MSK Ultrasound Visualization for Tendonitis, Ligament Laxity, Bone Spurs, Trigger Points showing Cellular Anatomy for Bone Spur and Fibrosis. Injectional Treatment of Bone Spur and Tendon/Ligament Fibrosis with Ultrasound Guidance and Ultrasound Imaging and Guided Injection of Intevertebral Discs.
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MSK Ultrasound and Prolozone Injection Techniques
1. MSK Ultrasound Imaging
for Prolozone Applications
Dr. John C. Hughes, D.O.
April 11-13
AAOT Conference
(Dallas, Texas)
2. 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
3. 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
4. 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
5.
6. 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
7.
8. US guided Visualization of MSK injury:
Trigger Point
Trigger Point (initial)
Big mangled mass of muscle tissue
9.
10. US guided Visualization of MSK injury:
Bunionette
Visualize the loculated bunionette spur surrounded by
inflammation
11.
12.
13.
14. 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)
15.
16. 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
17.
18. Ultrasound of MCL with spur
See the ligament stretching over the spur
19.
20.
21. Ultrasound of L Hip with spurring
See the white attenuated joint space with osteophyte build
up in the joint space
22. 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
23. Normal Tendon with distinct elongated,
parallel fibers
Scar tissue (fibrosis) early: disorganized
collagen, fibroblasts infiltrate: loose and pale
appearance
Histology of Scar Tissue in Tendons
Adapted from The Journal of Bone and Joint Surgery
http://www.jbjs.org/article.aspx?Volume=81&page=259
24. 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 Tendons
Adapted from The Journal of Bone and Joint Surgery
http://www.jbjs.org/article.aspx?Volume=81&page=259
26. 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
28. 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.
29. 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)
30. 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
31. 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
32.
33.
34. 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
35.
36.
37. 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
38.
39.
40. 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
41. 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)
42. US guided injection of an Intervertebral Disc
MRI-L4-5 disc herniation US L4-5 disc herniation
43.
44. 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