PM R 7 (2015) 149-150
www.pmrjournal.org
Commentary
Revolutionizing Sports Medicine With Ultrasound Christopher J. Visco, MD Finally, we have a road map to a more thoughtful and comprehensive approach in the education and clinical application of sports ultrasound. Dr Finnoff and his team have articulated the path with 2 new well-thought-out pieces. One is in this issue of PM&R: the American Medical Society for Sports Medicine (AMSSM) Position Statement on Interventional Musculoskeletal Ultrasound in Sports Medicine [1]. Seven authors of this position statement, including 3 physiatrists, comprise representative constituents from the field of sports medicine. The second piece is an online publication for PM&R, “AMSSM Recommended Sports Ultrasound Curriculum for Sports Medicine Fellowships” [2]. The position statement takes aim at giving a complete review and grading of current evidence for providing ultrasound-guided injections, whereas the curriculum provides training guidance for teaching sports ultrasound. These 2 important documents consolidate the best practices for teaching and optimizing the application of this technology. This is a true interdisciplinary effort, resulting in mandatory reading for anyone applying ultrasound in his or her practice. Most practitioners apply ultrasound guidance to their interventions because it is an extremely safe and effective method of providing an injection. It makes patients more comfortable, greatly reduces the complications of neurovascular injury, and is extremely accurate. When the first injection has been placed accurately, it can result in improved efficacy and save patients from a repeat injection. This position statement supports that methodology and also challenges us to think hard about how we look at efficacy and the future direction of ultrasound guidance. After all, as the authors suggest, the future of injections will likely be more than just needles and corticosteroids. Novel tools and methodologies for tissue manipulation and regeneration already exist and are becoming a growing share of the interventional part of a sports medicine practice. In learning ultrasound, one of the first milestones is to understand the concept of anisotropy, which is when something looks different from different angles or different perspectives. Indeed, ultrasound itself may be
the ultimate anisotrope. Its versatility and ease of integration and the ability to use it in many clinical applications will only expand as we have additional data and more evidence supporting its use in various diagnoses. However, there may be a darker sideda massive increase in ultrasound guidance for injections during the first decade of this millennium of more than 700%. From the perspective of some persons, including payors, the utilization and cost of these interventions can be alarming. Dr Finnoff and the authors of this position statement make an effort to address costs and have indeed found favorable evidence supporting ultrasound’s use. However, it is truly difficult to fully ascertain the cost in our current systems construct. It only becomes apparent when taking into larger consideration the benefits of ultrasound for providing patient comfort, avoiding complications, allowing for a more refined treatment approach, and avoiding repeat injections. Our authors are releasing this position statement with a curriculum for sports ultrasound. There is no doubt this is a mandate for training. Without thoughtful training, the application of any interventional treatment runs the risk of complication or failure. Tumors, vascular anomalies, anatomic variants, and a host of other soft tissue surprises may await us each time we turn on the ultrasound machine. In my practice, I have aborted more than one intervention upon finding a tumor during a pre-scan. It is doubtful I would have found it had I not been trained with a focus on understanding diagnostic ultrasound. The imaging modality for guidance is only as good as the clinician’s ability to optimize and manipulate the machine, recognize normal and abnormal patterns, and practice treatments under mentorship. I believe we would all rather be good at what we do than be lucky. During training, ultrasound allows an individualized correlation of the palpatory examination and surface anatomy to deep structures, providing a real-time learning experience that enhances our ability to develop an understanding of 3-dimensional construct and visuospatial ability. All of these skills are needed for
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.01.008
150
Revolutionizing Sports Medicine With Ultrasound
a sports medicine assessment. The ability to use a clinical diagnostic tool and a clinical application simultaneously adds power and strength to the plan. A refined differential in real time provides a similar power that a handheld Glucometer gives a primary care physician in treating diabetes. Perhaps ultrasound’s greatest asset is that it is specialty free. No one owns ultrasound. From cardiologists to obstetricians, interventional radiologists to vascular surgeons, and now in sports medicine, it is a uniting tool, bringing together the expertise of multiple specialties of sports medicine, including physiatry, primary care specialties, emergency medicine, pediatrics, and surgical specialties. We are all simultaneously advancing our diagnostic acumen. The application of ultrasound opens a world of enhanced understanding of pain and functional anatomy. For example, a seemingly simple diagnosis of what we have historically diagnosed as “trochanteric bursitis” likely represents several different potential diagnoses about the lateral hip, the least of which is bursitis, because it is rare to demonstrate any true bursitis on ultrasound imaging. Furthermore, the subsequent therapeutic procedure
Disclosure C.J.V. Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, NY 10032. Address correspondence to: C.J.V.; e-mail: [email protected] Disclosure: nothing to disclose
(ultrasound-guided injection or not) must also be reconsidered, and best practices will have to change. We have reached an inflection point. As our educational programs refine, our knowledge base has been increasing. We are now at the beginning of a phase of improved understanding and application of regenerative medicine and novel techniques, with the ability to apply these treatments with improved accuracy. Next steps include further exploration of outcomes, implications of expanded utilization, and investigation of cost savings. We will move into the future with technology, embracing or rejecting it. Embracing ultrasound would serve us well because it will further define the role of physiatry in sports medicine. In my opinion, this is progress. References 1. Finnoff JT, Hall MM, Adams E, et al. American Medical Society for Sports Medicine (AMSSM) position statement: Interventional musculoskeletal ultrasound in sports medicine. PM R 2015;7: 151-168. 2. Finnoff JT, Berkoff D, Brennan F, et al. American Medical Society for Sports Medicine (AMSSM) recommended sports ultrasound curriculum for sports medicine fellowships. PM R 2015;7:e1-e11.
www.pmrjournal.org
Commentary
Revolutionizing Sports Medicine With Ultrasound Christopher J. Visco, MD Finally, we have a road map to a more thoughtful and comprehensive approach in the education and clinical application of sports ultrasound. Dr Finnoff and his team have articulated the path with 2 new well-thought-out pieces. One is in this issue of PM&R: the American Medical Society for Sports Medicine (AMSSM) Position Statement on Interventional Musculoskeletal Ultrasound in Sports Medicine [1]. Seven authors of this position statement, including 3 physiatrists, comprise representative constituents from the field of sports medicine. The second piece is an online publication for PM&R, “AMSSM Recommended Sports Ultrasound Curriculum for Sports Medicine Fellowships” [2]. The position statement takes aim at giving a complete review and grading of current evidence for providing ultrasound-guided injections, whereas the curriculum provides training guidance for teaching sports ultrasound. These 2 important documents consolidate the best practices for teaching and optimizing the application of this technology. This is a true interdisciplinary effort, resulting in mandatory reading for anyone applying ultrasound in his or her practice. Most practitioners apply ultrasound guidance to their interventions because it is an extremely safe and effective method of providing an injection. It makes patients more comfortable, greatly reduces the complications of neurovascular injury, and is extremely accurate. When the first injection has been placed accurately, it can result in improved efficacy and save patients from a repeat injection. This position statement supports that methodology and also challenges us to think hard about how we look at efficacy and the future direction of ultrasound guidance. After all, as the authors suggest, the future of injections will likely be more than just needles and corticosteroids. Novel tools and methodologies for tissue manipulation and regeneration already exist and are becoming a growing share of the interventional part of a sports medicine practice. In learning ultrasound, one of the first milestones is to understand the concept of anisotropy, which is when something looks different from different angles or different perspectives. Indeed, ultrasound itself may be
the ultimate anisotrope. Its versatility and ease of integration and the ability to use it in many clinical applications will only expand as we have additional data and more evidence supporting its use in various diagnoses. However, there may be a darker sideda massive increase in ultrasound guidance for injections during the first decade of this millennium of more than 700%. From the perspective of some persons, including payors, the utilization and cost of these interventions can be alarming. Dr Finnoff and the authors of this position statement make an effort to address costs and have indeed found favorable evidence supporting ultrasound’s use. However, it is truly difficult to fully ascertain the cost in our current systems construct. It only becomes apparent when taking into larger consideration the benefits of ultrasound for providing patient comfort, avoiding complications, allowing for a more refined treatment approach, and avoiding repeat injections. Our authors are releasing this position statement with a curriculum for sports ultrasound. There is no doubt this is a mandate for training. Without thoughtful training, the application of any interventional treatment runs the risk of complication or failure. Tumors, vascular anomalies, anatomic variants, and a host of other soft tissue surprises may await us each time we turn on the ultrasound machine. In my practice, I have aborted more than one intervention upon finding a tumor during a pre-scan. It is doubtful I would have found it had I not been trained with a focus on understanding diagnostic ultrasound. The imaging modality for guidance is only as good as the clinician’s ability to optimize and manipulate the machine, recognize normal and abnormal patterns, and practice treatments under mentorship. I believe we would all rather be good at what we do than be lucky. During training, ultrasound allows an individualized correlation of the palpatory examination and surface anatomy to deep structures, providing a real-time learning experience that enhances our ability to develop an understanding of 3-dimensional construct and visuospatial ability. All of these skills are needed for
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.01.008
150
Revolutionizing Sports Medicine With Ultrasound
a sports medicine assessment. The ability to use a clinical diagnostic tool and a clinical application simultaneously adds power and strength to the plan. A refined differential in real time provides a similar power that a handheld Glucometer gives a primary care physician in treating diabetes. Perhaps ultrasound’s greatest asset is that it is specialty free. No one owns ultrasound. From cardiologists to obstetricians, interventional radiologists to vascular surgeons, and now in sports medicine, it is a uniting tool, bringing together the expertise of multiple specialties of sports medicine, including physiatry, primary care specialties, emergency medicine, pediatrics, and surgical specialties. We are all simultaneously advancing our diagnostic acumen. The application of ultrasound opens a world of enhanced understanding of pain and functional anatomy. For example, a seemingly simple diagnosis of what we have historically diagnosed as “trochanteric bursitis” likely represents several different potential diagnoses about the lateral hip, the least of which is bursitis, because it is rare to demonstrate any true bursitis on ultrasound imaging. Furthermore, the subsequent therapeutic procedure
Disclosure C.J.V. Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, NY 10032. Address correspondence to: C.J.V.; e-mail: [email protected] Disclosure: nothing to disclose
(ultrasound-guided injection or not) must also be reconsidered, and best practices will have to change. We have reached an inflection point. As our educational programs refine, our knowledge base has been increasing. We are now at the beginning of a phase of improved understanding and application of regenerative medicine and novel techniques, with the ability to apply these treatments with improved accuracy. Next steps include further exploration of outcomes, implications of expanded utilization, and investigation of cost savings. We will move into the future with technology, embracing or rejecting it. Embracing ultrasound would serve us well because it will further define the role of physiatry in sports medicine. In my opinion, this is progress. References 1. Finnoff JT, Hall MM, Adams E, et al. American Medical Society for Sports Medicine (AMSSM) position statement: Interventional musculoskeletal ultrasound in sports medicine. PM R 2015;7: 151-168. 2. Finnoff JT, Berkoff D, Brennan F, et al. American Medical Society for Sports Medicine (AMSSM) recommended sports ultrasound curriculum for sports medicine fellowships. PM R 2015;7:e1-e11.
