Report from ISS: Ultrasound-guided therapy from U.K. intrigues North American interventionalists

If you use ultrasound to guide steroid and anesthetic injections to treat ankle injuries in high-performance athletes, chances are you do not practice in the U.S.

This tongue-in-cheek challenge came from Dr. Thomas L. Pope Jr., a professor of radiology and orthopedics at the Medical University of South Carolina, after a presentation by a British researcher at the 2006 International Skeletal Society meeting in Vancouver.

"We don't do it at our institution, but I think it looks like a wonderful technique," he said.

Pope moderated a special focus session on sports medicine on Sept. 16.

The lecture by Dr. Philip Robinson, a consultant musculoskeletal radiologist at St. James University Hospital in Leeds, discussed common injuries of the ankle in athletes and their diagnostic appearance on x-ray, MRI, and ultrasound. It was Robinson's talk on a new application for a decade-old technique, however, that piqued everyone's attention.

Robinson and colleagues refined a procedure described in the clinical literature in the mid-1990s for the treatment of ankle impingement in ballet dancers. They now use ultrasound guidance to inject steroids and anesthetics in professional soccer players with posterior ankle impingement. Early reports show the minimally invasive treatment could help players recover mobility and return to training and active competition sooner than with conventional treatment (AJR 2006;187[1]:W53-58).

Several members of the audience rushed to the microphone at the end of the presentation with questions about the procedure. In addition to the technical aspects of guidance with ultrasound, questions revolved around when to use steroids with anesthetics and when to use anesthetics alone. Recent studies have linked the use of steroids with serious musculoskeletal disorders, including tendon rupture and rare neuropathies.

"It's really through experience. When I got to practice, I was very concerned about using steroids, and certainly around the main weight-bearing tendons," Robinson said.

Although the risk of causing damage is minimal, Leeds physicians rarely use steroids at all, Robinson said. Most interventionalists need to keep an eye instead on applying the treatment only after the right diagnosis, preferably with MRI, to keep the drugs from concealing more serious underlying conditions.

Several physician attendees showed interest in the technique's potential application for chronic tendinopathies in older patients. Robinson does not use the technique in this population. These patients generally have severely diseased tendons, which often split or are hanging on by a few threads. Giving them steroids could help their symptoms for a while but won't cure the underlying problem. He usually sends them to the orthopedic surgeon first.

"In the athletic population, you are dealing with people with much less damage that can hopefully be corrected. But for older patients in the stage described, you are probably just giving pain relief, which isn't going to go anywhere," Robinson said.

For more information from the Diagnostic Imaging archives:

Ultrasound-guided therapy puts pro-athletes back in play

MSK MR goes deep to catch hidden American football injuries

Brazilian radiologists take on football injuries