One of the most frustrating parts of having a sports injury is not knowing exactly what your diagnosis is.

Is something torn?
Is it just a strain?
Should I rest it?

Dynamic Ultrasound Imaging can tell you in seconds.

That’s right… seconds! In this article, I will go through nine amazing facts that you need to know about diagnostic ultrasound and how it can give you answers to the questions above.

In case you don’t know me, I’m Dr. Sebastian Gonzales.

If you have met me, you know that I’m passionate about three things:

1. Coffee
2. Education on sports injuries
3. Musculoskeletal Ultrasound

Here’s my story of how I “saw the light” regarding ultrasound imaging.

NOTE** If you don’t care about my story, just skip on through to the bullet points.

In 2013, Dr. Levon Nazarian MD presented Musculoskeletal Ultrasound to a group of sports doctors at the Olympic Training Center in Colorado Springs. It was at this demonstration that I became fascinated with Musculoskeletal Ultrasound…the clarity, accuracy and simplicity of the imaging blew me away.

Dr. Nazarian was able to scan not only one shoulder, but also the second one for comparison in just a matter of minutes. The patient looked comfortable and relaxed as Dr. Nazarian instructed her to perform some motions with the arm, which also moved the soft tissue on the image in real time.

Looking back, the feeling I had about the images on the screen was probably analogous to how parents-to-be feel about seeing their unborn child on an Ultrasound screen. I’m still amazed at the ease of being able to bring a dynamic/movement related imaging study into a small office such as mine.

It really does bring sports doctors the ability to diagnose complex conditions which would otherwise be missed without the use of this imaging. As you can imagine, I bought one and have not since been disappointed.

You might say, “Why not just refer the patient out for an Ultrasound?” as I normally would for an X-ray or MRI. The reason is simple: I could not find a good, educated Musculoskeletal Ultrasound Technician in my area.

As I came to learn, Sonographers are as specialized as doctors. A shoulder specialist may not know anything about the foot. Emergency Room staff may not remember the complexity of the musculoskeletal structures as well as someone who works with them everyday.

Soon, I can across Mike Jablon at Orthopedic Ultrasound in San Clemente. When we spoke, I could see his passion for the small details of the musculoskeletal system, which I soon found were not overlooked on his imaging reports.

Passion for the musculoskeletal system is not something that’s taught. It’s innate and it grows within you with each new case you see. I could see Mike and I had this in common; I asked him to teach me and so I learned musculoskeletal ultrasound from him.

The following are some great points taken from an article by the great Levon Nazarian MD that I will reference at the end of the article. Although I will be explaining them in my own words, these are direct points from the article… just trying to spread the good word Doc! (Nazarian 2008)

1: There are no contraindications to Musculoskeletal Ultrasound

In certain situations, you are not allowed to use X-ray or MRI. Some of the negatives surrounding X-ray are radiation exposure, how much radiation is allowed per year, pregnancy, and more.

While x-rays are useful for some conditions, two more useful tools for evaluation of soft tissue, such as muscle and tendon, are MRI and Musculoskeletal Ultrasound.

MRI is great because there is no radiation transferred to the patient and it allows the doctor to see much more detail in the soft tissues, muscle, tendon, and cartilage. It’s even great for finding fractures missed on X-ray examination.

MRI machines are made of large magnets, which can present some issues. Patients with pacemakers, metal, and other implants cannot undergo MRI examination, but from a clinical standpoint, it is hard to ignore how much value there is in the detail that can be found on MRI. It is a very valuable piece of imaging.

Musculoskeletal Ultrasound is safe and can be done on anyone. There is no radiation, no magnets and it is commonly done on pregnant women, which demonstrates just how safe it can be.

2. Musculoskeletal Ultrasound can have MORE detail than an MRI

Validation of this statement would make us go into physics and things uninteresting to most people. Evidence for this statement can be found in our supporting references, but is dependent upon what type of Musculoskeletal Ultrasound transducer is being used and what type of MRI we are comparing it to.

3. Musculoskeletal Ultrasound is a Dynamic or movement-related image done in real time

This is where the magic of Musculoskeletal Ultrasound comes in. I have read numerous cases where an athlete can only feel pain with movement, which can only be visualized on a test such as Musculoskeletal Ultrasound.

MRI is what we call a “static image.” In fact, if you are in the MRI tube and move too much, the image will become useless due to motion artifact.

Some injuries can be categorized as “instabilities” and visualized extremely well on Ultrasound when the patient’s tissue or joint is stressed.

In an MRI, a slight dislocated joint might be visualized as edema and swelling around the joint, but on an Musculoskeletal Ultrasound you actually SEE the joint move out of place. It’s amazing to see and very confirmatory of this type of diagnosis.

4. Patient feedback allows us to pinpoint a pain source at the time of the image

Often on an MRI, a Vitamin capsule is used to mark the level of pain, but on Musculoskeletal Ultrasound, it is not uncommon for the technician to press on the skin “at painful spot” and visualize a depression in the image at the same point, which confirms the pain generator in real time. In fact, non-symptomatic abnormalities are found all the time on imaging, but in a report, it is important to be able to highlight the pain generator so it can be treated accordingly.

5. Metal and surgical implants are not contraindications and can be visualized on imaging

Metal implants are a contraindication to the use of MRI in any patient…plain and simple. The use of Musculoskeletal Ultrasound would be extremely beneficial to patients still experiencing pain after surgery. I have heard of a few actual cases where surgically implanted hardware was rubbing against a muscle or tendon creating extreme pain and constant irritation to the structure. Only with Musculoskeletal Ultrasound can you see this type of complication.

6. Doppler can point us in the right direction for an accurate diagnosis

Increase in Doppler flow can be a confirming factor that leads the doctor to a correct diagnosis. The information about changes in blood flow can essentially be like “arrows” pointing to a correct location and diagnosis.

7. Musculoskeletal Ultrasound will become the “Gold Standard” for needle procedures (in my opinion)

Blindly going into woods at night (lets say, without a full moon) will no doubt leave you with bumps on your forehead in addition to a real life experience that reminds you to take a flashlight next time. When a needle is used for a therapeutic protocol, typically the doctor is looking to hit a specific structure (bursa, tendon, joint, etc.).

Using Musculoskeletal Ultrasound to locate the exact structure to be treated will improve the accuracy of the injection, thereby directly improving the effectiveness of the procedure overall.

8. We can compare bilateral structures on the same testing day

Comparing possible pathology on both sides is helpful in determining if the pathology is in fact, the pain generator. For example, on occasion, thickening of a tendon can be seen on both sides of the body regardless if symptomatic or not.

On MRI, we are only able to view one side per imaging study, which can lead the doctor to an incorrect diagnosis or cause increased cost for the patient for follow up imaging.

9. Long structures (like nerves and muscle) can be viewed in their entirety all in one test

In my opinion, this is one of the best advantages of Musculoskeletal Ultrasound compared to MRI.

MRI can only show a section of limb or the body. Musculoskeletal Ultrasound is a dynamic study that allows us to follow a structure all the way from its origin to its attachment. Nerve symptoms, like numbness in the fingers, can be the result of compression or swelling around the nerve anywhere along its course down the limb. The majority of its course can be evaluated with this image. The same goes for a muscle, such as the hamstring.

It is common to feel tightness and pain along the course of the hamstring after a tear. An ultrasound can pin point the exact location and severity of the injury.

As you can see, there are lots of great things about both Musculoskeletal Ultrasound and MRI. Personally, in my practice, I use both and consider each based upon two factors: what I need to rule out and cost. There are numerous references on the cost benefits of Musculoskeletal Ultrasound, but we will not go into that this point.

The last point I will make about the comparison between the two studies is how similar each is in regards to sensitivity and specificity. For those not familiar with those two words:

Sensitivity of a test basically means that if there is something there, the test will find it… what are we looking for? I have no idea…sensitivity is like someone shining the headlights of a car in your face. You might not know what kind of car it is, but you know darn well there is a car there.

Specificity, on the other hand, says how confidently the test will tell you “what kind of car is there.”

MSUS:              Sensitivity: 85.1% Specificity: 92.0%

MRI:                 Sensitivity: 85.5% Specificity: 90.4%

What does this mean? They are pretty darn close. But considering all the points previously made above and the fact that Musculoskeletal Ultrasound costs a fraction of an MRI, personally, I guide my patients this way any time I can.

What is Musculoskeletal Ultrasound?

Musculoskeletal Ultrasound is a type of medical imaging which rapidly being utilized over MRI (when indicated) for high performance athletes on professional teams and the US Olympic Teams.

What can Musculoskeletal Ultrasound diagnose?

In the following sections, I will provide some pictures of real exams and some interesting stories about athletes I’ve imaged with Musculoskeletal Ultrasound.

We will take a look at the shoulder, ankle, foot and knee.

Shoulder Musculoskeletal Ultrasound

• Does your shoulder pop, clunk or pinch?
• Have you self diagnosed your injury as Impingement Syndrome?
• Does it hurt to sleep on?

If you answered yes to any one of these questions, you are a candidate for an Ultrasound image of the shoulder.

Ultrasound is extremely good at diagnosing conditions of the shoulder.

Can it see a rotator cuff?

Definitely!

Can it see bursitis?

For sure!

An MRI is a good image for seeing these injuries as well, but Ultrasound costs a fraction of an MRI and is way more comfortable to have done.

Claustrophobic?

I would hope not. Laying a tube, not moving for 30 plus minutes is the reality of an MRI. If you are lucky enough to fall asleep, you better hope you don’t twitch while sleeping or you will end up having to redo the test.

Here is a list of some of the conditions Ultrasound imaging can assist in confirming:

• Rotator Cuff tendonitis
• Impingement Syndrome
• Labrum Tears
• Bicipital Tendonitis

Actually, I have an interesting story about a shoulder that I imaged a few years back. A friend came into my office to pick up my dog while I was learning how to ultrasound shoulders so I asked her,

“Hey can I look at your shoulder? I know you had a small tear a few years ago.”

So we did and what we found was very unexpected.

We found a COMPLETE RETRACTED rotator cuff tear in her shoulder. So I had to ask…

“Can you raise your arm?”

She did so fully over her head…without pain.

“Does your shoulder hurt at all?”

“Nope.” The only thing that bothered her at that point was her neck on the same side.

This blew my mind, and I thought she could have been a patient. In fact, it frightened me. If she could come in showing full shoulder motion without pain, then any shoulder injury could.

I started to question everything I knew about shoulder exams. If she could slip through the cracks, then others could too.

I decided to properly diagnosis a shoulder, I needed to use Ultrasound more.

When did her tear actually happen?
I have no idea. Regardless, I’m very glad we looked because we might have treated her for “X” amount of time and not gotten anywhere because her rotator cuff is physically not attached.

Ankle Musculoskeletal Ultrasound

I wondered what I could have damaged and if it was safe to still run on.

At that time, I didn’t have my ultrasound skills, but if I did, I could have just placed the transducer on the ankle and seen within a minute if all of the muscle, tendons and ligaments were attached.

Ultrasound has allowed me to feel more control over my own injuries.

Here’s a list of some of the conditions Ultrasound imaging can assist in confirming in the ankle:

• Achilles tendonitis
• Anterior Ankle Impingement
• Peroneal Tendonitis
• Ligament strains/tears

Achilles tendonitis is an awesome diagnosis that even beginners are able to see. It is HUGE on an Ultrasound image.

Musculoskeletal Ultrasound

• Does your foot ache in the morning?
• Is walking after sitting for 15 minutes painful?
• Have you self diagnosed it as Plantar Fasciitis?

You could be right…or not.

The foot is an extremely complete joint. There are 26 bones in the foot and 33 joints!

If you are doing the math, the foot contains 25% of all of the bones in the human body.

Still sure that it’s Plantar Fasciitis?

I’m not even sure! Luckily, we have Ultrasound imaging to confirm the diagnosis.

Personally, I don’t have my own foot pain case that I can retell as a story, but I can tell you about the runner in the pictures below.

Case on Foot Pain

About 3 years ago, I was part of a running group called Team in Training (TNT). If you don’t know about TNT, it is a running group that does fundraising for cancer.

As we were raising awareness and building donations for leukemia, we packed on the miles, and some people developed running injuries. My good friend was one of those injured.

She was not able to run for about eight weeks because of her foot pain.

She was at her wits end and wanted to know why her foot hurt with every step.

She was so tender to the touch that I couldn’t even use the pressure it takes to bruise a banana on her foot before she jumped off the table.

She eventually did recover to run again, and the pivotal point in her recovery was the confirmation of what her injury was so she could treat it and rehab accordingly.

Here’s a list of some of the conditions Ultrasound imaging can assist in confirming in the foot:

• Plantar Fasciitis
• Metatarsalgia
• Heel Spurs
• Ligament Sprains

Knee Musculoskeletal Ultrasound

• Does your knee pop, click or catch?
• Have you self diagnosed yourself with IT Band Syndrome?
• Does it swell after running?

Frustrating, I know… but never fear Ultrasound is here!

Ultrasound is actually really good at inspecting the knee, especially if you are 30 years old or younger.

If you are over 30, sure, you can still have an ultrasound, but they are slightly less accurate.

Here is a screenshot from a presentation I did on the validity of Ultrasound for the knee versus MRI. As you can see, they are identical in a patient under 30 years old.

Chronic groin pain typically happens over time, which is why with sports hernias, we do not hear many stories of feeling a “pop” or a specific moment of injury. It is thought to be the result of “overuse” mechanics stemming from a combination of poor strength and endurance, lack of dynamic control, movement pattern abnormalities and discoordination of motion in the groin area.

There is a lot going on in the groin area. There are lot of muscles, tendons and fascia pulling in different directions. These contracting structures need to coordinate together for any athletic motion. This is also known as the injury prevention model.

Are you a runner?

If so, you may be interested in the insane ability of an ultrasound image to see around the outer side of the knee near the IT Band insertion.

IT Band Syndrome, Popliteal Tendinitis, and Lateral Meniscus Tear are all lateral knee conditions that cause very similar in pain patterns in runners.

I have found in my sports practice it is not uncommon for runners to come in telling us they have IT Band pain only to realize on MRI or Ultrasound exam we find tears in the meniscus or irritation to the popliteal tendon sheath.

The first image is that of my good friend’s son. You wouldn’t know by the picture, but he is in his mid 20’s and plays competitive soccer. He had come to me on and off for months, but his insurance company would not approve an MRI for his knee.

His knee was swollen, it clicked and popped, and he was even unable to fully extend it at times.

I was able to image him and we found a meniscal injury which did result in a surgery, BUT he was finally able to successfully rehab his knee and play soccer again without pain.

This case is an example of how proper imaging lead to the proper treatment plan.

How can you get an Ultrasound image?

Now that you have been reading for 5 minutes about how cool Musculoskeletal Ultrasound is, you may be wondering how you can get one done on your injury.

Great question.

You will have to ask around because your doctor probably will not refer you for one.

They are very hard to find, and only until recently, did Ultrasound schools even start to teach the musculoskeletal technique.

Feel free to contact me through the site and I’ll do my very best to make an on-going list of great sonographers around the country.

If you are in San Diego, CA, a great person is Michael Meng DC. In fact, he is awesome.

If you are north of Los Angeles, I would see Michael Jablon at Orthopedic Ultrasound. He is so passionate about Musculoskeletal Ultrasound; it will drip from his skin.

If you are in Orange County CA or the Long Beach area, you should just come into my place.

This list will continue to grow so keep checking back…

Ultrasound used in Athletics

Are you a coaching an athlete complaining about a training injury they cannot run through?

Have you often been frustrated as a coach or athlete about the general lack of medical support in your sport?

Are you a strength coach designing a program for an injured athlete with no exact diagnosis?

I have often heard coaches in many sports who are frustrated with designing programs around injuries that remain unresolved and are still painful despite months of “rest and ice”.

Musculoskeletal Ultrasound (MSUS) is quickly becoming the imaging test of choice for Sports Medicine doctors working with high performance athletes who need to obtain a quick and accurate diagnosis. This type of imaging can be used for very common injuries found in sports such as: muscle strains, tendonopathies, joint pain, bursitis, and even some bone injuries.

Non-traumatic sports injuries often occur at the musculotendonous junction, which is considered the weakest portion of the muscle-tendon complex. Most athletes will discredit this type of pain and train through it.

Research shows Musculoskeletal Ultrasound is highly repeatable and can even monitor the severity and progress of an injury dictating the correct care at the right time. For this reason, MSUS is considered to be a “must have” for making educated clinical judgments on when or if an athlete can return to play.

Did you know MSUS can see old tendonosis or tendonopathies?

Those old, lingering aliments your athletes might continue to have on a weekly basis, yet aren’t bad enough to put them on rest can be diagnosed and corrected. These tendonopathies can be seen on Musculoskeletal Ultrasound, even though don’t often present with the characteristic inflammation like a new or acute injury. Rather, they are infiltrated by fibroblasts and demonstrate angiogenesis (the formation of new vessels). MRI will only pick up swelling and edema in the area six weeks post injury, and in these cases, they are past that time frame. These types of injuries often come from chronic micro tearing of the tissues/tendons in question.

What about ligament sprains?

Ligaments, if sprained through acute injury, can be visualized and diagnosed within minutes by looking for edema or fluid around the site of the sprain, whereas in partial tears, areas of thickening can be seen. Full tears will have a region of discontinuity in the path where the ligament should be and a hematoma between the free ends.

How come you have haven’t heard about it before?

Being that most coaches do not have a background in sports medicine nor do they always update their knowledge in the area of rehabilitation, they often do not know about the “next best thing”.

Don’t get me wrong; collectively, the medical profession does not expect anyone outside to know since it’s our job. No coach should be expected to wear multiple hats, which can take away from their coaching time.

Most coaches and athletes know about MRIs and X-ray, which are not easily obtained by an athlete or by patients in general. Primary care doctors and insurance companies often deny MRI’s for various reasons.

Imagine you have an athlete looking to compete five days from now…
What is the typical timeline of tests/exams for a top-level athlete in college or high school?

Day 1: Training room treatment (ice, heat, stretch, etc.)

-To get a diagnosis, the athlete will need to be seen by a doctor
Day 2: Exam by a primary care physician

-Sent to X-ray, but they are negative
Day 3: Rest due to “soft tissue injury”

-Coach and athlete request an MRI to see what the problem is
Day 4: Exam by a primary care physician to get MRI referral
Day 7: Three days later, the MRI is scheduled (if your lucky since MRI schedules are often booked)

-The insurance company needs six weeks of physical therapy before granting MRI approval
Day 8: Physical therapy begins for six weeks

-Over 1 ½ months later: finally, an MRI

-MRI is negative or just small, soft tissue findings

Obviously, you see the athlete’s competition event is long gone, regardless if they feel better or not. The whole process to even “maybe” get an MRI took around a week. There is no urgency in this system, especially not for something non-life threatening.

True story from this past year: I had a patient who’d had back and leg pain, but was not allowed to have an MRI until she had completed six weeks of care, regardless of what the problem was.

In my opinion, it was necessary to have the MRI to properly give her a plan of attack. But instead, we were expected to treat her without fully knowing what her diagnosis was. Backwards thinking, right?

Also notice in the athlete’s scenario above that within one week, there is still no treatment plan in place; he or she has missed one event and will possibly miss the rest of the season (if it’s a short season). Also keep in mind: every athlete’s case is dealt with differently in the healthcare system.

There are many other variables at play in these scenarios:

• Will the school cover it?
• Does the patient have insurance?
• Will they have out of packet expenses?
• Do they have over $500 for an MRI in addition to $100 for x-rays & $100 per doctors visit?
• Do they make the immediate appointments to minimize down time?
• Are they willing to miss practice to make the appointment under short notice?

There are some HUGE issues and countless variables in the timely management of common soft tissue injuries such as Achilles tendonitis or high hamstring tendonopathy!

What is the solution?
The inability to get a proper diagnosis in sports medicine is well documented. It is the result of a combination of any or all of the following variables:

1. A healthcare provider’s lack of education regarding a specific sports injury
2. A lack of information or proper imaging to support or rule out a diagnosis
3. Use of proper imaging techniques to support a diagnosis, but incorrect interpretation of the image.

Finding the right sports medicine team to care for your team is critical. Having an educated and humble trainer, strength coach, team coach, sports medicine doctor and imaging center are a good start, but obviously, having great communication with an orthopedic surgeon and sports psychologist is better.

Imaging Solution:
MSUS or Musculoskeletal Ultrasound is a great option for the majority of soft tissue injuries, superficial cartilage and even some bone injuries. If an athlete strains something on the field, MSUS can have a diagnosis within five minutes.

Within ten minutes, that same information can be in the hands of the trainers, strength coach, team coach, and sports medicine doctor who can all then collectively agree on a proper treatment plan for that athlete.

This gives the athlete the best possible chance of returning to plan as fast as they can without endangering their long-term health by training through injuries and damaging their bodies further.

Cartilage Disorders:
Musculoskeletal Ultrasound has been shown to identify evidence of cartilage defects both in the knee at the femoral condyle, as well as the meniscus and labrum of the shoulder and hip.

Early degenerative changes (calcifications, osteophytes and boney changes) on the femoral condyles can be noted in patients with knee pain and indicative of osteoarthritis (Kazam, 2011). Meniscal injuries to the posterior horn can be clearly identified with a testing sensitivity of 100% and specificity of 95% (Najafi, 2006).

The research validates Musculoskeletal Ultrasound as a valid test for meniscal injuries, but controversy remains. However, the lower overall cost in combination with testing reliability makes it a great frontline test for the condition.

Tok, F. (2012). Musculoskeletal ultrasound for sports injuries. European Journal of Physical and Rehabilitation Medicine, (48), 651-663.

Kazam, J. (2011). Sonographic evaluation of femoral trochlear cartilage in patients with knee pain. Journal of Ultrasound in Medicine, (30), 797–802.

Najafi, J. (2006). The value of sonography with micro convex probes in diagnosing meniscal tears compared with arthroscopy. Journal of Ultrasound in Medicine, (25), 593–597.

Nazarian, Levon N. “The Top 10 Reasons Musculoskeletal Sonography Is an Important Complementary or Alternative Technique to MRI : American Journal of Roentgenology: Vol. 190, No. 6 (AJR).” The Top 10 Reasons Musculoskeletal Sonography Is an Important Complementary or Alternative Technique to MRI : American Journal of Roentgenology: Vol. 190, No. 6 (AJR). N.p., June 2008. Web. 20 Feb. 2014.

Alizadeh, Ahmad, Ali Babaei Jandaghi, Amin Keshavarz Zirak, Ali Karimi, Mohsen Mardani-Kivi, and Alireza Rajabzadeh. “Knee Sonography as a Diagnostic Test for Medial Meniscal Tears in Young Patients.” Eur J Orthop Surg Traumatol European Journal of Orthopaedic Surgery & Traumatology 23.8 (2012): 927-31. Web.