Why Diagnostic Ultrasound Is Much More Than A 'Gimmick'

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By Howard Rosenbaum, DPM

Congratulations to John McCord, DPM. The reaction from several sources to his recent Forum column on “gimmicks” (“Thinking Twice About Revenue Enhancement Opportunities,” page 82 in the April issue) has generated enough emotion to compel my response. In general, Dr McCord’s view of the podiatry profession is discouraging to podiatrists who desire to enhance their knowledge and skills. Furthermore, his portrayal of diagnostic ultrasound is inaccurate and misleading.
Actually, I am disappointed that a Podiatry Today Editorial Advisory Board member believes that a podiatrist is not as capable as a radiologist/technologist to perform and interpret sonograms of the foot. Obviously, Dr. McCord does not acknowledge the ultrasound achievements by his fellow podiatrists nor does he express appreciation for the diagnostic advantages of real time imaging of soft tissue trauma, needle placement or localization of a non-metallic foreign body.
The podiatric medical colleges are incorporating diagnostic ultrasound into their curriculum. Many of the “leaders” of the profession are utilizing ultrasonography in their podiatry practices. A fellow podiatrist, Martin Wendelken, DPM, has invented the patented Wound-Mapping/ Ultrasound Assessment Method to evaluate wounds with a FDA-approved scanner and FDA-approved disposable accessories.
Compared to all other imaging modalities, diagnostic ultrasound is now second only to X-rays in frequency of use so it is imperative to learn about the technology. More important than the financial rewards is the opportunity to add another tool to help distinguish you as a better practitioner.
There are several reasons ultrasonography has grown in popularity. Ultrasound is capable of producing superior images of tendons in stress and during ROM. It allows patient-doctor interaction during the exam of the entire region of interest. Furthermore, ultrasound-guided needle injections are more effective than palpation-guided injections. Some insurance companies are requesting sonograms before precertifying the much more costly MRI exam.
Due diligence is necessary before any capital equipment purchase and Dr. McCord is correct in his “think twice” advice. However, regarding diagnostic ultrasound, it is not the usefulness of the modality, but rather the quality of the equipment and the education support services that require scrutiny.
Image clarity is the most important consideration, followed by the breadth of training and the continued availability of support. Certainly, there is a learning curve for any technology, but it does not have to be as steep as you may initially believe. Proper training should include the explanation of basic principles and physics, terminology, equipment components and accessories.
Hawking a product as a “cash cow” is inappropriate. Abuse of ultrasound should neither be promoted nor tolerated. Nevertheless, it is reasonable to recognize that ultrasound offers a marketing advantage for your practice.
Be aware of misinformation that salespeople have disseminated. Despite what you may have been told, not all diagnostic ultrasound scanners are approved for imaging ulcers. Except for one other company’s products, the only scanners that are FDA-approved for imaging wounds have been thoroughly tested and labeled Hudson Models. The label also indicates a wound mapping serial number for that specific scanner. The Sound-Seal protective film dressing and one particular gel are the only FDA-approved disposables for this examination.
Common podiatric applications of ultrasonography include plantar fasciitis, plantar fascia tears, tendonitis/tears/rupture (e.g. Achilles tendon), capsulitis, intermetatarsal neuroma, bursitis, ganglion cyst, fibroma or soft tissue mass, metatarsal stress fracture, non-metallic foreign body, PT tendon pathology and guiding needle for injection, aspiration or biopsy. Many podiatrists appreciate the ability to immediately distinguish between an “-itis” versus a tear, a cyst versus a solid mass and a soft tissue injury versus a bone injury. They also enjoy documenting the true depth of an ulcer and determining the relative position of a soft tissue mass. Clearly, treatment plans depend upon this information.

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