Musculoskeletal ultrasound : for diagnostics and treatment guidance in the orthopaedic outpatient care

Abstract: Ultrasound (US) has shown to be of great value in diagnostics and treatment of injuries and chronic pain disorders of the musculoskeletal system. Today, it is considered to be a suitable method when investigating superficially located tendons. Another exciting field of application is the use of US for guidance of different invasive treatments. Traditionally, most diagnostic imaging have been performed at the radiologic departments but the interest for the technique at different care units, including orthopaedic out-patient clinics, has increased. The whole idea and design of this thesis is based on the use of US in an out-patient orthopaedic/sports medicine clinic, in contrary to the traditional use of US. The general purpose of this thesis was to highlight and evaluate the use and accuracy of US - for diagnostics, treatment guidance, and evaluation of treatment results regarding some of the most common musculoskeletal overuse injuries and pain disorders. All patients participating in the studies of this thesis were referred to the Capio Artro Clinic, Stockholm, Sweden with chronic disabling pain in either the Achilles tendon (AT), the patellar tendon (PT) or in the rotator cuff of the shoulder. In study I the main purpose was to assess the inter- and intra-observer reliability in measures of tendon thickness and in the use of a 4-graded evaluation score for US findings. Twenty-eight consecutive patients suffering from chronic painful Achilles- or patellar tendinosis were included. The reliability for measures of distance was found to be high. Inter-observer reliability concerning evaluation of neovascularization was moderate to strong, and poor to moderate concerning structural changes. Intra-observer reliability was moderate to strong for evaluations of both tendon structure and neovascularization. The aim of study II was to evaluate and compare the clinical results and the US and colour Doppler (CD) findings after treatment of patellar tendinopathy/ jumper’s knee, using US/CD guided sclerosing injections or US/CD guided arthroscopic shaving, respectively. Forty-three patients with a total of 57 treated tendons were included in this medium-term follow-up study. In the group treated with US/CD guided arthroscopic shaving the mean thickness of the proximal PT had decreased significantly from baseline to endpoint. Tendon improved significantly, and there was significantly less neovascularization at the short term follow-up compared to baseline, in both treatment groups. In study III we evaluated the accuracy of office-based US imaging of rotator cuff tears, performed by a biomedical technician, using arthroscopic surgery as reference method. A secondary aim was to evaluate the differences in the diagnostic value between US imaging in connection to the clinical examination, and the regular concept with MRI performed several weeks prior to the clinical examination. Eighty-two patients underwent all three examination modalities; MRI, US and arthroscopy. Regarding full-thickness tears, including all tendons of the cuff, US showed a sensitivity of 85%, a specificity of 91% and an accuracy of 90%. Based on evaluations of the supraspinatus tendon alone US showed a sensitivity of 100%, a specificity of 89% and an accuracy of 94%. The aim of study IV was to present the short term interim results (6 months) of a new ultrasound and colour Doppler-guided mini-invasive surgical treatment method on chronic painful midportion Achilles tendinopathy, in comparison with the results of eccentric calf muscle training (ECC) and sclerosing (Polidocanol) injections. Thirty-four patients with chronic painful AT (n=42 tendons) were enrolled in this randomized controlled study. All treatment methods led to clinical improvements. Patients treated with ECC reported less pain and were more satisfied with the treatment result at the follow-up 6 months after the start of the treatment when compared to the other two treatment methods. Conclusions: The modified, 4-graded, Öhberg score was found to be a useful and reliable instrument when evaluating status and progress of Achilles and patellar tendon tendinosis. Using the Öhberg score we could detect a remodelling and a sonographically more normal PT after successful treatment of jumper’s knee with US/CD guided arthroscopic shaving compared to US/CD guided sclerosing injections. Both treatment methods rendered good and equal clinical results at medium 4 years after treatment. However, US/CD guided arthroscopic shaving showed a significantly faster return to sport activity, and patient satisfaction could be noticed at an earlier point. Office-based US imaging of the shoulder, performed by a trained biomedical technician, showed a sufficient accuracy in detecting significant rotator cuff tears. When identifying those injuries the diagnostic value of US imaging performed in connection to the clinical examination was higher than the MRI performed several weeks prior to the examination. The US/CD guided mini-invasive surgical treatment, for midportion Achilles tendinosis showed a faster clinical improvement than sclerosing injections. In the short-term perspective the ECC seems to lead to the best result. However, the US/CD guided surgical treatment might be a more effective treatment for patients with difficulties in tolerating the uncompromising eccentric training program.

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