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Ultrasound and children

Should a 13 yr old girl be repeatedly be getting ultrasound on her knee for Patella tendinitis? Isn’t u/s contraindicated on children where there is a not closed growth plate?? Why is it contraindicated with children? Just curious, thanks.

Jen Sommerfeldt

1 month ago

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Prof Tim Watson
Prof Tim Watson

Will not repeat what has already been posted - and thanks to Prof Goh and Cliff for their contributions. I will add a couple of addenda. Ultrasound is commonly listed as a contraindication or precaution in guidelines (CSP in the UK 2006, Canadian doc 2010). This is certainly on the conservative side. There is evidence out there - animal studies - predictably - which demonstrates ultrasound having an effect on growth plates when direct exposure at high doses on very young animals - typically 1 month old rabbits. Because these detrimental effects were demonstrated, therapists tend to be (over) cautious. I can see nothing in the evidence that says that ultrasound, when applied at 'normal' therapeutic doses would have a detrimental effects - even over an active growth plate. In fact, a very high percentage of the applied would not reach the growth plate as it would be reflected from bone surface before it even got close. I would (personally) use ultrasound around a growth plate (for the rationale above), but I appreciate the the current guidance suggests that it should be avoided. There is a need for an Internationally agreed set of guidance, updated for 2018, but that is a big ask - though we are working on it! Also endorse the use of shockwave over ultrasound for patellar tendinitis - there is evidence of benefit

Prof Ah-Cheng Goh
Prof Ah-Cheng Goh

Sorry for the multiple posts... for some reason, the second part of my reply was truncated. I'm posting it here again...

However, I would like to clarify further on contraindications and growth plates. The literature does say that with regards to the electromagnetic spectrum, ionizing radiation (gamma, x-rays and UVC) are harmful to growth plates. Thats probably one of the reasons children are not routinely sent for repeated X-rays. However, non-ionizing radiation (UVA, UVB, visible light, infrared, microwave, shortwave) are NOT harmful to growth plates. However, as most of you are aware, therapeutic ultrasound is not part of the electromagnetic spectrum. It is classified as either mechanical or sonic energy (or both). And in this regard, therapeutic dosage of ultrasound does not affect growth plates EVEN WHEN they are applied directly over them. Hope this answers your concerns....

Prof Ah-Cheng Goh
Prof Ah-Cheng Goh

Hi Jen,

To add to the discussion.... the following paper may answer your concerns directly (and my point about dosage) i.e. therapeutic dosage does not affect the growth plates, whereas high dosage (beyond therapeutic) does, albeit in rabbits. But as Cliff pointed out, ethics prevents us from answering this in human subjects.

Lyon, R., Liu, X. C. and Meier, J. (2003), The effects of therapeutic vs. high-intensity ultrasound on the rabbit growth plate. J. Orthop. Res., 21: 865–871. Last updated 4 weeks ago

Cliff Eaton
Cliff Eaton

Dear Jen Firstly I heartly agree with Prof Ah-Cheng Goh. ESWT (shockwave) should be the go to modality (combined with progreesive loading strategies) given the quantity and quality of research. As far as I am aware there is no evidence to show that using US over a growth plate will cause harm. It is for this reason that manunfacturers will 'contraindicate it'. In order to get a licence to serll medical prodcuts in international markets THEY have to demonstrate that it will not cause harm. As they are not prepared to fund these studies, and quite frankly getting ethics and consenting subjects would also be difficult, it is easier for them to put in their handbooks that this ( and other things like pregnancy) is contraindicated Returning to ESWT (also using sound waves) Loher et at (2012) demonstrated ESWT's effective for treating Osgodd Schlatters, The average age of the cohort was 14years. Last year, 2016, they followed up on the subjects and not one reported having had any adverse reaction. So although there is nothing to say US will not cause harm equally there is nothing to say it will. All logic suggests that it will not If in doubt use or refer them for ESWT Bets wishes Cliff

Prof Ah-Cheng Goh
Prof Ah-Cheng Goh

Hi Jen, This is my first time posting a reply so forgive me if I appear to ramble on too much.... Your question was particularly interesting for the following reasons:

  1. Validity of contraindications taken out of context: While it is probably true that exposing growth plates to strong energy fields isn't advisable, it is difficult for me to imagine that ultrasound to the patellar tendon will result in this situation. In the first place, the energy from ultrasound is limited to the tissues directly under the transducer (unlike Shortwave or Microwave where the tissues exposed to the energy can be quite far reaching). So, as long as you restrict the effective radiating area (ERA) to the tendon, I don't see how this can be a problem since growth plates are not considered to be within this ERA, and therefore, SAFETY is not a problem.
  2. However, apart from SAFETY, the next important issue is EFFECTIVENESS. So far, the systematic reviews have not shown that ultrasound is effective in patellar tendinitis (granted, some of those reviews are a bit old). There is some encouraging evidence that ESWT is a better treatment option for patellar tendinitis, compared with therapeutic ultrasound.... assuming that you own an ESWT device and therefore is a possible treatment option.
  3. But, assuming you don't have an ESWT device..... here's what it comes down to. Under conditions where you do not have the growth plate directly under the ERA, it should be safe to use ultrasound. But given the evidence, ultrasound would not be your first choice for treatment effectiveness (that would be ESWT). And if you really want a good shot at getting a good treatment outcome using US, the real question is not about SAFETY (i.e. contraindications), the real question would be DOSAGE. And for that... it would take a much longer reply than this, and I've already tested your patience enough if you've made it thus far!
  4. Hope the others have more encouraging comments..

Last updated 1 month ago

tsjb356
tsjb356

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