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Ultrasound for orthopedic health

By Vanessa Grieve, Idaho State Journal
vgrieve@journalnet.com

DrJoseph_Ultrasound_patient-300x199POCATELLO — Using ultrasound image technology has taken some of the guesswork out of diagnosing musculoskeletal injuries.

“It’s one thing to touch somebody on the skin and say, ‘Does this hurt?’ That has some predictability,” said sports medicine physician Dr. Anthony Joseph. But when the source of the injury isn’t certain, ultrasound imaging can provide an instantaneous image.

“I’m seeing under the skin and seeing what the problem is and focus my treatment on that.” Joseph, who is a sports medicine physician at Pocatello Orthopaedics and Sports Medicine Institute, has been in sports medicine since the early 1990s. At that time, the field was taking off and acted as a bridge for surgical and nonsurgical treatment options.

“When I went through undergraduate training and then in medicine, I got very interested in exercise physiology — that adaptation that takes place with exercise (in the body) and how medicine is affected by exercise,” he said. “A lot of things were coming together in medicine at that time.”  

He was introduced to the idea of using ultrasound technology by a local rhumatologist who had attended a conference on ultrasound diagnostics and treatment, and noticed many attendees were sports medicine physicians.

Joseph began learning and using ultrasound technology in his practice in 2008. He believes the imaging helps him be more refined in his diagnosis, and thus more refined in treatments, which in turn can benefit patients. High-resolution ultrasound imaging is part of a wave of medical innovations in the sports medicine field. Ultrasound imaging is helping diagnose and treat a variety of musculoskeletal issues through real-time monitoring, assisting in locating and treating hernias and damaged tendons and offering less invasive carpal tunnel repair options.

Sports medicine is also at the forefront of regenerative medicine. One example is new uses for once discarded amniotic fluid to lubricate and assist cartilage growth. The Tucson, Arizona, native’s keen interest in sports medicine has opened a number of doors to bring innovative medical treatment to Pocatello.

Ultrasound imaging offers an alternative or additional means for diagnosing patient issues where X-rays, MRIs and exploratory surgeries may fall short. Trained physicians use ultrasound imaging for better accuracy and selectivity in treatment.

Real-time imaging

Joseph uses the SonoSite X-Porte machine, which is a portable and lightweight ultrasound machine. The machine is about the size of a laptop and can connect to a high-resolution screen. This high-resolution visual ultrasound technology is much like the machines used to view a growing child in a woman’s womb.

In one recent case, Joseph said he used the ultrasound imaging on a patient complaining of neck pain. He was able to identify a swollen tendon in the patient’s shoulder, and he administered an injection into the inflamed tissue in one visit. Following standard methods, he might have ordered an MRI on the neck. If the MRI didn’t show anything, then a CT scan might have been ordered. About $4,000 and four weeks later they may or may not have found the source of the problem.

DrJoseph_withpatient-300x199Tendons

In the past two years, Joseph has utilized a Tenex system to complete more than 200 tendon-related procedures, treating tennis elbow, plantar fasciitis and patellar tendonitis. The device is similar to what dental hygienists use to remove plaque and what eye doctors use to remove cataracts.

In surgery, when a tendon is cut, it can’t be reattached. The Tenex technology uses a different ultrasound frequency that removes old or bad tendons and stimulates tendon growth. These waves reflect or bounce off normal healthy tissue, leaving the remaining tendon to continue to function.

Carpal tunnel ‘surgery’ without the surgery

The MANOS system is used to treat and potentially heal carpal tunnel syndrome through carpal tunnel release.

On one of Dr. Joseph’s trips to gain experience and training at the Mayo Clinic, a hand surgeon from California approached a group of sports medicine physicians who knew ultrasound technology to try a new carpal tunnel “surgery” without the surgery, and were pleased with the results. They found most patients treated this way have a quicker recovery than from traditional surgery.

A big advantage of ultrasound imaging is it pinpoints the location of the tiny nerve that controls the thumb, so it isn’t inadvertently cut. That’s critical.

“If you cut it, they lose function of their thumb,” he said.

This is a huge shift to have sports medicine physicians perform a procedure traditionally done by hand surgeons.

Hernias

Dr. Joseph and general surgeon Dr. Drew McRoberts operate the Sports Hernia Clinic in Pocatello. This clinic treats hernias and groin injuries, and is one of a few in the world using ultrasound technology to treat hamstrings and abductors.

“We have a number of athletes that pull their groin,” Joseph said.

For example, they recently treated a rodeo bull rider. And they have a European basketball player on the schedule for treatment in the near future.

“We get a number of referrals.” Pocatello is somewhat of a “medical island,” Joseph said, bringing new patients and physicians here from other places who might not otherwise come to the region.

Joseph and PMC’s McRoberts have implemented a dynamic approach to diagnosing and treating sports hernias.

“It’s new because a lot of people — where if you pulled your groin and you were a professional soccer player — you were done,” he said. “We found that we could fix this problem, so it has sort of opened up a new procedure for how we treat athletic injuries.”

Hernias, for example, can be elusive. The best way to see a hernia is during physical activity, which causes the hernia to balloon. When at rest, a hernia will flatten against the abdomen wall. The dynamic process uses the combination of ultrasound image and patient activity to see the hernia.

“The same thing is done in surgery,” Joseph said. “They are awake for surgery, and after it is repaired, we make sure it doesn’t recur before we close them up.”

They are doing the final edits on a medical journal article on the topic, and how a dynamic approach has comparable success rates to those procedures done at top hernia clinics. The doctors hope to publish the article in coming months.

Regenerative medicine

Regenerative medicine is being explored to assist the body in the healing process, currently in the areas of arthritis, tendonitis and bones.

“A lot of people who are trained in ultrasound are sort of the pioneers in that sort of medicine,” Joseph said.

There are barriers in the body that prevent blood flow, Joseph explained. For example, studies have shown that by extracting bone marrow, refining it and injecting it into a bad disc, the bones getting this nutrient boost tend to heal or regrow structure.

The Pocatello Orthopaedics and Sports Institute is participating in the second phase of a clinical trial to use purified amniotic fluid to help arthritic patients. The first trial treated knee osteoarthritis. During this phase, Joseph said they are treating a number of arthritic joints.

The Pocatello clinic started its first four patients in mid-to late- June. They will be monitored for three to six months.

“We’re always looking for different treatments,” he said. “Not everybody wants to jump in and get a knee replacement.”

The amniotic fluid is electively donated from women having a cesarean section. The amniotic fluid has beneficial properties, being comprised of enzymes and premium stem cells. The fluid had previously generally been discarded. But Pennsylvania-based Liventa Bioscience found a way to purify and use the fluid, marketed as AmnioClear, and other components of birthing remains to harness its healing and regenerative properties.

“It has a natural anti-inflammatory … enzyme so the baby and the mother don’t react to each other,” he said. “Our stem cells become less active (as we age). Baby stem cells are ripe and ready to grow. Our hope is that it will implant in the knee and grow new cartilage.”

Practicing in Pocatello and developing new treatments is fun, said Joseph.

“It kind of gives you a new perspective,” he said. “It opens up a world instead of looking around and just relying on the area of the town you live in. It opens up a whole other world of people’s problems and opens up Pocatello to the world.”