MSK Ultrasound Imaging for Prolozone Applications

Dr. John C. Hughes, D.O.

April 11-13AAOT Conference

(Dallas, Texas)

MSK Ultrasound Visualization and Prolozone Applications

MSK Ultrasound Visualization Tendonitis, Ligament Laxity, Bone Spurs, Trigger

Points Cellular Anatomy for Bone Spur and Fibrosis Injectional Treatment of Bone Spur and

Tendon/Ligament Fibrosis with Ultrasound Guidance Ultrasound Imaging and Guided Injection of

Intevertebral Discs

US guided Visualization of MSK injury Creating a proper neuromuscular ultrasound image

takes years of training Visualization and understanding these images also

requires extensive work Download to a pdf can compromise some image

quality Injection of a substance such as a liquid or gas into

the view significantly It is all still better than going at it blindly

Ultrasound Benefits for MSK Injury Noninvasive; Real Time Easy to Use; Easy to Transport No DNA damage, No cutaneous burns Accurate placement of needle guided injections Able to see immediate results Cost-effective Done at major universities such as Johns Hopkins as an

initial diagnosis instead of MRI

US guided Visualization of MSK injury: R Shoulder

Notice the supraspinatus tendon The tendon widens from 0.75mm to 2.03 mm The area of widening is the area of laxity The US guided the prolotherapy injection with

precision

US guided Visualization of MSK injury: Trigger Point

Trigger Point (initial) Big mangled mass of muscle tissue

US guided Visualization of MSK injury: Bunionette

Visualize the loculated bunionette spur surrounded by inflammation

Ultrasound of Metatarsalgia with Metatarsal Head Spurring

Before injection into the bottom of the foot, a popliteal block was performed (1st image)

See the 3rd and 4th metatarsal heads with white attenuation (2nd, 3rd images)

Ultrasound of R Lateral Epicondyle See the tendon stretching over an spur or simply fibrosis Note the trigger point and widening just before the

attachment to the bone

Ultrasound of MCL with spur See the ligament stretching over the spur

Ultrasound of L Hip with spurring See the white attenuated joint space with osteophyte build

up in the joint space

Injectional Treatment: Scar Tissue/Bone Spurs

Scar Tissue (aka Fibrosis, Tendonosis, etc.): Fibrosis is the formation of scar tissue due to injury or

long-term inflammation. Fibrosis tissues form a web around the injured area in an attempt to support the muscle while it heals itself. (http://www.wisegeek.com/what-causes-muscle-scar-

tissue.htm)

http://www.parkwayphysiotherapy.ca/article.php?aid=245

Normal Tendon with distinct elongated, parallel fibers

Scar tissue (fibrosis) early: disorganized collagen, fibroblasts infiltrate: loose and pale

appearance

Histology of Scar Tissue in TendonsAdapted from The Journal of Bone and Joint Surgery http://www.jbjs.org/article.aspx?Volume=81&page=259

Electron micrograph of normal area of tendon: collagen with small and large

bundles, parallel arrangement

Electron micrograph of short fragments of collagen in scar tissue that completely lack

organization

Histology of Scar Tissue in TendonsAdapted from The Journal of Bone and Joint Surgery http://www.jbjs.org/article.aspx?Volume=81&page=259

Injectional Treatment: Scar Tissue/Bone Spurs

http://www.chiropractorspringfield.com/doctor/chiropractor/1012L/springfield-chiropractor/nova-chiropractic-and-wellness-

center.htm

Injectional Treatment: Scar Tissue/Bone Spurs

Bone Spurs (aka Osteophytes or Enthesophytes): Definition: Bone spurs, or osteophytes, are bony

projections that form along joints, and are often seen in conditions such as arthritis. Bone spurs are largely responsible for limitations in joint motion and can cause pain. (http://orthopedics.about.com/cs/arthritis/g/bonespur.htm)

Enthesophytes are bony projections which form at the attachment of a tendon or ligament. http://en.wikipedia.org/wiki/Osteophyte

Injectional Treatment: Scar Tissue/Bone Spurs

http://physioindia.blogspot.com/2011/05/radiological-interpretation-of-joint.html

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/appendicular-arthritis

http://orthopedics.about.com/cs/arthritis/g/bonespur.htm

Injectional Treatment: Scar Tissue/Bone Spurs

Basics of US guided MSK injections Diagnosis often aided by Xray, MRI, CT Palpatory diagnosis critical for interpretation of US

image Patient history also critical: how the injury occur, prior

surgeries, etc.

Injectional Treatment: Scar Tissue/Bone Spurs

Injection Technique Key: To determine what is scar tissue/bone spur versus

healthy tissue Bone spurs: With a needle, spurs feel like barnacles

next to a ship hull (healthy bone) Scar Tissue (Fibrosis, Tendonosis): With a needle, scar

tissue feels like thick, crusty spider webs versus tender chicken legs (healthy tendons and ligaments)

Injectional Treatment: Scar Tissue/Bone Spurs

Injection Technique Technique: Involves gentle needling and sometimes

chiseling for bone spurs all guided by ultrasound Goal: to free up the ligament, joint, tendon that may

overlap the spur and bring healthy blood flow and O2 to the area to encourage fibroblastic resorpion and prevent reattachment

Following injection of scar tissue/bone spur, a second injection (of a proliferant) is used to tighten the ligament or tendon or joint

Injectional Treatment: Scar Tissue/Bone Spurs

Injection Components: Injection solution is often simply a local anesthetic

(lidocaine, procaine, marcaine) may also include other trace agents that improve fibroblastic resorpion (eg. Trace amounts of HCl, MgSO4, Phosphatidyl choline, Ascorbate) followed by O3 at 20ug/cc

Post Injection Visualization by Ultrasound: Should demonstrate a “clean”, integrous, smooth bone

surface with elongated, parallel fibers in adjacent ligaments or tendons

Injectional Treatment: Ligament/Scar Tissue/Bone Spurs

L MCL ligament laxity (aka chronic sprain) with bone spur Pre-Injection: Notice the spur in the central part of the

ligament at the joint space(initial); the spur is partly visible as a white and partially hidden (due to shadowing by the US)

Post-Injection: Notice the absence of the spur (now in pieces floating in the ECM) and the tightening of the MCL ligament

Injectional Treatment: Ligament/Scar Tissue/Bone Spurs

L LCL ligament laxity (aka chronic sprain) Pre-Injection: Notice the extreme edema and

inflammation and laxity in the ligament Post-Injection: Note the decrease in the fluid and the

tightening of the ligament

Injectional Treatment: Scar Tissue/Bone Spurs

L ACL laxity (aka acute sprain with partial tear), minimal scar tissue Pre-Injection: Note the thickness of ACL and its more

horizontal position Post-Injection: Note the tightening of the ACL and its

more vertical position

Injectional Treatment: Scar Tissue/Bone Spurs

Side effects of Injectional Treatment of Ligament/Scar Tissue and Bone Spurs Pain-often acute, during the injection, even with local anesthesia;

it is difficult to anesthetize the nerve fibers imbedded in the scar tissue and bone spur (Patients are given Valium or pain-killer)

Pain-after the injection--usually for 1-3 days; secondary to the proliferative activity

Inflammation-can last 1-2 months; often seen in patients with hyperactive immune systems, chronic inflammatory conditions (such as arthritis, food allergies, genetic disorder)

US guided injection of an Intervertebral Disc

MRI-L4-5 disc herniation US L4-5 disc herniation

Intervertebral O3 injections From June 2000 to December 2006, the Muto group

performed the oxygen/ozone procedure on 2900 patients with lumbar disc herniation.

79.7% of patients with a herniated disc received good to excellent improvement