1. Ultrasound Guided Injections in a Sports Medicine Practice Edward W. Kelly, MD October 7, 2013 Annual Orthopedic Care Team Conference

2. Ultrasound Guided Injections in a Sports Medicine Practice Nothing to disclose

3. Musculoskeletal Ultrasound Goals Review Musculoskeletal Ultrasound Advantage and disadvantages of MSK US Demonstrate therapeutic US Guided Injections

4. Musculoskeletal Ultrasound What is Ultrasound High frequency sound wave Audible sound 20 Hz – 20,000 Hz Diagnostic US > 1,000,000 Hz (1MHz) –Above human hearing Musculoskeletal Ultrasound – 7-18 MHz

5. Musculoskeletal Ultrasound What is Ultrasound Sound waves travel through tissues at same speed How fast they return determines image

6. Musculoskeletal Ultrasound What Can MSK Ultrasound Image Bone Muscle Tendon Nerve Subcutaneous Tissue Fluid

7. Musculoskeletal Ultrasound What Joints Can MSK Ultrasound Image Small joints- Foot/Ankle – Hand/Wrist Knee Hip

8. Musculoskeletal Ultrasound What Joints Can MSK Ultrasound Image Shoulder/Elbow Glenohumeral Subacromial space AC joint Biceps Lateral epicondylitis

9. Musculoskeletal Ultrasound What Are Ultrasound Advantages The Rehabilitator Fact or Fantasy? https://www.youtube.com/watch?v=v1GGFR2mc9g

10. Musculoskeletal Ultrasound What Are Ultrasound Advantages Images muscle, soft tissue, and cortical bone surfaces No known long term side effects Dynamic or “live” images

11. Musculoskeletal Ultrasound What Are Ultrasound Advantages Portable No special room needed High resolution – 1 mm Accurate!

12. Musculoskeletal Ultrasound What Are Ultrasound Advantages 2009 Meta-analysis Am J Radiology 65 studies US as sensitive and specific as MRI to diagnose RC Tears

13. Musculoskeletal Ultrasound What Are Ultrasound Advantages Relatively inexpensive

14. Musculoskeletal Ultrasound What Are Ultrasound Advantages MRI shoulder cost $ 750 Medicare US diagnostic shoulder cost = $124 Medicare US guided needle placement $208 Medicare

15. Musculoskeletal Ultrasound What Are Ultrasound Disadvantages Can not see thru bone or gas Relatively limited depth of penetration Operator dependant Steep learning curve – about 100 scans

16. Ultrasound Guided Intra-Articular Injections Do you need guidance? Poor ability to get into desired joints blindly –Glenohumeral 90% vs. 27% –Biceps87% vs. 40% –Subacromial90% vs. 30% –AC Joint90% vs. 60% –Hip90% vs. 30%

17. Ultrasound Guided Intra-Articular Injections Do you need guidance? Better therapeutic response Less pain for patient Less likely to injure other structures

18. Ultrasound Guided Intra-Articular Injections Examples

19. Ultrasound Guided Intra-Articular Injections Glenohumeral Joint

21. Ultrasound Guided Intra-Articular Injections Subacromial Space

22. Ultrasound Guided Intra-Articular Injections Biceps Tendon Sheath

24. Ultrasound Guided Intra-Articular Injections AC Joint

27. AC joint injection

28. Ultrasound Guided Intra-Articular Injections AC Joint

29. Small Joints Elbow Lateral Epicondylitis

30. Small Joints Elbow Lateral Epicondylitis

31. Small Joints Elbow Lateral Epicondylitis F.A.S.T procedure –FOCUSED –ASPIRATION AND REMOVAL –SOFT –TISSUE http://www.fast-technique.com/

32. FAST for Patellar Tendonitis

35. FAST for Shoulder Calcific Tendonitis

38. Ultrasound Guided Injections in a Sports Medicine Practice Summary Ultrasound provides reliable in office diagnosis Lower cost guided injections more effective In-office procedure Can be used for any joint Steep learning curve