08/22/2013    Todd Lamster, DPM

Diagnostic Ultrasound (Michael Forman, DPM)

First, to those who don't believe in its utility,
have any of you used an ultrasound machine for
guidance during an injection? What is your
experience that leads you to believe that you
don't need it?

I used to be in that camp and thought the same
thoughts, and figured that if I can't inject the
fascia or a joint by now, I should be doing
something else. Wrong! I know anatomy as well as
anyone else, and I can tell you from my own
experience that injecting the fascia or small
joint with US guidance is superior, and my own
results have shown that many times over.

Do I use it every time? No of course not! (Are we
cookie-cutter clinicians, doing the same
treatment for every patient, the same bunion
procedure for every bunion???) And I have not
talked myself into needing or using any one
product or service. I constantly re-evaluate the
benefit of my services as I want to be the best
provider I can be for my patients. We all do this
in the way of honing our surgical technique,
using new and better instrumentation, deciding
what medications we inject/prescribe, and even in
just continuing to expand our knowledge
throughout our careers.

Ultrasound is just another tool available for
judicious use by those who know how to use it
properly.

Second, here is an interesting point that I would
like to share. I have found that many times,
especially in those patients who have had plantar
fasciitis for several months, that their heel
pain is generally in a broader area, or it
radiates around the heel to one or more points.
Where would one inject again? In the past, I
would inject in the area of maximum pain, as this
in my mind would seem to give the most benefit.
Or maybe I would inject the medial calcaneal
nerve or Baxter's nerve, thinking that it was a
localized neuritis. Again, I was wrong!

The greatest benefit of using the ultrasound is
having the ability to find the pathological
portion of the fascia, and directing the
corticosteroid to that area. It's impressive to
see how all those other pains dissipate once the
correct structure is injected. On the flip side,
if the fascia is normal, then I have more
accurately ruled out a fascial issue and can
focus on a neurologic or rheumatologic cause of
the patient's heel pain.

Todd Lamster, DPM, Scottsdale, AZ,
tlamster@gmail.com

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08/08/2013    Marc Katz, DPM

Diagnostic Ultrasound (Michael Forman, DPM)

There is no overuse of ultrasound. There is not
enough use of ultrasound. I completely agree that
ultrasound is invaluable for all of the
applications that you mentioned and serves as a
great diagnostic tool.

However, there are issues to be discussed. Many
doctors that use ultrasound have no clue what
they are viewing but they use this tool to add
dollars to their visit. Just add this to the list
of procedures and billing tricks done by
podiatrists each day to increase their revenue.

So when people say that ultrasound is overused, I
believe that they might mean that is abused. And
apparently Medicare and BCBS agree and have
recently made determinations that ultrasound is
not covered for the injections that we do. And
the value of an ultrasound exam has dramatically
decreased as well. It's just the story of
podiatry and history repeating itself. And you
know all insurances will follow.

So, anyone that believes that ultrasound is an
excellent tool for injections will either use it
for the good of the patient and just get paid for
the injection or collect cash from the patient
for the ultrasound. I prefer the latter. I spent
time and money to become proficient at using an
ultrasound and I believe that in many cases the
outcomes will improve so I should get paid for my
expertise.

The other issue is that companies are selling
ultrasounds while the profession is not producing
experts at sonography. There are courses
available but they are not comprehensive enough
for true expertise.

So, I believe that as doctors we should make it a
point to be the experts and use this valuable
tool but only if we are proficient. If you think
your expertise has no value then give away the
service for free; patients expect free services
from rich doctors that drive fancy cars!

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com