If you are a triathlete, chances are you’ve experienced a bone, soft tissue, or joint injury. If the problem does not improve with time and rest, it may be time to be evaluated by a sports medicine clinician.

However, just like running sneakers, not all physicians are the same. It is important to find a provider with the right tools to diagnose and treat these injuries. That is where ultrasound comes in.

Even though ultrasound has been around since the 1950s when the American Institute for Ultrasound in Medicine was founded, diagnostic and therapeutic ultrasound for musculoskeletal injuries has boomed in the last decade. Despite these advances, not all practices have kept up with the change. You will know you are in the right place when the doctor has an ultrasound probe rather than a stethoscope around his or her neck. 

Ultrasound, also known as sonography, is an imaging modality that converts an electrical current into high-frequency sound waves to produce real-time and dynamic images of the body. The sound waves generate an image of underlying soft tissue structures and bony surfaces with exquisite detail. This portable and safe modality can be used for both diagnostic and therapeutic purposes in sports medicine.

The diagnostic potential includes the diagnosis of tendon tears, tendinopathy, muscle strains or contusions, nerve entrapments, ligament sprains, joint effusions, arthritis and evaluation to look for foreign bodies. When traditional methods of management like rest, ice and anti-inflammatories fail to provide adequate relief, ultrasound offers another alternative to help guide injections. The therapeutic potential of ultrasound includes needle tenotomies, aspiration, lavage, barbotage and biopsies.

The type of guided injection can range from corticosteroid, hyaluronic acid (otherwise known as “gel”), platelet rich plasma, prolotherapy, and in some cutting-edge instances, stem cells. There have been multiple studies demonstrating that ultrasound guided injections are more accurate than palpation or “blind” injections. For example, one study demonstrated the accuracy of shoulder injection (also known as a subacromial subdeltoid bursa) was 100 percent with ultrasound verses 72 percent without ultrasound (1).

Another study demonstrated the biceps tendon sheath injection accuracy to be 100 percent with ultrasound and 66.6 percent without ultrasound (2). Despite the literature demonstrating the range of accuracy with blind injections, research is lagging about whether this makes a difference in clinical efficacy. 

It is no wonder that ultrasound has fallen into favor in sports medicine practices across the nation due to its long list of benefits. Ultrasound can be used on patients that have contraindications to MRIs, such as metal implants, pacemakers, obesity, or claustrophobia. The real-time dynamic exam allows the patient and provider to localize the pain and demonstrate provocative testing with bilateral comparison (3).

Furthermore, ultrasound machines are portable and can be done in a timely and cost-effective manner. Studies have demonstrated that ultrasound guided injections are more cost-effective than palpation guided injections. One study focused on knee injections demonstrated 13 percent less cost per patient per year when using ultrasound guided injections verses palpation guided injections (4).

Lastly, there is no radiation with ultrasound and contrast dye is not needed for therapeutic interventions, something that is a barrier with other forms of imaging such as fluoroscopy.   

Although there are many advantages to using ultrasound, there are also challenges. Difficulties exist in learning a new technique, especially one as operator-dependent as sonography. Because ultrasound is user dependent, the accuracy and success of the procedure is dependent on the provider’s experience.

In addition, the cost and quality of ultrasound equipment can vary. The limitations of the machine can also include a limited field of view, and incomplete evaluation of bones and joints due to limited penetration, which is why ultrasound can serve as an important complementary or alternative technique to MRI.

In summary, musculoskeletal ultrasound is a relatively new advancement in sports medicine with pros and cons when compared to other imaging modalities. Ultimately, it is a tool to better equip providers to complement your care. While it is never ideal to be injured, I recommend that you visit a physician with expertise in musculoskeletal ultrasound to help diagnose and treat your sports injury.

Some athletes race for competition and others race for fun. Regardless of your driving force, sports medicine doctors skilled in the cutting-edge world of ultrasound will help you get to race day, but more importantly, the finish line. 

Erika Sadeghi, MD is board certified in family medicine and sports medicine. After completing fellowship at Brown University in Providence, RI, she started practicing primary care sports medicine at Elliot Health System in Manchester, NH, www.elliothospital.org/website/elliot-family-medicine-at-amherst-meet-our-providers.php. She covers local high school sports and enjoys competing in endurance events in her free time.

Medical Editor Andrew Getzin, MD is the head team physician for USA triathlon. He is a USA Triathlon level I coach, multiple-time USA Triathlon All-American and has competed in Kona. He is a fellow of the American College of Sports Medicine.  Dr. Getzin is the medical director of Cayuga Medical Center Sports Medicine and Athletic Performance in Ithaca, NY, www.cayugamed.org/sportsmedicine and the director of their shortness of breath in the athlete clinic, www.cayugamed.org/sob. 

References:

(1) Daley, Erika L., et al. "Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review." The American journal of sports medicine 39.3 (2011): 656-662.

(2) Hashiuchi, Tomohisa, et al. "Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial." Journal of shoulder and elbow surgery 20.7 (2011): 1069-1073.

(3) Levine, Benjamin D., Kambiz Motamedi, and Leanne L. Seeger. "Imaging of the shoulder: a comparison of MRI and ultrasound." Current sports medicine reports 11.5 (2012): 239-243.

(4) Sibbitt Jr, Wilmer L., et al. "A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee." JCR: Journal of Clinical Rheumatology 17.8 (2011): 409-415.