Ultrasound Imaging of the Knee: Diagnosis and Needle Guidance

This is the Performance Place Sports Care Podcast, session number 40. Yeah, I stopped wearing a watch when I moved out here. I got a phone with a clock on it, so I really don't need it. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales again with the Performance Place Sports Care Podcast. And we're going to have on, actually, the ultrasound expert, or one of the ultrasound experts that we had on earlier, on a different session. It was session number 27.

This is Mike Jablone, who spoke about ultrasound for the first time there. We went over a couple things, like shoulders, my mom's shoulder, actually my oblique strain as well, that probably a lot of you have heard about or read about on my website or on YouTube. And just kind of how safe it is. So we're going to go a little bit deeper into that today and go over knee conditions and how well or how not well ultrasound can really see things on knees. So, first off, too, if you haven't subscribed already, please do so. And I did have a question by one of the listeners who said, I don't know where to subscribe.

And we found out that actually they were listening to it on someone else's website who had embedded it. So you've got to go on to iTunes. That's where you can subscribe. Just go on there. And that's also where you can write the reviews, too. So let's bring on Mike. Again, Mike Jablone, can you say hi? Good morning, Dr. Sebastian. Good morning to everyone. And thanks for having me on the show. Yeah, no problem. I think the last one was really, really good. I think it turned out really clear. And there was a lot of good information on there in ultrasound. So I think we should probably recap that before we go too far in case someone has not listened to the other session.

So can you tell us a little bit about ultrasound and why you think or why we should even go into it with the knees? Sure, sure. Ultrasound in general is the same ultrasound that we're all familiar with, with looking at babies, listening to hearts. It's technology that's been with us for quite some time. The uniqueness of musculoskeletal ultrasound is that we specifically focus on bone and joint, soft tissue. And this technology was supreme and number one in Europe most of the years. And now in today's time, the United States has caught on to this and it's becoming more and more popular. Yeah, I found it interesting the first time I saw ultrasound on a knee.

And by just all the things that you can see, I mean, it was so clearly that you can see like the patellar tendon, the quad tendon, the meniscus, hamstring tendons, like all these different, like especially tendonitis that people have, it's so easy to see. Yes, absolutely. That's my one of my favorite things about examining the knee is the the instant information that you can get in a very quick period of time at determining the condition of a knee joint in almost a matter of seconds just by looking inside immediately. So most people are accustomed to, usually when they have a knee condition, they'll be referred to x-rays and then they'll wait a little bit of time because a lot of times the insurance provider won't cover anything yet, but sometimes an MRI is, can ultrasound take over these two images?

Or is there still a need for those or is ultrasound completely out? Those are great technologies and they'll also always be in the front line, x-ray and MRI, incredible tools to look at the knee. But when you have an ultrasound machine at your fingertips and a competent technologist who knows what they're doing, it's really easy to get in there and look at the condition of the joint immediately before you even get to an x-ray. The fact that it's completely safe and that there's no side effects whatsoever gives you the freedom to just, in a matter of moments, start decision-making right away. And determining the status of the knee joint is a really important factor.

So ultrasound should be a go-to front line test if you have it available. Yeah, so how long does that one actually take? Because I know some of the other types of images, x-rays, MRIs, they take a little bit more time. Well, in general, on average, we'd like to allow about 15 minutes to take a look at a knee. Depending on the environment, we work in a very high-paced environment and patients, knee patients are coming in and decisions need to be made immediately. For example, are we going to aspirate the knee? Is this a surgical case or is this something that can stay in the sports medicine practice?

Or does this need to get referred to ortho? These decisions need to be made as quickly as possible. So 15 minutes is the average time. Yeah, I feel like as soon as you put the probe to the skin, oftentimes you can see. I mean, if you start around in the area where you think there's a condition or a pathology, can you at least relay some... I know that my experience with patients looking at the image, there's a lot of times they don't know what they're looking at. Just as in other... X-rays, they seem to gravitate towards like the skeleton. MRIs, they can't really tell. But how is their experience on ultrasound?

The best thing to do with ultrasound always is just to look at a series of normals. Take a patient, a young, healthy 20-year-old kid or athlete and start looking at normal knees. Get a good feel for what the osteochondral surface of the joint should look like in a perfect order. And then once you get comfortable with the spacing, how much space should there be? What do the margins look like? What does the articular cartilage look like? What does the meniscus look like? Once you get a good feel for the normal anatomy, then you can start to appreciate the changes, the pathologic changes that take place.

You went through a couple of terms there. I'll just interpret them. So osteochondral surface is the bony cartilage surface, so bones have cartilage on them. You said the articular cartilage, so that is the cartilage that kind of looks like... I guess if we get a chicken drumstick, it's on the end of the nub, right? I'm sorry, can you say that last part again? When you get a chicken like a drumstick, like at the end of the drumstick, that's where the articular cartilage is. I was just trying to make it so everyone can understand what the articular cartilage is. That's an analogy that I use often, and I hate to draw comparisons to food that we eat, but it's absolutely a similar texture.

We're all familiar with the head of a chicken bone and that cartilage surface on there, and in an interesting way, it's very similar to our own. You know, I don't think I've ever seen actually a chicken bone that has cartilage degrade. Maybe they get off really quickly in their life. Yes, and try not to look very peculiar as you're examining these chicken bones, because it's very tempting, and it looks so similar to our anatomy, but you will definitely look strange if you're caught examining your food at the table, so do it discreetly, I recommend. Yeah, and then you said the meniscus, which is a different type of cartilage, but a lot of patients will see that as almost like a buffer between the upper thigh and the calf area.

So ultrasound can see all those types of things, you said. Absolutely, it definitely can, and it can see them in a great bit of detail. And if things run short, that's where we bring in other things. So we bring in the x-ray, of course. That shows the bone, and you can't take away from an x-ray. And the MRI is incredible as well. But we save that for when we need that. So if we look into a knee right away, and we see that there's excellent joint space, that the surfaces are nicely preserved, that the meniscus look good, we might be looking at a bursitis, or there could be something soft tissue-wise, maybe a ligament strain, and something that we don't necessarily need to go to the extreme of an MRI.

Yeah, I can actually think of, actually going back to the chondral surfaces, so I guess to equate this to what everybody is probably thinking, like, well, I have a condition here. Like, what can this look at and diagnose my condition? So chondromalacia patella, you could see parts of that, right? Yes, we can. We measure the thickness of the articular cartilage, as we've been talking about, and we look for breakdown or degeneration of that cartilage, fragmentation. And that's how chondromalacia appears on ultrasound. Okay. So I'll probably give you a couple here, just to tell them what you think on each.

So medial meniscus tears? Yes. Okay. Let's see. What else have we got? Pez anserini? Yes, that's a biggie. We deal with that daily. Okay. LCLs, LCLs, or medial collateral, lateral collateral ligaments? Yep. Those are unobstructed. We have a clear view of those structures. IT band syndrome. That's another structure that we have clear view, no obstruction. It's just beneath the skin surface. So we get a beautiful view of the IT band from start to finish. Yeah. Funny thing with that one, actually, on my imaging experience so far, I feel like the IT band usually ends up being a lateral meniscus tear.

Because it's so close there, right? Yeah, that's where it gets very interesting with the diagnosis, because there are a lot of differential diagnosis, and that's a real good one that you pointed out. But that's where ultrasound comes in to separate these things out. When we can clearly identify the IT band and follow it distally to where it attaches onto Gertie's tubercle, right along the front of the knee, we can look for any type of change along the IT band. And usually the symptoms will be compatible to that compared to a lateral meniscus tear, which has a different set of symptoms, buckling, instability, things like that.

Yeah, that's actually another point. I think you might have been there when we imaged this person, but there was a girl, she was a college runner, and she had, we were looking for a bony injury, actually. Actually, no, you weren't there. I'm sorry. We didn't do an ultrasound. We did an MRI. And it came back with all these tendonitis everywhere, like Achilles tendonitis, peroneal tendonitis, tibial tendonitis as well. And she didn't have any pain with them either. So we pointed out all these spots. And so clinical correlation and how the patient feels is obviously a huge thing. So, I mean, do you often find things in ultrasound where people don't have pain or where they're feeling like, well, I had no idea that was even there.

Like, even tumors and stuff like that, do you find odd things that they didn't know were there? Absolutely. That's something to strongly consider. And if you recall, some years ago, there was that fad that came along called full body scanning. And you could go into the malls or different places like that and get your entire body scanned from head to toe. And there was some controversy on that for that very reason, that it could uncover a lot of things that we might have just had normal degenerative changes. Like, for example, an AC joint, an acromioclavicular joint in the shoulder. Almost everyone over the age of 40 has some kind of a bone spur or degenerative change, if you look at it.

So you're right. If you have the immediate ability to look at things, you might start uncovering. But that's where point of care comes in. And it's really important to follow the patient's symptoms and look at things that hurt and try to differentiate between what's real and what's not. Yeah. I find even sometimes, like, there's, I mean, there's certain types of findings that patients typically will gravitate to. So I actually went, I don't know if I told you, I went to, I did a podcast where I actually went over my own MRI when I was 15, 16, and all the parts that look kind of freaky to me then don't look freaky anymore.

But, like, degenerative changes and, like, they gravitate towards that stuff. So if they do a full scan, I'm sure there's a lot of things that are going to come out that they have questions on. Yeah. And you just have to consider the situation. We always consider the patient age. So we're starting to build a picture of what we're going to find before the patient even comes back. We see the year they were born. We start to learn about what they did for work, like a plumber, for example. I'm always amazed at the injuries that are sustained by plumbers and people in that type of a field. They have to crouch down into tight spaces.

They have to wrench their arms into positions. And someone like a plumber can develop problems and degenerative changes like an athlete would, just to give you an example. Probably shoulder, elbow, low back all over the place. Probably knees, too. So in regards to the last thing I want to ask about with at least structures of the knee that you can see, the ACL, because I know a lot of people have heard of the ACL, and it's a big topic, and it's a big, big money generator in regards to rehab. Can you actually see the ACL? Yes. We could see the ACL, and what I feel comfortable with ultrasound is red flagging an ACL tear.

And let me explain. So the ACL runs on an oblique angle, and due to artifact and whatnot, it could be difficult to look at with ultrasound. So it requires a little finesse. But we can definitely get in there and take a good look at it. And if there's a blatant tear to the ACL, the first thing we're going to see is a large area of swelling, usually, and inflammatory changes all around. When the ACL tears, it usually breaks up into pieces, and you can catch those pieces. So you could see when there's a big, juicy ACL tear, as they say. It would show up nice on ultrasound to at least red flag it.

But the gold standard is MRI to really take a good look at the ACL, because you could see it from point to point. You get a really good view of it. So we use ultrasound in the clinic for frontline rule in or out. So in other words, we could take a look right away in and see if there's pathology or any type of change to the ACL. And then we'll put in our report, it's suspicious, suspicious for an ACL tear. And at that point, they might get an MRI or arthrogram or something like that to confirm it. Yeah, no, I agree. The red flagging, I always say if there's smoke, there's a fire or probably a fire with it.

I know there's a couple ladies that I looked at that had one at an ACL, one at a full tear, one at a partial. Surprisingly, actually, the partial had more signs of the fire than the other one did. But the one thing that I saw was that the absurd amount of fluid coming up into underneath the quad, into the superior lateral patellar recess. I mean, that in itself, I mean, that just means there's a big problem in there. It's not just a minor tendonitis or extra-articular injury, you know? Yes, yes. And one of my favorite things, again, with ultrasound, the more we do this day-to-day, the advantage by far that ultrasound has over anything else is that we're right there with the patient, that we are literally face-to-face with the patient.

So when they come in after a skiing injury over the weekend, and they describe to us face-to-face what happened, that their knee flipped over the other way, it dislocated, they were taken off the hill in a stretcher, and their knee swelled up like a balloon, et cetera, et cetera. We could start to gather the clinical evidence that there's probably going to be an ACL tear here, and then we can really focus in on it more. So that's a strong advantage of ultrasound is being literally face-to-face with the patient while making the diagnosis. Yeah, and actually, too, I don't know. Actually, I feel like the times that I've watched you do images, like the patients are always like they're magnetized.

They're like they're looking at the screen, you know, they see that you're poking and prodding and looking at the thing and saying, does that hurt and so on, and do a couple tests here and there. So your experience, at least, you can do some orthopedic testing or you're doing some, I guess, I don't know, I guess, I don't know the licensing issues with everything. But I know that some of the sonographers that I've seen, they don't go that far, and when I do it, I had the background in orthopedic testing and history-taking and all that stuff. So kind of on the same level as you, we do the same thing, and that does build a really, really good comprehensive exam when you have the image involved as that front line.

But, like, when did you actually start doing, like, where did you learn all that? Did they teach that in sonography school, or did you just get along the way? There are different levels of certification in sonography. For example, there's the current musculoskeletal training is called the RMSK, and that's, by the RDMS, it's a certification that you can get. That has a certain level of training. But there's another training called the RMST, and this is older. This is rooted in the European Society. The registry of musculoskeletal technologists is rooted back into the late 80s, early 90s. And this particular registry and training has all kinds of requirements, including clinical testing and orthopedic testing.

So it's part of the training to learn the different clinical exams, such as an anterior drawer test to examine the ACL. So while we're examining the ACL real-time, we're actually performing an anterior-posterior drawer test just to assess the integrity of the ACL. So in my particular training that's rooted in the European Society, x-ray, MRI, surgical time, and certainly orthopedic testing is all included in that training. So you don't happen to have any research that you've seen on just doing an image and being able to diagnose it versus doing an image plus testing at the same time for accuracy, do you?

Well, I'm not sure exactly. That'd be a cool one. I know that every exam that we do is an interaction between still images and dynamically working with the joint. That's definitely one of the top advantages of ultrasound is the dynamic ability of the test. So every test that we do is very interactive. And there are images that are taken in still positions, but majority of the test is done video recorded. We're maneuvering the knee into positions, putting a little bit of valgus stress, for example, on a medial collateral ligament if we suspect a tear. We're able to do a valgus stress test while we have the transducer in our hand imaging the structure simultaneously.

And you'll be amazed at how little tears, even the smallest little tear, could open up and become visible with a little bit of stress put on the structure. So with movement, when you're moving the patient and have the probe on it, all those clicks and pops and creaks that people feel and hear, could you see what is causing those? I find clicks and pops and creaks to be interesting because I think they're somewhat misleading to patients. And we all know this from this side. We all have clicks and pops, and I never want to minimize them because everyone is unique into itself. But I find that patients sometimes are a little misled when they hear a pop or a click.

It might seem more dramatic than it really is. In reality, it could just be a little pressure release, a little bit of fluid built up in the joint, just like your knuckles when you wake up and crack your knuckles. But then there are other clicks and pops, such as with the labral tear, where you have a detached piece of labrum in the shoulder. And with some dynamic range, you can hear the clicking or the catching of that cartilage. So clicks and pops are very unique. You really have to take them into or put them into perspective. It could be a simple little pressure release, or it could be attended, maybe an IT band snapping over a bone spur, or a little bit of femoro acetabular impingement in the hip.

So there are a lot of different reasons for clicking and popping. Yeah, I totally agree. Actually, I had a player come in the other day that he strained one of his shoulders, and actually on his throwing shoulder, his other one, while batting. And he's talking about, hey, it feels like it clunks around now. And I looked at his other side, and I'm like, these are the same. I'm like, if you're looking for, you know, like a hands-on treatment to get rid of the clunk, it's probably not going to you. Don't hold your breath. You know, we got other fish to fry. This is just something that you probably started noticing now because it started hurting you.

So I totally agree with you on that. Yes. In regards to injections, because I know that there are injections that can go into the knee of all these different types and styles and materials and so on. You can guide these injections with ultrasound. Can you tell us a little bit about that? Because I know you've had some experience with it. Yes. That's one of the main things that we do on any given day. We probably do. I think yesterday we did close to 20 different knee procedures, injections, aspirations, all day long throughout the day. And this is why we have to move very quickly. So when we have a packed waiting room and a patient comes back and they want to know from ultrasound, what are we doing here?

Are we draining? Are we aspirating this knee? Are we injecting? And where are we going to do that? What's the best option? This is the type of information that we need to gather. So for example, we look at a knee and right away we determine that in the suprapatellar recess, there's a large effusion. And that literally takes seconds to do. Seconds. You could take the transducer, place it on top, just above the suprapatellar pole, the top of the kneecap, and you can determine literally in seconds how much effusion is in there. So if we put the transducer up and we see a large fluid collection in the suprapatellar recess, you can't miss it for one.

Fluid stands out on ultrasound like a big black sack. And we can determine approximately by measurements how much fluid is in there. Is it 5 cc's, 10 cc's, 15 cc's? So in a matter of seconds, we're determining where the fluid is, how much fluid is there so that you can prepare for it. We have to know how many syringes to bring in and how much fluid we're actually going to be taking out. We don't want to come up short. We don't want to not have enough supplies right in the middle of an aspiration. So we have to determine quickly what the probability of what we're going to get out. And also, with the ultrasound, we can determine the texture of the fluid.

Oh, yeah, that's huge. Yeah, that's huge. For example, we could determine if the fluid's been in there for too long. If it sits in there for too long, it becomes very viscous, very thick. And we might determine by the echo texture of it, the appearance of it, that it's not a likely aspiration, that it looks too much synovitis, for example. It might not come out so easy. And that might influence the gauge of needle that is used, too. We might have to go with a lower-gauge needle because we need a larger space to aspirate that fluid. So these are the kinds of things that we're determining. Yeah, actually, I forgot about the viscosity or the texture of it.

I remember seeing on one ultrasound where that space under the quad was enlarged. And then you sat there long enough with the probe, and you saw like a tumbleweed roll by. Yeah. So that was kind of cool just to see things actually moving in there. But yeah, that's a huge point. And with the accuracy of hitting it, I mean, you guys can visually see the needle going in, and I'm guessing the fluid coming out. These are one of my favorites. Needle-guided ultrasound. Needle-guided ultrasound is a craft. It is not something that you can just do. It's something that you cannot just take a simple weekend course.

Needle-guided guidance with ultrasound is a skill that needs to be refined every day. But of all the things that we do, I particularly like knees. I think knees are the easiest because we have a really clear window to follow that needle. So, for example, when we do a knee aspiration, which is very routine in our office, everyone shifts into gear. We prep the patient, we get them ready, we prop the knee up in just the right way. We find the top of the kneecap up at the suprapatella pole of the kneecap, and we usually come in laterally. That's our main approach. We come in from a lateral approach.

But we're all shifting into gear and getting ready, making our little mark. We take a little cap of a pen tip, and we make a little mark where we're going to come in. So, I like knees with needle guidance because we have an unobstructed view, and we can see that needle. Nine times out of ten, we're going to see that needle and guide it exactly to where we need. So, for patients that are looking for needle guidance, because I know not everyone does needle guidance in regards to at least people that are doing injections. So, is there a way they can find or ask if their injection they're going to get is ultrasound-guided?

Absolutely. I think patients have become a lot more savvy nowadays. They've been to a lot of different facilities, and a lot of people do needle-guided ultrasound. But what I would want to know always, whether it's needle guidance or diagnostics, I'd want to know the reality of how long the facility has been doing ultrasound. What is the background? And I encourage patients to press that issue. Don't just take it face value. Hey, we do ultrasound, and we do needle guidance. Take it a step further. Find out how long they've been doing needle guidance. Find out who's actually guiding the needle, and what is their background?

How much experience do they have? I've encountered a lot of people out there, doctors and various people, that have ultrasound. But it's somewhat misleading because they're using it, they're making a little mark with it, and they put the ultrasound away. They're not actually guiding the needle specifically to where it needs to go. That is a skill that needs to be refined. So that's my advice to patients. Ask for ultrasound, ask for ultrasound, and then quantify or qualify who's doing it and what's their experience with it. It's funny, the red dot thing. So can they actually put the probe on and do the needle at the same time, or are they just trying to free up a hand?

Well, what happens is that a lot of doctors that have been doing this longer than I've been alive, and this is what I've been told. Mike, why do I need ultrasound to guide a needle? I've been doing this longer than you've been alive. So a lot of doctors, they know where they need to go. They palpate the area. They've been doing this. They feel it with their hand. So it's hard for them to wrap their mind around, why do I need to complicate this? Why do I need to guide anything? I've been doing this for 20, 30-plus years. So they might take the ultrasound transducer if they have it. They might put it over the area that they know they're going to go anyway.

They may make a dot right over that spot that they know they're going to go anyway, and then move the ultrasound out of the way because it gets in the way at times. It's a few extra hands in the mix. I mean, it's much easier for a doctor to just palpate, grab with no ultrasound, and do an injection. So there is a little bit of complication. You have to start entering patient information in. You have to start having extra hands in the mix. But the truth of the matter and the reality is that it's a very precise thing. And if you want to put the tip of that needle into a bursa, you're talking about millimeters.

If you're a few millimeters off, you're going to miss the bursa. You might not penetrate the joint capsule. If you're going to do an injection into a knee joint, there's a very good chance that you don't get into the capsule, that you might not get inside of the knee joint. And that's why you hear a lot of times patients say, well, did the injection help? Oh, no, not really. But then the next patient will say, it worked great. Yeah, actually, I think I don't know if I brought this one up in the last podcast or not, but I have a person right now who have a really complex hip condition. I know we're talking about knees, but this is on that same note of you're saying that you got to make sure it gets in the area because they've looked at her back.

They've looked at her hip. They've looked at, they've done an NCV on her looking for neurological types of contributions, but she had an MRI with contrast and we're looking at a labrum and they did an injection and she was very, very disappointed with, like she was excited at first thinking like, okay, this is going to be it. I've been dealing with this for a year or so. This is going to be it. We're going to know that this, the labrum is it and we can rehab it or repair it or whatever. And nothing, you know, and she talked to some friends and they're like, well, sometimes it takes two weeks. So she's waiting and waiting and waiting and nothing.

So she's wondering if she should do a second one. And my question to her originally in the beginning, I don't know the doc who did it with her, but I'm like, did they guide the needle? And she's like, well, yeah, they had an ultrasound, but I'm like, well, they can actually see the fluid going in and the needle going in. So we need to make sure that, like, I always like to play the game of identifying the pain generator. So if we can confirm that as her pathology, we stop looking at the other stuff. So I think it's super important to know that the needle went in and that it's doing what it's supposed to do, right?

I mean, just like you said, so with her. There's never been a way, there's never been a way to tell. So if you can imagine before ultrasound, all the injections, there's never been a way to watch whether or not the injection went in. So it's hit or miss. So did it work? Yeah, it did. Or no, it didn't. But I could tell you firsthand with absolute certainty that each and every injection and aspiration that we do is negotiated a millimeter to millimeter, even if it's a simple shoulder bursa injection, a simple thing. So we're guiding that needle across and we're communicating back and forth saying, okay, come on, come on, millimeter to millimeter.

And then we could feel, we could see the tip of that needle right on the edge of the bursa. And if we stop short a millimeter or two, the fluid's going to go outside of the bursa. It's going to not get to where it needs to go. So we literally guide these needles step by step by step. And that is something that is not easy. And there are not many people, there are not many people that I know around that are masters at putting that needle to where it needs to go. It is a true art form. Yeah. And I know that there's probably going to be people listening to this podcast who have said, well, like my doctor didn't guide the needle.

And I guess I want to start with first, I don't, we're not, we're not trying to bash any doctors for their technique because they might be really, really good and masters at it, but we're just bringing to light a new technology or I guess it wouldn't be new, but bringing, I'm sure a lot of people haven't heard of it yet. But I think guiding the needle, I mean, if I was to get, especially like these expensive injections like PRP and a stem cell, I want to know that it got in the spot, you know, really, really badly. Like similar to like with, um, like fluoroscopy or like epidurals, they do fluoroscopy every time.

I believe so. Yeah. With epidurals, I believe that they do. They use fluoroscopic imaging for that. And with many other types of, uh, injections and with no disrespect, I am well aware that there are masters out there, uh, orthopedic surgeons and others that, that this is what they do. And they can feel that Bursa and there, there is a real skill to that. You can feel the joint capsule. So I think a real competent orthopedic surgeon or, or anyone that is a master of, uh, injections can tell you that they don't need to see it. They can feel it. Yeah. But the reality is that each and every patient is unique.

I'll give you a quick example from yesterday, late in the afternoon, we were doing a simple, straightforward aspiration of a knee, but this particular patient had such severe osteoarthritis that there were calcifications, little calcific bony deposits strewn all throughout the suprapatellar recess where we needed to go. So we need, we needed to use the ultrasound to navigate around those calcifications so that we can get in there. The needle was coming in and it was, it was, uh, abutting or, or poking, getting into the calcium. We had to navigate around it so that we can get the fluid and we did get the fluid, but it took a little bit of negotiating.

That's an example of a variation that can happen at random. That's, that's so funny that I just imagine you like, uh, going through hyperspace in your, in your rocket ship, just avoiding asteroids. It looks like, that's what it looked like in there. It really looked like that. Uh, uh, so let's go back a little bit to, um, accuracy of, uh, just diagnostic imaging. We'll come off of injections here. Um, but I'm sure everyone wants to know how good these images are or aren't. Um, can you, I don't want to say compare them to the other types of images, um, but how sure are you that you are looking at what you're looking at when you see an image of a knee?

Well, in our case, in our clinic, I'll give you an example of a certainty. And I've said these words. I've said, I put my whole career on the line. I've said in our surgeries, I know last time we talked about how we go into the operating room and we make beds and we talk about what it could be. Um, and I have said the words before that if this is not a bone on bone, uh, medial compartment with a, with a grade three, which we'll talk about meniscal tear, um, I'll never do another ultrasound as long as I've, as long as I live. I've said those words because when it's a bone to bone, I'll give you an extreme example.

You have someone that has severe osteoarthritis of the medial compartment of their knee and it's bone against bone. And the medial meniscus is so severely degenerative, it's macerated. And what happens is it actually extrudes out of the joint, almost like a toothpaste tube. We squeeze it and it comes out. The meniscus actually gets squeezed or extruded out of the joint. It is, it is an impossibility to miss that. And if any one of our technicians that works for us, our technologist missed something like that, they wouldn't be able to work for us. It's, it's, uh, it's something that we can't, it's something that we can't miss something like that.

That's an extreme example. The real challenging, uh, cases come in where we're borderline, uh, where it could go either way. It's the ones that are in the middle that are, that are the most difficult for us. The ones that the meniscal tears that are kind of teetering back and forth on, does it communicate with the joint or not? Is it, there's this magical signal there. The MRI calls it a grade one, two, or three signal. And the orthopedic surgeons know that the grade three signals are the ones that need to be operated on. That's where the tear actually communicates with both surfaces. And that's a surgical fix.

So the difficult cases for ultrasound are those tears that are almost communicating with both surfaces. A high grade two, it's kind of sitting on the high end of a grade two. Those are the most challenging, but the bone to bone medial meniscus blown out of the joint, we should never miss one of those. And if we do miss one of those, we need to hand in the ultrasound transducer and give up the career. Um, there's actually a, there's a, there's a study that I pulled up for, I had to do a, a short presentation on meniscal tears. And this was for medial anyways. I don't, I don't search around for, for, uh, studies on meniscus too much, but I wrote this whole elaborate page.

Um, gosh, it was probably like 20 pages on musculoskeletal ultrasound on my site. And I have this slide in there and it's on, uh, under 30 years old, uh, of menial meniscus tears. So MRIs, the sensitivity is about a hundred and the specificity is around 88.9. It says, and ultrasound was exactly the same. Um, and I thought it was interesting to see that the, the overall conclusion of the study was patients with negative ultrasonography findings will have no, they have no further need for any investigation of any type of, um, imaging. So you're right. I think we shouldn't miss those. If you know, some of the studies say a hundred, like roughly a hundred, a hundred percent, especially under 30 has a tear.

You should find that thing, you know? Yeah, you should see it. And the real secret is the real thing to do. I encourage anyone who's a sonographer with musculoskeletal start looking at normals. Everyone, you can't, everybody you can get your hands on that's willing to volunteer a knee that has zero knee pain. They're young and healthy and fit. Uh, take a look at these knees, look at them over and over and over again, and your eyes will become accustomed to seeing what the joint is supposed to look like. What is the cartilage and the bone? How is the, what's the spacing supposed to be like? Um, if you have a chance to correlate x-rays, I encourage anyone to constantly, constantly correlate our ultrasound with x-ray.

If you can get MRI, do that. And over time, you'll start to build up and build up a knowledge base to where when you look into a knee, you could tell in a matter of seconds, whether or not there's joint pathology or not. And a case comes to mind again from yesterday in the rheumatology center where there was a severely inflamed knee. It was a severely inflamed knee, but there wasn't one problem with the joint itself. The joint itself was in perfect order. The menisci were in perfect order, but yet there was about 30 cc's of fluid into the patient's knee. We still don't have an answer to this. We did an aspiration and we sent the fluid out to the laboratory for testing.

So we're looking for crystal deposition and it's possible that it's a, a gout patient has a history of gout. So we're thinking things like that. But as far as the quality of the joint and the meniscus, everything looked perfect, but yet there was a large, severely inflamed knee with a large effusion in there. Yeah. It's definitely nice to play that rule in, rule out a game a little bit. And like, just knowing that you just can't look at this knee and say, well, this is early onset arthritis. This is a meniscal tear. Cause you could have like weird stuff like that. I don't know how common gout is in the knee.

I know it's pretty prevalent in the big toe, but yeah, you'd want, you'd want to know that it spreads to the knee. And I've learned working in this, in a rheumatology center out in thousand Oaks and, and in Beverly Hills, uh, the, the pathology that we see not only to knees, but to all the joints of the body, it's really something to be, uh, sensitive and appreciative to it. It's a serious thing, inflammatory art, arthropathies and inflammatory conditions such as rheumatoid arthritis is a very serious problem. And, and the, the destruction that occurs to joints is mind boggling. Yeah. And especially knowing that you have that type of condition, the treatment plan is completely different.

Um, I mean, I wouldn't rehab if I knew someone had, uh, gout of the knee and I wasted like two months of their time, like rehabbing. And I'm like, I would have done them no favors whatsoever. We should have, we should have looked ahead of time because it's a completely different plan of attack. Um, yeah, it is. And that's something that we're working. We're doing a research project right now. We're about to launch a very large research project on gout. We've been studying it for years and ultrasound as a side note, ultrasound has an incredible ability to visualize tiny crystals that are normally very difficult to see on something like x-ray until they're more advanced.

Um, the, the goal with gout is to get the earliest possible confirmation of it. And really the only way to really confirm gout is to get a little fluid out and send it in for testing, put it under a microscope and see if there are crystal deposition or crystal formation in there. So that's something that when we suspect gout, and this is another great example of the ultrasound, ultrasound can show us where to get that fluid. So let's say we're in an ankle and gout can easily spread into the mid ankle. And I've seen it plenty of times around the medial or lateral malleolus. It could settle into, to any area there.

We want to look for where's the best place to get fluid. And is there enough fluid to take out? Ankles are very difficult to drain. Uh, it can be done of course, but it's not nearly as straightforward as a knee. Getting fluid out of an ankle is not a simple, straightforward thing. And it's also very painful. So you have to be very careful. There are a lot of structures like vascular and neurovascular structures that have to be avoided. So ankle aspirations are tricky and ultrasound is critical in that, in those situations. Oh yeah. I think anything around the foot and the ankle, I might just cringe with a needle coming towards it.

I've heard what even hangnail, uh, needles look like. So, uh, uh, yes, it's something. And that's why we love lidocaine. Yeah. We always, we have a little expression. We say we need a side of Lido for this one, for sure. Oh God. Um, uh, so I know we'd spoken about it before, but I want to confirm that it's a possibility because, uh, ultrasound, I think is, it's amazing to hear about, but at the same time, it's better to see. And there are some videos on YouTube that I've seen doing ultrasound, but they're very, they're very techie. Um, they're intended for sonographers to watch and not necessarily patients.

Uh, I put a couple of videos up, uh, in the beginning on ultrasound, but, um, since then, actually I put two up recently over the last year, but I'd like to see if you'd be able to do one on the knee and we can identify the structures and like, uh, we'll talk about them just kind of brainstorm a little bit and just show everybody all the things that you can possibly see. And hopefully we don't see any, you can do it on me. Hopefully you don't see any abnormals, but would you be willing to do that? Oh, absolutely. Yeah. That, that would be fun to do. And what I always like to do is to build a little series from start with a perfectly normal knee and get a volunteer that we know that has a severe, uh, surgical knee ready for replacement and, and, and try to see the differences between those two extremes.

And if possible, get a bunch of, um, stages along the way. So the best way to learn knees, the quickest way to learn knees with ultrasound is to see a progression, almost like a time-lapse. You know, you watch the weather, they show you the time-lapse throughout the day, what happens? It's nice to see a time-lapse with the knee from a perfectly pristine joint surface and follow it through its course up to the end, to bone to bone, to ready for replacement. That's the best way and the quickest way to learn knee sonography. Yeah. I've never seen actually anything like that. That would be so cool.

But, um, I know it would take a lot of, we have to get the exact same image shot and even zoom to lapse those together. That would be sick though. That would be great. Um, yeah, let's spend some time doing that actually. So, uh, everybody, if you're looking for that video, uh, you know, I'm going to um, when it is complete, it'll be on the show notes to this, uh, podcast. You can find that at p2sportscare.com slash podcast. Um, and even if you go to the home menu, you'll see podcasts, a podcast link right there, but this is session number two. I don't know which one it's going to be yet. So I guess I shouldn't, I shouldn't go there.

Um, but it'll be a link down there too. Um, and Mike, how do we get ahold of you? I know that, uh, you have, uh, multiple offices now. So how, so how would someone get ahold of you? They could, they can easily get ahold of us by calling, um, area code 949-338-5365. It's 949-338-5365. That's a direct link to us. You can get through. And we have offices throughout Southern California from South Orange County, all the way up to Bakersfield actually. So we have, uh, locations that we can have you scheduled anywhere in between those areas. Nice. Um, oh, again, I should probably hit then if you're looking for that video too, and can't find for the life of you, uh, where the show notes are, uh, if you go onto, uh, YouTube, it'll be on there, uh, type up performance place and then scroll down our videos and you'll see, um, this one and I'll have Mike's name on it.

So, uh, also too, if you're wondering about if you have a rehab or if you have a knee condition and you're thinking about rehab as well as anatomy, we do have, I do have some other podcasts on anatomy and rehab. So session number 33 is with Davis Koh. He's a PT or a doctor of physical therapy. Um, he talks about earning your surgery. Uh, 32 is me just talking about boring knee anatomy stuff. So I've, Mike went over all those, uh, terms like chondromalacia, chondromalacia patella or osteochondral surface or meniscus. And if you don't understand anything we're talking about, you got to start back there.

And obviously I should have said this at the beginning of the podcast. Um, but I think that will really help you guys in regards to learning what we're talking about and make good educated decisions about your healthcare. Um, Mike, we're about to close up here. Is there anything that you would like to add? One thing I'd like to add to anybody listening, if you're interested in research, if you're a student, if you're looking for a project or something exciting to be involved in, we have a research project that we are launching now that we need everyone's help. Uh, we literally have tens of thousands of films over the years that we're trying to compile and, and, and put together, uh, training for future students so that the, we can cut down the time of training.

So if anybody's interested in, uh, helping us with research, something you need for school or time that you need, uh, for your school education, call directly to that nine, four, nine, three, three, eight, five, three, six, five. You could speak directly to me and I'll talk to you in more detail about that. Otherwise, Dr. Sebastian, thank you so much for the opportunity to be on your program. And thank you to all the listeners and wishing everybody a wonderful day. Nice. Uh, thanks for being on, Mike. I'll, I'll close out the show now. Now. Okay. Thank you guys. Take care. Yeah. Thanks, Mike. Okay, everybody.

So, uh, that was Mike Jablon again. Um, by the way, if you want to know a ton on ultrasound, because we will probably do a couple podcasts in the next coming year about different areas of the body that you can do ultrasound on and get good information about your injury, uh, your tendonitis is your bursitis is your cartilage injuries. Um, I have a whole page on it. And as I said before, I wrote about 20 pages. Um, it is p2sportscare.com slash musculoskeletal ultrasound. If you don't know how to spell musculoskeletal, I'd probably look that, um, just type it all in the Google and it will probably find this page.

So there's tons of images on there of the knee, the shoulder, um, some, some accuracy, uh, of the images themselves. Um, also there's some cases on there that my mom's cases on there that we spoke about last time with the shoulder. Uh, there's a killer, there's an Achilles tendonitis case. There's one on a plantar fascia and there's some on kind of that, um, the toothpaste appearance that Mike was speaking about on a knee. So if you're wondering about what these things look like, that's going to be one of the best references that I can give you. Um, I'm sure there's some other great references out there on the web, but, uh, I compiled this for a reason because I don't want you to have to go anywhere else.

So just read it, um, look at it. And, um, but I think it's about it. Subscribe to the podcast. Um, go on to iTunes, review me, please review this podcast. It helps me out a ton. My mission is to be able to get as much information to you guys as possible. And one of the best ways that you can help is actually promote this video to the top of iTunes or closer to the top. So people find it. It's really, really hard to get people to find your content and podcasts sometimes, even though I think I putting out the best information I possibly can, um, and writing some, I think really, really good articles.

Sometimes you just need a little help from the listeners. So review it, like it, share it, please. Um, if you want to get ahold of me, go on to p2sportscare.com and I will talk to you guys next time.