Ultrasound Technology in Sports Medicine – PediaCast 477
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- Drs Drew Duerson and Jonathan Napolitano visit the studio as we explore the use of ultrasound technology in sports medicine. How do ultrasounds work, when are they needed and why so popular? Find out in this week’s episode!
- Ultrasound Technology
- Sports Medicine
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 477 for November 4th, 2020. We're calling this one "Ultrasound Technology in Sports Medicine". I want to welcome all of you to the program.
It is the day after election day here in the United States of America. And I guess it shouldn't surprise any of us because it's 2020. And 2020 is a crazy year.
So we don't know the results yet, but I will say this. In the days moving forward, it's going to give us a lot of opportunity to talk to our kids about what's going on in the world and just having real conversations and learn as we go through this together.
It's going to be stressful but we can get through this. We're going through COVID. We've gone through racial unrest. And we can go through a contested election as well.
And we got to do it together as a family, as families, and as an American family. And my hope is that when all is said and done, regardless of who our next president is here in the United States, that we'll come together. That we'll come together and improve the lives of all Americans.
So hopefully, that is on the horizon. Speaking of hope, Halloween has passed and Christmas and the holiday season is a favorite time in our house. And I have to tell you and maybe give your family permission to do this, we're decorated for Christmas.
We put up the tree, we got the Christmas lights going. We just needed it. We needed some hope and cheer and so that's what we have done here in the Patrick household.
We usually do it a little early anyway. It used to be that right after Thanksgiving was over, we would get the Christmas stuff out. And it's been eking forward, so the last few years, really, I think it was before Thanksgiving.
And I used to criticize, back in my younger years, when the stores would have Christmas decorations right after Halloween, like, "No, it's too soon!" But no, this year, we need it. And so, the Christmas lights are a-blinkin' here in Hilliard, Ohio. Or Columbus, Hilliard's a suburb.
Okay, the Sports Medicine team returns to the studio today as we consider the many uses of ultrasound technology in student athletes. When you hear the word ultrasound, you may not immediately think of sports medicine, right? Most of us think about obstetrics and pregnancy and prenatal ultrasounds.
Ultrasound is also used in cardiology during an imaging procedure called an echocardiogram. It's used in emergency medicines, sometimes during trauma evaluations or to quickly characterize skin and soft tissue lesions. Ultrasounds are actually becoming a popular bedside tool in many specialties, including sports medicine where they can be used to diagnose injuries, evaluate healing, and provide visualization during certain procedures like the injection of anti-inflammatory medicine into knees and shoulders and other joint spaces.
But what exactly is an ultrasound? How does it work, when is it used? What advantages do ultrasounds have in the care of student athletes and what challenges do medical providers face when using them?
We'll answer these questions and more as we explore the use of ultrasound technology in sports medicine.
We have a couple of returning experts joining us this week. Dr. Drew Duerson and Dr. Jonathan Napolitano, both with Sports Medicine here at Nationwide Children's Hospital.
Before we get to them, I have a couple of housekeeping items for you. First, a quick reminder that you can find PediaCast wherever podcasts are found. We are in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show, so you don't miss an episode.
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So, let's take a quick break. We'll get our experts connected to the studio and then we will be back to explore the use of ultrasound technology in sports medicine. It's coming up right after this.
Dr. Mike Patrick: Dr. Jonathan Napolitano is a sports medicine physician at Nationwide Children's Hospital and assistant professor of Physical Medicine and Rehabilitation at the Ohio State University College of Medicine. Dr. Drew Duerson, also sports medicine physician at Nationwide Children's and assistant professor of Pediatrics at Ohio State.
They're here to talk about the use of ultrasound in sports medicine. So let's give a warm PediaCast welcome to our guests. Thank you both so much for stopping by today. Really appreciate you taking time out of your busy schedules.
So Dr. Duerson, let's start with you. What exactly is an ultrasound? I think it's one of those things that we all hear, ultrasound. And parents may think about it in terms of like a prenatal ultrasound. But what exactly is an ultrasound?
Dr. Drew Duerson: Yes, I would agree, most people come in to clinic familiar with the obstetrics part of ultrasound. But ultrasound is essentially an imaging tool used by a medical provider to help image structure in the body.
So for the OB, it is important to be able to look at the anatomy and look through issues with the baby. But for us, we're looking at musculoskeletal issues. And really, ultrasound utilizes the unique properties of sound waves and especially those sound waves that are outside the audible range.
So when you look at sound waves that are measured in hertz, which is the number of sound waves that happen in a second. And for ultrasound, that's technically a definition greater than 20,000 hertz. So a very fast sound wave that you really can't hear.
Then, with the technology that ultrasound machine uses, you can actually see the tissue interfaces as sound waves are sent in to the body and then sent back to the probe.
And by using some calculations, you can measure the time that it takes to do and then plot the distance on a screen. And that typically comes in the form of a black wider, a grey dot on the screen. And then, with multiple scan lines, we can get a full image and really again be able to see most all tissues in the body.
Dr. Mike Patrick: Yeah, very interesting. So there's no radiation exposure at all like you would have with an X-ray. It's just sound waves and then a computer analyzing. It sends out the sound wave, it bounces off, it comes back and a computer analyzes that and gives you a gray scale image on the screen, right?
Dr. Drew Duerson: Correct, yeah. That's one of the big advantages of ultrasound which I know we'll talk about later.
Dr. Mike Patrick: And then we hear the terms diagnostic and interventional. So you can have diagnostic ultrasound and an interventional ultrasound. What is the difference between those two things?
Dr. Jonathan Napolitano: So the main difference here, the most common one, when we think about ultrasound, we think about it as a diagnostic tool. Dr. Duerson gave the example of the obstetrics or the prenatal ultrasound. Ultrasound imaging is also used for evaluation of abdominal structures, cardiac properties as well because you can see motion in real time in an ultrasound.
So diagnostic gives you a picture and you're using it to learn more information about anatomy and illness or damage or pathology, as well call it. And so that helps us make decisions about what may be going on, what may be causing pain, what may be contributing to symptoms. Whereas interventional ultrasound, you can use those same properties of ultrasound to kind of guide what you may need to do to treat a condition.
So in that regard, providers like Dr. Duerson and myself will use the ultrasound tool to direct an injection or a treatment traditionally in sports medicine prior to the utilization of this modality. We would just use our palpation or feeling along the skin to identify landmarks as to where we may need to give them injection into a joint or a tendon or a bursar or something like that.
Whereas with ultrasound, we can see those structures perfectly and know exactly where to direct our needle or our medications to. And then, also, ensure that it's going to the right spot that gives us the confirmation of where you are, but also the confirmation of avoiding other structures on your way to your destination, for lack of better phrase. So avoiding passing through blood vessels, nerves, other things that may become irritated by poking them with a needle or a shot.
Dr. Mike Patrick: Yeah, absolutely. So diagnostic, you're getting an image in order to make diagnosis. Interventional, you're getting an image to help you with a procedure. When you Google sports medicine and ultrasound, one of the things that pops up pretty high on the list is a therapeutic ultrasound. So using ultrasound to treat injuries, is that really a thing?
Dr. Drew Duerson: Yes, so I think for us, we consider ultrasound as a therapeutic tool to again guide our percutaneous procedures. But like you said, sometimes, it will be used as an actual treatment. And that's a different type of ultrasound than what we're doing in our clinic, usually a lower frequency ultrasound that is a modality mostly used by physical therapists.
And speaking with some of our physical therapists and just knowing from our interactions with them and shared patients, we know that it's not a commonly used tool in pediatric physical therapy. It's going to be a more widely used tool for treatment of adult muscular skeletal injuries. And a lot of the treatments are still lacking good evidence-based medicine to support those.
But essentially, what it is, is a more of a continuous wave of ultrasound instead of a pulse wave, where we use that to heat or increase the tissue extensibility and maybe provide some pain relief. And with that, you can see injuries such as tendonitis or muscle strains be treated with ultrasound.
One of the unique things about pediatrics is the presence of growth plates, obviously. And one of the things that our physical therapists here at Children's will do is, obviously, try to avoid those growth plates and if they do use ultrasound to treat.
And then, there is some different non-heat related types of ultrasound that you can do to treat more bony injuries. And there's some I think growing evidence that that might be a reasonable approach for things like stress fractures.
And then, if you go way outside of our field and look at things like lithotripsy and other forms of ultrasound to say treat kidney stones, there's a lot of different uses for it. But again, going back to what we see mostly, it's probably not a very commonly used tool.
Dr. Mike Patrick: Very interesting. Dr. Napolitano, what are some of the most commonly used reasons that you would go right to ultrasound? So you talked about using it to diagnose certain things and then interventionally. What are some specific injuries or interventions when you would absolutely to go that sort of first?
Dr. Jonathan Napolitano: That's a great question. I feel like that list is forever growing as we gain more knowledge and experience in using this tool. There are certain things that we use various imaging modalities for. So for example, we typically start with an X-ray to evaluate a fracture. However subtle and small, fractures or even early stress fractures that may not have changes on X-rays can be visualized on ultrasound.
So that's one of the things we look for, is bony injuries themselves. Otherwise, the other most commonly used imaging modality in sports medicine is the MRI machine. MRI work with magnets to recreate images of the anatomy within the body. And that remains are go-to tools for deep structures with inside of joints.
However, superficial structures are really often best viewed with tool like ultrasound. So we can look for superficial muscle or tendon injury, a tear, or a strain. We can also look at ligaments that as far as they're stretched or sprained.
It becomes a very helpful modality because it is real time and available in the clinic, so that we can make an immediate assessment and diagnosis of something rather than scheduling a test into the future.
The other advantage of it is because it is real-time and provided by your sports medicine doctor themselves, as we go through different diagnostic testing and exam skills with the ultrasound in combination. So therefore, we're able to stretch and move a joint or pull on a tendon or stress a ligament to see if that actually moves.
For example, if you have a injury to one ligament on the inside of your elbow, when you're laying still on an MRI machine, you may not be able to see how that ligament may stretch or open up.
Where in the ultrasound, I can move your arm in a certain direction to reveal that not only is it injured but it's unstable. And that can be more helpful oftentimes than other modalities that we don't have that movement component assessed with.
Dr. Mike Patrick: Dr. Duerson, how widespread is ultrasound availability in sports medicine? Is this something that most sports medicine folks have at their hands? Or is this more specialized that some folks will have it and others won't?
Dr. Drew Duerson: So I think what we're talking about today is point-of-care ultrasound. I would say it is becoming more and more available. Not every sports medicine physician is going to use this tool but I would argue that more and more are. And then, eventually here in the near future, I would say this is a tool that most all of us will be using once we continue to train our fellows.
But this isn't just sports medicine, too. This includes a long list of other medical providers that use this tool including emergency medicine, rheumatology, physical medicine, critical care. And I think you're going to see this become a tool that's widely available and widely used.
And I think some could argue that this tool is kind of like a stethoscope for us, if you would compare us to a cardiologist. So I think it really is a tool that is becoming more and more available.
And I think in pediatrics, we're catching up and we'll eventually get to where our kind of adult sports medicine colleagues are. But yeah, I think this is a very available tool for a lot of us and I think it's an important tool that I think we all should probably know how to use.
Dr. Mike Patrick: Yeah, absolutely. So when you were training, was this a big thing in your training program, to learn how to interpret ultrasound. And I'm sure that it's becoming big now, but a few years ago, was it big then, too?
Dr. Drew Duerson: Yes. So again, I think for our adult sports medicine colleagues, it's been part of our practices for decades. In pediatrics sports medicine, we're starting to catch up.
For me, personally, I was trained in my fellowship. And it was after my training that it became a ACGME requirement for all fellows. So now, year to year, all our fellows that will come out of our fellowships, whether that's pediatric or adult, will be trained to use this tool.
And I think it's a good thing. And I think it's something that is best taught in a fellowship that can be taught in other ways, too. And it's one of those things that you learn as you use it. And it's kind of a lifelong learning process.
Dr. Mike Patrick: Dr. Napolitano, you mentioned that these are pretty portable machines, so you can move it from one room to another in the exam room. And I've even seen like if you've searched online, ultrasound, sports medicine, and other thing that comes up is even a little gadget that will attach to a smart phone.
And so, as the technology gets smaller and less expensive and more portable, then the next question becomes is this something that could be used even on sports sidelines? Could it be when you're practicing sports medicine on the field, do you have access to ultrasound then? Is there a place for it there?
Dr. Jonathan Napolitano: Yeah, technology is a fun thing. The traditional ultrasound machines and tools are kind of thinking back to the original computers, like something that would be a big console that would sit up in the room. And when we refer for ultrasound to our radiology colleagues, those are some of the similar equipment is used in the same way, that it sits in the single room and the patient comes to the machine.
In our Sports Medicine Department here at Nationwide Children's, we just added to newer machines that are laptop-based units. So Dr. Duerson and myself are able to bring those to our various satellite offices. It sits on a cart and we wheel it into the different rooms with different patients. That way, I'm seeing somebody who I determined during their exam may need some further evaluation, that I can bring with me at that time.
So that's the initial portability where we're at now. You mentioned that hyperportability of it. So the even smaller unit, there's at least two, if not more, really small units where actually the technology is all loaded within the probe itself, so the part of the equipment that goes directly on to a patient.
And that can hook into a tablet or a phone, as you mentioned. These are originally developed and accessible in underserved areas or international mission trips and other areas where the larger hospital resources aren't available. But, you're right, we are seeing that in the sidelines as well.
So we have one of those units as well. We use it primarily as a training tool within our fellows, so that our fellows have that flexibility to take the unit home and train on it. And bring it with them to the sideline.
So does that future hold that where that's on the sideline in one of those medical tents right there? I think certainly can be.
The biggest challenge that we have with ultrasound is patient positioning, if we need to move someone in the unique position and how they are. That's not going to be sitting on the 50-yard line in the middle of the field that you bring up your machine. But I think certainly, in a controlled environment, simulated in the sideline, I think there's certainly is or a developing a role for this in that environment, too.
Dr. Mike Patrick: Yeah, very interesting. It's one of those things where as technology evolves, you wonder five, ten years from now, what will these machines look like and how will we be using them in the future. The possibilities are endless.
We've talked about evaluating injuries and interventions. What about conditioning before an athletic season? Is there a role for ultrasound in that situation?
Dr. Drew Duerson: Yeah, I think at this point, most of the use of the ultrasound best come after an injury to, again, diagnose and help guide the rehabilitation process. We've talked a little bit about how we can use ultrasound to actually treat injuries.
As far as preventative uses of ultrasound, I think that's going to be limited. But there are some technologies that are coming out to, I think, be able to look at things like tendons to be able to maybe predict injury. And that would be something that could eventually lead to injury prevention programs.
I specifically think of the technology called elastography, where it can look at the softness or hardness of specifically a tendon for us. And the softer the tendon, the more likely the tendon might be prone for injury.
So I could see it as a tool in the future. As of now, I don't have a big use for that pre-injury. But like you said, the opportunities I think to expand this tool are somewhat endless. And I could see that as a possibility in the future.
Dr. Mike Patrick: In terms of rehabilitation of previous injuries, not only can you use it then to diagnose but you could also, during the healing process, be able to judge that healing without exposing someone to radiation over and over again, right?
Dr. Drew Duerson: Right. And it's going to be a great way to help guide that rehabilitation. Instead of having to repeat X-rays or CT scans, you can follow these patients in the clinic using our point-of-care ultrasound.
And again, I think of soft tissues mostly, but today even, I saw an injury for a hamstring. And that will be something I can follow clinically and be able to use my ultrasound and compare images from prior exam to help assess healing and help ultimately guide the return to play. And then help determine when the athlete is ready to go.
Dr. Mike Patrick: Dr. Napolitano, when we think about ultrasounds compared to X-rays, CAT scans, MRIs , the pictures are sort of grainer, not quite as high-definition as you can get, especially when we're talking about CT scans and MRIs. Do you still get the same information? I mean, is it really as helpful as those other things?
Dr. Jonathan Napolitano: Good question. So I give you kind of a preview of this earlier in one of other questions, but even as Dr. Duerson was mentioning the training. We talked about training and interpretation of imaging, but it's also training and performing it. How do you maximize that image to give you the best picture that you can see?
You can go and get an X-ray at most places and the technology doesn't necessarily change. The technician format and positioning doesn't really change. But that's not the case with ultrasound. It's how you do the exam, the machine that you're doing the exam with and how that image is really maximized to look at.
We've talked about it doesn't have radiation associated with it. But it's also as I've described earlier, it's really best seen with those more superficial structures, in my own experience. So looking at the more shallow structures, which actually view pretty much completely clear and even better than a lot of our other modalities.
The other advantage is we're going kind of around. And we can change that image to see around the corner, for example, on an X-ray that you may not have that three-dimensional view on.
Dr. Mike Patrick: So it's one data point. And even though it may, in some cases, not be as clear of a picture, you're using that along with your physical exam. And if there's any question, you could go to move on other imaging modalities, right?
Dr. Jonathan Napolitano: Absolutely. That frequently is something that we encounter. The barriers of this test, we use it as a starting point. We may even use it to rule out one thing to determine how to best image something better.
So as we talk about the penetration, we don't see inside of a joint. So if I can see on the outside, the front of your knee, tendon and everything looks good, that leaves me with the bigger question mark of what's going on inside of the knee. And that's when we would refer for in MRI to look closer there.
Dr. Mike Patrick: Dr. Duerson, what other advantages does ultrasound have over plain X-rays, CT scans and MRI?
Dr. Drew Duerson: We've touched on a lot of these already, but portability, point-of-care use, little to no bioeffects, no ionizing radiation like in X-ray or CT scan, the ability to be able to follow patients closely with repeat scans in our clinic settings.
I think another big advantage is the relatively cheaper cost, compared to more expensive test like MRI.
And I think the ability to get information to the patient right away. Again, if you see someone and you feel like you need a more advanced image like an MRI, a lot of times that takes time to schedule and to actually get the images done and interpret it. And sometimes, that's weeks. With an ultrasound, you can do it right away on that first visit a lot of times.
Another good thing is the patient is able to watch. And they can see the screen just like you and you can talk through the exam and really interpret those results in real time, which I think is a neat thing for the patient and provides a different experience for them in clinic.
I guess another big one is the dynamic part like Jon's already talked about, but most all other imaging modalities are static. And with ultrasound, we can actually move things and put stress on things and see what's happening underneath the surface while it's moving.
Those are just a few of, I think, the advantages and how do we use some of the image quality especially for superficial structures near the surface of the skin, the resolution is sometimes even better than what you would get with an expensive MRI.
Dr. Mike Patrick: And for folks who would like to share this information outside of the podcast, I know Dr. Duerson, you had written a blog post, Diagnostic Ultrasound: Evaluating Athletes at Faster Pace. And I'll put a link to that blog post in the show notes over at pediacast.org for this episode, 477, so folks can find it easily.
Dr. Napolitano, what drawbacks or challenges are associated with ultrasound? It's not perfect, right?
Dr. Jonathan Napolitano: Certainly, everything comes with upsides and downsides. When I think the biggest downsides that we encounter right now are availability and then the experience. It's really kind of what we look at.
We've talked about how this is becoming more and more available in clinics, really, across the country and across the city. But it's still not all providers who are able to offer this service. As we continue to train more doctors, we learn more about this modality.
But then, the other part of that is the experience in doing so. Unlike a CT scan or an X-ray that you can take with you and be portable and share to get a second or a third opinion, the ultrasound I feel is best interpreted by the provider performing it and using that to shape their clinical decision-making real time.
These images are stored and portable in the same way. However, the interpretation is not as simple as it would be in interpreting an MRI or a CT scan, when we're looking at kind of complex anatomy or dynamic changes or positions that's unique.
I think the downside is what can and can't you see as well. We talked a little bit about being able to get visualization into the joint. So you got to be careful not to make assumptions on the limited visualizations that you may have.
It's possible to interpret something from the periphery of the joint, for example, a meniscus. But without a full visualization, you may be pretty cautious about making that assessment and assumption.
I think the advantage of guiding our procedures is something we didn't speak a lot on today. We highlighted it earlier, but I think the ability to see where you're going is a huge advantage to put the medication in the right spot.
But the downside there is there are some things that aren't visualized well. For example, injections of our spine are still most typically performed under fluoroscopy or an X-ray guidance because you have full assessment. I think that can continue to change and we can have more roles for this.
But what images are guided by ultrasound or what procedures are guided by ultrasound is a limitation until we gain that more exposure and experience as well.
Dr. Mike Patrick: Yeah, very interesting. And again, as I've said, if we've had the same conversation five, ten years from now, maybe a little more evolved than where we are today. So it'll be more exciting to see where this technology goes in all medicine, but in particular, sports medicine.
Dr. Duerson, remind us again about the Sports Medicine Program here at Nationwide Children's. It's really quite a program.
Dr. Drew Duerson: Yeah, so we're a large team and we're made up of nine physicians, so me and John and seven of our close colleagues. It's a bigger group than that but we have a much larger number of athletic trainers that work with us in clinic but also go and take care of our athletes at our surrounding high schools. And then, we have a lot of people behind the scenes, clinic assistants and other administrative folks that really play a big role in our team.
We specialize, obviously, in the care of the young athlete but we see a variety of patients. And we have clinics that are spread out across Columbus. As of now, I think we have eight clinics. And we are open five days a week and really have the same-day policy. So we can see an injured athlete that same day if needed.
So we are available and we're really there to try to diagnose the problem, but then try to come up with an effective treatment for that injury. So we can quickly get those athletes back to their sport, but also get them back safely.
Dr. Mike Patrick: And then, you have all the resources of Nationwide Children's. So physical therapy nutrition, psychology, really, anything that an athlete would need, you are ready for him.
Dr. Drew Duerson: Correct, yes.
Dr. Mike Patrick: All right, well, we really appreciate both of you stopping by today. And we'll have some links in the show notes for everybody. The Sports Medicine Program here at Nationwide Children's Hospital, we'll put a link to that and also that blog post that I have mentioned about diagnostic ultrasounds.
So Dr. Drew Duerson and Dr. Jonathan Napolitano, thank you both so much for stopping by today .
Dr. Jonathan Napolitano: Thanks, Mike.
Dr. Drew Duerson: Thank you. We appreciate it.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Drew Duerson and Dr. Jonathan Napolitano, both with Sports Medicine here at Nationwide Children's Hospital.
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