Dec. 5, 2002 Minimally-invasive ultrasound-guided needle therapy may help treat a wide variety of sports injuries, said Jefferson radiologist Researchers at Thomas Jefferson University Hospital have found that they can successfully treat chronic tendon problems such as "tennis elbow," "jumper's knee" and Achilles tendon, with the help of diagnostic ultrasound, as an alternative to surgery.
The ultrasound is used to better visualize abnormal tendons, identify areas of the tendon containing scar tissue and determine if the scar tissue is infiltrated with calcification, explained radiologist Lev N. Nazarian, M.D., professor of Radiology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, one of the investigators. Then needle therapy is applied to treat the problem.
The study is co-authored by John McShane, M.D., clinical assistant professor of Family Medicine, Jefferson, and sports medicine specialist at the Rothman Institute at Jefferson, who performs the procedure with Dr. Nazarian.
Many of the 400 patients who participated in the trial were able to resume athletic and other activities after 12 weeks, Dr. Nazarian said. "These are small abnormalities that a surgeon wouldn't touch, but can still cause considerable symptoms," the Jefferson radiologist said. "It's the kind of problem that falls between the cracks, so to speak, when it come to treatment. This procedure provides effective treatment to patients who may not have been able to get relief before, with minimal disruption to a patient's life."
The study's findings will be presented at the 88th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA) on Wed., Dec. 4, in Chicago. The study is also authored by Jefferson Family Medicine/Sports Medicine specialist Marc I. Harwood, M.D., of the Rothman Institute at Jefferson.
Athletes and non-athletes alike are prone to chronic tendon problems that can be caused by a wide variety of activities and can range in severity from mildly annoying to completely debilitating.
"Tendons are sinewy, somewhat elastic connective tissue that attach muscle to bones," Dr. Nazarian said. "They are vulnerable to wear and tear, particularly as we get older. Over time, tendons become weaker than normal and become subject to tiny breaks and tears in their fibers. When the tendon is overused, strained, or injured, some of the tendon tissue is replaced with scar tissue instead of normal elastic tendon tissue.
"Scar tissue is not elastic," he said. "It is thick and dense and it occurs right at the location where the tendon attaches to the bone. So when the muscle contracts, the normal tendon that is remaining pulls on this now dense, non-elastic tissue that then pulls against the bone. And that interface causes pain."
Treatments to date for chronic tendon problems have been imperfect in that they either do not fully remedy the problem-- or they entail major orthopaedic surgery and long recovery periods, said Dr. Nazarian.
The ultrasound-guided hypodermic needle procedure can be used to treat a variety of problems including:
* Easing inflammation by injecting corticosteroid at the site
* Smoothing out bone adjacent to the tendon
* Eliminate calcifications rubbing against the tendon
"Roughing up" tissue around small tears in the tendon to promote healing "Once we see the abnormality on the ultrasound, we can make a diagnosis right away and tell exactly what is wrong. Additionally, we can treat the problem immediately," said Dr. Nazarian said. Traditionally, physicians have used magnetic resonance imaging (MRI) to assess problem areas. But the researchers found that ultrasonography provides a more accurate look.
"In fact, in many ways, ultrasonography is preferable to MRI. It's quicker, less expensive, and better tolerated by patients," Dr. Nazarian said. "Furthermore, because the ultrasound examination is performed in so-called 'real-time,' any abnormalities can be directly correlated with the physical examination."
The study found that approximately 65 percent of the participants (151 males, 155 females, ages 13-82) reported improvement. They suffered from various tendon, muscle and ligament injuries, including tennis elbow, golfer's elbow, jumper's knee, hamstring and rotator cuff injuries and Achilles tendon problems. They had not responded to more conservative therapies such as medication, bracing, physical therapy or rest, and had been living with symptoms from three months to 15 years.
To treat the identified problem, local anesthesia is administered. Then, with the guidance of ultrasound, a needle is inserted down to the areas that contain scar tissue. The needle tip breaks up scar tissue and any calcifications.
Depending on the exact problem being treated, the procedure is often completed with an injection of cortisone-like medication into the area. "The procedure encourages blood vessels to enter the area and enables the body to dissolve the scar tissue and lay down new, healthier tissue. After the procedure, stretching and physical therapy encourage this tissue to become more elastic and lengthened, enabling the tendon to function more normally," the Jefferson radiologist said.
This minimally-invasive procedure takes between five and 15 minutes, and patients are awake and comfortable, watching the procedure. After the procedure, patients may be outfitted with a splint or brace.
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