Real Time Ultrasound

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Real Time Ultrasound

Real time ultrasound allows the capturing of real time pictures of structures within the body, using high frequency sound waves that are inaudible to human ears.The sound waves, which are completely safe for human tissue, are sent into the tissues, and the sound waves that are bounced back are used to create the picture. This amazing technology is widely used in medicine for assessing internal organs, blood vessels and developing babies. Ultrasound is also extremely useful for imaging muscles, tendons and ligaments when assessing the consequences of an injury or the cause of persisting musculoskeletal pain. Twenty years ago physiotherapists began using ultrasound not only to look at the size and health of muscles, but to look at activation patterns of muscle groups. There is now a large volume of scientific research confirming the validity, reliability and usefulness of such techniques.

While we can see and palpate the superficial muscles, it is not possible to accurately assess size, quality or activation patterns of deep muscles, as these muscles lay beneath other larger, more superficial muscles. While superficial muscles are generally our power producers for movement, the deeper shorter muscles hug around our joint providing protection, stability and fine control of movement. Researchers have shown that there are often ongoing problems in our deep muscle systems in persisting pain states or recurrent injury. General strengthening programmes in these cases have often failed to normalise function in the deep system, even though the superficial system has become larger and stronger. This can sometimes make the problem worse – if you have larger muscles placing greater loads across joints that are relatively unprotected by an inefficient deep system, worsening pain or re-injury can occur.

Deep muscles are often inhibited and superficial muscles overwork to compensate in persistent pain states or recurrent injuries, resulting in muscle imbalance, pain and stiffness, and reduced efficiency and physical performance.

Deep muscles are particularly prone to inhibition. We know from research that pain inhibits deep muscles, and a lack of weightbearing or poor postures can also negatively influence deep muscles around the spine and pelvis. The superficial muscles have been shown to be much less susceptible to inhibition, so if the deep system is not doing its job the brain ‘upregulates’  the superficial system to ensure you can still get from A to B (hunter & gatherer survival instinct).

However when superficial muscles try to do the ‘stabilising’ job – 1. You become much less efficient using lots more energy for each task (remember you usually only use small muscles to do this task with less metabolic cost) and 2.  The underlying joints are exposed to much higher compressive loads and shear forces imposed by the big superficial muscles. This can make you feel tight, rigid or less fluid in your movements, more fatigued, and more painful, and the loss of efficiency may reduce athletic performance.

Real time ultrasound provides an incredible opportunity to assess the health and function of these muscles, not only at rest, but during active movement. No other imaging modality has the same versatility as ultrasound. Physiotherapists can then use ultrasound to train you how to consciously activate your deep muscle systems and protect your joints more effectively prior to and throughout movement. It also helps us to teach you to ‘downregulate’ your superficial system making you less rigid and more efficient in your movements, and then we can strengthen the both systems together in safe and balanced way.

Real time ultrasound provides a unique window into the function of our deep muscles during movement. This level of information cannot be provided by visual assessment, palpation or any other imaging modality to date.

Real time ultrasound and lower back pain

The greatest volume of research surrounds the use of real time ultrasound in the assessment and retraining of muscles around the trunk in those with back and pelvic pain. Ultrasound is used to assess and retrain muscles of the abdominal wall, deep lumbar stabilisers (multifidus), and the pelvic floor musculature. Retraining these muscles with real time ultrasound is often an excellent first step in the recovery of optimal function.

Transversus Abdominis Ultrasound At Rest
Ultrasound retraining of the abdominal wall - Transversus abdominis

Ultrasound image of transversus abdominis contracted
Transversus abdominis contracted - note the deep muscle shortened to the right

Real time ultrasound and hip and groin pain

Dr Alison Grimaldi has pioneered the use of real time ultrasound for assessment and retraining of the deep musculature of the hip and groin. She has been using these techniques very successfully for over 10 years, and teaches these techniques to other physiotherapists around Australia and abroad.

Optimal function in the deep trunk and hip musculature is the foundation for optimal weightbearing function and ability to transfer load between the legs and body. These techniques can be useful for almost any musculoskeletal condition of the hip and groin.

Ultrasound retraining of the deep gluteal muscle - gluteus minimus.

Real time ultrasound and the foot intrinsics

Ultrasound is a fantastic tool for assessing and retraining the deep muscles that lie within your foot. These muscles are crucial for support of the arches of your feet and for helping you monitor and adapt to the surface on which you are walking or running. They connect you to the earth and sensors within these muscles provide essential information for your brain and nervous system to help you plan how you should balance your body weight, or where you might place your next foot.

These muscles often become inhibited and atrophied due to lack of stimulus – too much time sitting, not enough time barefoot or on stimulating surfaces (not that you should through off your shoes if you have foot pain – the muscles need to be strengthened first). Like other deep muscles these deep short muscles can be difficult to assess, especially when you are standing.

Ultrasound however allows us to see these muscles and provides feedback on-screen so you can be sure you are activating them properly. This is great for plantar fasciopathy (plantar fasciitis), forefoot pain (metatarsalgia, Mortons neuroma), bunions (hallux valgus), arthritis, tibialis posterior dysfunction/tendinopathy, shins splints (medial tibial stress syndrome MTSS) and many more conditions of the foot, ankle and shins.

Ultrasound of foot Intrinsics forefoot
Ultrasound of foot intrinsics - we can imagine right through the foot with ultrasound

Real time ultrasound and patellofemoral pain (PFPS - syndrome)

Dysfunction of the quadriceps, particularly of the Vastus Medialis Oblique (VMO) has been shown to occur in those with pain around the kneecap (patella). The VMO is thought to be important in controlling loads, particularly shear forces, across the patellofemoral joint – where the kneecap slides up and down in a groove in the lower end of the femur.

The VMO has become very inhibited but getting some real time biofeedback with ultrasound can help your brain connect with the muscle, and get it working for you again. Poor function of the hip abductors and rotators has also been closely linked in patellofemoral pain research studies. We also use ultrasound to help optimise muscle function at the hip in patients with patellofemoral pain.

Ultrasound image of VMO
Ultrasounding vastus medialis oblique (VMO)

Real time ultrasound and shoulder pain and instability

Real time ultrasound can also be an invaluable tool for managing shoulder pain and instability. It can be used to help you improve function of the muscles that control scapular position and movement, and for retraining of the rotator cuff. This is useful for conditions ranging from postural related pain, to rotator cuff tendinopathy or tears, glenohumeral joint instability or arthritis.

Ultrasound imaging of the posterior cuff of the shoulder
Ultrasound image of the rotator cuff- infraspinatus at the back of the shoulder