musculoskeletal ultrasound in sports medicine fmf 2015

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www.usask.ca 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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Page 1: Musculoskeletal ultrasound in sports medicine FMF 2015

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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

Presenter
Presentation Notes
In order to highlight differences in approach; with and without MSK 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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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

Presenter
Presentation Notes
Predictor of intra-articular injury (Boomberg 1990)
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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