All right, well, it is 5 o'clock, so we will get started right on time. I'm John Fowler. We're going to talk about musculoskeletal ultrasound and how you can incorporate this in your practice. So here's the schedule. Mark Recant is going to start talking about kind of ultrasound basics and how you hold the transducer. I'll come back up and talk about carpal tunnel syndrome, my passion. Tom Hughes is going to talk about ultrasound guided injections. Kevin Cruz from Dallas, Texas, is going to talk about the basic rotary cuff exam, and then I'll kind of come back up at the end and talk about how do you bill, how do you pay for a machine, what codes you use, and they'll have some kind of free time for questions. I think we'll probably go over this initial schedule a little bit, so that question-and-answer period might decrease, but feel free to ask questions. All right, Mark. Oh, perfect, thanks, Dr. Fowler. So some of this, it won't be necessarily slide-based, because some of this is kind of just how you position yourself, and we'll digress a little bit. This slide's super valuable, because this is what you'll be asked tonight at Handapalooza or other places is, why are we doing ultrasound? Why waste the time learning this stuff? First off, relative to other studies, it's inexpensive. There's no radiation concern. You don't have to have your patient walk away with a lead apron. It's painless, which is huge, particularly in my practice. You get real-time results. You don't have to go digging around for your MRI report or your nerve study report. This is right in front of you. You have complete control, and again, you can use this in dynamic situations if you're trying to identify tendon gliding, for instance. Very helpful. Nothing comes necessarily without its disadvantages. There's certainly going to be an upfront cost if you're in a private practice world, and John will cover this a little bit, regarding the cost of the machine. If you're with a hospital-based system, it's not as much of a concern. There are some imaging limitations as far as identifying fracture patterns and ligament injuries per se in the wrist are a little bit more challenging, and again, along that same lines is there's a learning curve with just repetition. I think Dr. Fowler spoke of this quite well this morning, so I'm stealing his line, is when you start using ultrasound in your clinic, do things that are easy and reproducible, so you have less frustration than if you're going to start off with your first case, ultrasound trying to identify a mallet finger injury would be a difficult place to start, for instance. On this slide here, number two is kind of most pertinent, is you're going to develop your own protocol as you continue to gain experience. The setup is, again, sort of that same thing, just like we teach our residents and fellows to be comfortable when they sit down and, you know, where the patient position is. Same thing with ultrasound. You want to be comfortable. The patient should be comfortable so you're not, you know, sweating, and the patient can read that if you're kind of in a weird position, you're just not getting it right. Along those same lines, you want to rest your hand or, you know, three fingers. For me, it's my ring and small. For Mike Travis, who's an excellent ultrasonographer, he rests his owner three fingers, and then you're just using the index and the thumb for pinch. And it's very similar to wrist arthroscopy or small joint arthroscopy. If you rest your hand on the patient, it gives you that fine ability to make small adjustments to the transducer. So, again, that's really the key to really understanding and getting started. The frequencies matter. For small joints and the wrist, the higher frequencies give you more clarity, although they certainly don't go as deep as the low frequencies that they might use for bellies or hips. So, we really are sort of in that 10 to 14 megahertz range. We really don't have to be that deep. And looking at the carpal tunnel, as you see, it's two or three centimeters down at worst. So these are sort of the terminology where you have hypochoic and that really just is black and then hypochoic is that bright signal and then you'll hear the term isochoic, which is sort of neutral. There is some reflective findings that you want to try to avoid, because that can kind of throw off what you're looking at. So other things we can do, we want to identify the normal anatomy and the pathology and I think John will probably talk about that and somewhat with your coding. As you're dictating a note, you want to describe both the abnormal and the normal structures to help with facilitating of reimbursement. We're looking for nerve compression, which we'll hear about with the next speaker. Guidance of injections, guidance of aspiration, again, is very helpful. We can see tendon injury, we can see ligament injuries. If you get really technical and good, you can see foreign bodies, particularly glass shows up and again, identifying various masses and you can sort of prevent someone from getting an MRI. The classic would be trying to have your 16-year-old patient not have to sit through an MRI. Her parents don't have to take another day off, et cetera. So this is kind of what the skin and subcutaneous are going to look like with the ultrasound probe. Here's kind of the two other terminologies with using the probe is a long axis, commonly referred to as the longitudinal axis, and you can see sort of what the tendons will look like in that trilaminar appearance. And then the short axis, also known as the transverse axis, you sort of have this starry night appearance of the tendons and then that halo around is the pulley. And again, sort of fibular in the short axis is another way to think of it and using the anisotropy to your advantage. So again, that's as you get more practice with wiggling the transducer from side to side, you will pick up different nuances of either the nerve or the tendon or the ligament, depending on how you adjust the transducer. I think lacerations, trigger fingers we'll talk about. The climber's finger I think has been huge for me. Getting that A2 pulley rupture right in my office has been a game changer for me. Adhesions versus tendon rupture, also super valuable. It's one of those things that you really don't want to wait necessarily to get the results back from an MRI. You really want that real time information so you can make a valuable decision. And these are the things you're sort of looking for, hyperemia, tendon thickening, fluid. In the case of an A2 pulley, you can see fluid underneath the tendon. So if the tendon is not adherent or adjacent to the bone, similar to what you would see on an MRI findings, that's pretty pathognomonic for an A2 pulley rupture. These are sort of some common things. Again, looking over the A1 pulley with your longitudinal probe. You can see the flexor tendons and then I kind of highlighted those with the structures, the metacarpal head, which is a good landmark. The profundus tendon in purple, superficialis in green. And what's neat with the patient when you first start doing this, and it helps build some rapport with the patient, is have them flex their fingers. Have them, you know, hold their DIP and have them just flex the profundus and see that glide. You get lots of oohs and ahhs in the office, which is quite nice, you know, for all the other struggles that we have, at least you get some positive feedback in your day, which is brilliant. Moving down into the A2 pulley region, you can see on this short axis or transverse, the flexor tendons in blue and green respectively. And that halo then would be your A2 pulley. Going more distally, you can see the profundus tendon that's highlighted. This is actually a quite nice view of the A4 pulley. And then as you get really magical, you can kind of see the neurovascular bundles to the lateral sides that are circled faintly in red. And then lastly, you can flip over and look longitudinally at the A4 pulley. You can see the DIP joint, the volar plate quite nicely. So if you were trying to identify a volar plate rupture that you couldn't identify clinically, this is also a valuable tool. And you can do this similarly at the PIP joint. And that's kind of a small probe, which is very, very nice if you can afford it. Or you have a medium-sized probe, which allows you to do both the carpal tunnel and the finger. My perfect world would have one of both, if you have wealthy hospital folks willing to do that for you. So again, here carving out the A2 pulley in green, just to make that a little bit more obvious on that slide. And again, here's sort of that concept of the A2 pulley. A, you're not necessarily going to see the A2 pulley. As you do more and more of these normal scans, you'll see a very faint black line on your longitudinal scan and that's absent on this study. But even more obvious is that hypochoic area below the tendon. That's pretty obvious. So moving into extensors real quick, as you get to the next level, identifying extensor lacerations, a little more challenging given how thin they are, the mallet finger. But this is what this would look like with a small probe in the longitudinal fashion. Seeing the terminal tendon, you can see the DIP joint that's marked out in yellow. And then getting even more nutso, you can kind of identify nail bed deformities as you get to the next level, seeing the cuticle, nail root, and the underlying distal phalanx. So in closing, you can look at the gamekeepers, again, getting you that real-time view. Fairly painless. You don't need to get an MRI study. And this is what the ulnar collateral ligament will look like. Here's where the probe is. You can kind of see that the ligament is not holding in this dynamic view. And then real quick, this is what the carpal tunnel scan plane is going to look like. But I think that's going to be covered next. I'm going to just flip through that. Some references, and again, just continuing the educational process. The more you can use the probe, the more experience you get, the easier it will be. And then you can teach others. So thank you. Thanks, Mark. That was a good review just of, you know, I think sometimes just knowing what it should look like is so important. What's normal anatomy? How do you position the probe? I think all that's a good place to start. So when we kind of talk about ultrasound, and we ran the ultrasound course this morning, we talk a lot about where to start and what's the low-hanging fruit. And I think that carpal tunnel syndrome is a great place to start because it's a very superficial structure, it is relatively easy to identify, and it's something we all see a lot of. If you're going to try to master thumb UCL injuries, I mean, I might see one of those a month or two a month. You're just not going to get the reps. But then I see, you know, 50 carpal tunnels a month, so you just see more people. Those are my conflicts of interest. So I like to rail against nerve studies. I think there's a lot of dogma. I think we order them for all the wrong reasons. And so they actually have a pretty high rate of false negatives and false positives, if you truly look at the data. They are costly, although that cost has come down most to the chagrin of the nerve specialists. They can be painful. I don't know if anybody's had one. It's not the end of the world. If you had to choose to have one, you would pick not to. And for most practices, they're relatively inefficient. I know a lot of private practices have a nerve specialist kind of in their office, and you can send someone down the hall. But it still may take, you know, at a minimum, 45 minutes or an hour, and then that patient has to come back, and you have to talk to them again. Atroshi, who's an orthopedic surgeon out of Sweden, way back in 99, sent out 3,000 surveys and got the best response rate I've ever seen in my life. Like, when I do these survey studies, I'm not sure if anyone here has, the response rate's like 15%, 12%. They got, like, a 75% response rate, which is crazy. And in that study, or in that survey, 14% of people described numbness and tingling in the median nerve distribution, and they were able to get 287 of those people, so almost 10% of the cohort, to come in for an exam. And this gets a little bit busy, but Atroshi, orthopedic hand surgeon, examined these people and defined them as either clinically certain carpal tunnel syndrome or uncertain carpal tunnel. They did nerve tests on all of them, and you can see at the bottom that 30% of patients that a hand surgeon identified as having clinically certain carpal tunnel had stone cold normal nerve tests, and that should be a little bit concerning for you. They also got 125 people who reported no symptoms in that survey to come in for an exam as well, and in that group, 18% of people that had no symptoms at all had positive nerve studies. And I think I see that all the time. I would get referrals from the PCPs. The patient actually has a trigger finger, but the PCP thought it was trigger carpal tunnel, because that's the only word they know in hand surgery, and so they order a nerve test. And the patient comes in, oh, what's your complaint? Well, my finger gets stuck. Okay. Does your hand go numb? No. Does waking up at night? No. And so what do you do with that information? And so if you kind of bring all that data together in this Atroshi study, nerve studies basically missed the diagnosis in 23% of all their patients, and that's unacceptably high in my view. This is another study that kind of looks at the same type of issue, 99 patients with clinical evidence of carpal tunnel. You can see 24 positive nerve studies, 25 normal nerve studies. So in this one, 25% of patients that had true signs and symptoms of carpal tunnel had normal nerve tests. I think one of the issues I have with electrodiagnostic testing is this is one of the practice parameters from the AANEM, American Association of Neuromuscular and Electrodiagnostic Medicine, which is a mouthful. They have so many different tests they can run, and the issue becomes, like, if you order 20 tests and one of the 20 becomes positive, is that really meaningful? Like, do they really have carpal tunnel, or was that just like the standard error? And so that's one of the issues I kind of have with some of these many different tests. And I said my slide ahead of it, sorry. So I would tell you the future, and hopefully the present, because you're here, is that you should use ultrasound to measure the cross-section area of the median nerve. So a radiologist, Bookberger, started this back in 1992. This is the first published study you can find talking about ultrasound and carpal tunnel syndrome. They took 20 patients with nerve study-confirmed CTS. Now, we just said that was a bad gold standard, but it's kind of what we had. And they had 28 normal controls. They did both MRIs and ultrasound of all these patients. What you see is the cross-sectional area. So the idea is if the nerve is compressed inside the carpal tunnel, it will swell proximal and distal. And it's much easier to measure proximal, because the forearm's flat. It's very superficial. So you can see in normal controls, that was about 8 millimeters squared, and in patients with carpal tunnel, it was 14 and a half. So very clear difference. And I think the important part was there was no difference at all in the measurements between ultrasound and MRI. So this really validated that, yes, ultrasound can do this. Then the question become, well, what level do we measure at? I mean, you can measure anywhere along the nerve. You try to measure inside the carpal tunnel, distal, proximal. So this was out of Japan, and a huge study, 401 wrists, 201 with carpal tunnel, again, confirmed with nerve studies, and 200 asymptomatic. These were all, quote, unquote, Japanese housewives, based on the study. They measured in four different levels, the edge of the retinaculum, center of the hook of the hamate, the wrist crease, or the distal third of the forearm. And what this study showed was that, actually, the first three, all of them, edge of the retinaculum, hamate, or the pisiform, all were significant. But the one with the best sensitivity and specificity was at the level of the pisiform or the proximal wrist crease. And so all of my research going forward is really focused on that. One of my first studies I did when I was back as a resident at Temple in Philadelphia was a meta-analysis. And I think I've updated this slide multiple times. When I first presented this, it was 20 studies. Then it's 30 studies. Now it's 40 studies. Everyone wants to compare ultrasound to nerve studies for diagnosing carpal tunnel. And it really matters on which reference standard you use. Like, you can't really use nerve studies because they can't be 100% sensitive and specific, though many studies do. So here's what the meta-analysis said, that if you just kind of took all of these studies, and there was 19 that we included based on the inclusion-exclusion criteria, the sensitivity of ultrasound was 77%, and specificity was 87%. And if you use the clinical exam as the reference standard, that specificity goes up to 93%. And really what you want for a confirmatory test is high specificity. You don't want false positives. You don't want to operate on somebody that you're saying has carpal tunnel, but they don't have carpal tunnel, because then they shouldn't get better. And then they get all the complications with no benefit. So I did that study first in residency. And then when I came to fellowship, thankfully, the people in Pittsburgh had an ultrasound machine. So I just ultrasounded everybody I could. And so we did a prospective study up there in Wexford and Pittsburgh, 85 patients. I did all the ultrasounds. We had CTS-6 done by someone else who was blinded. And then the nerve study people down the hall did the nerve studies. We used CTS-6 as the reference standard. So if you had a positive CTS-6, then you had carpal tunnel. If you had a negative one, then you didn't. And these are kind of pretty classic findings. And in general, if your score was more than 12 out of the points in the right-hand column, that was a positive diagnosis. And so here's the numbers. Again, look over there. Sensitivity and specificity. The sensitivity was the same between ultrasound and nerve studies. And again, ultrasound had a better specificity. If you look at the left-hand side, look at the median nerve cross-section area. So people with a positive CTS-6, it was 12.7 millimeters squared. And people with negative CTS-6, it was 8. So that's just another thing to kind of prove this really works. If you just looked at accuracy, again, ultrasound was a little bit more accurate. And even if you just said across the board, I still like nerve tests, I want to know what they say, ultrasound was actually very good as well using nerve studies as a reference standard. When I get up and talk about this, everybody always says the same thing, yeah, John, but ultrasound is operator-dependent. That's like the classic line of people that don't like ultrasound. So I said, fine, I'll test it. So after one of these meetings, I went back, and Dave Hirsch was one of our interns. And Kevin, who's going to talk next, was the fellow. And what we did is we went to morning conference. We grabbed the fellows. We brought them out one by one. And we ultrasounded their wrist. And then we brought them back two weeks later, and we did it again. And each of us were blinded to everyone else's measurements. So the problem is Kevin kind of screwed things up here. If you look at the fellow over there and the attending, that correlation coefficient was only 0.79. And David and I, the intern who had never picked up an ultrasound machine, it was almost perfect. So Kevin, thanks for messing up my study. But what this did show was that all of us were right around near perfect agreement. So even an intern who had never picked up an ultrasound probe before can do this very well compared to my measurement. So in cases where you don't have a good reference standard, and we've talked about how with carpal tunnel syndrome we don't have that, there's a statistical method called latent class analysis. And what this does is it looks at associations between different tests. And so like if I asked you, is it raining out right now? You know, it's a dark room. We can't really see. What could you do? Well, you could pull up your phone. You could look at the radar. You could phone a friend. You could look at barometric pressure. You could have watched the weather forecast this morning. But you don't actually know until you go outside and put your hand outside. But what latent class analysis would do is it would look at all those different tests and then try to come together for a diagnosis to tell you if it's raining or not. So we did that for carpal tunnel syndrome. We used a lot of that same data we used in one of the previous studies. and, again, look at the sensitivity specificity. Ultrasound, 91% and it had the best specificity of all the different tests. We talked about false positives. We think false positives are kind of a problem, especially if you're offering someone surgery. And so what I did was I used CTS-6 and I picked a CTS-6 of zero. So those patients had none of those things. No numbness in the internal distribution, no nocturnal symptoms, negative phalen, no atrophy, normal two-point discrimination. If you had none of those things, you probably don't have carpal tunnel syndrome. I guess you still could, but it's going to be pretty unlikely. And we looked at the ultrasound findings and the nerve conduction findings in that group. I think the bad thing for me, because I love ultrasound, is that even still in that group, 23% of people had a positive ultrasound, which is super confusing. But nerve conduction studies were positive 43% of the time. So you can see that nerve studies are almost double the number of false positives as ultrasound. We talked about efficiency. I think I sat in the symposium downstairs just talking about how efficiency is so important for a number of reasons, cost savings and patient preference. At least in my practice, I have to refer people to either PMNR or neurology to get a nerve test. It often takes several weeks to get that scheduled and they have to come back. And the testing takes 45 to 60 minutes. If you do the ultrasound yourself, which I do, I wheel a machine in. I do it right then and there. There's no second office visit. It's a minute at the end of the information. I don't even do that anymore because I don't really need a bill for it technically. And then I can get a measurement in less than 30 seconds. So it really speeds things up. So here's my wrist. That's my pisiform and my distal wrist crease. We're going to do a short axis. Mark Rican kind of talked about that. Short axis, long axis, short axis, and then here's basically what you see. It's kind of not projecting all that well, but the median nerve is the most superficial structure. You circle it and it gives you a number. And what we've kind of used, well, I'll get to that, sorry. So this is the longitudinal axis. There's so many uses for ultrasound. Like say you put in a distal radius plate. You can see over here is the distal radius. Here's the perineum quadratus. You can see if your plate is too prominent. But this kind of shows the tendons and long axis view. So in my current practice, 10 millimeters squared. If it's 10 millimeters squared or greater, that patient absolutely has carpal tunnel syndrome. If it's not, then I might do other things. I might do a steroid injection. I might do something called wrist forearm ratio where you measure the distal forearm and see what that ratio looks like. I just, I don't order nerve studies. I haven't for probably five or six years. It's made my life so much better. I still get them for other things. Like if I really think they might have radiculopathy, and I still think there's some value for cubital tunnel syndrome, and we can talk about that offline if you want. So thanks. Thanks. All right, John has to run to another room and give another talk before he comes back to finish here. So I'm going to get in the mix here. So I'm going to talk a little bit about ultrasound-guided injections. All right, I have nothing to disclose. So why should we do this? You know, there's a lot of data showing that there is more accurate placement of the needle. There's some data suggesting that there's better clinical effectiveness because of that better placement. And often people do it because it helps to pay for the technology, right? Having an ultrasound in your office is a huge value for a lot of reasons. It may not be for injections, but it is something that is expensive, and so that's one way to help to fund that so that you can have it there for the other things you may want to use it for. And then we will talk about the difference between the long and the short axis, which changes the injection technique a lot. I will put out as a full disclosure, I don't do a lot of injections under ultrasound, but I have it for when I need it. I think early on, doing more of them that way is helpful, so you become comfortable with the different methods for the reasons you may choose to use it. I find it hard to get it into the flow of my patients if I haven't seen a ton of people, but it's definitely something that can be helpful. We'll come back to the data. So accuracy. So there's really no study that doesn't show that we can be more accurate with ultrasound. So looking at all these joints, I can read them out, but STT, CMC, PIP, and MCP, really every study that you look at shows better accuracy with ultrasound guidance. And I will point out that most of these studies are not done by orthopedic surgeons, and I think that we probably biasly feel like we have a better understanding of the anatomy since we operate on it, and that's probably true, and we probably can do better than non-operative physicians at placing the needle where we want it. But there's no doubt that when you can watch it go in, you feel more confident. I still do a lot of shoulder injections fluoroscopically guided for arthritis because I'm deciding to do a shoulder replacement on someone based on whether or not this cortisone injection helps them or not. And so seeing the dye in the joint certainly makes me feel more confident. So similarly, as you get more comfortable with ultrasound, seeing the needle can really help you say, hey, particularly for diagnostic injections, if you're trying to decide is this a trigger finger, is this MCP arthritis, seeing the needle go into the joint, getting the symptoms to resolve, that can certainly be helpful. This is another study looking at elbow injections for inflammatory arthritis, 22 elbows were injected, accuracy with ultrasound was 91%, landmark guidance 64%. Wasn't statistically significant, but still, with greater power, this is something that would still show an advantage. In the shoulder, this study, again, shows for the AC joint, subacromial joint, biceps tendon sheath, and glenohumeral joint, ultrasound certainly exceeds what we can do by pure palpation. This is where I use ultrasound the most, is in my shoulder patients. As the soft tissues get bigger and bulkier, it gets harder and harder to be as positive that you're in the correct spot. Biceps tendon sheath injections in the majority of non-super thin patients is almost a crapshoot in my experience. So I find that the ultrasound adds more value here than maybe in the trigger finger injection. But still, if you want to be certain you're in any given location, the ultrasound can add to that. This study looked at shoulder results after subacromial injection. They had greater reductions in pain and improvement in function with ultrasound-guided injections. Same with the bicep sheath, again, likely because they're in the sheath as compared to just near the sheath, greater reduction in pain and improvement in function with ultrasound-guided injections versus landmark-based. So techniques. So we're going to kind of show some pictures and videos. But this is hard until you get your hands on an ultrasound machine. But this is a study basically showing a good graphic. So what we talk about, long axis and short axis are in the plane of the ultrasound. So basically, you can either come in from the side, or you can come transversely to the probe. And the difference here, when you look at this image, when you come in from the side, you're going to see your needle kind of coming down under the ultrasound. And that's what we're seeing right here. When you come in the short axis or out of plane, you're basically coming in only the part of the needle that is under. So if this needle, if I just continue to draw it, continue to draw it over here, you're not going to see any of this part of the needle here. You're just seeing the part that's under the ultrasound beam. And it shows up as a little dot. And that takes, I think, a little extra skill to see that. So when you're placing the needle under the ultrasound beam, when I find that dot, what I'm always curious about for myself is, is the needle tip just gotten to that beam? Or have I missed it? Am I not seeing it well? So what I like to do is, once I have it, then I'll back that needle out until that dot disappears again and then advance it again. And if it comes out and back right where I think I am, that means the tip of the needle is right under my beam. And that tells me it's time to inject. Then the other confirmation you have when you're in plane is you'll see the fluid. You'll see that when you make the injection. So long axis means in plane. Short axis means out of plane. Again, just like we were talking, the pros of in-plane injections is you can see the entire needle. The cons are you have to stay in plane. It's a little technically more difficult to do that. You also can sometimes see less anatomy because you're really focusing on the needle rather than the structure you're injecting. Whereas with the out-of-plane injections, you have lateral anatomy. It's harder to adjust left to right. But you're seeing just the tip. And both hands have to move at the same time when you're doing this. So just like Sheryl Sandberg, when you're doing this, you've got to lean in. So to get your best image of your needle, you need the beam of your ultrasound to be perpendicular to the needle so that it reflects the ultrasound beam back to the transducer. And so the best way to do that is to angle the probe. If you have this situation where you go flat, as it hits here, it mounts off to the side and you miss some of it. And the image is not as strong. So leaning in with your probe, kind of pushing to the patient, using a lot of gel. When Mark showed that image of trying to image the extensor tendon, you could see they had like a ton of gel on that finger. Because if you're going to lift your probe off the body in any way, any air is going to make your image be horrible. So you want to put a ton of gel so that as you're leaning in, that part of the probe that may lift off the skin is still in gel and you can still image through that and get a better image of your needle. And this is just a demonstration of that, where on the image on the right, they're really digging in with the middle finger of the examiner to really push that as parallel. The other thing you can do is change the angle of induction of your needle. So when you put that needle in, instead of maybe injecting like you typically would, straight down at your trigger finger, coming in at an angle is going to give you a better chance of keeping your needle parallel to the transducer and perpendicular to the beam. Yeah, so angle of insertion. So you can see the difference there. And you can see in the quality of these two images how this is just a little bit grainier. And this is really crystal clear to the point where you can actually see the bevel of the needle when you get that needle parallel to the surface of the transducer. So this is how you do a carpal tunnel injection in the short axis. And you can see here is the little point of the needle. And what you try and do is you get your median nerve off to the side and your ulnar artery off to the side. You pick a point in the middle, and then you place in the short axis. I typically do most of my injections in the long axis. I feel like the short axis is for the next level ultrasonographer, which I feel like I'm a moderate level ultrasonographer. And seeing the needle come in makes me feel more confident that I'm in the right spot. But as you get more and more comfortable, these sorts of injections I think are a reasonable option. Again, just showing that picture, that arrow shows the needle right there. And usually you're trying to stay in your flexor tendon area away from your median nerve when you're doing this out of plane. This is how you would do it in the long axis. And again, you kind of can do it either way in the long axis. I prefer this method where you're kind of seeing everything transversely, and then you're coming in from the side with your needle. I do not typically do this. This is an image off my reference on the previous slide right here. But I typically do not like to have my needle that close to the median nerve. Again, I'm a B-level ultrasonographer, and that seems awfully close to me. So I am really aiming, again, for around the flexor tendons, trying to just decrease inflammation in the carpal tunnel, not necessarily inflammation within the median nerve. But you can also do it in long plane this way, where you see the nerve and then come in from the side here. And here you can see their needle right on top of the median nerve. Here's your transverse carpal ligament. Again, that's the A-level ultrasonographer there. And this is more likely how I'm going to do it, from the side coming in, where I can see the whole needle, but I'm also away from my nerve. Similarly, with CMC injections, you can do long axis. You can see here's a still image. Here is your metacarpal. This is your trapezium. Here's the CMC joint. Here's the tip of your needle kind of coming in from the side. This is a video. These images, these videos are off the internet, and I put the citation in the talk, so if you want to look at them. Is that projecting well? From my direction, it's not. Is it pretty dark? You can see here. Okay, here's basically the first metacarpal right here. Here's the tip of your needle getting in. Here's your trapezium right here. So kind of coming in long axis, you can see the fluid go out in that last little bit there. Let me just come back to that. So right here, you can see the fluid flowing in, kind of filling up the joint. Again, with this, that band of fluid that you were seeing in the CMC joint, it's really hard to feel like you're not in the joint, whereas as many CMC injections as I give without ultrasound, I know that I miss the joint occasionally, and at least I would know that if I was doing it with ultrasound. Again, you can do it with short axis, same sort of thing. You go perpendicular to the long axis of the probe, and there you can see your needle, and that tells you that you're right between your metacarpal and your trapezium. Here's a de Quervain's injection. Again, either direction, this is transverse. I kind of like transverse for these sometimes, as far as, again, imaging transversely, but coming in long axis, so you can see your needle coming from the side up here at the top. Here's a video, again. Tip your needle over here. Here are your EPL and APB tendons. This is your first dorsal compartment sheath, and this person is very slowly trying to torture this patient, bringing the needle in, but again, it's hard sometimes to get your image well, and that's what you're working at. Now, you can see the tip of your needles right over here, kind of next to your tendons through your sheath, and this would be the time to inject, and you'll see the fluid fill in, and you can be really certain, and then you can also, sometimes what I'll do is I'll drop my hand and scoot the needle across to the other side. Here you can see it's really just filling up around this one tendon, so there's probably the APL over here, EPB here, and to get this, when you see that, if you see, you can really see the fluid really just flowing around that tendon, probably worth, you assume that they have a sub-sheath there and that you want to advance across that. This is the short axis injection. Again, you can see the needle, kind of the single dot, and it's just a little less fulfilling than seeing that needle coming from the side. Trigger injections, again, not something that I do often, but sometimes, again, when I'm trying to differentiate between MCP, joint arthritis, and triggers, I really want to be sure I'm in the sheath and just fixing that problem and see if that helps them. Here's again a video of that. You can see here's your flexor tendon here. Right here is your A1 pulley. It's a little hard to see on this image. They're not imaging it well. Here comes the tip of your needle, and again, once they start to inject fluid, you'll see kind of the sheath lift up a little bit from the tendon itself. Any second now, there you go, there's the fluid. You can kind of see it bubbling up here over the flexor tendon. Sorry, this is on an auto-repeat. Radial carpal injections, again, you can really see this well when you're coming in. Here's the distal radius here. Here's the carpal bone, probably your lunate right here. Here's the tip of your needle. Here's a video of that in the same injection. In this case, I think it's reversed. I think distal radius is to your right. Here comes the needle kind of over the carpal bone into the radial carpal joint, and I think, you know, you have to be pretty close to this area for it to work, but what the advantage here is when you start to see the fluid, you'll see if it kind of fills up in this area, you're probably not in the joint. You'll have to redirect a little deeper, and you can tell when the capsule lifts up as you get into the radial carpal joint. As we get into the shoulder, again, subacromial injection, there's pretty good studies showing like 97% accuracy with pure palpation, so I'm not sure that this is as valuable. It is like if you have calcific tendonitis, some people will do needling for this, and that can be helpful. Here you can see your needle kind of being introduced. Here's your rotator cuff. This is your deltoid. You can just see that bursa just filling up with fluid, that black band, and you hear, you know, just a really great image here of them being in the exactly correct spot, and you're like, geez, just go all the way across the rotator cuff. AC joint injections, I like this particularly for weightlifters who I'm thinking that I'm going to do a distal clavicle excision if this does not work, and here I think this imaging is not as good as some of the other ones, but here you can see that needle kind of coming to the side, and I don't know if there's a good, yeah, there's not a good image of the fluid filling it up, but you can definitely feel that and see it even, you know, they're usually pretty thin there. And then lastly, glenohumeral injection. This is probably why I got my ultrasound initially was I was just trying to deal with arthritic patients, and I'll do this posterior in plane again. You can see the needle. You can see the tuberosity there. Let's see this video here. Here you go. There's a lesser tuberosity right here. This image doesn't show it, but humeral head is going to be kind of over here. This technique is perfectly adequate. I typically tend to come from the other side. I tend to kind of come in like this, and you kind of get between the humeral head and the glenoid. You can see your labrum often, but you can see as they inject that it just basically lifts the rotator cuff off the joint, meaning that you're intraarticular. So these injections are more precise, at least for non-surgeons, but even for us, you know, amazing surgeons, we miss occasionally, and so having the guidance certainly increases the precision with which we place the needle. It definitely can lead to better efficacy when you see people that have had injections where you've missed, they do not do as well as the one where you get the joint injected or the correct location placed, but becoming comfortable with these injections increases your treatment options. So by doing these routinely for simple things where you say, oh, I don't need it, then you start to become so facile, and you understand the anatomy, and then you can use it when you really do need it. So all right. Thank you very much. So next, Kevin is going to talk to us about shoulder exam. All right, thank you guys very much for having me here. Always fun to talk about ultrasound on the shoulder. In the upper extremity, John has done a ton of research in the last 10 years for carpal tunnel. I think the next biggest bang for your buck and for your patience is, if you do treat shoulders, learning how to ultrasound the shoulder is huge because it can supplant MRI. In my practice, it has supplanted MRI for rotator cup tears. So just like with John, no more nerve studies for carpal tunnel. For me, no more MRIs for cuffs. And that's the bulk of my practice. And it's awesome for patients, from time, money, et cetera. So it's a massive amount of value for your patients. And people talk about workflows and all these things. And John's got a busy practice, so does Tom. And we see 50, 60 people in a day pretty routinely. And I do a complete ultrasound exam on all new shoulders over the age of 35 unless there's something that's, if they have an MRI, I don't do the ultrasound. If they're severely arthritic, then I don't. Because it doesn't add much to what I'm, but if they have a normal x-ray and they're over the age of 35, this is just part of my exam. And this is the full exam. This is actually how it goes. And I just started hitting live video now. So I just take a video recording the whole time. So, you know, there what I looked at, I looked at subscap, I looked at biceps, I looked at supra, infra, teres minor, right? Like that was it. And so it's down to about 27 seconds. So if you don't have 27 seconds, then I guess this isn't good for you. But if you do have 27 seconds, then maybe like you shouldn't incorporate this. The other question we get all the time is, you know, how many, how long did it take you to get good at this? This has actually been published. There was a really good JBGS article that looked at novices and how long did it take for them to get to the same accuracy as a radiologist reading an MRI. And they found it was about 50 exams if you're an orthopedic surgeon. So just like Tom said, and with, you know, with, with surgeons, you have a deep understanding of the anatomy better than any other physician. And and if you do 50 exams of the shoulder, you will obtain the accuracy for sensitivity and specificity as a musculoskeletal radiologist reading an MRI for the diagnosis of rotator cuff tears. So not that many. So this is something I'm big on with shoulders. I think having rotating stools is huge in your office. It just allows you to kind of flow around their body better. So just get a couple of rotating stools and, and it just, it'll just make your life easier. So this is where we start, this is kind of the lighthouse, we say. So the first thing you want to find is the biceps tendon and you want to find it in the inner tubercular groove. And if you notice just medial here, right, I don't know if you can see that, is the subscapularis. So this allows you to learn, you know, you want to look at biceps pathology here, which if there's fluid in the groove or the biceps is subluxed medially, that's pathology. If you ever see the biceps perched here just a little bit, they have to have a subscap tear. Like they can't not have a subscap tear. So you automatically know there's a cuff tear and the biceps is dislocated. And then also what I look here too is, is there any, is there a little bit of fluid above the subscap? And if you see kind of fluid in this line here, then you'll, that's typically a full thickness cuff tear because fluid's leaking out of the shoulder. So this is, you know, the, how the patient externally rotate, you can see like the full view of the subscap, but really now I'm just kind of focusing on that upper two thirds because you almost never see a subscap tear that's below the upper two thirds. It's either off there and if it's not, then it's intact lower. So I'm kind of looking at that leading edge of subscap just at the tuberosity. And then if I don't see it there, then I'll keep going down and seeing how big it is. And then this is, this is an important view. So you want to look at biceps, subscap, and then the next part is having the patient kind of bring their hand back. And we call this the grab your gun position, right? So they, you bring your hand back in your pocket like this and have your elbow a little bit tucked and everybody in Texas knows what that means. So that's good. But, and then you want to have the angle of the probe, we call it contra-shoulder ipsy hip. So it's, the probe is angled about 45 degrees and that gives you your long axis supraspinatus view. So this is just like getting a coronal MRI and this is important because the majority of rotator cuff tears involve the supraspinatus. So you need to be able to get this view. And then as you, as you kind of probe or scroll slightly back, you get in the infraspinatus and I call this kind of the anterior infraspinatus facet. You can go short axis. I really don't do this anymore because I just didn't really feel like it added anything to my decision making. It's like, do they have a tear or not? And we can talk about, you know, once you see pathology, how to kind of judge it. But I don't really do this much anymore unless we're at a course and you want to see it. You can, if you wanted to do this, you could, or you know, one way you could justify this is measuring, right? Like if you want to measure your cuff from like, there's the biceps here in the corner, right? We call this at the end of the rainbow. And then this is like a sagittal scan MRI. So if you wanted to measure how big your cuff is, anterior, posterior width, this is a way to do that if you're doing research. But I care more about retraction than that. And so this is posterior infraspinatus and then you see the humeral head and this is the view that you get for doing a posterior glenohumeral joint injection. And by the way, that supraspinatus view is the view you get for a subacromial injection. And then this is going down in the teres minor. Again, you can see the humeral head and then the labrum back right here in the corner. So this is big. If you had to take away one thing, like one thing only from this whole lecture, and you want to know how I diagnose a cuff tear, just remember the dip in the deltoid, right? And this is a normal rotator cuff here. You see how everything is convex and you see the shape of this tendon. This is perfectly normal. When someone has a tear, you get this little bit of a dip and it's very subtle. And you may think like, oh, well, maybe this is still attached here. No. If there is any type of dip whatsoever in the deltoid, that is either a full thickness tear or like a 95% partial tear where, you know, essentially the entire rotator cuff is torn. And then this is looking at it again in kind of the short axis view. This is the dip again in the deltoid. And this is a normal short axis view. So you see that dip. And this is just a patient with a relatively large tear here. And we can see this is our ultrasound image. And then this is what we look like arthroscopically. Massive tear. And then that's it. Thank you very much. All right. Thanks, Kevin. Let me go back for a second and try to sync this. Any questions from the audience as we kind of wait? Thank you. All right, since theirs weren't working, we'll use our own. So I mean, I talked earlier about people asking questions about operator dependence and how to get started. I think one of the most important things, especially if you're in private practice, is how do I afford or pay for a machine? You know, sometimes it's easy in academics because we have a lot of resources and maybe it's there for research or we have a bunch of PM&R people or sports that want to use it. So how do you as a hand surgeon get a machine? I think one of the important things to know is that you do not have to be a radiologist to bill for or to do MSK ultrasound. What kind of the CPT book would say is that it should be within the scope of your practice, kind of vague, and that you should be appropriately trained, whatever that means. So, you know, kind of one of my things that I hope to do for the Hand Society long-term is I want to make it part of the fellowship education track. I don't think there's any reason in 2022 that it shouldn't be almost a requirement of our fellowships. They get a week of MSK ultrasound training or they should go to a course or something like that because as you all know, when you go to apply for credentials and privileges, it's really based on what you did in your training. And if you did ultrasound in your training and you can prove it, then you can do that in practice and no one can really tell you you can't. If you've never used ultrasound at all, then sometimes that is a little bit of an issue from a credentialing standpoint. Some states it matters a lot. I would tell you in Pennsylvania, it actually doesn't matter. There's no requirements from the insurers. I've heard that Boston in particular is a very rigid place. And so I know like Kyle Eberlin from MGH, like actually went and did a formal course and got a certificate and he had to like give that to Mass General for them to let him bill for ultrasound. So kind of in that disclaimer section below, you basically have to check with your practice manager and your billers and see what the requirements are for your specific state. But in general, there's no certification program nationally to get this stuff. So if anyone wants these slides, you can email me fowlerjrupmc.edu. It's a lot easier just to send the slides than to try to get to write down all the codes. So this first code 76881, Kevin, can you talk about the code you use for your exams? Yeah, so if you're gonna do a complete shoulder exam, this is the code you would use. Now, technically you have to describe all these different structures in order to build a complete exam. And so a lot of times what people do is they have a smart set. You type in .ultrasound, complete, and this comes up and you basically just fill in each one. Yeah, so Kevin said that when he even does a carpal tunnel exam he will bill for this and I don't think you have to get crazy like he was saying like you know you look at the tendons you see the muscle tendons junction you see these things to just just say what you see and you could do the same thing for this you have to have an indication so it's easy you know indication shoulder pain indications carpal tunnel it doesn't matter what the indication is you have to store it in an image just just one technically and then you have to have a separate written report so like I know I use epic so I have my normal office note and then I'll like open a second tab note and just do my little ultrasound smart set so that is the complete exam seven six eight eight one the other exam is seven six eight eight two it's a limited exam so this is the one I typically use because I don't know if I don't care I don't spend the time but basically you just have to talk about whatever you're looking at so if I'm doing this for carpal tunnel syndrome I would just comment on the nerve media nerve or indication carpal tunnel syndrome ultrasounds perform media nerve cross-section areas 14 millimeters squared done that's all you need save an image and you're set so those are the two kind of diagnostic codes then you're going to start talking about needle codes for injections and you'll see on the next slide if you're doing a joint or a bursa injection it gets bundled into that ultrasound code I'll talk about the next if you're not doing any of those and for example if you're injecting the carpal tunnel that's not technically a joint or a bursa so you would build for that carpal tunnel injection I think it's like two zero five five zero or something like that and then you would add on this needle guidance code same thing you have to an indication carpal tunnel syndrome you know perform an ultrasound I localized the media nerve and then I injected you know one CC of beta methadone into the carpal tunnel under ultrasound guidance same thing save an image and you're set one of the issues with seven six nine four two is you can only use it one time per day so say that the patient's bilateral carpal tunnel syndrome you just get one guidance code you can't actually build twice there's no like 51 modifier for bilateral as I mentioned the joint personal codes are bundled so if you're going to do like a CMC injection without guidance you would build two zero six zero zero but if you use ultrasound guidance you actually use a different code you wouldn't code two zero six zero zero and then seven six nine four two you would do the separate code the nice thing about that is that if you inject bilateral CMC's or you do both shoulders both CMC's like those my patients everything hurts when they come in they want nine injections you can bill for all those separately here is the reimbursement at least in Pennsylvania as of last year when I made this talk so you can see that if you come down to the two zero six zero four if you did just a regular injection it's 0.6 RV use or $50 if you add the ultrasound guidance it bumps up to 0.89 RV use or $75 you can see for a small joint injection using ultrasound it adds an additional $25 for a medium joint it does an additional $31 and for a shoulder joint it does an additional $32 and this varies greatly by state I think Texas is a pretty good state for this stuff Kevin does a little better than that on some of those shoulder codes Kevin what do you think you're getting for a shoulder injection with ultrasound hundred yeah all right so seven dollars more everything's bigger in Texas right all right so that's that's the billing that's that's what you can you can get for these things and so like how much is an ultrasound machine cost I mean it greatly varies you have seen a lot of models in the $25,000 range and if anyone was at the pre-course the other day we had a couple of very nice machines for around $25,000 with two probes you can get really expensive machines too like I don't think anyone here needs like an OBGYN hospital based enormous machine like that you're just wasting your money kind of thing so you can you can just pay for it outright a lot of companies will let you lease to own so say that you're gonna get kind of a mid-level machine $40,000 $50,000 that is going to charge you about $1,500 a month for a couple years and you can basically cover that cost if you do on average about 50 injections per month so using those numbers we kind of talked about earlier say that you are in that that bottom row so you do three limited ultrasound evaluations so that's seven six eight eight two code and then you do two ultrasound guided injections per week now I stole the side slide from Jay Smith he's one of the rehab doc so they see patients five days a week a surgery probably see patients three days a week or even less but basically five uses a week you can pull in about an additional $23,000 a year and that's not a lot you we talked about how do you get started I mean don't go back to your practice and try to use ultrasound on all 40 of your patients you're gonna hate it be miserable you'll stop if you pick three to five people a day to use it on you're gonna be able to bill enough to pay for your machine now if you're gonna get really fancy look at the one you know 30 uses a week so you have three office days you do ten injections a week and that's probably what I do because I mean I'm gonna inject three or four CMC's I'm gonna do a couple carpal tunnel exams see a lot of shoulder impingement and inject that so you can see I mean that's probably bringing in almost $150,000 a year to you know pits practice just by billing appropriately and then you can see towards the bottom there I just kind of put those those codes down again so you know it doesn't make sense financially I looked up my numbers are in January in January I did 90 injections over the course of the month so is that you know three office days a week you're looking at you know seven eight injections a day and so even if you just did that and I think when you look at the previous slide that's kind of like the total value of the injection but if you look at just the added cost or the added reimbursement it's about $30 we looked at the numbers small medium large it was like 25 31 33 that's an additional $32,000 that I wouldn't have gotten had I not done the injections so it can make some sense from a financial standpoint so that is our formal talks any questions yes go ahead you want to come to the mic you just want to shout it out It's a great point, because now that patients have not only co-pays but co-insurances and people on high deductible plans, they potentially could get charged for those things. To your point, I often don't charge for any of those things. Like in general, I don't bill a ton of diagnostic exams. I know I could. If I pulled out to look at a foreign body, I think I could. But I often don't. So I personally don't have that conversation a lot. I think that you should probably describe it to the patient like, this is a different another way to help your diagnosis. It'd be just like me sending you down the hall for an x-ray. Or you could even frame it as, hey, I could send you for an MRI, which would probably cost you $1,000. Or if you want, I can do this ultrasound right now and give us an answer, too, and that may cost you whatever the charge is. And that's kind of the funny business of this, is that you can see the reimbursement rates, but who knows what the charge is? If they're reimbursing us at $50, the hospital may be charging them $300, and then what is their insurance cap to cover? So I think it's kind of complicated. But I think you're right. I mean, from the full transparency, if you're going to do that and bill, you should probably at least discuss with the patient, this is like getting an additional x-ray or getting an MRI. And then, I mean, sometimes with injections, it's that way, too, right? If they're on a high-deductible plan and you just do a trigger finger injection, I've had patients come back that gets an extra charge for the trigger finger that wasn't included in the office visit, and sometimes they can be upset about that, too. But it's a great point. I'm glad you brought that up. Sir? Thank you. Thank you. I'm just thinking about efficiency. Lalonde. Butterflies. Yeah, they're exciting. I mean, they work on different technology. So Mark can't really talk about but most ultrasound machines use the transducers use piezoelectric crystals And then you run electricity through that that generates the sound wave it hits the tissue and bounces back off And then it receives the sound wave with the same crystals and that So it makes the picture basically, but those things like butterfly and Clarius. They actually work on different technology There's actually just little microprocessors at the tip not piezoelectric crystals And so I I think they're gonna get better at that I've used the first generation butterfly and Clarius, and I didn't think they were all that good they were nice because they were portable, but I didn't have quite the Picture quality that I felt I needed to be able to do true truly diagnostic things I think they worked better for you know scanning thyroids And if you're like a general surgeon you need to see is there is there air in the belly kind of thing like you could See that pretty well, but they weren't really ready for prime time Someone today though had a second generation Clarius, and it was a lot better the picture was better It was clear and so you know some of this the efficiency standpoint and just setting up your clinic Like do you do you drag the machine in each time to a new room? Do you have one room you do all your injections? You can imagine if you have a Clarius in your your coat pocket And you just bring it in and it transits to an iPad it might be a little bit more portable But my experience so far is it's not quite good enough to do the stuff that I wanted to do

musculoskeletal ultrasound

clinical practice

low cost

real-time results

diagnosis

injections

shoulder examinations

coding and billing

patient care