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. 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 6. US guided Visualization of MSK injury: Trigger Point  Trigger Point (initial)  Big mangled mass of muscle tissue 7. US guided Visualization of MSK injury: Bunionette  Visualize the loculated bunionette spur surrounded by inflammation 8. 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) 9. 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 10. Ultrasound of MCL with spur  See the ligament stretching over the spur 11. Ultrasound of L Hip with spurring  See the white attenuated joint space with osteophyte build up in the joint space 12. 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 13. 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 14. 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 15. Injectional Treatment: Scar Tissue/Bone Spurs http://www.chiropractorspringfield.com/doctor/chiropractor/10 12L/springfield-chiropractor/nova-chiropractic-and-wellness- center.htm 16. 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 17. 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 18. 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. 19. 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) 20. 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 21. 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 22. 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 23. 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 24. 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 25. 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) 26. US guided injection of an Intervertebral Disc MRI-L4-5 disc herniation US L4-5 disc herniation 27. 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