MSK US Research Articles

Subclinical carotid atherosclerosis in gouty patients: relation to musculoskeletal ultrasonographic findings and serum sclerostin level

Objectives. To detect subclinical carotid atherosclerosis in gout patients and its relation to musculoskeletal ultrasound (MSK US) manifestations and serum sclerostin (SCL) levels. Patients and methods. Thirty Egyptian gouty patients were classified into two groups: Group A included 15 patients with diagnostic MSK US manifestations of gout (double contour sign), and Group B included 15 patients without MSK US findings. MSK US was done for both knees and the first MTP joints. Carotid duplex ultrasonography was done to evaluate carotid intima-media-thickness (CIMT) and serum SCL level was measured in all patients by ELISA technique. Results. Gouty patients with MSK US findings had a significantly higher increase in serum SCL levels than those without MSK US findings (p <0.01). Group A patients had a significantly greater CIMT than patients of group B (p <0.01). Serum uric acid and SCL levels were found to be significantly positively correlated. The ROC curve revealed that the optimal SCL cutoff value for detecting positive MSK US findings in gout patients was >25.05 ng/ml. At this level, there was a significant difference between the patients with a CIMT >0.9 mm and the patients with a CIMT ≤0.9 mm (p <0.05). Conclusions. Patients with MSK US manifestations of gout are more liable to have subclinical carotid atherosclerosis than patients without these manifestations. SCL at a certain level >25.05 ng/ml in gout patients might predispose patients to radiographic findings of MSK US of gout and subclinical atherosclerosis.

Use of Diagnostic Musculoskeletal Ultrasound in the Evaluation of Piriformis Syndrome: A Review for Rehabilitation Providers.

Piriformis Syndrome (PS) is a neuromuscular condition caused by the entrapment of the sciatic nerve at the level of the piriformis muscle (PM) and can cause significant discomfort and disability. PS is often misdiagnosed due to its overlapping symptoms with other lumbar and sciatic issues and as such, diagnosing PS remains challenging despite recent invasive and non-invasive diagnostic methods. Diagnostic musculoskeletal ultrasound (MSK US) offers a non-invasive, cost-effective alternative for the identification and evaluation of PS, providing dynamic, real-time imaging of the PM and adjacent structures. This article reviews the applications, advantages, and procedural insights of MSK US in the diagnosis of PS, emphasizing its relevance in rehabilitation settings. We discuss the technical aspects of ultrasound use, interpretation of findings, and integration into clinical practice, aiming to enhance the diagnostic accuracy and therapeutic outcomes for patients with suspected PS.

Long Head of the Biceps Tendon (LHBT)

Pathology of the long head of the biceps brachii tendon (LHBT) is a common source of shoulder pain. While a careful history and a thorough physical examination are important steps in the assessment of LHBT pathology, it is still difficult to differentiate the type and severity of the pathology. Currently, the gold standard for confirming a diagnosis of LHBT pathologies is arthroscopic examination. Additionally, MRI is commonly ordered for diagnosis. Since an accurate diagnosis of pathology is critical for treatment success, musculoskeletal ultrasound (MSK US) is an attractive adjunct to the diagnostic process for long head of the biceps pathology due to it being safe, inexpensive and non-invasive. When used in combination with clinical special tests, MSK US can drastically increase the diagnostic accuracy of the clinical examination.

Diagnostic Role of Ultrasonography Compared to Magnetic Resonance Imaging in Ankle Pain

Background: Ankle pain is common in clinical practice. Various lesions including trauma, impingement syndromes, inflammatory arthritis, soft tissue, and bony lesions affect the ankle joint. Imaging is crucial in the determination of the pain cause and management. Objectives: This study aimed to evaluate the role of high-resolution musculoskeletal ultrasonography (MSK US) compared to the role of magnetic resonance imaging (MRI) in ankle pain. Patients and Methods: This studyconducted on 29 patients who presented with ankle pain during the period from September 2018 until September 2019 at Qena University Hospitals, South Valley University, Egypt and evaluated by plain radiographs, US and MRI. Comparative analysis was done between US and MRI. Results: The US was able to detect various lesions affecting the ankle ( tendinous and ligamentous injury, plantar fasciitis, joint effusion, bursitis, ganglion cysts, tarsal tunnel syndrome) with sensitivity and specificity of 100% regarding tendons pathology and sensitivity 80 %, specificity 100 % regarding ligamentous injuries with overall accuracy 95 % compared to MRI. US was negative in all MRI positive bony lesions. Conclusion: The US is a useful imaging modality in identifying a large spectrum of causes of ankle pain and should be considered a first step diagnostic tool when an osseous lesion is not suspected.

Focused, radial and combined shock wave therapy in treatment of calcific shoulder tendinopathy

ABSTRACT Objective: The aim of this work is to compare the clinical, functional, and ultrasonographic outcomes of focused, radial, and combined extracorporeal shock-wave therapy (ESWT) in the treatment of calcific shoulder tendinopathy. Methods: we enrolled 45 patients with calcific shoulder tendinopathy, their ages ranged from 30 to 68 (50.93 ± 9.44) years, classified according to the line of treatment into three groups, all received four sessions of ESWT 1 week apart. Group I: 15 patients received focused shock waves (F-SW) 1500 shocks. Group II: 15 patients received radial shock waves (R-SW) 2000 shocks. Group III: 15 patients received combined focused and radial shock waves (C-SW). All patients were evaluated by musculoskeletal ultrasound (MSK US) before treatment, at 1 week and at 3 months after the last session. Results: In the three studied groups, there was a significant improvement in shoulder pain, active range of motion (ROM), and shoulder function by shoulder disability questionnaire (SDQ) at 1 week after the end of treatment and after 3 months follow up. Moreover, there was a significant sonographic reduction in calcification size in the three groups. At the end of the study, the best improvement as regards a decrease of calcification size was obtained in group III when compared with group I and group II. Conclusion: These results demonstrated clinical, functional, and sonographic improvement in all groups. The best therapy in calcific shoulder tendinopathy appears to be combined focused and radial ESWT compared to interventions alone. Level 1 Evidence Randomized control study.

Diagnostic Accuracy of Imaging Techniques for Rotator Cuff Pathology: An Evidence-to-Practice Review

When comparing imaging techniques for rotator cuff pathologies, clinicians tend to consider musculoskeletal ultrasonography (MSK US), magnetic renaissance imaging (MRI), and magnetic renaissance imaging with arthrogram (MRA) as diagnostic imaging techniques. Since the most recent systematic review on imaging conducted in 2003, imaging technology has improved, indicating the need for a meta-analysis to evaluate the accuracy of new diagnostic techniques (MSK US) for evaluating rotator cuff pathologies. The accuracy of MSK US readings between radiologists and non-radiologists was also analyzed. Data were extracted from three different databases and included articles exploring diagnostic imaging and the accuracy of technique at the shoulder joint. All research findings were then rated for any risk of bias using the revised version of the quality assessment of diagnostic accuracy studies (QUADAS-2). Statistically, the authors used hierarchical summary receiver-operating characteristics to compare accuracy of diagnostic imaging techniques across the literature. The results from the guiding manuscript indicated that MSK US, MRI, and MRA were considered highly sensitive diagnostic imaging techniques for full-thickness rotator cuff tears (Sn: US: 0.86-0.94, MRI: 0.85-0.95, MRA: 0.83-0.95). For partial-thickness rotator cuff tears, likelihood ratios indicated an increased accuracy in MRA diagnostic ability (Sn: MRA: 0.83), though MSK US and MRI were still considered highly sensitive for diagnosing partial-thickness rotator cuff tears (Sn: MSK US: 0.68, MRI: 0.67). When comparing radiologists and non-radiologists use of MSK US, there was no significant difference in diagnostic accuracy based on the reading provider. As the diagnosis based on imaging determines the need for surgical intervention, the guiding review indicated that all three diagnostic tools (MSK US, MRI and MRA) were considered highly sensitive for rotator cuff pathologies (average SN of all diagnostic tools: 0.90-0.91). Determining which imaging technique to use should be based on patient-centered factors, such as possibility of the presence of other shoulder pathology, invasiveness of the procedure, and financial implications. Diagnostic MSK US optimizes these factors, in addition to being highly sensitive.

Efficacy of microcurrent therapy for treatment of acute knee pain: A randomized double-blinded controlled clinical trial

Objective: We would like to determine whether electrotherapy, specifically microcurrent therapy, increases function and decreases pain in people who have acute knee pain. Design: Randomized, double-blinded, placebo-controlled clinical trial. Setting: University laboratory and patient home. Subjects: A total of 52 subjects (35 females and 17 males) with acute knee pain. Intervention: Treatment group (n = 26) wore the active microcurrent therapy device at home for 3 hours per day for 4 weeks and the control group (n = 26) wore the placebo for 3 hours per day for 4 weeks. Main Measures: Numeric Pain Rating Scale (NPRS) and Short Form 12 (SF-12) health scale were used to measure the pain level and the functionality of the participants. Secondary assessments included musculoskeletal ultrasound imaging (MSK US) and Lower Extremity Functional Scale (LEFS). Results: A total of 52 subjects completed the study; 26 in the treatment group and 26 in the control group. Microcurrent therapy significantly reduced pain over 4 weeks. Especially week three was significant (P < 0.01) after adjusting for the family-wise error rate. The analysis on SF-12 revealed those with microcurrent therapy showed an increasing trend in the improvement of physical function score until week three. Conclusion: An active microcurrent therapy device decreased knee pain and increased function. Microcurrent therapy may be an alternative or used with a pharmacological approach for people with acute knee pain.

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT

Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM. The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus. The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved. This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis. Therapy, Level 5.

Correlation of knee ultrasonography and Western Ontario and McMaster University (WOMAC) osteoarthritis index in primary knee osteoarthritis

BackgroundKnee osteoarthritis (KOA) is the most common cause of a painful joint, and it is associated with significant health economic consequences. About literature, KOA is usually diagnosed according to changes seen on conventional radiography, but the radiographic features of OA do not correlate with its symptoms. Nowadays, ultrasonography is becoming a non-invasive imaging tool for OA in the clinical setting. Thus, the purpose of this study was to evaluate the correlation between musculoskeletal ultrasound (MSK US) and the Western Ontario and McMaster University (WOMAC) osteoarthritis index findings in patients with primary knee osteoarthritis (KOA).MethodsBetween August 2015 and October 2017, 50 patients with a mean age of 46.72 ± 9.12 years who fulfilled the American College of Rheumatology (ACR) criteria for KOA were included. All the patients underwent a clinical assessment with the calculation of the WOMAC index, and they underwent knee US examination and conventional radiography (CR). Spearman’s rho was used to assess the association between MSK US findings and the WOMAC index.ResultsThe mean pain score was 10.08 ± 2.89, stiffness was 3.34 ± 1.72, physical function was 26.26 ± 9.6, and the total WOMAC score was 39.68 ± 12.83. Forty-seven knees showed radiographic femorotibial degenerative signs. The mean thicknesses of the ultrasound-measured articular cartilage of the medial condyle (MC), intercondylar notch area (IA), and lateral condyle (LC) were 0.23 ± 0.60 cm, 0.33 ± 0.69 cm, and 0.30 ± 0.81 cm, respectively. The US findings also included suprapatellar joint effusion (50%), medial meniscal extrusion (40%), and osteophytes (70%). A positive correlation was found between the mean articular cartilage thickness of the IA, mean pain score, and stiffness subclasses of the WOMAC score (r = 0.342, p = 0.015; r = 0.414, p = 0.003), respectively.ConclusionsThe severity of KOA, based on articular cartilage thickness, showed good correlation with the pain and stiffness subclasses of the WOMAC score.

Knee painful arc, imaging by dynamic sonography: A novel technique 1Muhammad Dughbaj, 2Diaa Shehab, 3Salem Alkandari, 4Levent Ozcakar

Patellofemoral movement biomechanics is poorly understood and patellofemoral impingement is scarcely described in literature and only by MRI .We describe in this study a novel technique to visualize soft tissue impingement at and above patellofemoral joint using simultaneous goniometry and real time dynamic sonography and to coin the term Knee Painful Arc. Fifteen patients referred to PMR MSK US Unit with anterior knee pain and tenderness over quadriceps tendon underwent simultaneous goniometric measurements of the painful ROM during Keen flexion Extension and real time dynamic US to visualize which soft tissues are impinged at and above the patellofemoral joint (Fig. 1). Dynamic US examination of two patients showed quadriceps fat pads and bursa impingement underneath prominent superior patellar osteophytes (Pincer Type) (Fig. 2a) reproducing pain at the last 30 degrees of extension Seven patients showed quadriceps tendon (QT) impingement over prominent anterior osteophyte arising from femoral condyle (Cam Type) (Fig. 2b) reproducing pain during the range of 60 degree to full flexion and six patients showed mixed impingement of QT, fat pads and bursa between femoral and patellar osteophytes (Mixed Type) (Fig. 2c) with pain free arc between 30 to 80 degree flexion. To our knowledge this is the first study to use dynamic US and goniometry to diagnose and coin the term Knee painful arc, though painful arc of the shoulder is well described in literature, this technique can help understand mechanism and type of soft tissue impingement, modify exercise prescription using pain free arc exercise and improve rehabilitation outcome.

High-Resolution musculoskeletal ultrasound in India: The present perspective and the future

High-resolution musculoskeletal ultrasound (HRMSK US) has evolved tremendously from being performed in dark lit scanning rooms to being done at a remote setting, being one of its kind of modalities where live streaming is making remote diagnosis possible; like self-scanning by an astronaut in outer space, or, an on field assessment of an acute injury in a high-stake football match , or a hand-held device used for scanning at a remote location, with the images streamed over the net for interpretation. It began as gray scale imaging; however, as power Doppler came into practice, it gave a leap to the use of ultrasound in inflammatory arthritis. Three-dimensional power Doppler, beam steering, sonoelastography, contrast ultrasound, and fusion imaging are the new weapons in the armamentarium of MSK US. The role of MSK US ranges from detecting various changes in rheumatological diseases; be it active synovitis, bony erosions, enthesitis, assessment of crystal deposition, salivary gland changes, and vessel changes, aiding in diagnosis, especially in children. HRMSK US has an established role as a diagnostic tool, both as a primary modality and as an adjunct to other modalities in orthopedic practice and sports medicine also, and has evolved as a primary therapeutic tool in these fields, be it pinpoint-guided steroid injections, platelet-rich plasma injections, and barbotage of calcium deposition in situations such as calcific tendinitis. Even with all these advantages, it is still sparingly used in the practice of rheumatology in India. The authors believe that it is likely to be more widely used in the future given the enormous scope of its applications.

Diagnostic errors in musculoskeletal ultrasound imaging and how to avoid them.

The article reviews the major challenges related to the principles of the correct technique of musculoskeletal ultrasound (MSK US). All the crucial aspects of correct MSK soft tissue diagnosis have been discussed, including equipment settings, use of recent image software innovations and ultrasound standoff pads, and correct transducer positioning. The importance of the fundamental principles of MSK US, facilitating good quality image and limiting the occurrence of artifacts, has been highlighted. The most common artifacts of the musculoskeletal system have been described, including those that diagnostically helpful, such as the presence of echo enhancement deep to a fluid-filled structure, or an acoustic shadow behind a calcification. The presence of acoustic shadow in the context of lesions of a different type has also been discussed. The common anisotropy-related artifacts, frequently leading to diagnosis of a pathological condition where none is present, have been elaborated on. The frequently encountered mirror reflection artifact has been described. Special attention has been paid to the means of either eliminating, or taking advantage of artifacts for the correct diagnosis of musculoskeletal lesions. The possibilities and technique of correct differentiation of hypoechoic or anechoic foci, commonly found in the pathological conditions of the musculoskeletal system, have been analysed. Non-typical ultrasound findings leading to misdiagnosis of given pathological conditions have been discussed.

Dynamic Musculoskeletal Ultrasound (MSK US) of the Knee Joint, from Simple Supine Dynamic Scans to Kinematic Scans

Dynamic Musculoskeletal Ultrasound (MSK US) of the Knee Joint, from Simple Supine Dynamic Scans to Kinematic Scans

Poster 137 Delayed Diagnosis of Popliteal Artery Entrapment Mistaken for Exertional Compartment Syndrome, Novel Use of MSK US to Improve Diagnostic Sensitivity: A Case Report.

Poster 137 Delayed Diagnosis of Popliteal Artery Entrapment Mistaken for Exertional Compartment Syndrome, Novel Use of MSK US to Improve Diagnostic Sensitivity: A Case Report.

Medial Ankle Mass in a Division-I Volleyball Player

HISTORY: 19 year old NCAA Division-I Men’s Volleyball player with PMH of multiple left ankle sprains presented with 5 days of left medial ankle pain with swelling. He developed mild pain without audible pop or snap while doing leg presses but was able to finish. He then gradually developed numbness in the plantar left 2nd, 3rd, and 4th toes spreading into the metatarsals. The ankle pain improved spontaneously over 2 days but numbness persisted. Ice, NSAIDs, and mobilization exercises provided little relief. PHYSICAL EXAMINATION: He was afebrile with stable vital signs. His gait was normal. There was a 15x5mm fluctuant mass without cyanosis or bruising in the left tarsal tunnel that was tender to palpation. Ankle and toes exhibited full range of motion, but there was mild weakness on plantarflexion of the left 2nd, 3rd, and 4th toes. Posterior tibialis and flexor hallucis longus strength were normal. Plantar left 2nd, 3rd, and 4th toe sensation to light touch were decreased. Dorsalis pedis pulse was full and intact but the posterior tibial pulse was difficult to palpate. Capillary refill of the toes was normal. Tinel’s test over the tarsal tunnel reproduced pain and exacerbated the numbness and tingling in the toes. DIFFERENTIAL DIAGNOSIS: 1. Aneurysm/Hematoma 2. Malignancy/Neoplasm 3. Accessory Soleus Strain 4. Tarsal Tunnel Syndrome 5. Posterior Tibialis Tear 6. Flexor Digitorum Longus Tear 7. Flexor Hallucis Longus Tear 8. Osteochondral Defect of the Ankle TEST AND RESULTS: MSK US: 19x6mm complex clotted hematoma in the tarsal tunnel with compression of the tibial nerve. Posterior tibialis, flexor digitorum longus, and flexor hallucis longus tendons were normal FINAL WORKING DIAGNOSIS: 1. Tarsal Tunnel Hematoma 2. Tarsal Tunnel Syndrome TREATMENT AND OUTCOMES: 1. He was treated with gentle range of motion exercises and warm compresses. 2. The hematoma and symptoms slowly resolved over 3 weeks. 3. He returned to volleyball 1 week after hematoma resolution without any issues.

Future of Musculoskeletal Ultrasound

In this article, we review the recent updates in musculoskeletal ultrasound (MSK US). The progressive development in ultrasound scanners including both hard- and softwares has already been reflected in its ability to diagnose different MSK diseases efficiently. We discuss here the recent applications of conventional US techniques as peripheral nerve imaging and image-guided therapies. The role of color Doppler US and contrast-enhanced US is also discussed with its impact especially in soft tissue tumors and small joint arthropathies. Sonoelastography as a new and promising technique is discussed in detail in this review. It may provide better and more robust diagnosis for many MSK diseases and may replace some of the relatively old routine techniques applied nowadays. In the end, 3D imaging and image fusion are discussed with their impact in image guidance of therapy as well as their teaching applications.

Introduction: “Adult MSK US” in a Pediatric World

Introduction: “Adult MSK US” in a Pediatric World

American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships.

The following sports ultrasound (SPORTS US) curriculum is a revision of the curriculum developed by the American Medical Society for Sports Medicine (AMSSM) in 2010. Several changes have been made to the curriculum with the primary aim of providing a pathway by which a sports medicine fellow can obtain sufficient SPORTS US training to become proficient in the core competencies of SPORTS US. The core competencies of SPORTS US are outlined in the learning objectives section of this document. The term "SPORTS US" was purposefully chosen rather than "musculoskeletal ultrasound" (MSK US) because it was recognized by the panel that the evolving field of SPORTS US encompasses non-MSK applications of ultrasound such as the FAST examination (focused assessment with sonography for trauma). Although the SPORTS US core competencies in this curriculum are all MSK in nature, they represent the minimum SPORTS US knowledge a sports medicine fellow should acquire during fellowship. However, additional training in more advanced MSK and non-MSK applications of ultrasound can be provided at the fellowship director's discretion. Completion of this SPORTS US curriculum fulfills the American Institute of Ultrasound in Medicine's (AIUM) requirements to perform an MSK US examination and the prerequisites for the American Registry for Diagnostic Medical Sonography's (ARDMS) MSK sonography certification examination.

Kinesio® Tex Tape: Valuable Conservative Treatment for Plantar Fasciitis?

Purpose: To determine if Kinesio Taping® as a therapeutic intervention will decrease plantar pain and improve functional outcomes in individuals with plantar fasciitis (PF). Methods: 10 (7 F/3 M; mean age 40.3 years old) subjects reported for three sessions: baseline measurements, after 1 week of taping application, and after 3 weeks of taping application. At each session, the following data were collected: 1) Musculoskeletal Ultrasound (MSK US) imaging of plantar fascia thickness via a long-axis scan at the insertion of the calcaneus; 2) Numerical Pain Rating Scale (NPRS); and 3) Foot and Ankle Ability Measure Scores (FAAM). At the initial session, patients were instructed on Kinesio Taping® protocol and supplied with enough product for daily re-application throughout the study. A 1-way ANOVA was used to compare the outcome measures from the three visits. Results: There was a trend towards significant decrease in thickness between the baseline and final measures (P=0.063). This study also revealed a significant and clinically meaningful decrease in NPRS scores (MCID=2) from baseline measurement to week 3 (P=0.031). No significant changes in FAAM scores for the ADL (P=0.639) or Sports (P=0.107) subscales were revealed over the treatment period. Conclusion: Kinesio Taping® may be considered an effective, conservative, and practical intervention in the treatment of plantar fasciitis for short-term pain relief when used with the exercise protocol. However a larger sample sized study with a control group is needed to warrant these results.

Euroson 2015

Η Οργανωτική Επιτροπή του EUROSON 2015 έχει αρχίσει τον σχεδιασμό του Προγράμματος του. Βασικοί άξονες του Προγράμματος είναι τα Categorical Courses και τα Refresher Courses. Έχει επιλεγεί η πραγματοποίηση οκτώ Categorical Courses: US in the GI-Tract, MSK US, Chest-Emergency US, US in Oncology, Interventional US, Gynecology-Obstetrics, US in Urology, Cardiovascular US. Παράδειγμα CC ακολουθεί: