Chronic Tendon Pain: Can The Ultrasound Have An Impact?

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On the left, you can see a high resolution ultrasound image of a normal Achilles tendon.
On the right, the high resolution ultrasound image reveals a ruptured Achilles tendon that shows complete disruption of tendon fibers.
Here is an example of an MRSA infection with accompanying cellulitus. (Photo courtesy of Lawrence Karlock, DPM)
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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.

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