Chronic Tendon Pain: Can The Ultrasound Have An Impact?

By Gina DiGironimo, Production Editor

Should DPMs give more consideration to using ultrasounds when treating tough Achilles tendon cases? Ultrasonography may help provide a more accurate diagnosis, improved treatment and shorter recovery time for patients with chronic tendon problems, according to the authors of a new study, which was recently presented at the 88th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA) in Chicago. During the study, conducted at the Thomas Jefferson University Hospital in Philadelphia, researchers performed an ultrasound on 400 patients, who had various tendon, ligament and muscle injuries, and ranged in age from 13 to 82. Using the ultrasound as a guide, the researchers used needle therapy after administering a local anesthetic to treat any problem areas. According to the study, the authors were able to achieve improvement in 65 percent of the patients and they were able to resume athletic and other activities after 12 weeks. While current treatment options for chronic tendon problems often require major orthopedic surgery and long recovery periods, Lev Nazarian, MD, a Professor of Radiology at Thomas Jefferson University and one of the study’s investigators, says ultrasound-guided needle therapy offers a minimally invasive option with less disruption to the patient’s life. Paul Quintavalle, DPM, concurs, noting that the ultrasound is “very good” for needle-guided injections whereas the MRI cannot be used for this purpose. In regard to the ultrasound’s diagnostic capabilities, the study researchers believe ultrasonography is preferable to traditional MRIs due to its “real-time” advantage, its cost-effectiveness and its higher tolerability among patients. Dr. Quintavalle and Richard Bouche, DPM, agree that the ultrasound is a more cost-effective modality. Dr. Quintavalle, the Residency Director at Virtua Health System in Camden, N.J., adds that the economical nature and immediacy of the ultrasound enables you to do “follow-up examinations to see if the treatment is working … this is where ultrasound will have a big impact.” He says the modality allows you to see the pathology and visualize the motions of joints and tendons. Whereas serial X-rays are the standard of care for determining the healing of fractures, Dr. Quintavalle believes ultrasound can eventually be used in a similar manner to monitor the healing progress of soft tissue injuries. However, while the study researchers found ultrasonography to provide a more accurate look, Drs. Bouche and Quintavalle still consider the MRI to be the current standard of care in treating tendon injuries. In his experience, Dr. Bouche has found the MRI to be “much more sensitive for more subtle Achilles tendinopathy such as paratenonitis and tendinosis.” Dr. Bouche, a Past President of the American Academy of Podiatric Sports Medicine, adds that MRI resolution is “superior to that of conventional ultrasonography,” which he feels is very technician dependent. However, Dr. Bouche, a Diplomate of the American Board of Podiatric Surgery, says an ultrasound would be “fine” for gross tendinopathies, such as partial or total Achilles ruptures. He also notes that high resolution ultrasonograpy “could be superior or equal to MRI” for certain conditions such as Morton’s neuroma. Dr. Quintavalle feels the ultrasound will “become more standard in time” but holds fast to the MRI as the current standard of care. In his practice, he says he diagnoses general pain with an MRI and incorporates the ultrasound to look at specific tendons and ligaments. While the study’s researchers laude ultrasonography’s tolerability among patients, Drs. Quintavalle and Bouche differ slightly regarding its effect on patient compliance. Dr. Bouche says compliance is “not necessarily” enhanced with ultrasound. Dr. Quintavalle says using ultrasonography allows patients to see the progress of their injuries and believes it does enhance patient compliance. MRSA Deaths Are On The Rise In The U.K. Methicillin resistant Staph aureus (MRSA) is becoming an increasing problem and MRSA deaths are on the rise in the United Kingdom, according to a recent report in the British Medical Journal. Researchers determined the number of deaths in the U.K. in which MRSA was listed as a contributing factor increased from 7.5 percent to 25 percent between 1993 and 1998. During the same time period, the study revealed that death certificates in which Staph infection was listed as the underlying cause of death and MRSA was specifically mentioned increased from 8 percent to 44 percent. Are the statistical increases the result of better reporting? The study authors believe that is unlikely. According to a article on the study, “The greatest rise in MRSA occurred for deaths where invasive staphylococcal infection was given as the final underlying cause, so antimicrobial resistance probably influenced the success of medical management.” Andrew Boulton, MD, a Professor of Medicine at the University of Manchester in the United Kingdom, notes the infections reported in the study were mainly nosocomial, affecting previously very ill patients. He says the question of MRSA is “a very important one” and in a 1999 study, he found 40 percent of Staph isolates from diabetic foot ulcers were MRSA. The problem is getting worse, according to Dr. Boulton, who says he will soon publish a new study in Diabetic Medicine, which shows a rising prevalence of MRSA in Staph isolates and MRSA patients with slower ulcer healing. “Having said this, in the diabetic foot, MRSA is associated with prior antibiotic use. In most cases, this represents opportunistic colonization after antibiotic therapy rather than true infection by a virulent organism,” says Dr. Boulton, a Visiting Professor of Medicine at the University of Miami Medical School Division of Diabetes. Dr. Boulton urges practitioners to be “very cautious” in using antibiotics for diabetic foot ulcers and emphasizes that antibiotic use should be limited to clinically infected ulcers. He notes using linezolid is an effective oral option for MRSA infections. The study authors concur, noting that further improvements in monitoring and controlling nosocomial infections and mortality are essential for preventing MRSA-related fatalities. – Brian McCurdy Associate Editor Panel Revisits Controversial Footwear Study A leading practitioner recently revisited a controversial study at the Diabetic Foot Update conference in San Antonio, Texas. Study co-author Douglas Smith, MD, and a panel discussed a diabetic footwear study in which the authors concluded that evidence in their study did not support the use of therapeutic footwear. Some DPMs had previously questioned the study’s conclusions. The randomized study, presented last year in the Journal of the American Medical Association, followed 400 diabetes patients who had a history of foot ulcers. After two years, researchers found similar re-ulceration rates in the three study groups. There was a 15 percent re-ulceration rate in the first group of 121 patients who wore extra-depth therapeutic shoes and customized cork inserts. There was a 14 percent re-ulceration rate in the second group of 119 patients who wore therapeutic shoes and prefabricated, polyurethane inserts. Researchers saw a 17 percent re-ulceration rate among the control group of 160 patients who wore their own shoes. All participants wore specially designed slippers when not wearing their shoes and the study excluded the 5 percent of diabetic patients with severe foot deformities or other problems who might benefit from therapeutic footwear. Acknowledging the study had been “much talked about,” Dr. Smith said the study did not conclude that therapeutic shoes do not work but rather that the study could not prove the effectiveness of shoes. “Careful attention to foot care by physicians may be more important than therapeutic footwear,” noted Dr. Smith, an Associate Professor of Orthopedics and Sports Medicine at the University of Washington. “We do make a difference. What we all do is more important than shoes.” Andrew Boulton, MD, commended the group and its study but had a concern that he has found ulcer recurrence rates are 50 percent, higher than what was found in the study. A DPM in the audience applauded the effort but expressed concern about how the population was different than in his clinic. Dr. Smith said the study population was 75 percent Caucasian, based on the high Asian-American and low African-American population in Seattle, where the study was conducted. He said researchers spent $2 million over several years on the study and scanned 21,000 patient records to narrow them down to the 400 study subjects. The study found 577 non-ulcer lesions and ulcers in the 400 patients, and patients were in the study shoes for nine to 10 hours a day, according to Dr. Smith. In his experience, Alexander Reyzelman, DPM, says he has found that therapeutic shoes are effective in helping to reduce ulcerations in compliant patients who have the right indications. Specifically, Dr. Reyzelman notes that using therapeutic shoes allows you to use a total contact orthotic with various modifications that helps “decrease peak plantar pressures and shear stress on an area that is at risk for ulceration.” However, there is a large learning curve in prescribing orthopedic shoes, according to Dr. Reyzelman, the Chairman of the Department of Medicine at the California College of Podiatric Medicine. He says he has seen “many” cases in which patients developed new ulcerations as a result of incorrectly prescribed and dispensed therapeutic shoes. Dr. Smith also pointed out that “danger moments” can sidestep the effects of therapeutic shoes. He gave the example of a patient who always wore his therapeutic shoes but wore wingtips to a funeral, kept them on for 12 hours and developed an ulcer. “You can give everybody in the world therapeutic shoes and it doesn’t necessarily eliminate danger moments,” noted Dr. Smith. Dr. Reyzelman agrees that compliance is a “major problem.” In the majority of cases he has seen in which patients have returned with ulcerations despite using therapeutic shoes, Dr. Reyzelman usually finds out from the patient that he or she has worn a dress shoe or sandal one or two days prior to developing the ulcer. “We would like to believe there is a magic wand but the puzzle is much more complicated than that,” said Dr. Smith. – B.M. New Diabetes Bill Signed Into Law In mid-December, President Bush signed a bill into law that will provide $1.5 billion dollars in funding for diabetes research and programs over a five-year span. The new bill extends the Special Diabetes Program through 2008. Two components comprise the Special Diabetes Program: type 1 diabetes research at the National Institute of Health (NIH) and diabetes prevention and treatment programs for American Indians through the Indian Health Service (IHS). The program was originally slated to expire after fiscal year 2003. David G. Armstrong, DPM, applauds the bill, calling it “enormously encouraging.” He says it indicates the “importance that the government is putting on diabetes awareness and research.” Francine Kaufman, MD, President of the American Diabetes Association (ADA), commends the President’s effort, thanking the government administration for their leadership and “serious commitment” to the issue of diabetes. Over the years, advocacy groups such as the National Congress of American Indians and the Juvenile Diabetes Research Foundation in conjunction with the ADA have worked diligently to push for an extension and expansion of the Special Diabetes Program. Dr. Armstrong credits these groups for the progress they have made with the recent funding extension and for increasing awareness of the disease. He encourages more activism and advocacy in Washington, and encourages doctors and advocacy groups to continue their work in an effort to keep diabetes research in the spotlight. — G.D.

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