Clinical reasoning is a procedure that contains a series of cognitive process where a practitioner collect the information about a patient, merge that information then develops and implements the treatment method to manage the patient condition (Orrock et al., 2014). Clinical reasoning also requires different tools to identify pathology and diagnose patient condition. Due to advances in technology and wide availability of various diagnostic tools there is a trend among practitioners of various specialties to integrate Ultrasound (US) into their regular clinical assessment (Patil and Dasgupta, 2012). According to Naredo et al., (2006) US is a non-invasive, cost-effective and easy accessible diagnostic tool to study the musculoskeletal system and it provides the real time visual feedback of the structures and its function for both clinician and patient. It improves clinician’s ability to evaluate and treat the patient (Teyhen, 2006). The technology has noticeably improved the US from compound to real time scanning. The greater resolution of the US transducer improved the diagnostic accuracy. US is used in both clinical and research physiotherapy practice set up to assess the muscle wasting, to test the effectiveness of the treatment and for the visual feedback to assist the treatment (Stokes et al., 1997). Hence, US may be a useful diagnostic tool in my physiotherapy practice. A patient Mr. NP (see appendix) presented a limping gait with pain in the calf region of the left leg. Patient was unable to train for his marathon. His general practitioner provisionally diagnosed his condition as Achilles Tendon (AT) pathology and referred him for radiological investigation. Meantime, Mr NP was referred to physiotherapy, awaiting his magnetic resonance imaging (MRI) results. US is the most commonly used to diagnostic tool to identify the musculoskeletal lesions such as partial and complete tears, tendon pathology in Achilles, patellar and rotator cuff tendons (Chhem et al., 1994). The above mentioned studies suggested that US is a favourable tool in the diagnostic management of AT pathology. This essay will discuss how US imaging can have an impact on the management of Mr. NP in physiotherapy clinical practice settings.
According to Chang and Miller (2009), US imaging has greater resolution and it is a rapid examination procedure than MRI and that can be used to perform a dynamic examination of tendons and muscles. US imaging is a readily available diagnostic tool, which has clinical applications that are important to the physiotherapy practitioner to diagnose and treat soft tissue injuries. It is safe, proven technique and it has the capability to image the soft tissue pathology non-invasively with appropriate resolution (Loudon et al., 2005). AT is one of the most common sites for tendon injuries in athletes (Gibbon et al., 2000). A diagnostic study on AT pathology among runners was conducted by Maffulli et al., (1987). In this study forty seven athletes complaining of AT problems from an average six months were selected after thorough examination by a surgeon. The two radiologists were analysed the ultrasound photographs after performing the ultrasound examination. The study showed that eight athletes with bilateral pathology, five patients (10.7%) with paratendonitis, twenty eight cases (59.6%) showed the features of tendonitis and six patients (12.8%) presented enthesopathy. The study concluded that the US gives a precise visualised structure of an affected tissue and assist the practitioner in the anatomy- pathological based diagnosis. This study revealed that US is an accurate and cost effective tool compare to combined clinical examination and xeroradiography. Even though, this study diagnosed the AT pathology among athlete using US, this study cannot be generalised due to the fact that this study has mentioned neither age nor the sex of the patients, nor the experience and the skill of the radiographer. However, it would have been more use full, if the researcher had selected a different age and sex groups and experienced radiographer, and had measured the specificity and the sensitivity of this study for the accuracy. However, Jacobson (2009) stated that accuracies of previous US studies should be ignored because these data were acquired from lower resolution on those machines compared with current high resolution ultrasound machines. In another study, Hartgerink et al., (2001) determine the accuracy of the US in differentiating full-from partial-thickness tears or tendinosis of AT. The result of this study showed that the use of ultrasound findings has 100% sensitivity, 83% specificity and 92% accuracy in distinguishing the full-from partial-thickness tears. This study concluded that US has 92% accuracy in differentiating full-from partial thickness tears or tendinosis of the AT. According to Teh et al., (2003) power Doppler imaging plays an important role in monitoring response to treatment. A study conducted by Alfredson et al., (2011) evaluated the US and colour Doppler findings in patients with suspected partial rupture of AT. This study investigated the high blood flow in the disrupted dorsal tendon line, which indicated a partial rupture. The study concluded that US and Doppler examination are useful tools to diagnose the partial mid-portion AT ruptures. Similarly, Loudon et al., (2005) explained that US has been used as an important tool to diagnose AT pathology over a decade and it provides real-time data that can be stored as permanent records and this reduces the time and patient suffering, and also US is affordable. From the above studies it is evident that US has evolved into better technology over the period with high resolution. US now have been used for guiding needle in injection therapy and for aspiration. It also emerged as an important diagnostic tool in detecting the AT pathology. From the above studies it is also understood that the US is accurate, cost effective, and readily available, saves time and also an important tool to diagnose AT pathology than other diagnostic tools. Hence, US may have good impact in identifying and managing pathology in Mr. NP, who presented similar clinical symptoms.
US is a reliable alternative tool to MRI in diagnosing musculoskeletal pathology. It is non-invasive and alternative to arthrography (Lin et al., 2000 and Ptasznik, 2001) and has many advantages over more costly imaging techniques such as MRI. Nazarian (2008) stated that patients with cardiac pacemakers and certain metal implants are contraindicated to MRI and many patients are unable to complete the MRI examination due to claustrophobia. However, there are no such contraindications with US. In addition, Girish et al., (2007) stated that the high frequency, dynamic, real time ultrasound is an alternative imaging and bio feedback tool to MRI. Since US obtain the real time image, it can be used at bed side examination and also has the benefit of patient feedback. From the above studies it is evident that US has high specificity and accuracy, has more advantage than MRI and there are no contraindications. Therefore, US may be useful tool with accuracy than the MRI to diagnose the pathology of AT in patients such as Mr NP. Even though, US have more advantage than MRI, it has disadvantage such as, it requires skills especially during US guided injection therapy and aspiration procedures. Hertzberg et al., (2000) conducted a study to assess the physician competence in the performance of the US. The results of this study showed the progressive improvement in US performance skills with increasing numbers of cases during the training period. This study concluded that the training with two hundred or smaller number of cases is not sufficient for physicians to develop the knowledge and skills in US. However to use the US appropriately, practitioner like me can develop the knowledge and skills by obtaining proper training. In addition, practitioner should adhere to the legal and professional guidelines of the United Kingdom association of Sonographers, ethics and regulations of respective professional bodies. In practice setting evidence based management is essential for the patient care and for the reimbursement. According to Hides et al., (1998) the assessment and treatment through US should be emphasised in physiotherapy practice and therapist should use the ultrasound judiciously and appropriately to gain the credibility and the benefit. Loudon et al., (2005) reported that the physiotherapy practitioner should use the US as a diagnostic tool to assist them in the prevention and treatment of musculoskeletal pathology. Thus, US can play an important role in providing reliable evidence in identifying pathology, would assist in treatment, monitoring and prognosis in patients like Mr NP. This may have better impact on the management of this patient in my physiotherapy practice settings.
In conclusion, US imaging is non-invasive, cost-effective, safe and easy accessible diagnostic tool to examine the musculoskeletal pathology including Achilles tendon pathology in Mr NP. The literature suggests that US has high accuracy, can be used at bed side, saves the time, and there are no contraindications compare to the other methods of investigations such as xeroradiography and MRI. However, proper training is essential for the physiotherapy practitioner to use US in their day to day practice. In addition, further studies are needed to prove the evidence that US will have an impact in the management of patients within physiotherapy practice settings.