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Ultrasound over growth plate in peadiatric patient

I have a 13 year old male patient who sustained an elbow injury during a rugby match 1 year ago. There was an impact to his elbow whilst it was in full extension, and he was diagnosed with a lateral epicondylar flake avulsion injury. Subjectively he complains of pain when his arm is in sustained elbow flexion, e.g. writing or brushing his teeth. Objectively he has full ROM with pain at end range flexion. He has slightly reduced strength in elbow flexion and extension, with pain on resisted elbow extension.

The patient has been advised that ultrasound may be an effective treatment for his symptoms, however I am concerned that ultrasound over the growth plate in minors is contraindicated; favouring instead exercise therapy, soft tissue work and mobilisations.

Does anyone have any thoughts on this subject, or can anyone recommend any appropriate research articles that may support or refute my hypothesis that ultrasound is an inappropriate treatment for this case study?

Natasha Cassidy

9 months ago

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natasha.cassidy177
natasha.cassidy177

Thank you very much colleagues for your input on this topic. It is clearly a debatable subject! I did decided not to use ultrasound in the end, mainly for the reason that I felt other therapies were more appropriate for this chronic pain pattern. I agree that it seems unlikely that any harm would come from a superficial therapeutic dose, however I do feel that even if there is a small chance of doing lasting damage , I would rather not use it.

Thank you again, Natasha

Prof Tim Watson
Prof Tim Watson

The use of ultrasound over growth plates in children and teenagers is something which comes around and around - and has done for years. As you will have seen from previous contributions, US in this kind of circumstance is commonly listed as either a contraindication or a precaution. The evidence is all animal model based (fairly predictably - nobody is going to lend us a load of children to do experiments on!!). The evidence of a detrimental effect is not strong - even with high dose US applied with high frequency on very young animals. In therapy, the US energy COULD have a detrimental effect on growth plate activity, and thus the general advice would be not to deliver directly over active growth zones. My general clinical thinking would be: ?? (a) does the applied energy reach the active growth plate?? and (b) if it does, would the applied energy have a detrimental effect?? Applied at low dose (intensity) and in a pulsed mode, I can not actually see any evidence for a detrimental effect, and I suspect that the general guidance is over conservative (for understandable reasons). Clearly this does not give you a definitive answer, but without additional evidence, I would have thought that the chance of having a detrimental effect on the underlying growth area is extraordinarily small. (There is an additional argument that a very high percentage of the applied energy will be reflected from the bone/cartilage surface, and thus is unlikely to actually reach the active epiphysis)

patrick.debock99
patrick.debock99

Hi Natasha,

The question whether US can or cannot be used on epiphyseal plates may go on for quite a while. On the other hand I thought why bother? Wouldn't it be an option to use microcurrent? This technique is known for causing tissue repair and there's no doubt that your patient has a tissue damage. In the case you described I couldn't see any contraindication for microcurrent. So why not try?

Patrick De Bock, PT, University of Antwerp, Belgium

Last updated 9 months ago

Dr Ethne Nussbaum
Dr Ethne Nussbaum

Hello Natasha & colleagues. Early warnings that US affected growth plates arose from studies that applied US to isolated ex vivo animal bones maintained in culture . Extrapolation to clinical situation is questionable. I agree with views expressed by others that it should be used judiciously over growing bone - i.e. apply the lowest possible dose for effective treatment & end as soon as the goal has been achieved. However, I also cannot see how US would be helpful in the case you mention given that ROM is full (no need for thermal US to stretch scar tissue) & healing is complete (no indication for pulsed US).

Dr Sandy Rennie
Dr Sandy Rennie

Hello Natasha.

I am unaware of any human studies/situations where ultrasound used near pediatric growth plates has accelerated metabolism leading to joint deformity. As I indicated earlier, if the level of US intensity is kept low (i.e. less than 1.0 W/sq.cm.) and the soundhead is kept moving, there should be no issues for treatment in this situation.

Regards, Sandy

Prof Oscar Ronzio
Prof Oscar Ronzio

Dear Natasha, maybe you will found interesting the information included in these articles, published in a scientific database in latin america,

http://pesquisa.bvsalud.org/portal/resource/pt/lil-450212 http://pesquisa.bvsalud.org/portal/resource/pt/lil-495056

Best, Oscar

Cliff Eaton
Cliff Eaton

Dear Natasha Your question posted on the electrophysicalforum site is not appearing. If you have your answer that is fine. My thoughts: For manufacturers to get International product licenses they have to demonstrate they they will NOT do harm. It would be very difficult to get ethical approval for such studies over epiphyseal growth plates. Therefore it is easier for manufacturers to blanket contraindicate such uses with their machines. So that is to say that US may well not cause harm, although in this particular presentation, personally, would not consider US as a useful adjunct I hope that is helpful Cliff

natasha.cassidy177
natasha.cassidy177

Dear Dr. Rennie,

Thank you for your reply and for these resources.

From the research I have read, my understanding was that US may accelerate the metabolism of the growth plate, and my worry was therefore that there may be potential joint deformity?

Regards, Natasha Cassidy

Dr Sandy Rennie
Dr Sandy Rennie

Hello Natasha.

Research has indicated that low intensity pulsed or continuous ultrasound can be used over bone-growth plates in adolescents. Houghton, Nussbaum and Hoens, Physiotherapy Canada, Vol 62, No. 5, 2010. Recent textbooks indicate the same, that ultrasound can be used with caution, and the patient should experience no pain. (Michlovitz's Modalities for Therapeutic Intervention, 6th ed, 2016; Cameron's Physical Agents in Rehabilitation, 4th ed., 2013.

Regards, Sandy Rennie, PT, PhD

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