Sounding Off On Ultrasound

Allen Jacobs DPM FACFAS

The utilization of diagnostic ultrasound by podiatric physicians has increased substantially over recent years. Diagnostic ultrasound offers musculoskeletal diagnostic opportunities, particularly for soft tissue pathology, is superior to standard radiographs and, in some instances, is equal to or superior to magnetic resonance imaging (MRI). In addition, ultrasound guided interventions such as injections offer the potential of increased efficacy by virtue of increased accuracy of site directed therapies to sites of pathology.

However, the effectiveness of ultrasound is very much dependent on the use of proper technique and proper interpretation of the images obtained. The increased income derived from the office-based technology also makes diagnostic ultrasound and ultrasound guided therapies attractive.

However, the potential for misuse and abuse of this modality is reflected in recent insurance carrier denials of billings by podiatric physicians for the employment of this modality, or the requirement for “certification” in diagnostic ultrasound by those wishing to employ and charge for the use of this modality.

The following alleged malpractice case illustrates the problem at hand. It also, in my opinion, calls for our profession to establish podiatry profession guidelines for the use of ultrasound and for podiatric certification.

The Case: When A High School Athlete Has Continued STJ Pain Despite Multiple Ultrasound Guided Injections

A high-level competitive high school athlete presented to a podiatric physician with medial ankle pain and swelling. The chart contains no examination (range of motion, gait evaluation, stress testing, anything). In lieu of any examination, the patient received a diagnostic ultrasound. The diagnosis via ultrasound was an anterior talofibular ligament injury although the chart indicated a diagnosis of deltoid ligament injury. The physician made an ultrasound guided injection to "the medial ankle gutter," utilizing a steroid injection and local anesthesia.

The patient returned three months later with “subtalar joint pain." Once again, there was no documented examination of any type whatsoever. Instead, a diagnostic ultrasound examination demonstrated "bursitis of the subtalar joint." The patient underwent another ultrasound guided injection.

Two weeks later, the patient returned with continued subtalar joint pain. Once again, with no clinical examination performed, an ultrasound examination revealed "subtalar joint bursitis" and the patient had another "ultrasound guided injection."

One week later, the patient returned with continuing subtalar joint pain. Again, there was no examination of any type. An MRI demonstrated a complete rupture of the posterior tibial tendon with 2.5 cm of gapping, partial thickness rupture of the deltoid ligament, and high-grade injury to the anterior talo-fibular and calcaneal-fibular ligaments.

The patient sought the care of an orthopedic surgeon and underwent surgery for the tendon rupture and ligamentous disruption.

The Problem: Substituting Ultrasound For A Physical Exam

Obviously, there was significant pathology, which the examining "podiatric ultrasonographer" did not diagnose. Compounding the failure to diagnose the actual pathology was the fact that these injuries occurred in a competitive, scholarship seeking, high-level athlete.

Were the ultrasounds properly performed? Were the ultrasounds properly performed but not properly interpreted?

Why would a physician substitute diagnostic ultrasound for any type of physical examination?

The training of this physician will be called into question. Are several hours with an ultrasound salesperson sufficient to represent to the public competency in the use and interpretation of ultrasound?

Our profession needs to set its own standards for the utilization of modalities such as diagnostic ultrasound. We are the foot and ankle experts and authorities. Do we need ultrasound to inject plantar fasciitis, a ganglion or Achilles tendon? Do we need ultrasound to inject a neuroma? Where is the literature to support the proposition that ultrasound guided injections provide superior outcomes to non-ultrasound guided injections in order to justify the significant increase in healthcare cost? I hear a lot of rationalizations for this at meetings and a lot of talk of increased income for the office. But where's the beef?

Our profession needs to provide its own mechanism for certification in this modality and needs to determine when diagnostic ultrasound is indicated. Our profession needs to set standards for training and certification in foot and ankle diagnostic ultrasound and ultrasound guided therapeutic interventions. We must advance the science and at the same time protect against abuse and ineffective utilization of this modality.

Why not sound off about your ideas? Reflect on ultrasound a bit. Let’s hear from you.


If you need u-sound to inject any part of the foot, then you shouldn't be injecting the foot. It is very obvious when a physician injects the plantar fascia under ultrasound guidance, it is for the financial gains. If the same patient presents with an insurance that doesn't authorize u-sound guided injections, will they still Inject the PF?

I think diagnostic ultrasound for therapeutic injections is a joke! Any podiatric physician worth their salt should be able to provide very accurate therapeutic injections based on their knowledge of anatomy. There is likely some benefit in soft tissue lesion diagnosis if the ultrasound unit is of sufficient quality and the physician technician is of good competence.

Dr. Jacobs is absolutely correct. It is the responsibility of the APMA and ACFAS to help create standards for our profession. Whether you believe ultrasound is worthwhile or not, it is being used with greater frequency in many medical offices. As such, it can and will be prone to abuse. However, if protocols are established, we can help direct and formulate appropriate use..

It is standard practice to order X-rays, MRI , CAT , bone scan and make the diagnosis after a detailed history and physical examination. This isn't about the topic of ultrasound. This is about standards of practice and common sense. Bad title. It should be: When to order an ultrasound and/or MRI or any test for that matter.

I believe diagnostic ultrasound, when performed with competence and appropriate instrumentation, is a useful adjunct to history, thorough physical examination, and (usually) plain films.

In 6+ years of using US in the office, I have given 2 or 3 "guided" injections in fairly inaccessible mid-tarsal joint areas only. It may make neuroma injections more predictable with appropriate skills and learning curve, and supportive literature. I prefer to use ultrasound for diagnostic purposes, selectively, and perform injections in the traditional manner in which I was trained. Just my opinion.

I have utilized ultrasound for eight years in practice. I do a lot of them for diagnostic purposes and it is always with a thorough exam. This is exactly what I do with ordering x-rays, MRIs, etc.
It has proven to be huge benefit for patient care.

In regard to guided injections, I do not do a lot of them but I feel that there is a place for them. Many regional anesthesiologists use ultrasound guided nerve blocks and literature shows benefits including lower amounts needed and quicker response time. Rheumatologists will utilize ultrasound to monitor response to treatment. Radiologists such as Levin Nazarian at Thomas Jefferson prefer ultrasound over MRI for tendinosis. In fact, his 2006 study showed after review of over 3000 MRIs, 46% of the diagnosis could have been made with ultrasound alone without the need for MRI. He then figured out the cost savings to health care, which as you can imagine, is an impressive figure.

Dr. Jacobs is right in the need for certification. We need to embrace this modality and use it as it should be used. Those wanting to use it need to have more than weekend workshops to learn from. What we don't want is to attack the ultrasound itself and stop using it. This would be a disservice to podiatry.

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