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13 y/o and ultrasound/phonophoresis for RTC tendinitis
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13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 9:00:00 AM
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ysumpt2006
Posts: 114
Joined: March 31, 2005
From: Youngstown, Ohio
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I have a patient presenting with chronic tendinitis in his shoulder. He is an athlete (baseball, basketball, lacrosse, football) and was referred by a local head of childhood orthopedics physician.
His order is for ultrasound of the affected tissues using hydrocortisone gel. No exercise at all (script covers 6 weeks).
I know that ultrasound is contraindicated over an active epiphysis, but the doc has the father convinced I need to do this procedure.
How long is considered active? If I look at an x-ray, can I be sure that it isn't active?
My gut (and my co-workers) tell me not to do it and I have voiced my opinion to the father and he agrees, but when he asked the doc the doc said it was OK because the pt was 13.
Any suggestions?
I'm going to see if I can get the doc to release exercise, also. He did it before, but he is adamantly against exercise for any pediatric condition (knee, back, shoulder, whatever).
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Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 12:41:00 PM
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KAK
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Wow Ken,
That’s a tough position to be in. As I understand it, the epiphysis is “inactive” when he is done growing. I’m quite sure that a 13 year old boy is not done growing. From experience with my son, this is when the “growing overnight” began. I wouldn’t do it. I’d try to get an OK for iontophoresis as an alternative. Pretty amazing that the doctor would be against exercises, especially with an athletic population… I hope he’s agreeable for you!
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 5:08:00 PM
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tc
Posts: 137
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From: Los Angeles area
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As a peds therapist, I agree with Kathy. Do not do something you know is contraindicated. The doc may very well not be informed well enough and is putting you at risk for doing harm. When you contact the doc I'd have your references at hand about why it is C/I over a epiphysis and express that you do not feel comfortable proceeding w/that, but would prefer to do xyz treatment. Hopefully the doc will listen, but some orthos are not very open to listening :(
good luck.
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 5:18:00 PM
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ysumpt2006
Posts: 114
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From: Youngstown, Ohio
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I definitely won't do this procedure and I have talked to the father (an attorney) regarding my not wanting to complete the procedure and he agrees.
When he talked to the doc (and mentioned our previous discussion re: ultrasound and the need for exercise), the doc supposedly said something to the effects of "I can understand his (my) thoughts, but your son is 13 and it will be fine".
I'm gonna send something over to him and see if he will reconsider.
_____________________________
Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 5:23:00 PM
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Dr.Wagner
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well...honestly I think you are putting too much faith and power in the mystical Ultrasound machine.
5 reasons why you will be OK
1. Do you plan on leaving the head on the epiphysis for an extended period of time without movement? Isn't that when the studies seem to indicate potential "bad outcomes" occur?!
2. If the above were to occur, wouldn't likely deep tissue and periosteal pain be overwhelming. And cause withdrawal before osteoblasts EXPLODE in a pubescent Hiroshima!?
3. Do you think the machine can literally penetrate to the epiphysis...really.
4. Have you ever ever ever seen a adolescent with a significantly shorter upper extremity that wasn't a birth defect or the result of trauma? Seriously.
5. Ok...find the epiphysis!
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 5:55:00 PM
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TC PT
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Where I practice, we now have surgeons doing ACL reconstructions on skeletally immature pts., drilling tunnels through growth plates. Could a pulsed US for phoresing be more damaging to a growth plate than that?
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 15, 2007 6:48:00 PM
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Rwantz
Posts: 84
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From: Middletown, PA
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I would agree with the previous posts. I will share an excerpt from Modalities for Therapeutic Intervention. Michlovitz and Nolan. 2005.
"There is no clear consensus regarding the safety of therapeutic ultrasound over epiphyseal plates in children. Historically, it was considered contraindicated based on animal research demonstrating retardation of growth and damage to the epiphyseal plate following high-intensity ultrasound delivered using a stationary transducer. More recently, some texts have reported that at clinically applicable intensities, ultrasound over open epiphyseal plates should be safe and is no longer considered a contraindication but, rather may be used with caution." The authors do go on to say that "it is this author's opinion that in the absence of compelling date to suggest otherwise, application of therapeutic ultrasound at any intensity over epiphyseal regions in skeletally immature patients is contraindicated."
I added the second part only to offer balance. It is my personal belief that there is no danger. Allow me to give the references that are provided.
Bender, James, Herrick. Histologic studies following exposure of bone to ultrasound. Arch Phy Med Rehabil. 35:555, 1954.
DeForest, Herrick, James. Effect of ultrasound on growing bones: an experimental study. Arch Phys Med Rehabil. 34:21, 1953.
Nussbaum EL. Therapeutic ultrasound. In Behrens BJ, Micholovitz SL (eds), Physical Agents Theory and Practice for Physical Therapist Assistant. Philadelphia: FA Davis, 1996, p. 105.
McDiarmid TM, Ziskin MC, Michlovitz SL. Therapeutic ultrasound. In Michlovitz SL (ed), Thermal Agents in Rehabiliation, 3rd ed. Philadelphia: FA Davis, 1996, p. 205.
Belanger A-Y. Acoustic radiation: ultrasound. In Evidence Based Guide to Therapeutic Physical Agents. Philadelphia: Lippincott Williams & Wilkins, 2002, p. 249.
Starkey C. Ultrasound. In Therapeutic Modalities, 2nd ed. Philadelphia: FA Davis, 1999, p. 298.
The research from the 50s is a little dated for me.
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 1:28:00 AM
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ysumpt2006
Posts: 114
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From: Youngstown, Ohio
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Thanks folks, exactly what I wanted. And Dr. Wagner, the tone conveyed in your post seems to indicate that I am the one who came up with the contraindication--I'm just going on what was drilled into my head all through PT school. I'm a new clinician in the PT field and havent' researched the effects of ultrasound and epiphysieal plates. All of my "pseudo-research" led me to believe what my PhD'd professors (and the textbooks we used) indicated.
Now back to the other part of the question--what benefit would phonophoresis give in this condition, especially if it is the only thing in the plan of care?
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Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 2:24:00 AM
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Sebastian Asselbergs
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I'd like to see the rationale behind the "against any exercise for any pediatric condition" of this orthopod. Has he taken the old tenet: "no weight training for prepubescents and pubers" too far?
How does he see the exercise of 8 -9 year olds in competitive figure skating? Or gymnastics? Or hockey? Obviously these are rethorical questions, showing my opinion of the orthopod...
Guided exercise programmes, especially for a neuromuscular complex area as the shoulder, are a must - and can be very short term, in view of the age of the pt.
But then again, I am not under the restrictions that you are with regards to doctor's orders....
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Mundi vult decipi
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 2:29:00 AM
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SJBird55
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From: Michigan
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Ummm... heck with any contraindications... does ultrasound really give any benefit? LOL How is it that we are the supposed "experts" with physical therapy and we are bound to "orders" from physicians who have no clue? issues...
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 3:12:00 AM
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Alex Brenner PT MPT OCS
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SJ,
Exactly; the bigger question should be, why is ultrasound even being considered a treatment option in the first place? I have yet to find any evidence to suggest it has any beneficial results at all and certainly there is way more evidence based interventions. I have not turned on an US unit in years. Thank God I can practice autonomously and don't have to worry about crap like this.
Dr. Wagner - Right on!
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Alex Brenner, PT, MPT, OCS
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 3:37:00 AM
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ysumpt2006
Posts: 114
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From: Youngstown, Ohio
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The no-exercise is a "protocol" this doc uses because he feels that a person should be pain-free before strength training begings. One of my colleagues has been "reamed out" by the doc on a couple of occasions just for suggesting exercise for lumbar stabilization (he ordered ultrasound and massage for 6 weeks--same order for this shoulder, too, lol).
As far as phonophoresis for RTC/Bicipital Tendonitis? I have heard mixed results, but I have treated many people without it and they got better pretty quickly.
_____________________________
Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 4:27:00 AM
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PhysioThis
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From: New York
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Looking at it just from a legal perspective, would it not be more prudent to just avoid the US? Despite what we can assume and deduce physiologically, the fact that there is a long history of teaching and documentation of contraindication for this particular application of US creates potential ammo for litigation if this kids shoulder never gets better, no?
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Ed, PT, MTB-XC
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 4:48:00 AM
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ysumpt2006
Posts: 114
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From: Youngstown, Ohio
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Exactly what I was thinking, too--especially since his father is an attorney.
Not doing the US since there is little to no documented proof that it will do any good, and the whole "epiphysis" deal.
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Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 5:08:00 AM
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Shill
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From: Madison WI USA
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You could call the orthopod and ask for the study showing the benefit of phonophoresis for similar conditions in similar patients, so that you can accurately replicate the parameters used. Guess what. You wont get a reply, because it doesnt exist. You could simply ask the doc how set he or she is on actually using this modality, and politely explain the dilemma. Fear of being reamed out will likely prevent you from doing this, but we have to get over this when orders are not consistent with current best evidence. What you have to lose is treating patients with prehistoric orders that wont help anyway.
That said, I would not be worried about causing any epiphyseal problems, as the intensities of the animal studies are ridiculously high, and the parameters that might be used in this situation would be pulsed US at 20% DC, 0.5-0.8 w/cm2. (Young and Dyson 1990, and Enwemeka eta all, 1990, both in Ultraound in Med. and Biol Journal) I dont think we are comparing apples to apples on this, but I can see the CYA aspect as well.
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Steve Hill PT
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 6:21:00 AM
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ysumpt2006
Posts: 114
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From: Youngstown, Ohio
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I have no fear of being reamed out--especially in dealing with these types of things.
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Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 6:46:00 AM
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Shill
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From: Madison WI USA
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Cool. There are a number of people who would avoid this conflict. Kudos to you.
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Steve Hill PT
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 16, 2007 4:25:00 PM
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Dr.Wagner
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Seriously, there will be absolutely no problems, direct trauma to the epiphysis can do damage (ie Salter Harris IV) but that is ABSOLUTE OBLITERATION. An ultrasound done with CLINICAL intensity and CLINICAL technique will do no CLINICAL damage to the growth plate. I would bet my HOUSE on it. Really just think logically about it.
Also, medico-legally you are safe as there have been NO case studies that I know of in the human population to show this, plus you could do a retrospective analysis of thousands of pediatric PT charts and note no damage. Lastly, you could be doing ultrasounds to 21 year olds with open Physis and NOT EVEN KNOW IT.
Oh yeah, then there is the point of the mystical ultrasound and the questionable benefit in the first place.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 18, 2007 6:23:00 AM
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jwb
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Is the problem really a tendonitis or a tendonosis? Probably tendonosis, therefore US, phonophoresis, iontophoresis will have little affect since tendonosis is non-inflammatory based on recent research.
Secondly, my initial thoughts for this patient are a GIRD (Glenohumeral Internal Rotation Deficit). Assess internal rotation with the scapula stabilized at 90 degrees abduction. Greater than a 25 degree difference indicates GIRD and he needs mobilization and stretching of the posterior capsule. The relocation (containment) test will be positive.
Third, the patient may have instability as history would indicate. Drawer tests, load and shift, sulcus would be priority special tests, then labral tests.
Despite the above, the kid probably needs to have instruction in throwing mechanics and scapular stabilization is a must.
Finally, talk to the doctor and explain the kids findings on your exam. US/phonophoresis MAY improve symptoms, but will not resolve the problem long term.
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PT, OCS
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Re: 13 y/o and ultrasound/phonophoresis for RTC tendinitis - March 27, 2007 5:50:00 PM
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rwillcott
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From: Canada
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ultrasound. ultrabullshit
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