Sounding Off On Ultrasound

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.