Musculoskeletal Ultrasound Imaging for sports injuries
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 to your sport?
Are you a strength coach designing a program for an injured athlete with no exact diagnosis?
I have often hear coaches of many sports frustrated designing programs around injuries which have gone unsolved and still painful after months of “rest and ice.”
Musculoskeletal Ultrasound (MUMS) is quickly becoming the image of choice for Sports Medicine doctors working with high performance athletes to attain quick and accurate diagnosis This type of imaging can be used for some very common injuries found in the sports such as: muscle strains, tendonopathies, joint pain, bursitis, and even some bone injuries. Non-traumatic sports injuries often occur at the musculotendonis 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 a “must have” for making educated clinical judgment 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 have on a weekly basis, yet is not bad enough to put them on rest, can be diagnosed and corrected. These tendopathies on Musculoskeletal Ultrasound do not often present with the characteristic inflammation as a new or acute injury. Rather they are infiltrated by fibroblasts and angiogenesis or formation of new vessel formation. MRI will only pick up swelling and edema in the area 6 weeks following an 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 sprain and 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 do not know about the next best thing. Don’t get me wrong; collectively the medical profession does not expect anyone but us 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 is MRIs and X-ray, which are not easily attained by an athlete or patients in general. MRI’s are often denied by primary care doctors and insurance companies for varies reasons.
Imagine you have an athlete looking to compete 5 days from now…
What is the typical timeline of tests/ exams for even a top-level athlete in college or high school?
• Day 1: Training room treatment (ice, heat, stretch, etc.
o To get a diagnosis the athlete will need to be seen by a doctor
• Day 2: Exam by a primary care physician
o Sent to X-ray but they are negative
• Day 3: Rest do to “soft tissue injury”
o Coach and athlete request 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)
o This insurance company needs 6 weeks of therapy before approval
• Day 8: Physical Therapy Day 1 of 6 weeks
• Over 1 ½ months: Finally gets MRI
o MRI is negative or just small soft tissue findings
Obviously you see the athlete’s 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 last year, I had a patient whom had back and leg pain but was not allowed to have an MRI until she had completed 6 weeks of care, regardless of what it 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 within one week there is still have no treatment plan in place, you’ve missed one race and maybe the rest of the season if you have a short season. Keep in mind every case the athlete is dealt with in the healthcare system is differently.
Many other variables lay in the way:
• 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 doctor visits?
• 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 timely management of even a soft tissue injury such as Achilles tendonitis or High hamstring tendonopathy!
What is the solution?
The lack of proper diagnosis is well documented in sports medicine due to a few variables:
1. Lack of education of the healthcare provider in that specific injury
2. Lack of information or supporting imaging
3. Lack of proper interpretation of the correct supporting imaging
Finding the right team 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, sports psychologist is better.
Imaging Solution:
MSUS or Musculoskeletal Ultrasound is a great option for 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 5 minutes. Within 10 minutes that same information can be in the hands of the trainers, strength coach, team coach, and sports medicine doctor whom can 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 hindering 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 in the knee at the femoral condyle, meniscus and labrums 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) Meniscus 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.