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MSK Ultrasound Imaging
for Prolozone Applications
Dr. John C. Hughes, D.O.
April 11-13
AAOT Conference
(Dallas, Texas)
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
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
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
MSK Ultrasound Imaging for Prolozone Applications
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
MSK Ultrasound Imaging for Prolozone Applications
US guided Visualization of MSK injury:
Trigger Point
 Trigger Point (initial)
 Big mangled mass of muscle tissue
MSK Ultrasound Imaging for Prolozone Applications
US guided Visualization of MSK injury:
Bunionette
 Visualize the loculated bunionette spur surrounded by
inflammation
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
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)
MSK Ultrasound Imaging for Prolozone Applications
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
MSK Ultrasound Imaging for Prolozone Applications
Ultrasound of MCL with spur
 See the ligament stretching over the spur
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
Ultrasound of L Hip with spurring
 See the white attenuated joint space with osteophyte build
up in the joint space
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
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
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
Injectional Treatment: Scar
Tissue/Bone Spurs
http://www.chiropractorspringfield.com/doctor/chiropractor/10
12L/springfield-chiropractor/nova-chiropractic-and-wellness-
center.htm
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
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
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.
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)
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
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
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
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
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
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
MSK Ultrasound Imaging for Prolozone Applications
MSK Ultrasound Imaging for Prolozone Applications
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
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)
US guided injection of an Intervertebral Disc
MRI-L4-5 disc herniation US L4-5 disc herniation
MSK Ultrasound Imaging for Prolozone Applications
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
MSK Ultrasound Imaging for Prolozone Applications

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MSK Ultrasound Imaging for Prolozone Applications

  • 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
  • 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
  • 8. US guided Visualization of MSK injury: Trigger Point  Trigger Point (initial)  Big mangled mass of muscle tissue
  • 10. US guided Visualization of MSK injury: Bunionette  Visualize the loculated bunionette spur surrounded by inflammation
  • 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)
  • 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
  • 18. Ultrasound of MCL with spur  See the ligament stretching over the spur
  • 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
  • 25. Injectional Treatment: Scar Tissue/Bone Spurs http://www.chiropractorspringfield.com/doctor/chiropractor/10 12L/springfield-chiropractor/nova-chiropractic-and-wellness- center.htm
  • 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
  • 27. 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
  • 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
  • 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
  • 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
  • 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
  • 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