Category Archives: MSK

Greater Trochanteric Pain Syndrome

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In a study funded in part by AIUM’s Endowment for Education and Research, Jon Jacobson, MD, and his team from the University of Michigan set out to determine the effectiveness of percutaneous tendon eer_logo_textsidefor treatment of gluteal tendinosis. The full results of this study were recently published in the Journal of Ultrasound in Medicine.

Greater trochanteric pain syndrome is a condition that most commonly affects middle-aged and elderly women but can also affect younger, and more active, individuals. It has been shown that the underlying etiology for greater trochanteric pain syndrome is most commonly tendinosis or a tendon tear of the gluteus medius, gluteus minimus, or both at the greater trochanter and that tendon inflammation (or tendinitis) is not a major feature. This condition can be quite debilitating and often does not respond to conservative management.

Treatment of greater trochanteric pain syndrome should therefore include treatment of the underlying tendon condition. Ultrasound-guided percutaneous needle fenestration (or tenotomy) has been used to effectively treat underlying tendinosis and tendon tears, including tendons about the hip and pelvis. Similarly, autologous platelet-rich plasma (PRP), often combined with tendon fenestration, has been used throughout the body to treat tendinosis and tendon tears.

Although studies have shown patient improvement with PRP treatment, the true effectiveness of this treatment compared to other treatments remains uncertain. Although percutaneous ultrasound-guided tendon fenestration has been shown to be effective about the hip and pelvis, there are no data describing the use of PRP for treatment of gluteal tendons, and there is no study comparing the effectiveness of each treatment for gluteal tendinopathy. The purpose of this blinded prospective clinical trial was to compare ultrasound-guided tendon fenestration and PRP for treatment of gluteus tendinosis or partial-thickness tears in greater trochanteric pain syndrome.

We designed a study in which patients with symptoms of greater trochanteric pain syndrome and ultrasound findings of gluteal tendinosis or a partial tear (<50% depth) were blinded and treated with ultrasound-guided fenestration or autologous PRP injection of the abnormal tendon. Pain scores were recorded at baseline, week 1, and week 2 after treatment. Retrospective clinic record review assessed patient symptoms.

To break this down a little further, the study group consisted of 30 patients (24 female), of whom 50% were treated with fenestration and 50% were treated with PRP. The gluteus medius was treated in 73% and 67% in the fenestration and PRP groups, respectively. Tendinosis was present in all patients. In the fenestration group, mean pain scores were 32.4 at baseline, 16.8 at time point 1, and 15.2 at time point 2. In the PRP group, mean pain scores were 31.4 at baseline, 25.5 at time point 1, and 19.4 at time point 2. Retrospective follow-up showed significant pain score improvement from baseline to time points 1 and 2 (P < .0001) but no difference between treatment groups (P = .1623). There was 71% and 79% improvement at 92 days (mean) in the fenestration and PRP groups, respectively, with no significant difference between the treatments (P >.99).

These results led us to conclude that both ultrasound-guided tendon fenestration and PRP injection are effective for treatment of gluteal tendinosis, showing symptom improvement in both treatment groups.

What is your experience with treating greater trochanteric pain syndrome? Are you familiar with the Endowment for Education and Research?  Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Jon A. Jacobson, MD, is Professor of Radiology, Director of the Division of Musculoskeletal Radiology, Assistant Medical Director of Northville Health Center, and Medical Director of Taubman Radiology within the University of Michigan Health System.

Ultrasound Set to Transform Occupational Medicine

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There is no question that medical ultrasound is quickly becoming a valuable tool in musculoskeletal (MSK) medicine. Providers are realizing that this modality allows for quick evaluation in the office and even has a higher resolution than MRI. Research shows, for example, that scanning a shoulder to evaluate for a rotator cuff tear is faster, cheaper, and at least as sensitive and specific as ordering an MRI.

dr sayeedWhere using this modality for MSK medicine will have a huge impact is within occupational medicine.

In occupational medicine, we are tasked with providing quality care for patients while simultaneously enabling patients, institutions, corporations, and the overall health care system to save money. For practitioners, MSK ultrasound allows us to accomplish both of these goals. Widely utilized by our counterparts in European medical schools and hospitals, MSK ultrasound’s use in occupational medicine is still in its early stages in the United States. This means that occupational medicine is one specialty that stands to reap significant clinical benefits from its use.

But in order to understand the potential, and to position MSK ultrasound at the forefront of occupational medicine education, I conducted a little research.

Last year, I conducted a survey to learn how many occupational medicine program directors and residents were using MSK ultrasound and how many wanted to use it. The survey results confirmed that it was not widely used in occupational medicine residency programs. In fact, only a couple of programs use it and they do so cursorily.  The results also showed that most had a sincere interest in learning to use it, but there was not a program in place.

Since residency programs produce the field’s future physicians, I designed a multidisciplinary MSK ultrasound course to teach the basics to attendings and residents. Weekly sessions focused on specific anatomic regions to help provide a foundation for identifying pathology and improve interventional skills. This “how to” manuscript was recently published in the Journal of Occupational and Environmental Medicine.

Moving forward, I am presenting an introductory level lecture at the occupational medicine national conference (AOHC) to further demonstrate how MSK ultrasound could potentially be widely used in our field. I hope to introduce “hands-on” workshops over the course of the next few years to give the field a chance to learn this modality and implement it into practice. My goals are to see occupational medicine practitioners provide the highest standard of health care for this unique hardworking population of patients, while concurrently reducing costs for workers’ compensation claims.

What can AIUM provide occupational medicine to help further the use of ultrasound? What other areas are on the verge of being transformed by ultrasound? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Yusef Sayeed, MD, MPH, MEng, CPH, is an occupational medicine Chief Resident at West Virginia University in Morgantown, WV.

Why I Attended AIUM’s MSK Course

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In late 2014, I attended the AIUM MSK ultrasound course that was held at the USOC facilities in Colorado Springs. Why, you might ask? Well, here are four reasons I did.

  1. Focus—I do a lot of MSK ultrasound (I have my RMSK and my practice is AIUM accredited) but I do not see a lot of hand and wrist. Since the focus was going to be on upper extremity I felt that this would be a chance to get a good review of hand, wrist and elbow.
  2. USOCKiller faculty—Jay Smith, Lev Nazarian, Tony Bouffard and Jon Jacobson were all on the schedule. Combine them with a limited number of attendees and I knew I would get to interact with them on a more personal level.
  3. Great format—The way the content was structured really appealed to me. I like how we had a lecture, followed immediately by a live scan and then the ability to scan patients. It was excellent and really brought the lecture material right into practice.
  4. Location and price—I had never been to Colorado Springs, much less the Olympic training center. And when I looked at how focused the course was as well as the faculty, I felt the price was very reasonable—especially with the option of staying on site.

For me, the thing that stood out most at the course was getting an appreciation for scanning the scapholunate ligament (SLL). My scanning preceptor was very adept at showing us how to visualize the ligament and how to easily locate it. When I went back to the office and actually had an SLL injection, I was able to do it effectively and get my patient good relief.

I hope that if or when the AIUM does this course again, or another MSK course, they keep the number of participants limited and the topics varied. At some point, I think the course could become stratified so that whether you are at a beginner, intermediate or advanced level, you can participate and learn. Personally I’d like to see a course focusing on the hip and spine with injections.

All in all, given the hosts, the course faculty, the limited number of attendees and topic scope, the price and location, this was one of the best MSK ultrasound courses that I’ve attended.

What’s the best course you have attended? How can AIUM make its courses better? Have you heard about AIUM’s newest MSK Course? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Amadeus Mason, MD, is Assistant Professor of Orthopaedic Surgery and Family Medicine at Emory Sports Medicine Center in Atlanta.