MSK Masters Biocellular Blog: Optimal Response with Precise Placement
UC San Diego Hemophilia Center
Randy Moore, DC, RDMS, RMSK and Dr. Annette von Drygalski are working together to develop and validate the JADE Protocol, the Joint Activity and Damage Exam to monitor and quantify joint status in the hemophilic patient. See Dr. Annette von Drygalski here at UC San Diego Hemophilia Treatment Center performing an ultrasound guided elbow injection.
“Turning the Page”… MSK Masters Online Curriculum
Digital format handouts to accompany the registry review are available, and I have developed a hardcopy book of the same handouts that will be available as well, for those who need something to “scratch notes” on. The curriculum is not only comprehensive, but I decided to make it financially accessible/affordable. The next project will be a textbook for ultrasound guided procedures in the similar format of “Sonography of the Extremities”.
I am excited for the future, but the future is built on the past. Presenting a solid foundation of MSK fundamentals in an understandable and reproducible fashion has proven to be essential to sonographers, doctors and physical therapists employing MSK over the last 25 years.
I remain steadfast and convinced through many, many personal experiences that on site “home turf” training is more effective than remote destination courses, especially in the field of regenerative medicine and its inseparable relationship with ultrasound. Live teaching remains my passion, and I encourage everyone to consider on-site training or workshops.
Hands On Seminar
This past weekend, I spent three days teaching MSK Ultrsaound in New York City. On Friday and Saturday I presented lower extremity procedures to doctors of physical therapy at the Hands-On Seminar workshop in Astoria. On Sunday, I presented shoulder and lumbar spine scanning protocols to the International Society of Regenerative Medicine.
I also had my right patellar tendon injected with PRP. The advanced tendinosis that I have came as a result of training and completing a 60 mile run on my 60th birthday. Perhaps not the most wise choice to make at that age, but it is still a very fond memory for my family and me.
I have posted a picture of normal and abnormal patellar tendons. Please stay tuned as we do follow up images at four (4) week intervals. Remember, in previous blogs, that I have said, “Your injection is no better than your image” and “A picture is worth a 1000 words.” In Regenerative medicine, the serial studies become invaluable.
March 24, 2017
This week I arrived in San Diego and became a “Million Miler” on Delta Airlines. They gave me a nifty little bag with a water bottle and an umbrella! I can honestly say that the vast majority of those miles came by flying to offices, hospitals and universities to teach MSK onsite. It remains my true passion in teaching. People learn MSK best on their home turf.
This week in San Diego, I am filming a post-course video of the JADE (Joint Activity and Damage Exam) Protocol that I helped develop for joint assessment in Hemophilic patients.
It has been a good ride!
March 22, 2017
This past weekend, I had the privilege to present MSK Ultrasound to the North Carolina Ultrasound Society, the nation’s largest organization representing sonographers in a single state with over 300 sonographers attending. I was also dazzled by the venue, the Omni Grand Park Inn, located in Asheville, North Carolina. The picture below simply does not do it justice. The two 36-foot wide fireplaces in the lobby were hard to walk away from! One last treat this year before I get to MSK Ultrasound. . . . . . I observed a live time-trial of sheepdog herding. It was quite impressive! Remember the movie Charlotte’s Web?
One lecture I shared was titled, “Shoulder Sonography by the Numbers”. It is a focused and concise scan protocol providing a high diagnostic yield in 10 minutes or less – 5 images and 6 measurements. It readily provides imaging and quantification for the biceps tendon, supraspinatus/rotator cuff, sub-deltoid bursa and the AC Joint stability.
One thing that I found perplexing in chatting with the sonographers afterwards was the common assumption by doctors ordering MSK ultrasound in a hospital setting that they – the sonographers – had been trained in MSK. They had not! Watching a YouTube video right before bringing the patient into the scan lab seemed to be a common confession.
I am always impressed with the level of integrity and professionalism of sonographers, and this was once again displayed by their eagerness to be trained and certified.
1. The minimized/reduced loss of revenue when participants travel to workshops.
2. More staff can be trained without additional cost
3. Participants learn imaging and guided procedures on their “home turf” and on their own patients.
4. Cadaver labs are expensive and do NOT translate into useable, reproducible skills.
5. Ultrasound guided procedures are SAFE and efficient. MSK Masters teaches the “mechanics” of guided procedures!
It is Not Your Job to Hunt Pathology
March 15, 2017
20 + years ago, most everyone in medicine had not heard of MSK Sonography, and those who had, scoffed at the idea due to the presence of MRI. Today, as I am privileged to participate and assist in workshops and conferences around the country, I have observed that MSK has become an informational monster. It is common to hear comments of feeling overwhelmed during the first morning session of a two or three-day workshop. MSK Ultrasound can quickly become a daunting task instead of an exciting addition to a practitioner’s skillset.
The opening lecture of my MSK Fundamentals has one slide that has not been changed or updated for over 15 years. Why? Because it still works. It still helps people “get it”. It is a simple description of how to obtain and interpret MSK images in a reproducible and efficient fashion. The slide is below . . . A straightforward algorithm to performing MSK.
A portion of the slide is cut off by intention. It states that it is not your job to hunt pathology. By following the scanning protocols religiously, and understanding normal sonoanatomy completely . . .pathology will present itself! This raises the objectivity of the images and minimizes the user variability issues. Clinical signs in presentation often will not be collaborated on ultrasound images. Allow the ultrasound to do its own work. Follow the protocols. Endeavor to produce normal anatomy . If you cannot. . . then the finding is reliable.
Including our Physical Therapy Friends
February 28, 2017 | Randy E. Moore, DC, RDMS, RMSK
In the opening lecture of my musculoskeletal sonography classes, I cover the fundamentals of MSK Sonography and the all-important normal sono-anatomy. One of the statements that I find myself repeating is that MSK Sonography has made its presence known in every field of medicine. That is no exaggeration!
The material today does not completely fall under the heading of “bio-cellular”; however, there is a growing desire and need in the United States and around the world for physical therapists to use dry needling. Below is simply a transcription of an email of a good friend who is a doctor of physical therapy. He has recently begun to utilize MSK Sonography in his practice.
“Yesterday I used the ultrasound to needle the common flexor tendon on the same lady that I did the common extensor. What is very interesting is that when I needled the common extensor insertion, (you might remember) I was a bit too distal. (I sent you all the images.)
She came in yesterday. I had not seen her for over 2 weeks. The first thing that she said was “That needling that you did with the ultrasound worked . . . Virtually pain free since!” I had needled WHAT I THOUGHT was the extensor tendon and associated anatomy many times in the past with no benefit. She asked if I could needle the medial side this time as it had been problematic. This was challenging as I had to hold the probe with the right hand and guide the needle with my left hand.”
Your Injection is No Better than Your Image: Raising the Bar in Regenerative Medicine Treatment
This statement is not meant to be confrontational in any sense of the word. It is, though, an irrefutable fact, and a call to maintain the highest standard of bio-cellular delivery. In a previous post, the direct relationship of optimal response to precise placement of the regenerative/bio-cellular project was emphasized. It’s true!
I have had the opportunity to develop MSK protocols in four regenerative practices. Without exception, the facilities reported vastly more positive response to treatment. Why? For example, in a shoulder case, MSK Ultrasound readily identifies bursal verses articular side supraspinatus defects . . . such as the degenerative changes of tendinosis. It is not always a tear!
AC Joint Instability and/ or Separation of Dynamic Real-Time Imaging
I have found supraspinatus impingement under the acromion to be rare and AC Joint Impingement on a frequent basis. AC Joint instability responds very well to precise placement with fenestration of the of the ligament/capsule complex. Multiple Sites within the same tendon, ligament or muscle often require specific deposits of bio-cellular product. Full spectrum or comprehensive treatment of an extremity can be as many as 8-10 specific sites. Ultrasound is the only modality that can offer this amazing specificity of treatment.
Additional Frequent Sites of Shoulder Treatment
Rotator Cuff Interval: Plays a Prominent Role in shoulder stability
Subscapularius Tendon: Range of Motion restrictions with calcification of tendinosis
True Intra-Articular Glenohumeral injections avoiding the labrum.
Build a Firm Foundation of MSK Skills. MSK Masters presents a simple, straightforward learning model.
1. Image Generation: Standardized/Reproducible patient and probe positioning
2. Image Recognition: Standardized Interpretation Algorithm
3. Image Interpretation: Pathology identified via keen understanding of normal sonoanatomy.
Is it Really Bursitis?
February 2, 2017 Randy Moore, DC, RDMS, RMSK
Trocanteric bursitis is best diagnosed and treated with musculoskeletal sonography. Outpatient of the trochanteric region does often illicit pain response; however, without imaging, a precise diagnosis is elusive.
This is a 46 year old male demonstrating a significant response to bio-cellular therapy under MSK ultrasound guidance. Initial imaging revealed a sub-gluteal medius muscle bursal infusion with simple fluid and classic findings of tendinosis. (Hypoechoic, non-fiber echo texture and thickening)
Four (4) months post treatment, the gluteal medius bursa is resolved, and more normal presentation of the glut medius tendon is demonstrate.
In my 5 years of training doctors involved in the orthopedic applications of bio-cellular/regenerative medicine therapies utilizing musculoskeletal ultrasound, I have received comments relative to improved patient outcomes. Not only does real-time ultrasound provide accurate diagnosis and precise delivery of the bio-cellular product at target sites, it reveals the remodeling anatomy.
Serial studies performed at 8 week intervals can demonstrate the effective and positive response to the procedure. Below is a medial meniscus study at approximately 99 days pre- and post-treatment. Fibro cartilage is not highly vascular; however, the posterior horn and vascular watershed of the medial meniscus are typically imaged on MSK ultrasound, and it appears to respond well to accurate placement in the study below by demonstrating more fibro cartilage substance and increased echo density.
It is also important to remember that the remodeling process can continue for up to six months.