Musculoskeletal ultrasound · Ultrasound-guided diagnostic injections · Glastonbury, CT
No regenerative treatment is recommended here until the structure generating your pain has been identified. That work is done with dynamic musculoskeletal ultrasound in the exam room, and where the picture is still ambiguous, with a numbing injection placed precisely into the suspected source.
Quick answer
Diagnostic musculoskeletal ultrasound is a painless, radiation-free scan performed by Dr. Tortland himself during your visit. Unlike an MRI, it shows tendons, ligaments, muscles and nerves while you move, which is often the only way a problem becomes visible. When imaging alone cannot say which of several structures is producing the pain, a small amount of numbing medicine is placed into one suspected structure under ultrasound guidance: if the pain drops, that structure is the source. Only then is a treatment recommended.
Where it happens
In the exam room, during your visit
Radiation
None
Discomfort
Scan is painless — gel and a probe
Unique strength
Live imaging during movement
Scanned by
Dr. Tortland, not a technician
Diagnostic injection
Minutes, local anesthetic only
Answer window
Same visit, or hours after a block
Insurance
Diagnostic imaging and injections are often covered
The principle
Most patients who arrive here have already had injections. Many of them did not work — and in a meaningful number of cases the reason was the target, not the treatment.
Pain is a poor witness. Hip pain is routinely blamed on the back, shoulder pain on the neck, buttock pain on a disc. An MRI read as normal does not mean nothing is wrong; it means nothing was wrong in the plane, position and resolution that study captured. Meanwhile a lax ligament, a partially torn tendon insertion or an entrapped nerve can be invisible at rest and obvious the moment the joint is loaded.
This is why diagnosis is treated as a distinct piece of work here rather than a formality before the injection. The whole picture is assembled first — history, examination, your prior MRI and X-ray films, and a live ultrasound scan — and where two or three structures remain plausible, they are eliminated one at a time with anesthetic blocks rather than guessed at.
Diagnostic MSK ultrasound
You point at the spot that hurts, and the structure under your finger appears on the screen next to you — in the same visit, with no radiation and no waiting on a report.
Musculoskeletal ultrasound uses high-frequency sound waves to image soft tissue at a resolution MRI cannot match for structures near the surface. Gel is applied, a transducer is moved across the area, and tendons, ligaments, muscles, bursae, nerves and joint linings are examined directly. Because the probe is in the hand of the physician making the diagnosis, findings can be checked against your symptoms in real time: press here, rotate the shoulder, resist against my hand, and watch what the tissue does.
That last part is what static imaging cannot do. Subluxating tendons, snapping hips, dynamic nerve entrapment, ligament instability and tears that only gap under load are movement problems, and they are diagnosed by watching movement. Both sides can also be compared in seconds, which is often how a subtle abnormality is proven to be abnormal.
Skill matters more than equipment here. A weekend course produces someone who can hold a probe; competence in MSK ultrasound takes years. Dr. Tortland has been scanning since 2008, teaching MSK ultrasound to other physicians since 2009, and lectures on it nationally.
Findings
Typical findings that change the treatment plan — and, just as often, rule a suspected diagnosis out.
Diagnostic injections
A diagnostic injection is not a treatment. It is a question: if this structure is numbed and your pain goes away, the pain was coming from there.
A small amount of local anesthetic is placed into a single suspected structure — a joint, a bursa, a tendon sheath, around a nerve — under live ultrasound so there is no question about where the medicine went. Then you move, and you report. Marked relief points to that structure as the pain generator. No relief is equally useful: it eliminates a suspect and the search moves on. Structures are tested one at a time, so the answer is never confounded.
The procedure takes minutes, uses only numbing medicine, and is frequently the step that ends years of guessing — particularly in the hip, shoulder, sacroiliac joint and foot, where several structures refer pain to the same place and MRI is often read as normal.
Guidance is not optional for this to mean anything. A blind injection that misses the target produces a false negative and sends the diagnosis in the wrong direction — and published accuracy figures for palpation-guided joint injections are sobering: as low as roughly 40 percent in the knee in some studies, against 75 to 100 percent under ultrasound. Ultrasound also shows the nerves and vessels that should not be injected, which fluoroscopy cannot.
Step by step
01
What the pain does, when it started, what makes it worse, what has already been tried and what happened. Most diagnoses are narrowed here before anything is touched or scanned.
02
Osteopathic structural examination and orthopedic testing, including how the joints above and below the painful one are moving. A knee is often a hip problem, and a scan does not tell you that.
03
Bring the films or the disc, not just the report. Prior MRI and X-ray images are reviewed personally, because what a radiologist notes and what explains your symptoms are not always the same finding.
04
The suspected structures are scanned at rest, then under load and through range of motion, and compared with the opposite side. Findings are shown to you on the screen and explained as they appear.
05
If two or more structures remain plausible, one is numbed under ultrasound guidance and your response is recorded. If needed, a second structure is tested at a later visit — never two in the same sitting.
06
With the pain generator identified, the options are ranked honestly — rehabilitation, prolotherapy, PRP, cellular treatment, hydrodissection, or a referral out if surgery is genuinely the right answer.
07
Follow-up ultrasound is used to judge whether treated tissue is actually changing, rather than relying on how you happen to feel on the day of the appointment.
Comparison
Not competing tests. Each answers a different question, and the wrong test is a common reason a diagnosis takes years.
Frequently asked
Because a normal MRI answers only the questions that study was capable of asking. MRI is acquired at rest, in fixed planes, and it is comparatively insensitive to small tendon and ligament changes near the surface and to problems that appear only under load. Ultrasound is performed while you move, at higher resolution for superficial tissue, with the opposite limb available for comparison. Your MRI is still reviewed — the two studies are complementary, not rival.
No. There are no needles, no incisions and no radiation. Warm gel is applied and a probe is moved over the skin. The only discomfort is the pressure of the probe on an already painful area, and that is deliberately part of the examination — tenderness under the probe while the abnormal tissue is on the screen is a meaningful finding.
Nothing special. Unlike obstetric or abdominal ultrasound there is no fasting and no need to drink water. Wear or bring clothing that allows the painful area to be exposed, and bring your prior MRI or X-ray images on disc if you have them. The office will tell you if anything else is needed for your particular exam.
A small volume of local anesthetic placed under ultrasound guidance into one specific structure suspected of causing your pain — not a steroid, and not a treatment. If your pain markedly improves for the duration of the anesthetic, that structure is very likely the source. If it does not, that structure is largely excluded and the next candidate is tested. It is a process of elimination, run one variable at a time.
Useful, but not infallible, and it is worth being honest about that. Anesthetic can spread beyond the intended structure, expectation influences reported relief, and false positives and false negatives are documented in the pain literature. Accurate ultrasound placement, testing one structure at a time, and interpreting the result against the history, examination and scan — rather than in isolation — is what makes the information trustworthy.
Because a substantial share of injections placed by feel alone miss the intended target. Published accuracy for palpation-guided knee joint injections has been reported as low as roughly 40 percent in some studies, compared with 75 to 100 percent under ultrasound; in the hip the difference is starker still. A missed diagnostic injection does not just waste a visit — it produces a wrong answer. Ultrasound also lets the needle be steered away from nerves and vessels, which no palpation technique and no fluoroscopy can do.
Usually not. Ultrasound happens in the same visit as your examination, and a treatment can often be planned that day. A diagnostic block adds a short visit and a few days of observation. Weighed against months of treating the wrong structure — or the cost of a regenerative procedure aimed at the wrong tissue — it is the fastest route to an actual answer.
Diagnostic musculoskeletal ultrasound and diagnostic injections are established billable services and are frequently covered, unlike the regenerative treatments that may follow. Coverage still depends on your specific plan, so the office verifies benefits and tells you what to expect in writing before anything is scheduled.
Resources
The guidance documents, accuracy studies and reviews behind this page, including those that qualify the claims.
01
Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review. Am J Sports Med. 2011;39(3):656–662.
02
Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36(9):1892–1902.
03
Klauser AS, Tagliafico A, Allen GM, et al. Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology. Eur Radiol. 2012;22(5):1140–1148, with the 2018 update.
04
Sconfienza LM, Adriaensen M, Albano D, et al. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology. Eur Radiol. 2020.
05
American Institute of Ultrasound in Medicine. AIUM Practice Parameter for the Performance of a Musculoskeletal Ultrasound Examination. AIUM; most recent revision.
06
Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am. 2004;86(4):708–716.
07
Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: part 1, fundamentals; part 2, clinical applications. PM R. 2009;1(1):64–75 and 1(2):162–177.
08
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Philadelphia: Elsevier; 2018.
09
Bogduk N. Diagnostic blocks: a truth serum? Clin J Pain. 2010;26(2):89–90.
10
Hall S, Buchbinder R. Do imaging methods that guide needle placement improve outcome? Ann Rheum Dis. 2004;63(9):1007–1008.
11
Mulvaney SW, Tortland PD, Shiple B, Curtis K. Regenerative medicine options for chronic musculoskeletal conditions: a review of the literature. Endurance and Sports Medicine. 2018.
This page is written for patient education and does not constitute medical advice or establish a physician–patient relationship. Diagnostic accuracy figures cited above are drawn from the published literature and describe study populations rather than any individual result. Diagnostic ultrasound has real limitations, and diagnostic anesthetic blocks carry documented false-positive and false-negative rates; both are interpreted alongside history, examination and other imaging rather than in isolation. Dr. Tortland reports no financial interest in the imaging equipment described on this page.
One visit with a hands-on examination and a live ultrasound scan usually tells you what is actually wrong — and whether anything offered here can help.