08/14/2013    David E. Gurvis, DPM

Diagnostic Ultrasound (Bryan Markinson, DPM)

Regardless of the utilization of ultrasound or
not, 10 injections of a steroid into a ganglion
cyst seems to fall beneath the standard of care.
I think that is the issue here, rather than the
use of ultrasound, which is peripheral. As to Dr.
Markinson's musings about how much steroid would
remain in the body of the plantar fascia,
I “guess” that it is mostly due to the nature of
the structure, but I cannot, of course prove it.
Your study would be most interesting if indeed it
could be accomplished morally in a manner where
it could be measured.

If a new technology comes along, and some pick it
up and are front-runners in utilizations of same,
and if the insurance companies decided to limit
the payments, or deny it, that DOES NOT in and of
itself prove the procedure has been fraudulently
applied or over-utilized. It only proves the
insurance company does not want to pay for it. I
do think that those who use it for every
injection – including the simplest – may be over-
utilizing, but even then I am unable to make a
clear statement.

In the past year, I remember an article in a
radiology journal purporting to show that U.S.
guided intra-articular injections work better
than non-guided. Will we now all accuse those of
doing guided intra-articular injections of being
frauds? Will we proclaim how stupid they are for
needing U.S. to get a needle into say, the 1st or
2nd MTPJ. Those joints can be difficult to enter,
and if U.S. saves the patient from my “walking
the bone” to enter the joint, then it was well
worth it.

David E. Gurvis, DPM, Avon IN, Deg1@comcast.net

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08/16/2013    Bill Greco, DPM

Diagnostic Ultrasound (Bryan Markinson, DPM)

Is the example of ten ultrasound-guided steroid
injections an example of the fallibility of
ultrasound or the incompetence of care, bordering
on malpractice, of one individual?

Ultrasound as a practice adjunct will provide the
practitioner valuable information. Is the mass
cellular or fluid? Is it lobulated or a single
chamber? Are there extensions of the mass beyond
the palpable boundaries? Is it extending from a
tendon sheath or a joint capsule? Ultrasound can
be a valuable tool in the armamentarium of
podiatric medicine. It can often be the
difference between a successful outcome or a
reoccurrence.

That is not to say that aspiration and cytology
is not applicable. That is another valuable tool
in assisting our diagnostic regimen. From the
insurance perspective, it is a low cost
diagnostic tool that can assist is the diagnosis
and treatment of many podiatric conditions. Can
it be abused? Yes, as can every other diagnostic
modality. Are more studies needed? Yes, as with
many other modalities ongoing studies on outcome
based medicine and efficacy are always welcome.
Does this make it a poor tool? In the wrong hands
any tool can be used improperly? If ultrasound
improves a clinician’s outcomes and improves
his/her overall confidence in their diagnostic
decisions and treatment protocols, how can you
find fault in the modality?

We should be promoting improved education in
proper use of the modality, CME and or
Certification in its use and continued research
and scientific study into its capabilities and
limitations. Podiatry needs to raise the bar of
understanding in every aspect of medicine and
surgery in our scope of our practice. As my
father once told me to my annoyance, “ do not
throw the baby out with the bath water.” Improve
our understanding and use of ultrasound as a
profession rather than harp on its flaws. That
is how we will grow, in spite of the one who
thinks ten ultrasound-guided steroid injections
is proper medicine.

Bill Greco, DPM, New Rochelle, NY,
William.Greco@va.gov