forced that fluid into the cyst, removed it, and then that was it.

We were able to get the whole thing.

Now I've learned that before I aspirate a baker cyst, I always check for an effusion.

If there's a large effusion present, then I will aspirate the effusion first and then go ahead and aspirate the baker's cyst.

Therapeutic Injections

Okay, now moving on to therapeutic injections throughout the body, there are a wide range of processes that will respond to a combination of corticosteroid and local anesthetic.

The total volume injected depends on the size of the injected joint bursa, et cetera.

A general rule of thumb is between 0.5 and two ccs of triamcinolone or the equivalent mixed with lidocaine and or bupivacaine.

Under ultrasound, you can monitor the injection in real time and then you can assess for symptomatic relief.

Subdeltoid Bursa Injection

Here's a very common bursa that's injected the subdeltoid bursa and this is the deltoid muscle.

Here's the rotator cuff and here's the needle placed in the plane between the bursa and the cuff.

And here is the bursa filling with local anesthetic mixed with corticosteroid.

Now you might say, what's the purpose of this?

Aren't these injections done blind?

And the answer is, yes, they are.

But there's growing literature to suggest that injections done under ultrasound guidance are much more likely to hit their target and also provide for better patient outcomes.

Biceps Tendon Sheath Injection Case

Here's a patient whose ultrasound of the shoulder was normal, but his pain localized to the front of his shoulder and that's where his ultrasound findings were.

He had marked flow around the biceps tendon, seen longitudinally and transversely.

So this was a biceps tenosynovitis.

I do caution you that most of the time when you see fluid or inflammation around the biceps tendon, it's often a reflection of what's happening in the shoulder joint because the joint itself communicates with the biceps tendon sheath.

However, in this patient, it was clear that the pain was coming from the biceps tendon.

What to do?

Well, we decided to do an ultrasound-guided injection.

Now what I'm doing here is coming down with a needle and seeing that the first space I get into when I'm doing a test injection with lidocaine is the subdeltoid bursa.

So I'm not yet deep enough I'm gonna continue to advance the 22 gauge needle until I get into the biceps tendon sheath.

Here's the biceps tendon itself.

So in a moment you'll see the sheath start to open.

There it is.

Now I know that I'm in the right place.

I can exchange out for the corticosteroid and inject that.

And this patient had excellent result.

Peroneal Tendon Sheath Injection Case

Now here's a tenosynovitis of the common peroneal tendon sheath in the ankle.

Here's peroneus longus and peroneus brevis.

And you can see fluids surrounding both of these tendons and the area of the fluid surrounding the tendons corresponded to the area of maximal tenderness.

Here is in real time the injection.

We got the needle into the peroneal tendon sheath and we started to inject.

And what was very interesting about this injection was that it helped show some of the pathophysiology of her problem because as we injected, we were starting to see these little synechiae or these little webs that were forming within the peroneal tendon sheath.

And when you talked to this patient, she said that her main symptom was that when she was walking, she felt like something was pulling on her tendons.

And if we look at a still image, we can see that these were in fact synechiae that were pulling on her tendons every time she moved her ankle.

Now that we could identify these on ultrasound, we could actually go in with the needle and try to break these up and then put in the corticosteroid.

And that is really what helped bring her to a satisfactory result.

Baker's Cyst Injection Case

Now, sometimes when we're asked to aspirate a fluid collection, it's not a fluid collection at all.

And this was a baker cyst that was filled with rheumatoid pannus.

So what to do?

Well, we can go ahead and inject this baker cyst because none of this is aspirable.

Here's a needle within the baker cyst.

And by putting in a cc of Kenalog in this patient mixed with a cc of local anesthetic, we got the patient about six months of relief.

We then injected her again and about six months later she came back again.

And yes, we didn't cure the problem, but we did give her substantial period of relief.

And in patients with chronic pain, any relief is certainly very welcome.

Hip Labral Cyst Injection Case

Here's another procedure that we thought would be simply an aspiration of a cyst, but it turns out that this hip labral cyst was mostly solid material.

So again, we couldn't aspirate the ganglion, but we could inject it.

And also the other thing with paralabral cysts or ganglion cysts is we take the needle and we actually poke holes in the wall of the cyst because if we can decompress the pressure within the cyst, that can often really help their symptoms.

Hip Joint Injection

Now, injection of the hip joint itself can be done using fluoroscopic guidance, but I like ultrasound guidance 'cause it's quicker and there's no radiation.

And plus we can see any vessels along the way.

This is the acetabulum, this is the femoral head and femoral neck.

The femoral head here is a little bit irregular because of the osteoarthritis.

And what we do is we guide a needle down into the region of the neck because that is where the hip capsule is the most loosely applied and the easiest place to inject.

So I'm gonna run the video here and we'll see that the needle is going to go into the joint and then you'll see the joint blow up here with fluid confirming that in fact we are within the hip joint, no doubt about it.

And that way we have the highest chance of helping the patient.

Sometimes in very large patients it may be difficult to discern whether our needle is actually in the joint.

It can be hard to see the needle tip.

So one trick that I and others use is we put on the power doppler because within the material that we inject, there's often little dissolved air bubbles or even the crystals from the corticosteroid can create echoes.

And so if we're not sure where the needle is, we put on the power doppler and here we're injecting under power doppler guidance and we can see that the injectate is going exactly where we want it into the region of the hip joint.

Now, power doppler is an important adjunct also just to show us where it should be injected.

And this is a posterior tibial tendon with a lot of inflammation around it.

And you can see the beautiful guidance that ultrasound can give you showing the bevel, we can put the bevel up to minimize any risk of injury in the tendon and inject the tendon sheath.

There are anecdotal reports when you inject in tendon sheaths that you can weaken tendons and predispose them to rupture.

My personal feeling is that many of those reports are due to the fact that the injections were performed blind and the needle injecting into the tendon is what predisposed the patient to rupture with careful injection into the tendon sheath, that should not be as much of an issue.

Morton's Neuroma Injection

Another painful condition we get asked to inject are Morton's neuromas, which are fibrous pseudo tumors that occur in adjacent.

They are fibrous pseudo tumors that occur in close proximity to the plantar digital nerve, which lives between the metatarsal heads.

So this is a needle placed within such a Morton's neuroma.

And then after we inject, we can see that not only the neuroma but the whole intermetatarsal bursa fills with medication and gives the highest chance of success.

Rotator Cuff Calcification Treatment

Now, rotator cuff calcification is a common problem and they can indeed cause pain, especially when they impinge in the subacromial space.

And therefore there has been for at least the last 10 years literature on using ultrasound to guide needle treatment of rotator cuff calcifications.

This is also just done under local anesthetic and either an 18 through a 22 gauge.

Somewhere in that range needle is guided through the abnormal region of the tendon.

I usually tend to use the smaller needles for calcifications that tend to be softer, but for very firm calcifications, sometimes an 18 gauge needle is needed to break them up successfully.

And what we can do is we can not only break up the calcifications, but we can also lavage and remove the calcifications physically from the cuff itself.

So here's an example of a patient with longstanding shoulder pain.

He had multiple negative MRIs and he was not responding to physical therapy.

He had blind injections of corticosteroid into his subdeltoid bursa that did not work.

So we brought him over to ultrasound.

We saw that there were actually tiny calcifications that were not seen on MRI and ultrasound is more sensitive to these tiny calcifications than any other modality.

Here is a needle that we got into the calcifications and here's a video of actually going and chipping those calcifications away from the tendon insertion.

And after we chipped them away, we went ahead and we injected into the subdeltoid bursa.

And this patient got tremendous relief and we're now more than six years out and he's had no recurrence of his pain.

But when the calcifications are very large, they tend to create some shadowing and also will distort the outer contour of the rotator cuff and needless to say, can cause impingement symptoms.

So here's one such patient with a large calcification, we get a needle into the calcification and we inject, you can inject either sterile saline or local anesthetic into the calcification and you can lavage the calcification out.

And this is an image that's shown in a different color pattern to accentuate the fact that there is all of this debris that came into the syringe, which is the debris that we removed, the calcific debris that we physically removed from the rotator cuff.

And that was a way to eradicate this calcification without surgery.

Now this is the alternative.

Calcium can be removed arthroscopically, but of course anytime you save a patient's surgery, they certainly are very grateful and you've saved quite a bit of cost as well.

Tendinosis and Percutaneous Tenotomy

Now when we talk about conditions that are chronic, repetitive stress injuries in the musculoskeletal system, we always talk about tendinosis rather than tendonitis.

Now why do we use the term tendinosis?

Well, the word tendonitis implies inflammation.

But if you do histologic analysis of many chronic tendon conditions such as tennis elbow or Achilles problems, there is scant or any inflammatory cells within these tendons.

These, so these conditions are not tendonitis.

These conditions are so-called tendinosis.

This is histologic correlation of a normal tendon and then a tendon that has tendinosis.

And all of these findings can be seen pathologically in tendinosis.

And the important thing to realize is that not on this list are acute inflammatory cells.

So these are degenerative conditions and that's why sometimes they have a prolonged course that ultimately needs surgery and they will at some point stop responding to anti-inflammatories because they're not inflammatory conditions, at least when they're chronic.

So they are difficult to treat.

And if they do lead to surgery, we want to see if we can avoid surgery by using less invasive treatments.

Now if you look at the literature, there's something called percutaneous tenotomy where basically a needle or a scalpel is placed through the skin and the cutting instrument is used to break through the scar tissue within the diseased tendon and try to incite a healing response.

And this has been reported with a scalpel for tennis elbow for the Achilles and for patellar tendinosis and with a needle.

This has been reported for tennis elbow and the rotator cuff.

Now how is this procedure done?

Well, it involves repetitive needling of the abnormal tendon.

This needling breaks up the degenerative calcified scar tissue, creates bleeding, and we believe stimulates a healing process.

And there is some experimental evidence to back this up.

This principle can be applied to any tendinotic area, not just tennis elbow, but the rotator cuff, common extensor tendon is, which is the tennis elbow, patellar tendon, achilles tendon, or plantar fascia.

The way we do this procedure, and these are methods that I developed with my colleague John McShane from the Division of Sports Medicine, is we put local anesthetic again, we guide an 18 to 22 gauge needle to the abnormal region of the tendon.

We break up the scar tissue and calcification.

We also, with the edge of the needle abrade the bone because when a surgeon goes in and fixes these problems, one of the last things he or she does is to take the scalpel and abrade the bone to create bleeding and to stimulate the periosteum to bring in new blood vessels to heal the pathologic process.

So we try to do that with a needle.

So our first study is we looked at patients only who had chronic pain and disability and who had failed at least three of the following corticosteroid injections, non-steroidal anti-inflammatory drugs, counterforce bracing, physical therapy and wrist splints.

We used simple free hand technique to get into that tendon.

And the first thing we did when we entered the tendon, and here you see the needle within the common extensor tendon was to anesthetize.

So local anesthetic in the tendon all the way down to the periosteum.

It was quite remarkable to us that it would not too great a dose of 1% lidocaine.

You could actually achieve a very, very nice anesthetic response so that the patients end up feeling almost nothing when you actually do the procedure.

We then went ahead and took the needle after it was anesthetized and repeatedly punctured the tendon.

Tendinotic tendon just went back and forth, back and forth.

And what we felt often was that these tendons were very gritty and we could actually feel the scar tissue that we were fenestrating or breaking up with the needle tip.

And again, repeatedly went through the tendon until we felt that the tendon had softened adequately.

In certain cases, then we would come from superiorly to inferiorly to try to get right at the enthesis, which is the area where the tendon attaches to the bone.

Because a common problem in these chronic conditions is that the abnormal traction by this diseased tendon, it causes a little bone spur to form or an enthesophyte.

And by taking the needle and breaking off the enthesophyte, we can help improve the symptoms.

And that's what we're seeing here.

Here's a still image of a needle removing an enthesophyte at the lateral epicondyle of the elbow.

And so here's the needle, and here is a little piece of bone that had been attached, but now we've broken it off with the needle.

Once we break it off, we can go ahead and break it up with the needle and basically turn it into dust.

And often if the patient has been symptomatic before, they won't be symptomatic after we do this.

Of course, they will be in quite a bit of pain for a few days after the procedure, but they will undergo a healing response and usually within six to eight weeks have quite a nice result.

In fact, here are our results for this procedure for tennis elbow.

So our original results were reported in Journal of Ultrasound and Medicine in 2006.

We had 58 patients respond to a phone survey between six months and five years of follow-up.

62% of patients had excellent results, meaning that they were either completely better or almost completely better.

20% had good results, meaning they were satisfied with the procedure, although they did have some persistent symptoms and 18% had fair or poor results.

But the key thing was that there were no major complications within this group.

But the one thing we did in that study is after we were done, we placed some corticosteroid in and around the tendon, which was something that we were hoping that we could avoid because we thought maybe the corticosteroid would impair the healing response and also predispose the tendon to perhaps higher risk of tearing.

So we did a follow-up study where we stopped using the steroid.

This was recently published in the Journal of Ultrasound Medicine in 2008 52 patients responded to this phone survey, six months to three years of follow-up.

And of these patients, 58% had excellent and 35% had good results with only 7% reporting fair or poor results.

So based on these data, we feel that the needling itself and the bleeding and the healing response that it creates is sufficient to bring on a healing response without the need for corticosteroid.

Again, we are postulating that these procedures create a healing response with the tendon.

Now we need to do more study in this area, but this is a colleague of mine from the Department of Radiology who on baseline had a very tendinotic tendon and had a little bit of flow, but really not a lot of flow within the tendon.

Now I treated her and she did very well and came back 10 weeks later almost symptom free.

And I said, let's take a look at your tendon and see what it looks like now.

And on follow up imaging on gray scale, the tendon really didn't look so great.

I mean, in fact it didn't look any better than what it was before, but it was completely pain free.

And what we noticed was when we put on the doppler, there was abundant flow within this tendon.

So clearly there was a pathology within this tendon that part of which was ischemia, not enough blood flow to this tendon.

And by doing this procedure, we're able to open up all these blood vessels that were able to bring in blood cells and repair this tendon.

And that's why she was presumably why she was no longer symptomatic and had much better strength in that elbow.

External Oblique Tendon Case

Now here's a 38-year-old woman who had two years of increasing right hip pain and she had an MRI of the hip that was negative.

In fact, twice she had an MRI of the hip and an MRI of the lumbosacral spine that was negative.

And when she came into my office, she was in severe pain and had so much discomfort.

Basically you just touched her area of discomfort and she started to cry and her tender area was in the region of the right iliac crest.

Here's the iliac bone.

And here was a very thick structure that I just didn't know what it was at first I did bilateral comparison, which is very useful in musculoskeletal ultrasound.

And I saw that this pathology was not on the other side.

And then I used extended field of view to show that this was a tendon that was very thick and calcified and it led up right to the external oblique muscle.

So I asked the patient what might be the cause of this?

So I asked her if she did twisting motions, if she did some kind of exercises where she did that.

She said no to everything, but she said, maybe that's something to do with my job.

I said, what is your job?

She said, I'm a blackjack dealer in Atlantic City.

So then I thought, yeah, you know, when you deal blackjack, you do twist your torso quite a bit.

And she had been doing it for about 16 years and over that time she started to develop degeneration of her external oblique tendon.

Now she was in such severe pain and none of the other imaging tests probably showed this area, which is why they were all negative.

So how to treat it well, using the principles we learned from tennis elbow, we took a needle and went into the calcifications and the scar tissue and basically repeatedly fenestrated this tendon broke up all the scar tissue that we could probably discern and then no corticosteroid.

We just sent her out and said, check back with us in a few weeks.

And in about four weeks she was 50% better.

And then at eight weeks she was essentially a hundred percent better and was very, very thankful that we were able to, without surgery, cure a very chronic problem that was hard to diagnose as well as hard to treat.

Other Ultrasound-Guided Treatment Alternatives

Now we're talking about ultrasound guided needling of different structures.

It's important to realize there are other ultrasound guided treatment alternatives out there.

Shockwave therapy is one that has been commonly employed.

I do not use it myself, but it has been used for different conditions.

Sclerosis of neo vessels is extensively used in Scandinavia is where it was first reported, where using sclerosis agents such as polidocanol, one goes into the vessels that are felt to be abnormal within the tendinosis and to sclerose them to help dull the pain and stop the tendinotic process.

This is something with which I do not have direct experience either, but is in the literature.

Whole blood injections have been used.

There's a group of Connell et al in England that has used whole blood injections for tennis elbow and found good success.

Growth factor or platelet rich plasma injections have been used either alone or in combination with dry needling and dextrose injections.

So-called prolotherapy is another treatment that is out there for treating various tendon problems.

And there is some literature in the American Journal of Roentgenology showing that injecting dextrose solution into the achilles tendon does create a healing process, which is the same type we're trying to create when we're doing our needle procedure that we develop with Dr. McShane.

And then of course, stem cell injections or something that is in a research phase right now, but could be a wave of the future.

Ultrasound-Guided Nerve Blocks

Now we found out that many of our procedures were difficult to do without any kind of nerve blockade.

And it turns out that ultrasound guided nerve blocks are very often used for temporary blockade, not only by us, but anesthesiologists more and more are using ultrasound to guide their procedures.

And the anesthesiologists find that doing these nerve blocks ease the performance of musculoskeletal interventions.

You can always supplement it with local lidocaine, if needed.

This was a patient who had an acute pop in her thigh, 14-year-old soccer player and acute pain.

This was her normal muscle.

And when we came down, you could see the very different texture of her rectus femoris and there was a partial tear within the rectus femoris itself.

This was not healing.

Three, four months after the injury was not healing with physical therapy and patient and parents were very frustrated, as was the soccer coach.

But we felt that if we tried to do anything with a needle for this patient, we'd have a really hard time because she's so tender.

Here's the femoral artery and femoral vein and the femoral nerve right here.

And here's our needle coming into the region of the femoral nerve.

Once we get the needle into the region of the nerve, we can go ahead and do an injection of local anesthetic.

Once we do that, we can then take a needle, in this case, a 22 gauge needle and abrade the edges of the torn tendon.

And this is my colleague, Dr. McShane doing this procedure with me, providing the ultrasound guidance.

Once the edges of this tear were abraded similar to Turing, a non-union fracture, we are able to make this more sticky and perhaps get these edges to adhere to each other and create a little hematoma that would act like a glue to hold the whole muscle together.

We then put her in a brace and sent her out and brought her back a few, about three weeks later.

And this is her baseline ultrasound.

About three weeks later, she was completely asymptomatic and the follow-up imaging of that same muscle showed that the tear went away and the muscle was starting to return to its normal echogenicity.

So we feel that ultrasound guided procedures open up a new interesting future for interventions because Dr. McShane and I feel that there's a logical progression.

We started with open surgery and of course that led to arthroscopic surgery, which was a method of doing surgery without having to be as invasive.

And the question is, can we now enter an era of ultrasound guided surgery for certain conditions in which the pathology is easy to see with ultrasound And, one condition that we feel could be amenable to this is plantar fasciitis.

The plantar fascia can become very scarred and thickened and painful.

Again, it's a repetitive stress injury similar to tendinosis elsewhere in the body.

This is what it looks like, an ultrasound, a very thick, irregular degenerated plantar fascia.

Now ultrasound guided partial plantar fasciotomy was reported by Dr. Fields et al and presented at the 2005 RSNA meeting where they took 30 patients with persistent plantar fasciitis.

They used an 18 gauge needle, they repeatedly punctured the fascia and after they punctured the fascia, they put in one milliliter of steroid and all their patients showed improvement and most importantly, they had no complications.

So we started trying to do the same procedure and we found that our patients felt better if we put some local anesthetic first around their posterior tibial nerve, which was shown here.

Here's the nerve and here's anesthetic going around it.

Okay, so here's a needle that's being inserted now into the plantar fascia.

Here's what the bevel up and here, what the bevel down to go ahead and scrape the underlying bone.

And in this fashion, try to engender the same kind of healing response that we engender when we treat tennis elbow and other conditions.

Conclusion

So in conclusion, there's a wide range of ultrasound guided musculoskeletal interventional procedures, aspirations, injections, needle tenotomy, plantar fasciotomies.

And we feel there's a great potential for future investigation in this field because many procedures that are currently done surgically may be able to be done less invasively using ultrasound guidance as the medium.

Thank you very much for your attention.