Diagnostic shoulder ultrasound: The results are in

Orthopedic Sports Medicine

Clinical Conundrum

Numerous studies and meta-analyses have demonstrated that ultrasound is clinically equivalent to non-contrast MRI for full thickness rotator cuff tear diagnosis.i,ii Clinicians can also use ultrasound to guide injections into the AC joint, the glenohumeral joint, or the biceps tendon sheath, with significant proven increases in injection accuracy.iv So why aren’t more orthopedic surgeons using this office based, less time-consuming, less expensive test?

In the past, the main barrier to the use of ultrasound in an orthopedic practice was the lack of training at the residency and fellowship level. However, now many medical students orthopedic residents and orthopedic fellows have exposure to ultrasound training.iii For orthopedic surgeons already in practice, there are numerous training courses some even led by fellow orthopedic surgeons.v


The Value Proposition for the Use of Ultrasound
When a patient comes in with a shoulder injury, clinicians take a history and physical exam and then decide if any imaging is necessary. Radiographs are typically the first choice to look at the bony anatomy. The most commonly involved soft tissue structures involved in shoulder dysfunction are the rotator cuff tendons and the long head of the biceps tendon. To learn the status of those tendons, ultrasound is the best initial imaging modality, as it can reveal a problem without the patient or the physician having to leave the exam room.


Traditionally, the modality selected for soft tissue diagnoses is MRI imaging. For diagnosis of intra-articular structures, the MR arthrogram or 3T MRI remains the gold standard. But for extra-articular structures, ultrasound should be the new first choice. MRI scans require greater administrative burden at a much greater expense—and they return results in a matter of days or weeks, not minutes. To schedule a MRI (even within the same facility) there is additional staff time required at the very least. If the MRI precertification process requires a peer review, then there is additional physician time required to discuss the case with the precertification company's representative to get approval. If the test is not done on the same day there is additional time required for the patient to go to the imaging facility and then to return to the doctor's office to review the study. If the patient is employed and has to take off from work, or has to find child care then there are even more logistical problems to solve. All of these known and unknown additional costs with getting a MRI scan are not an issue with a point of care imaging modality such as ultrasound.


Patient and Physician satisfaction
Better workflow and increased access to timely care is the basis for the value proposition for adding ultrasound to your orthopedic practice. But patient satisfaction and peace of mind is an equally important consideration. The MRI appointment may take an extra 15 minutes for the clinic staff, but what about the patient time coming to and from these extra appointments, with all of the arrangements and travel that those disruptions pose?


The foremost advantage of ultrasound for the patient may be its immediacy. If the clinical information is the same in either scenario, patients deeply appreciate replacing a three-visit series with a single visit. (With an MRI, the patient has to meet with the surgeon, then make an appointment for the MRI scan, then come back to the surgeon’s office to have the results interpreted.) Patients’ time is valuable, too, and the practice that honors that value stands to earn patient loyalty and respect.


By opting to use ultrasound as a first choice for shoulder imaging, I have the advantage of knowing the status of their rotator cuff, biceps tendon and other soft tissue anatomy at the time of their visit. I believe this gives me a chance to fine tune my recommendations and to better guide my patients' care.


The clinical side: case closed
The research consensus is that ultrasound is clinically equivalent to noncontrast MRI scans for rotator cuff tear diagnosis. If the main clinical concern is about the status of any of the extra-articular soft tissues, then ultrasound is an ideal imaging choice.


• Traditionally, clinicians have to decide when it is appropriate to get a MRI scan for patients with shoulder dysfunction. In the pro-athlete set, for instance, athletes don’t want to wait a week for a diagnosis ; and therefore they are scheduled for an MRI the next morning or even the evening of an injury. But the typical patient doesn’t have those types of resources. Their insurance company needs to approve a MRI scan; they’ve got scheduling or work or child care issues; so as a result clinicians often wait on getting a MRI scan, which means limiting a patient’s activities even before we have all of the imaging information. If a patient doesn't improve with time and medications or therapy, then clinicians decide to proceed with a MRI scan with all of the extra time, money and logistics required to make that happen. With a point of care modality like ultrasound, we have all the information at the same office visit and the cost is significantly less than the MRI scan, especially when all of the associated costs are considered. Clinicians no longer have to wait to make a full diagnosis with imaging just because of a large insurance deductible or a patient's busy work schedule or the need to get precertification and travel to another off site facility for the test.

• The dynamic nature of ultrasound is truly unique. There is no other imaging modality where we can see the soft tissues in real time. We really don’t have any other practical imaging modality where we can follow soft tissue healing. In orthopedic surgery we’re real comfortable taking X-rays to follow fracture healing and bone healing, we often do that every two weeks to make sure that a fracture is healing properly. We don’t have any such mechanism to follow tendon healing or muscle healing or soft tissue healing other than ultrasound. We can do serial MRI scans, but they likely wouldn’t be approved and it would be expensive for the patient and our healthcare system to do it that way. In addition, you still wouldn’t get the immediate answer in the office.

• Ultrasound’s ability to image soft tissue without image degradation from surgical implants in bone makes it the perfect modality for determining the condition tendons, such as the rotator cuff, after surgery. We can use ultrasound to document and follow tendon healing and to guide recovery protocols. Instead of guessing how a shoulder is healing, we can see how the tendons have healed. This helps with fine-tuning any post-surgical treatment recommendations.


Saving our Patients and our Healthcare System Money
In a review of the Medicare claims data conducted by KNG Health Consulting, LLC in November, 2012 is was found that ultrasound was an underutilized diagnostic tool in extremity imaging. The study reported that by increasing the use of ultrasound in the Medicare population by just 2 percent while decreasing the use of MRI by the same amount would have saved the Medicare program $34 million in spending in 2011 and patient co-pays would have also been positively impacted.


In my own practice, I also conducted a study in 2011 for my insurers using an annual volume of 100 patients that required shoulder injury. Using Medicare reimbursement amounts at the time, I found that for one surgeon, when integrating ultrasound into a practice for diagnosing just shoulder injuries, the savings to the healthcare system was approximately $27,500. There actual savings was significantly higher if we consider the patient's time off work and the other administrative costs of MRI scans.


Future Trends in ultrasound use
With much published global research demonstrating the benefits of musculoskeletal ultrasound as a diagnostic modality and as a tool to guide soft tissue procedures, United States clinicians should continue to increase their utilization of this modality.



i. http://www.ncbi.nlm.nih.gov/pubmed/19457838.
ii. Naqvi GA, Jadaan M, Harrington P. Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears. Int J Shoulder Surg 2009; 3:94-7. DOI: 10.4103/0973-6042.63218.
iii. https://www.aamc.org/newsroom/reporter/dec2012/323592/ultrasound.html
iv. Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review. Am J Sports Med. 2011 Mar;39(3):656-62.
v. http://www.orthosono.com

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