Tag Archives: sports medicine

Musculotendinous Ultrasound Imaging Applications in Sports Medicine

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There is a clearly established role of ultrasound imaging in traditional medical contexts to optimize patient assessment and subsequent care. These same applications have been carried over into sports medicine settings, especially with recent developments in ultrasound portability. Such technological advancements enable athletic trainers and other sports medicine clinicians to perform sideline assessments for athletes who sustain musculoskeletal injuries during sports.

Beyond diagnostic applications of ultrasound imaging, sports medicine clinicians and researchers have begun to adopt this tool as a creative means to assess musculotendinous structures in response to sport and exercise. Ultrasound imaging has advantages over other measurement techniques given that it is relatively inexpensive equipment, fairly easy to operate (especially if you know your anatomy!), and can be rapidly implemented into assessments. Ultrasound imaging also enables clinicians to perform more dynamic assessments with patients to understand functional movement patterns, and noninvasively examine deeper tissue structures. The real-time visual platform uniquely provides the opportunity to enhance patient-clinician dialogue and provide feedback to target key muscle groups during fundamental exercises.

Below, several exemplary studies that leverage ultrasound imaging in musculotendinous contexts are presented to convey the depth and breadth of innovation in the sports medicine field and highlight opportunities for future ultrasound implementation into practice.

Muscle Morphology

Ultrasound has been most frequently implemented in sports medicine research to conduct table-top assessments of musculotendinous structures. This measurement approach provides insights to clinicians on patients’ muscle and tendon changes in response to exercise (eg, weight- and height-adjusted size, fiber arrangement and quality). For example, researchers have been able to examine lower limb musculotendinous responses across long-distance running training.1,2 Beyond training adaptations, clinicians are also able to get some insights into structural tissue changes in the presence of current or future musculoskeletal injury. This has specifically been done to examine musculotendinous adaptations at the shoulder complex,3 foot complex,4 and lumbopelvic hip complex5 across a range of pathological populations. Preliminary work has begun to identify signals in tendon tissue quality that relate to future pain in running athletes.1 Such studies will continue to help inform rehabilitative and training interventions to improve muscle and tendon quality to move toward injury risk reduction in sports medicine.

Dynamic Muscle Function

In addition to the role of ultrasound imaging in more static imaging contexts, ultrasound has been implemented in sports medicine research in more functional contexts. Researchers have inventively started to use foam blocks with Velcro elastic belts to secure portable ultrasound probes on patients to visualize deep lumbopelvic hip muscles across a range of exercises and movements to assess the role of these muscles during fundamental movements (Figure).6 Through this approach, researchers have examined athletes’ transverse abdominis muscle thickness during an abdominal draw-in maneuver across patient positions to determine which activity elicited the most “bang for your buck” in muscle activity.7 Additionally, this measurement approach has been used to assess gluteal muscle function throughout treadmill walking. In these instances, ultrasound videos were obtained to quantify muscle activity throughout movement and identify activity dysfunction among patients with lower limb injuries.8,9 These examples emphasize the utility of ultrasound imaging to supplement typical sports medicine clinical assessments and underscore the opportunity for clinicians to implement ultrasound imaging in more dynamic assessments.

An athlete with ultrasound probes attached to her leg. A screen in the fore ground shows the ultrasound image.

Real-time Feedback

Ultrasound imaging demonstrates great promise as a rehabilitative feedback tool for patients who have difficulty recruiting specific muscle groups as a result of injury.10 The most robust use of ultrasound for feedback has been taking dynamic assessments of the lumbopelvic hip complex muscles a step further and using ultrasound to allow patients to visualize their muscles during abdominal contraction exercises. In this manner, clinicians have been able to show patients their muscle activity, and encourage activation of select muscles during rehabilitative exercises. This approach has been found to be more successful for patient neuromuscular education than other feedback approaches, such as verbal encouragement. The visual interface not only helps patients to see and understand muscle recruitment in real time but also helps clinicians to see when patients are able to activate proper stabilizing muscle groups as opposed to “cheating” on an exercise and using global movers to achieve a movement. While there is less available information on the use of ultrasound for feedback for targeting other muscle groups during rehabilitation, these studies highlight the opportunities for ultrasound imaging to maximize patient benefit during clinical interventions.

The Future of Ultrasound in Sports Medicine

Ultrasound imaging can clearly play a key role in sports medicine assessments and interventions. Continued research is necessary to broaden our understanding of musculotendinous changes in relation to sports injuries and rehabilitation, as current research is still scraping the surface of ultrasound opportunities in sports. Ultrasound assessments may complement other forms of athlete assessments and provide more in-depth insights into muscle and tendon function in relation to performance and injury. It is plausible that with continued technological advancements and the miniaturization of ultrasound units, clinicians may be able to use imaging during more sport-specific activities at higher velocities to unearth real-time musculotendinous changes in physical activity. The prospects of ultrasound are promising, and this tool may continue to revolutionize patient care in sports medicine clinics.

References

  1. Cushman DM, Petrin Z, Eby S, et al. Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners. Phys Sportsmed. 2021; 49:410–419. doi:10.1080/00913847.2020.1847004.
  2. DeJong Lempke AF, Willwerth SB, Hunt DL, Meehan III WP, Whitney KE. Adolescent marathon training: prospective evaluation of musculotendinous changes during a 6-month endurance running program [published online ahead of print September 29, 2022]. J Ultrasound Med. doi:10.1002/jum.16105.
  3. Thomas SJ, Blubello A, Peterson A, et al. Master swimmers with shoulder pain and disability have altered functional and structural measures [published online ahead of print April 13, 2021]. J Athl Train. doi:10.4085/1062-6050-0067.21.
  4. Fraser JJ, Koldenhoven R, Hertel J. Ultrasound measures of intrinsic foot muscle size and activation following lateral ankle sprain and chronic ankle instability. J Sport Rehabil 2021; 30:1008–1018. doi:10.1123/jsr.2020-0372.
  5. Dieterich AV, Deshon L, Strauss GR, McKay J, Pickard CM. M-Mode ultrasound reveals earlier gluteus minimus activity in individuals with chronic hip pain during a step-down task. J Orthop Sports Phys Ther 2016; 46:277–285. doi:10.2519/jospt.2016.6132.
  6. DeJong AF, Mangum LC, Hertel J. Ultrasound imaging of the gluteal muscles during the Y-balance test in individuals with and without chronic ankle instability. J Athl Train 2019; 55:49–57. doi:10.4085/1062-6050-363-18.
  7. Mangum LC, Henderson K, Murray KP, Saliba SA. Ultrasound assessment of the transverse abdominis during functional movement: Transverse abdominis during movement. J Ultrasound Med 2018; 37:1225–1231. doi:10.1002/jum.14466.
  8. DeJong AF, Mangum LC, Hertel J. Gluteus medius activity during gait is altered in individuals with chronic ankle instability: An ultrasound imaging study. Gait Posture 2019; 71:7–13. doi:10.1016/j.gaitpost.2019.04.007.
  9. DeJong AF, Koldenhoven RM, Hart JM, Hertel J. Gluteus medius dysfunction in females with chronic ankle instability is consistent at different walking speeds. Clin Biomech (Bristol, Avon). 2020; 73:140–148. doi:10.1016/j.clinbiomech.2020.01.013.
  10. Valera-Calero JA, Fernández-de-Las-Peñas C, Varol U, Ortega-Santiago R, Gallego-Sendarrubias GM, Arias-Buría JL. Ultrasound imaging as a visual biofeedback tool in rehabilitation: An updated systematic review. Int J Environ Res Public Health. 2021; 18(14):7554. doi:10.3390/ijerph18147554.

Alexandra F. DeJong Lempke, PhD, ATC, is a clinical assistant professor of Applied Exercise Science, co-director of the Michigan Performance Research Lab, and a member of the Exercise & Sport Science Initiative within the U-M School of Kinesiology.

Interested in reading more about MSK ultrasound? Check out these posts from the Scan:

The Role of Musculoskeletal Ultrasound in Sports Injuries

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Approximately 20% of the U.S. population engaged in sports or exercise on a daily basis from 2010–2019.1 As expected, exercise and sports-related injuries are common, not only in the elite athlete but also in the general population. These injuries frequently lead to sport participation absence (SPA) and often, contact with the health care system. Although history and physical examination are the primary tools of diagnosis, musculoskeletal ultrasound (MSK US) has become the “stethoscope” for evaluation of sports medicine patients.

Even though MSK US has been widely used in Canada and Europe for years, the dramatic utilization increase in the United States has only occurred over the last two decades.2, 3 Between 2003 and 2015, there was a 347% increase in total MSK US volume within the Medicare population.3 The growth in subspecialties such as physical medicine and rehabilitation, rheumatology, and sports medicine has outpaced the growth in radiology. This Point-of-Care Ultrasound (POCUS) by clinicians may help facilitate diagnosis, expedite treatment planning, and reduce patient wait time and number of visits by offering one-stop clinics. 

Cristy Nicole French, MD
Cristy Nicole French, MD

POCUS can be quite useful to evaluate sports injuries. Propelled by advances in technology, the advent of compact, portable, and more affordable ultrasound machines may facilitate prompt diagnosis of sports injuries on the field and in the training room. The real-time nature of ultrasound provides the opportunity to interact with the athlete and correlate symptoms with sonographic findings. Patients enjoy this opportunity to “share their story” and often provide critical information to the diagnostic puzzle. They also appreciate the immediate findings the physician may be able to provide at the time of imaging. In fact, most patients actually prefer ultrasound to MRI.4 Other unique advantages of MSK US for sports imaging are the ability to easily assess the contralateral side as a control and the capability for dynamic imaging. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies.4 Sports clinicians often encounter a treatment gap for a substantial percentage of young, active patients with a strong desire to return to activity, yet for whom conservative measures have failed and surgery is not indicated. Fueled by media coverage of the treatment of high-profile professional athletes, the field of orthobiologics has exploded in recent years. Ultrasound can provide target localization during administration of a wide array of injectable agents (prolotherapy, autologous whole blood, and platelet-rich plasma) in addition to image-guided peritendinous corticosteroid injections, tendon needling or fenestration, and even percutaneous ultrasonic tenotomy (Tenex).

With the development of high-frequency transducers, MSK US has equal diagnostic accuracy to magnetic resonance imaging (MRI) for evaluation of many superficial tendon and ligament abnormalities. In the current era of cost containment, the utilization of MSK US as an alternative to other more expensive imaging modalities may represent an effective way to save healthcare dollars.5, 6 However, many issues related to accuracy, observer variability, and high-quality training need to be considered, aside from pure economics, to ensure that MSK US is ethically and adequately performed in the best interest of patient care.

As any of us who have picked up a transducer know, some of the most significant disadvantages of ultrasound are the relatively long learning curve and inherent operator dependence. These challenges are compounded in MSK US by the complex anatomy, pathology, and terminology not often included in general ultrasound education programs. Dedicated training and standardized technique can minimize these limitations. Many subspecialty residency and fellowship programs have recognized the necessity of standardized, high-quality training and have strategically designed curricula to become proficient in the core competencies of MSK US.

In recent years, quantitative ultrasound methods, such as shear-wave elastography (SWE) and contrast-enhanced ultrasound, have emerged as an adjunct tool to standard B-mode imaging in the evaluation of various structures throughout the body. In particular, SWE has seen an exponential increase in the number of musculoskeletal applications. Shear-wave elastography can assess tissue stiffness by applying a mechanical stress that generates shear waves, which then travel through the tissue at a speed proportional to its stiffness. By quantifying mechanical and elastic tissue properties, SWE may provide important information about pre-clinical injuries in musculoskeletal tissues as well as tissue healing after injury. Although SWE is FDA-approved on most ultrasound platforms, its use for clinical imaging in musculoskeletal ultrasound has lagged behind research due to lack of standardization in study protocols, techniques, and outcomes measures. Nonetheless, SWE has a promising role in the future of ultrasonography in sports medicine and may help practitioners to better estimate injury severity and individualize the retraining plan for the injured athlete.

References

  1. Hauret KG, Bedno S, Loringer K, Kao TC, Mallon T, Jones BH. Epidemiology of Exercise- and Sports-Related Injuries in a Population of Young, Physically Active Adults: A Survey of Military Servicemembers. Am J Sports Med. Nov 2015;43(11):2645-53. doi:10.1177/0363546515601990
  2. Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am Coll Radiol. Feb 2012;9(2):141-6. doi:10.1016/j.jacr.2011.09.008
  3. Kanesa-Thasan RM, Nazarian LN, Parker L, Rao VM, Levin DC. Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015. J Am Coll Radiol. Mar 2018;15(3 Pt A):402-407. doi:10.1016/j.jacr.2017.10.015
  4. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. Jun 2008;190(6):1621-6. doi:10.2214/ajr.07.3385
  5. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. Mar 2008;5(3):182-8. doi:10.1016/j.jacr.2007.07.016
  6. Bureau NJ, Ziegler D. Economics of Musculoskeletal Ultrasound. Curr Radiol Rep. 2016;4:44. doi:10.1007/s40134-016-0169-5

Dr. Cristy French (Twitter: @cristy_french) is an Associate Professor in the Division of Musculoskeletal Radiology at Penn State Health Milton S. Hershey Medical Center. She is the Director of Musculoskeletal Ultrasound as well as the Musculoskeletal Fellowship Director.

Ultrasound-Guided Musculoskeletal Injections

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I began using Musculoskeletal (MSK) ultrasound (US) in 2010. It has been incredibly exciting to observe the growth of applications of this amazing technology for both myself personally as well as for the entire MSK US practicing community. MSK US has become an integral part of my Sports Medicine practice and I certainly anticipate its’ role to continue to expand and be able to provide cutting-edge medical care to my patients.IMG_8265

There is great variability with which MSK US is used among practitioners. Some providers do complete diagnostic scans of the shoulder, for example, to evaluate the extent of a potential rotator cuff tear to guide with potential surgical decision making, while others perform selective nerve blocks and finally, some practitioners simply use it to assist with the accuracy of various MSK joint and soft tissue injections. I would like to illustrate to all of you the applications for which I most commonly use MSK US to improve patient care.

Probably the most common application for which I use MSK US is to assist with the accuracy of joint and soft tissue injections. It has been clearly documented that MSK US improves the accuracy of certain MSK injections. While I do not use MSK US for all injections, ie, simple knee intra-articular and shoulder sub-acromial injection, I routinely employ MSK US to assist with certain injections. Common joints and soft tissue areas for which I employ MSK US for either cortisone or pro-inflammatory injections like Platelet Rich Plasma (PRP) are:

Shoulder: Glenohumeral and acromioclavicular joint and long head biceps tendon sheath

Hip: Femoroacetabular, hamstring origin (tendon or bursa), mid-portion hamstring, pubic symphysis, gluteal tendons and bursa, iliopsoas bursa and tendon

Knee: Pes anserine and iliotibial bursae, patella and quadriceps tendons, Baker’s cyst aspiration

Wrist: Triangular fibro cartilage complex (TFCC), various wrist extensor and flexor tendons, aspirate ganglion cysts, numerous hand and wrist joints

Elbow: Lateral and medial epicondyle area, triceps insertion, olecranon bursitis, distal biceps and intra articular

Ankle: Achilles, tibialis posterior, peroneal tendons, numerous foot and ankle joints, plantar fascia

Back: Sacroiliac joint

I would also like to illustrate some interesting recent cases supporting the utility of MSK US in a Sports Medicine practice.

I am consulted numerous times a week by my orthopedic surgeon colleagues for diagnostic joint injections. Oftentimes, a patient’s hip pain may be multifactorial or difficult to specifically isolate. I will perform an intra-articular injection to see if it alleviates that patient’s pain, thus identifying that the area in which I placed the injection as the pain generating location. Correct identification of the pain generating source will help to assist with treatment considerations.

I also recently had a patient with greater than 1 year of hip pain. He had seen 8 different providers and had an extensive workup with imaging and injections only to have continued pain. He had hip joint and hamstring origin injections and felt no improvement. I was able to use the US to identify and isolate the obturator internus as the source of his pain by providing a diagnostic injection. This injection helped to make the appropriate diagnosis and ultimately influenced treatment.

Last month, an orthopedic surgeon asked me to evaluate a patient for refractory symptoms from a Baker’s cyst. The cyst persisted despite multiple intra articular-injections. I evaluated the cyst with US and noted that it was multilobulated. I was able to specifically aspirate each of the loculations and the patient has remained symptom-free.

I was also asked to see one of our varsity basketball players for refractory lateral knee pain. His athletic trainer was treating him with rehabilitation and multiple modalities but the pain persisted and was affecting the athletes’ ability to play. I was able to identify an inflamed Iliotibial band bursa with the US and subsequently inject it. He became pain-free and was able to play in that weeks’ game as well as the rest of the season.

Another exciting application of MSK US that has piqued my interest recently is the use of the US to assist with appropriately identifying the compartments of the lower extremity for chronic exertional compartment testing. I can employ the US to guarantee that I am in the appropriate anatomic compartment for testing.

With any new technology, the application and utility of MSK US can be user-dependent and it can be affected by a somewhat steep learning curve. MSK US curriculums are frequently being added to Sports Medicine fellowships to train some of the future leaders of medicine. I certainly anticipate that this technology with continue to evolve and its’ treatment applications will continue to expand.

How do you use MSK US? How has it improved your practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Bryant Walrod, MD, CAQSM, is Assistant Professor: Clinical at Ohio State University, is Team Physician for the Ohio State Athletics, and practices at The Ohio State University Wexner Medical Center.