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Murciano Casas MDLP, Rodríguez-Piñero M, Jiménez Sarmiento AS, Álvarez López M, Jiménez Jurado G. Evaluation of ultrasound as diagnostic tool in patients with clinical features suggestive of carpal tunnel syndrome in comparison to nerve conduction studies: Study protocol for a diagnostic testing study. PLoS One 2023; 18:e0281221. [PMID: 37948425 PMCID: PMC10637656 DOI: 10.1371/journal.pone.0281221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/10/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Carpal Tunnel Syndrome (CTS) is the most common compressive neuropathy, accounting for 90% of all neuropathies. Its prevalence ranges from 3.8%-7.8% in the population. The gold standard for its diagnosis is the neurophysiological study (85% sensitivity and 95% specificity), with the disadvantage of being invasive, complex and expensive, which means an increase in cost and time for the diagnosis of the disease. The main objective of this diagnostic test evaluation study is to investigate the value of ultrasound in the diagnosis of CTS, and among the secondary objectives, to establish the ultrasound parameters that are predictors of CTS in comparison with neurophysiological studies, attempting to standardize a protocol and reference values that determine the presence or absence of CTS. METHODS Prospective, cross-sectional study. The reference test with which we compared the ultrasound is the neurophysiological test (NPT). Patients will come consecutively from the Neurophysiology Department of the Virgen Macarena Hospital, with clinical suspicion of CTS and fulfilling the inclusion/exclusion criteria. To calculate the sample size (EPIDAT program) we proposed a sensitivity of 78% and specificity of 87% with a confidence level of 95%, requiring 438 patients (264 NPT positive, 174 NPT negative). We followed an ultrasound study protocol that included the ultrasound variables: cross-sectional area at the entrance and exit of the tunnel, range of nerve thinning, wrist-forearm index, flexor retinaculum bulging, power Doppler uptake and the existence of adjacent wrists or masses. We propose a timeline for the study to be performed between 2020 and 2023. Finally, we propose a cost-effectiveness analysis. DISCUSSION Ultrasound not only allows to objectify the alterations of the median nerve but also the underlying pathological mechanisms in CTS. A multitude of ultrasound parameters have been described that should be regarded in syndrome's study, among which we included the cross-sectional area, the range of nerve thinning, the wrist-forearm index, flexor retinaculum bulging, power Doppler uptake and assessment of anatomical alterations. The use of ultrasound as a diagnostic tool in CTS has many advantages for both doctors and the patients, as it is a non-invasive, convenient, and fast tool increasingly accessible to professionals. TRIAL REGISTRATION Trials registry number: NCT05556278.
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Georgeto SM, Andraus RAC, de Oliveira Júnior E, da Silva RA, Ngomo S, Fernandes KBP. Bilateral Idiopathic Carpal Tunnel Syndrome: Clinical-Functional Characterization and Efficacy of Two Combined Postoperative Physiotherapeutic Treatments. Orthop Surg 2023. [PMID: 37154094 DOI: 10.1111/os.13705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/27/2023] [Accepted: 02/19/2023] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy of combined association instrument myofascial mobilization (IASTM) and stretching in patients with idiopathic bilateral carpal tunnel syndrome (CTS) operated on one hand and to analyze the response of the operated (OH) and non-operated (NH) hand according to the sequence of therapies. Research on these parameters has not yet been found in the literature. METHODS Randomized controlled crossover study with 43 participants using the objective and subjective outcome variables. Patients were randomly assigned to two groups: starting with stretching followed by IASTM and starting with IASTM followed by stretching. Then patients underwent surgery on the hand with more severe involvement and physical therapy rehabilitation was started 30 days after for a period of 4 weeks. After the 1-week interval the participants who started with stretching were referred to IASTM and vice versa, following the same previous patterns. The outpatient reassessments took place at 3 to 6 months. Crossover ANOVA and effect sizes were used as analysis methods. RESULTS Time was the most significant outcome for all variables both during therapies and at 6-month follow-up. Regarding response to the combined therapies between OH and NH, there were differences for both OH and NH, with the greatest impact on NH for the palmar grip and VAS variables. The treatment sequences were significant for pain on the NH and mental SF-12, suggesting that starting with IASTM followed by stretching had a superior outcome for these outcomes. CONCLUSION The combination of IASTM with stretching, used in the postoperative period of bilateral idiopathic CTS, proved to be supplementary, with significant results and large effect sizes for most of the outcomes assessed, both during the time of application of the therapies and in the 6-month follow-up for both hands, and may constitute a viable therapeutic alternative for this population.
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Affiliation(s)
- Sergio Murilo Georgeto
- Department of Neurosurgery, Irmandade da Santa Casa de Londrina (ISCAL); Doctoral Program in Rehabilitation Sciences UEL/UNOPAR, Universidade Pitágoras UNOPAR, Londrina, PR, Brazil
| | | | - Eros de Oliveira Júnior
- Instituto Avançado de Ensino, Pesquisa e Tecnologia de Londrina (IAEPETEL), Londrina, PR, Brazil
| | - Rubens A da Silva
- Département des Sciences de la Santé, Centre Intersectoriel en Santé Durable, Laboratoire de Recherche BioNR, Université du Québec à Chicoutimi (UQAC); Centre Intégré de Santé et Services Sociaux du Saguenay-Lac-Saint-Jean (CIUSSS SLSJ), Services Spécialisés de Gériatrie - Hôpital de La Baie, Saguenay, Québec, Canada
| | - Suzy Ngomo
- Département des Sciences de la Santé, Centre Intersectoriel en Santé Durable, Laboratoire de recherche BioNR, Université du Québec à Chicoutimi (UQAC), Saguenay, Québec, Canada
| | - Karen Barros Parron Fernandes
- School of Medicine, Pontifical Catholic University of Parana (PUCPR), Londrina, PR, Brazil; Département des Sciences de la Santé, Centre Intersectoriel en Santé Durable, Laboratoire de recherche BioNR, Université du Québec à Chicoutimi (UQAC), Saguenay, Québec, Canada; Instituto de Ensino, Pesquisa e Inovação da Irmandade da Santa Casa de Londrina (IEPI-ISCAL), Londrina, PR, Brazil
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Farias Zuniga A, Keir PJ. Thirty Minutes of Sub-diastolic Blood Flow Occlusion Alters Carpal Tunnel Tissue Function and Mechanics. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1110-1121. [PMID: 35300878 DOI: 10.1016/j.ultrasmedbio.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/05/2022] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
There is evidence that carpal tunnel syndrome (CTS) development is driven by vascular factors, specifically those resulting from ischemia and edema. The purpose of this study was to investigate the vascular hypothesis of CTS development by quantifying the temporal effects of 30 min of sub-diastolic brachial blood flow occlusion on median nerve edema, intraneural blood flow velocity, nerve function as measured through nerve conduction study (NCS), tendon-connective tissue mechanics and carpal tunnel tissue stiffness. Forty healthy volunteers underwent 30 min of sub-diastolic brachial occlusion while an NCS and ultrasound examination were performed consecutively every 5 min. Motor latency (p < 0.001), sensory conduction velocity (p < 0.001), sensory amplitude (p = 0.04), nerve blood flow (p < 0.001), peak relative flexor digitorum superficialis tendon-sub-synovial connective tissue displacement (p = 0.02) and shear strain (p = 0.04) were significantly affected by partial ischemia. Our results highlight the dependency of carpal tunnel tissue function on adequate blood flow.
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Affiliation(s)
- Amanda Farias Zuniga
- McMaster Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Peter J Keir
- McMaster Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada.
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Farias Zuniga A, Ghavanini AA, Israelian G, Keir PJ. Ultrasound examination predicts 6-month progression in carpal tunnel syndrome patients. J Orthop Res 2021; 39:609-618. [PMID: 33098574 DOI: 10.1002/jor.24893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/03/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
Carpal tunnel syndrome (CTS) is a peripheral neuropathy resulting from chronic median nerve compression. Chronic compression leads to neurological changes that are quantified through nerve conduction studies (NCS). Although NCS represents the gold standard in CTS assessment, they provide limited prognostic value. Several studies have identified ultrasound as a tool in diagnosing and potentially predicting the progression of CTS in patients. The purpose of this study was to evaluate the predictive value of ultrasound examination in CTS patients. Twenty patients recruited at their first visit with the neurologist completed two NCS and ultrasound examinations approximately 6 months apart. Ultrasound examination consisted of B-mode, pulse-wave Doppler and colour Doppler ultrasound videos and images to quantify median nerve cross-sectional area, intraneural blood flow velocity in three wrist postures (15° flexion, neutral, and 30° extension), and displacement of the flexor digitorum superficialis (FDS) tendon and the adjacent subsynovial connective tissue (SSCT) of the middle finger during repetitive finger flexion-extension cycles. A questionnaire was administered to assess the work-relatedness of CTS. Linear regression analyses revealed that intraneural blood flow velocity (R2 = 0.36, p = .03), assessed in wrist flexion, and relative FDS-SSCT displacement (R2 = 0.27, p = .04) and shear strain index (R2 = 0.28, p = .04) were significant predictors of nerve sensory and motor changes at 6 months. Results suggest the possibility of using a battery of ultrasound measures as viable markers to predict median nerve functional changes within 6 months.
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Affiliation(s)
| | - Amer A Ghavanini
- Canadian Neurologic Center, Mississauga, Ontario, Canada.,Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gaspar Israelian
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Peter J Keir
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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Schrier VJMM, Evers S, Geske JR, Kremers WK, Villarraga HR, Selles RW, Hovius SER, Gelfman R, Amadio PC. Relative Motion of the Connective Tissue in Carpal Tunnel Syndrome: The Relation with Disease Severity and Clinical Outcome. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2236-2244. [PMID: 32600671 PMCID: PMC7429249 DOI: 10.1016/j.ultrasmedbio.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 05/07/2023]
Abstract
Excursion of the median nerve and the surrounding subsynovial connective tissue (SSCT) is diminished in patients with carpal tunnel syndrome (CTS). This study sought to determine if SSCT excursion could be utilized to predict surgical outcome. Idiopathic CTS patients were reviewed with ultrasound and electrodiagnostic tests at baseline. A speckle tracking algorithm was used to determine SSCT relative to tendon motion (shear index). Analysis of variance tests were used to compare SSCT motion with disease severity at baseline. Adjusted linear regressions were used to test the association with patient-reported outcome. A total of 90 CTS patients were analyzed and found to have an average shear index of 79% (95% confidence interval: 76.3%-81.6%). SSCT motion was lower in CTS patients with increasing electrophysiological severity (p = 0.0475). There was no significant association of pre-operative SSCT motion with symptomatic improvement (p = 0.268). Overall, SSCT motion is decreased in CTS patients, but exhibits limited correlation with clinical severity.
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Affiliation(s)
- Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefanie Evers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven E R Hovius
- Department of Plastic and Reconstructive Surgery, Radboudumc University Hospital, Nijmegen, The Netherlands
| | - Russell Gelfman
- Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Tse CTF, Keir PJ. External Compression and Partial Ischemia Decrease Human Finger Flexor Tendon and Subsynovial Connective Tissue Relative Motion. J Orthop Res 2020; 38:1038-1044. [PMID: 31793674 DOI: 10.1002/jor.24540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 10/14/2019] [Indexed: 02/04/2023]
Abstract
Cumulative shear strain of the subsynovial connective tissue (SSCT) surrounding finger flexor tendons plays a significant role in the development and progression of carpal tunnel syndrome. Biomechanical risk factors can alter tendon-SSCT shear strain but the effects of external mechanical compression and localized ischemia have yet to be investigated. In a laboratory study with 19 healthy participants, color Doppler ultrasound imaging was used to quantify relative motion between the flexor digitorum superficialis tendon and SSCT during repetitive finger flexion-extension under various conditions of external mechanical compression (palmar and forearm compression), ischemia and different movement speeds (0.75 and 1.25 Hz). Forearm compression reduced tendon displacement (baseline = 28.5 ± 4.1 mm vs. forearm = 27.0 ± 4.6 mm; p = 0.043) and showed a trend for reduced SSCT displacement, while palmar compression had no significant effects on tendon-SSCT motion. Compared with baseline, partial ischemia decreased SSCT displacement (baseline = 22.9 ± 3.3 mm vs. ischemia = 22.0 ± 3.3 mm; p = 0.015), while tendon displacement remained unchanged. In all experimental conditions, faster movements elicited greater tendon-SSCT relative motion. Our findings suggest that palmar compression may not negatively impact tendon-SSCT relative motion, but forearm compression may require further investigation. Localized ischemia in the forearm may alter the gliding conditions within the carpal tunnel and affect tendon-SSCT relative motion, which bridges an important gap between blood flow in the carpal tunnel and shear injury risk. These findings contribute to the growing body of literature, supporting the role that cumulative tendon-SSCT shear injury may have on the pathomechanics of carpal tunnel syndrome. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1038-1044, 2020.
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Affiliation(s)
- Calvin T F Tse
- Motion Analysis and Biofeedback Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter J Keir
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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Blood flow velocity but not tendon mechanics relates to nerve function in carpal tunnel syndrome patients. J Neurol Sci 2020; 411:116694. [PMID: 32001379 DOI: 10.1016/j.jns.2020.116694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 12/22/2022]
Abstract
Carpal tunnel syndrome (CTS) develops from chronic compression of the median nerve. Chronic compression results in a number of vascular, structural and functional changes to the carpal tunnel tissues which ultimately manifest in the characteristic symptoms of CTS. The purpose of this study was to investigate the interplay of median nerve function, median nerve hemodynamics, and finger flexor tendon and subsynovial connective tissue (SSCT) mechanics in CTS patients. Thirty-five patients were recruited following nerve conduction study for this double-blinded imaging study. Ultrasound B-mode, pulse-wave Doppler, and colour Doppler images and videos were collected at the proximal carpal tunnel to quantify: (1) median nerve cross-sectional area, (2) intraneural blood flow velocity in 3 wrist postures (neutral (0°), flexion (15°), extension (30°)), and (3) flexor digitorum superficialis and SSCT displacement. Results demonstrate that intraneural blood flow velocity is dependent on median nerve function and wrist posture such that patients with mild CTS are more susceptible to the effects of non-neutral wrist postures. Tendon-SSCT mechanics do not appear to differ based on severity. This study stresses the importance of limiting exposure to non-neutral wrist postures in patients with early signs of the condition.
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Schrier VJMM, Evers S, Geske JR, Kremers WK, Villarraga HR, Kakar S, Selles RW, Hovius SER, Gelfman R, Amadio PC. Median Nerve Transverse Mobility and Outcome after Carpal Tunnel Release. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2887-2897. [PMID: 31488311 PMCID: PMC6768738 DOI: 10.1016/j.ultrasmedbio.2019.06.422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 05/13/2023]
Abstract
Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm2 and decreased to 13.3 ± 3.8 mm2 (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (β = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (β = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome.
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Affiliation(s)
- Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefanie Evers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven E R Hovius
- Department of Plastic and Reconstructive Surgery, Radboudumc University Hospital, Nijmegen, The Netherlands
| | - Russell Gelfman
- Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Weresch JA, Keir PJ. Development of an Ergonomic Tool to Predict Carpal Tunnel Syndrome Risk Based on Estimated Carpal Tunnel Pressure. IISE Trans Occup Ergon Hum Factors 2018. [DOI: 10.1080/24725838.2018.1454360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Justin A. Weresch
- McMaster University, Department of Family Medicine, Hamilton, Ontario, Canada
| | - Peter J. Keir
- McMaster University, Department of Kinesiology, Hamilton, Ontario, Canada
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Evers S, Thoreson AR, Smith J, Zhao C, Geske JR, Amadio PC. Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel. Muscle Nerve 2018; 57:25-32. [PMID: 28622409 PMCID: PMC5722677 DOI: 10.1002/mus.25723] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The aim of this study was to assess alterations in median nerve (MN) biomechanics within the carpal tunnel resulting from ultrasound-guided hydrodissection in a cadaveric model. METHODS Twelve fresh frozen human cadaver hands were used. MN gliding resistance was measured at baseline and posthydrodissection, by pulling the nerve proximally and then returning it to the origin. Six specimens were treated with hydrodissection, and 6 were used as controls. RESULTS In the hydrodissection group there was a significant reduction in mean peak gliding resistance of 92.9 ± 34.8 mN between baseline and immediately posthydrodissection (21.4% ± 10.5%; P = 0.001). No significant reduction between baseline and the second cycle occurred in the control group: 9.6 ± 29.8 mN (0.4% ± 5.3%; P = 0.467). DISCUSSION Hydrodissection can decrease the gliding resistance of the MN within the carpal tunnel, at least in wrists unaffected by carpal tunnel syndrome. A clinical trial of hydrodissection seems justified. Muscle Nerve 57: 25-32, 2018.
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Affiliation(s)
- Stefanie Evers
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, United States
- Department of Plastic, Reconstructive and Hand surgery, Erasmus MC, Rotterdam, the Netherlands
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Andrew R. Thoreson
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, United States
| | - Jay Smith
- Departments of Physical Medicine and Rehabilitation, Radiology and Anatomy, Mayo clinic, Rochester, MN, United States
| | - Chunfeng Zhao
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, United States
| | - Jennifer R. Geske
- Department of Biomedical Statistics and Informatics, Mayo clinic, Rochester, MN, United States
| | - Peter C. Amadio
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, United States
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Festen-Schrier VJMM, Amadio PC. The biomechanics of subsynovial connective tissue in health and its role in carpal tunnel syndrome. J Electromyogr Kinesiol 2017; 38:232-239. [PMID: 29108853 DOI: 10.1016/j.jelekin.2017.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/21/2017] [Indexed: 01/12/2023] Open
Abstract
Carpal Tunnel Syndrome (CTS) is the most common surgically treated problem in the hand. Aside from the neuropathy itself, the most common findings are fibrosis of the subsynovial connective tissue (SSCT) and increased intra carpal tunnel pressure. Normally, the SSCT is a multilayer tissue interspersed among the carpal tendons and nerve. As the tendons move, successive SSCT layers are recruited, forming a gliding unit and providing a limit to differential movement. Exceeding this limit, damages the SSCT as has been shown in both cadavers and animal models. This damage leads to a non-inflammatory response with progressive fibrosis and nerve ischemia leaving the SSCT more susceptible to injury. Although the direct consequences for patients are not fully understood, ultrasound research shows that this fibrosis restricts median nerve displacement during tendon loading. This article aims to provide insights into the mechanical properties of SSCT described so far and place it in the context of CTS pathophysiology. A theoretical damage model concerning the SSCT is proposed showing a chain of events and vicious cycles that could lead to the nerve compression as it is found in CTS. Although not complete, this model could explain the pathophysiological pathway of idiopathic CTS.
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Affiliation(s)
- V J M M Festen-Schrier
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus MC, The Netherlands.
| | - P C Amadio
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Filius A, Thoreson AR, Ozasa Y, An KN, Zhao C, Amadio PC. Delineation of the mechanisms of tendon gliding resistance within the carpal tunnel. Clin Biomech (Bristol, Avon) 2017; 41:48-53. [PMID: 27939953 PMCID: PMC5280089 DOI: 10.1016/j.clinbiomech.2016.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 10/25/2016] [Accepted: 12/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Forceful, high-velocity, and repetitive manual hand tasks contribute to the onset of carpal tunnel syndrome. This study aimed to isolate and identify mechanisms that contribute to tendon gliding resistance in the carpal tunnel. METHODS Eight human cadaver hands (four pairs) were used. Tendon gliding resistance (force, energy, and stiffness) was measured under different conditions: with intact and with divided subsynovial connective tissue, at 2mm/s and 60mm/s tendon excursion velocity, and with and without relaxation time before tendon excursion. RESULTS Subsynovial connective tissue stretching substantially contributed to increased gliding resistance force and energy during higher tendon excursion velocities, and subsynovial connective tissue stiffening was observed. Poroelastic properties of the tendon (and possibly the subsynovial connective tissue) also appear to be involved because relaxation time significantly increased gliding resistance force and energy (P<0.01), and the difference in energy and force between high- and low-velocity tendon excursions increased with relaxation time (P=0.01 and P<0.01). Lastly, without relaxation time, no difference in force and energy was observed (P=0.06 and P=0.60), suggesting contact friction. INTERPRETATION These findings are consistent with the hypothesis that the mechanics of tendon motion within the carpal tunnel are affected by the integrity of the subsynovial connective tissue. While not tested here, in carpal tunnel syndrome this tissue is known to be the fibrotic, thickened, and less-fluid-permeable. An extrapolation of our findings suggests that these changes in the subsynovial connective tissue of carpal tunnel syndrome patients could increase contact friction and carpal tunnel pressure.
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Affiliation(s)
- Anika Filius
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA,Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, The Netherlands,Department of Rehabilitation Medicine, Erasmus MC
| | - Andrew R. Thoreson
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA
| | - Yasuhiro Ozasa
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA
| | - Chunfeng Zhao
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA
| | - Peter C. Amadio
- Biomechanics Laboratory, Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota, USA
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Tat J, Kociolek AM, Keir PJ. Relative displacement of the tendon and subsynovial connective tissue using ultrasound captures different phenomena than mechanical tendon shear. J Biomech 2016; 49:3682-3687. [DOI: 10.1016/j.jbiomech.2016.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 09/23/2016] [Accepted: 09/30/2016] [Indexed: 01/16/2023]
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Matsuura Y, Thoreson AR, Zhao C, Amadio PC, An KN. Development of a hyperelastic material model of subsynovial connective tissue using finite element modeling. J Biomech 2015; 49:119-122. [PMID: 26482734 DOI: 10.1016/j.jbiomech.2015.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/26/2015] [Indexed: 12/31/2022]
Abstract
Carpal tunnel syndrome (CTS) is one of the most common disorders of the hand. Assessment of carpal tunnel tissue mechanical behavior, especially that of the subsynovial connective tissue (SSCT), is important to better understand the mechanisms of CTS. The aim of this study was to develop a hyperelastic material model of human SSCT using mechanical test data and finite element modeling (FEM). Experimental shear test data of SSCT from 7 normal subjects and 7 CTS patients collected in a prior study was used to define material response. Hyperelastic coefficients (μ and α) from the first-order Ogden material property definition were iteratively solved using specimen-specific FEM models simulating the mechanical test conditions. A typical Ogden hyperelastic response for the normal and CTS SSCT was characterized by doing the same with data from all samples averaged together. The mean Ogden coefficients (μ/α) for the normal cadaver and CTS patient SSCT were 1.25×10(-5)MPa/4.51 and 1.99×10(-6)MPa/10.6, respectively when evaluating coefficients for individual specimens. The Ogden coefficients for the typical (averaged data) model for normal cadaver and CTS patient SSCT were 1.63×10(-5)MPa/3.93 and 5.00×10(-7)MPa/9.55, respectively. Assessment of SSCT mechanical response with a hyperelastic material model demonstrated significant differences between patient and normal cadaver. The refined assessment of these differences with this model may be important for future model development and in understanding clinical presentation of CTS.
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Affiliation(s)
- Yusuke Matsuura
- Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | | | - Chunfeng Zhao
- Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Peter C Amadio
- Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Kai-Nan An
- Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA.
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Tat J, Wilson KE, Keir PJ. Pathological changes in the subsynovial connective tissue increase with self-reported carpal tunnel syndrome symptoms. Clin Biomech (Bristol, Avon) 2015; 30:360-5. [PMID: 25753696 DOI: 10.1016/j.clinbiomech.2015.02.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 02/22/2015] [Accepted: 02/23/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fibrosis and thickening of the subysnovial connective tissue are the most common pathological findings in carpal tunnel syndrome. The relationship between subsynovial connective tissue characteristics and self-reported carpal tunnel syndrome symptoms was assessed. METHODS Symptoms were characterized using the Boston Carpal Tunnel Questionnaire and Katz hand diagram in twenty-two participants (11 with symptoms, 11 with no symptoms). Using ultrasound, the thickness of the subsynovial connective tissue was measured using a thickness ratio (subsynovial thickness/tendon thickness) and gliding function was assessed using a shear strain index ((Displacement(tendon)-Displacement(subsynovial))/Displacement(tendon)x 100). For gliding function, participants performed 10 repeated flexion-extension cycles of the middle finger at a rate of one cycle per second. FINDINGS Participants with symptoms had a 38.5% greater thickness ratio and 39.2% greater shear strain index compared to participants without symptoms (p<0.05). INTERPRETATION Ultrasound detected differences the SSCT in symptomatic group that was characterized by low self-reported symptom severity scores. This study found ultrasound useful for measuring structural and functional changes in the SSCT that could provide insight in the early pathophysiology associated with carpal tunnel syndrome symptoms.
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Affiliation(s)
- Jimmy Tat
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, ON, Canada, L8S 4K1
| | - Katherine E Wilson
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, ON, Canada, L8S 4K1
| | - Peter J Keir
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, ON, Canada, L8S 4K1.
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Tat J, Kociolek AM, Keir PJ. Validation of color Doppler sonography for evaluating relative displacement between the flexor tendon and subsynovial connective tissue. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:679-687. [PMID: 25792584 DOI: 10.7863/ultra.34.4.679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES A common pathologic finding in carpal tunnel syndrome is fibrosis and thickening of the subsynovial connective tissue. This finding suggests an etiology of excessive shear forces, with relative longitudinal displacement between the flexor tendon and adjacent subsynovial connective tissue. The purpose of this study was to validate color Doppler sonography for measurement of tendon displacement over time. METHODS Eight unmatched fresh frozen cadaver arms were used to evaluate color Doppler sonography for measurement of tendon displacement. The middle flexor digitorum superficialis tendon was moved through a physiologic excursion of 20 mm at 3 different tendon velocities (50, 100, and 150 mm/s). RESULTS We found that color Doppler sonography provided accurate measurement of tendon displacement, with absolute errors of -0.05 mm (50 mm/s), -1.24 mm (100 mm/s), and -2.36 mm (150 mm/s) on average throughout the tendon excursion range. Evaluating relative displacement between the tendon and subsynovial connective tissue during finger flexion-extension movements also offered insight into the gliding mechanism of the subsynovial connective tissue. During flexion, we observed a curvilinear increase in relative displacement, with greater differential motion at the end range of displacement, likely due to the sequential stretch of the fibrils between successive layers of the subsynovial connective tissue. In extension, there was a linear return in relative displacement, suggesting a different unloading mechanism characterized by uniform relaxation of fibrils. CONCLUSIONS We demonstrated the validity of color Doppler displacement for use in the evaluation of relative motion. Color Doppler sonography is useful in our understanding of the behavior of the subsynovial connective tissue during tendon excursion, which may elucidate the role of finger motion in the etiology of shear injury.
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Affiliation(s)
- Jimmy Tat
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Aaron M Kociolek
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Peter J Keir
- Occupational Biomechanics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada.
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Kociolek AM, Keir PJ. Development of a kinematic model to predict finger flexor tendon and subsynovial connective tissue displacement in the carpal tunnel. ERGONOMICS 2015; 58:1398-1409. [PMID: 25679821 DOI: 10.1080/00140139.2015.1013575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED Finger flexor tendinopathies and carpal tunnel syndrome are histologically characterised by non-inflammatory fibrosis of the subsynovial connective tissue (SSCT) in the carpal tunnel, which is indicative of excessive and repetitive shear forces between the finger flexor tendons and SSCT. We assessed flexor digitorum superficialis (FDS) tendon and adjacent SSCT displacements with colour Doppler ultrasound as 16 healthy participants completed long finger flexion/extension movements captured by a motion capture system. FDS tendon displacements fit a second-order regression model based on metacarpophalangeal and proximal interphalangeal joint flexion angles (R(2) = 0.92 ± 0.01). SSCT displacements were 33.6 ± 1.7% smaller than FDS tendon displacements and also fit a second-order regression model (R(2) = 0.89 ± 0.01). FDS tendon and SSCT displacement both correlated with finger joint thickness, enabling participant-specific anthropometric scaling. We propose the current regression models as an ergonomic method to determine relative displacements between the finger flexor tendons and SSCT. PRACTITIONER SUMMARY Relative displacements between the finger flexor tendons and SSCT provide insight into gliding and friction in the carpal tunnel. Our regression models represent a move towards mechanistic-based ergonomic risk assessment of the wrist/hand. This is a natural evolution of ergonomic methods based on tendon-joint interaction.
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Affiliation(s)
- Aaron M Kociolek
- a Department of Kinesiology , McMaster University , 1280 Main Street West, Hamilton, Ontario L8S 4K1 , Canada
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Ghasemi-rad M, Nosair E, Vegh A, Mohammadi A, Akkad A, Lesha E, Mohammadi MH, Sayed D, Davarian A, Maleki-Miyandoab T, Hasan A. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World J Radiol 2014; 6:284-300. [PMID: 24976931 PMCID: PMC4072815 DOI: 10.4329/wjr.v6.i6.284] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 03/28/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is the most commonly diagnosed disabling condition of the upper extremities. It is the most commonly known and prevalent type of peripheral entrapment neuropathy that accounts for about 90% of all entrapment neuropathies. This review aims to provide an outline of CTS by considering anatomy, pathophysiology, clinical manifestation, diagnostic modalities and management of this common condition, with an emphasis on the diagnostic imaging evaluation.
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Filius A, Thoreson AR, Yang TH, Vanhees M, An KN, Zhao C, Amadio PC. The effect of low- and high-velocity tendon excursion on the mechanical properties of human cadaver subsynovial connective tissue. J Orthop Res 2014; 32:123-8. [PMID: 24038298 PMCID: PMC3845004 DOI: 10.1002/jor.22489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 08/20/2013] [Indexed: 02/04/2023]
Abstract
Fibrosis of the subsynovial connective tissue (SSCT) in the carpal tunnel is the most common histological finding in carpal tunnel syndrome (CTS). Fibrosis may result from damaged SSCT. Previous studies found that with low-velocity (2 mm/s), tendon excursions can irreversibly damage the SSCT. We investigated the effect of tendon excursion velocity in the generation of SSCT damage. Nine human cadaver wrists were used. Three repeated cycles of ramp-stretch testing were performed simulating 40%, 60%, 90%, and 120% of the middle finger flexor tendon superficialis physiological excursion with an excursion velocity of 60 mm/s. Energy and force were calculated and normalized by values obtained in the first cycle for each excursion level. Data were compared with low-velocity excursion data. For high-velocity excursions, a significant drop in the excursion energy ratio was first observed at an excursion level of 60% physiological excursion (p < 0.024) and that for low-velocity excursions was first observed at 90% physiological excursion (p < 0.038). Furthermore, the energy ratio was lower at 60% for high velocities (p ≤ 0.039). Increasing velocity lowers the SSCT damage threshold. This finding may be relevant for understanding the pathogenesis of SSCT fibrosis, such as that accompanying CTS, and a relationship with occupational factors.
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Affiliation(s)
- Anika Filius
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA,Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands,Department of Rehabilitation Medicine and Physical Therapy, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Andrew R. Thoreson
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Tai-Hua Yang
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Matthias Vanhees
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Kai-Nan An
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Chunfeng Zhao
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Peter C. Amadio
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
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