Diagnostic and therapeutic musculoskeletal ultrasound applications of the shoulder

Effects of scapulo-humeral training on ultrasonographic and clinical evaluations in stroke: a randomized controlled trial

BACKGROUND

After stroke, the effects of focused scapulo-humeral training with simultaneous assessment of the changes in shoulder subluxation, related muscle thicknesses and upper limb performance have not been studied in the literature.

OBJECTIVES

This study aimed to investigate the effects of an 8-week scapulo-humeral training program in addition to conventional rehabilitation on upper extremity/trunk functions, shoulder pain, and sonographic measurements of the shoulder joint and periscapular muscles.

METHODS

Thirty stroke individuals were randomly separated into two groups as Group I-scapulo-humeral training (5F/10 M) and Group II - control (5F/10 M). Conventional rehabilitation program was applied to both groups, and a scapulo-humeral training exercise protocol was added for the scapulo-humeral group. All the treatments were applied for 1 hour/day, 3 days/week, 8 weeks. Clinical evaluations were made using the Fugl Meyer Assessment-Upper Extremity(FMA-UE), Action Research Arm Test(ARAT), ABILHAND, Visual Analog Scale, and Trunk Impairment Scale(TIS). Ultrasound was used to measure serratus anterior/lower trapezius muscle thicknesses, and acromion-greater tubercule/acromio-humeral distances.

RESULTS

FMA-UE, ARAT, ABILHAND and TIS scores increased in both groups, with greater increases in most parameters in the scapulo-humeral training group. Shoulder pain decreased only in the scapulo-humeral training group. Subacromial distances were decreased on the paretic side, and muscle thicknesses increased on both sides in the scapulo-humeral training group, and in the control group, only serratus anterior muscle thickness increased on the paretic side (p < 0.05 for all).

CONCLUSIONS

Additional scapulo-humeral exercises to conventional rehabilitation was seen to improve upper extremity/trunk performance and shoulder pain, and to increase scapula stabilizer muscle thicknesses in stroke individuals with mild-moderate upper extremity disability.

Current status of dynamic musculoskeletal ultrasound for application to treatment of orthopedic diseases

In recent years, dynamic musculoskeletal ultrasound (DMUS) technology has demonstrated great potential in the diagnosis and treatment of orthopedic diseases. As a non-invasive, real-time imaging technique, it provides a dynamic view of joints and soft tissues, offering crucial insight for evaluating muscle injuries and bone damage caused by motion. This article comprehensively reviews the latest research in the field of DMUS, discussing its significant roles in managing orthopedic diseases and enhancing clinical practice. The application of DMUS is wide-ranging, including but not limited to the diagnosis of tendon injuries, ligament tears, arthritis, and soft tissue diseases. Additionally, DMUS has significant value in monitoring treatment progress and evaluating post-operative recovery. Furthermore, we discuss the use of DMUS for improving the accuracy and effectiveness of orthopedic surgeries. DMUS can provide high-quality diagnostic and therapeutic services for patients without a need for expensive equipment or complex procedures. Despite its promising outlook in orthopedics, broader clinical adoption remains limited by factors such as the steep learning curve associated with its use, the demand for specialized skills in interpreting high-quality images, and the need for extensive clinical validation. Future research should focus on standardizing operational procedures, improving the automation of image analysis, and validating its application in different orthopedic diseases through clinical trials.

Development and Clinical Application of Artificial Intelligence Assistant System for Rotator Cuff Ultrasound Scanning

OBJECTIVE

We developed an intelligent assistance system for shoulder ultrasound imaging, incorporating deep-learning algorithms to facilitate standard plane recognition and automatic tissue segmentation of the rotator cuff and its surrounding structures. We evaluated the system's performance using a dedicated data set of rotator cuff ultrasound images to assess its feasibility in clinical practice.

METHODS

To fulfill the system's primary functions, we designed a standard plane recognition module based on the ResNet50 network and an automatic tissue segmentation module using the Mask R-CNN model. The modules were trained on carefully curated data sets. The standard plane recognition module automatically identifies a specific standard plane based on the ultrasound image characteristics. The automatic tissue segmentation module effectively delineates and segments anatomical structures within the identified standard plane.

RESULTS

With the use of 59,265 shoulder joint ultrasound images, the standard plane recognition model achieved an impressive recognition accuracy of 94.9% in the test set, with an average precision rate of 96.4%, recall rate of 95.4% and F1 score of 95.9%. The automatic tissue segmentation model, tested on 1886 images, exhibited a commendable average intersection over union value of 96.2%, indicating robustness and accuracy. The model achieved mean intersection over union values exceeding 90.0% for all standard planes, indicating its effectiveness in precisely delineating the anatomical structures.

CONCLUSION

Our shoulder joint musculoskeletal intelligence system swiftly and accurately identifies standard planes and performs automatic tissue segmentation.

Function and form of the shoulder in congenital and untreated growth hormone deficiency

OBJECTIVES

The shoulder is the most mobile joint in the entire human body. During arm elevation, it requires the integrity of a set of muscles, bones, and tendons. Individuals with short stature often need to raise their arms above the shoulder girdle and may have functional restriction or shoulder injuries. The impact of isolated GH deficiency (IGHD) on joints remains not well defined. The purpose of this work is to evaluate the function and structure of the shoulder in short-statured adult individuals with untreated IGHD due to the same homozygous mutation in the GHRH receptor gene.

METHODS

A cross-sectional study (evidence 3) was carried out in 20 GH-naive IGHD subjects and 20 age-matched controls. They completed the disabilities of the arm, shoulder, and hand (DASH) questionnaire and shoulder ultrasound (US). Thickness of the anterior, medial, and posterior portions of the supraspinatus tendon and of subacromial space was measured, and the number of individuals with tendinosis or tearing of the supraspinatus tendon was registered.

RESULTS

DASH score was similar between IGHD and controls, but IGHD subjects complained less of symptoms (p = 0.002). The number of individual with tears was higher in the controls (p = 0.02). As expected, the absolute US measurements were lower in IGHD, but the magnitude of the reduction was most pronounced in the thickness of the anterior portion of the supraspinatus tendon.

CONCLUSION

Adults with lifetime IGHD do not have functional shoulder restrictions, complain less of problems in performing upper extremity activities, and have fewer tendinous injuries than controls.

Frequency-domain full-waveform inversion-based musculoskeletal ultrasound computed tomography

Recently, full-waveform inversion (FWI) has become a promising tool for ultrasound computed tomography (USCT). However, as a computationally intensive technique, FWI suffers from computational burden, especially in conventional time-domain full-waveform inversion (TDFWI). On the contrary, frequency-domain full-waveform inversion (FDFWI) provides a relatively high computational efficiency as the propagation of discrete frequencies is much cheaper than full time-domain modeling. FDFWI has already been applied in soft tissue imaging, such as breast, but for the musculoskeletal model with high impedance contrast between hard and soft tissues, there is still a lack of an effective source estimation method. In this paper, a water-referenced data calibration method is proposed to address the source estimation challenge in the presence of bones, which achieves consistency between the measured and simulated data before the FDFWI procedure. To avoid the cycle-skipping local minimum effect and facilitate the algorithm convergence, a starting frequency criterion for musculoskeletal FDFWI is further proposed. The feasibility of the proposed method is demonstrated by numerical studies on retrieving the anatomies of the leg models and different musculoskeletal lesions. The study extends the advanced FDFWI method to the musculoskeletal system and provides an alternative solution for musculoskeletal USCT imaging with high computational efficiency.

Basic Differences and Most Common Findings in Ultrasound Examinations of Musculoskeletal System in Children: A Narrative Literature Review

We present basic differences in the musculoskeletal ultrasound examinations between adults and children. Examiners who deal with adults on a daily basis have shared concerns about examining children. Such concerns may arise from the different approach to child ultrasounds, but they also come from differences in anatomical characteristics according to developmental age. We discuss the presence of growth plates, as well as non-mineralized parts of the bones. We also refer to the pathologies most often found in ultrasounds in early developmental stages. In the PubMed database, the set of keywords: "msk ultrasound in children", "pediatric msk sonoanatomy", "coxitis fugax", "pediatric Baker's cyst", "Baker's cyst ultrasonography", "bone septic necrosis in ultrasonography", "ultrasonography in juvenile idiopathic arthritis", and "ultrasonography in juvenile spondyloarthropathies", was used to identify a total of 1657 results, from which 54 was selected to be included in the article. We discuss the problem of osteochondritis dissecans, Osgood-Schlatter disease, examples of ligament injuries (especially in relation to the knee and ankle joints), exfoliation of growth cartilages, osteochondroma, exudates and inflammations affecting joints, and Baker's cysts. In this way, we have collected useful information about the most common diseases of the musculoskeletal system in children.

The Effectiveness of Ultrasound-Guided Subacromial-Subdeltoid Bursa Combined With Long Head of the Biceps Tendon Sheath Corticosteroid Injection for Hemiplegic Shoulder Pain: A Randomized Controlled Trial

Background

Subacromial-subdeltoid (SASD) bursa and long head of the biceps tendon (LHBT) sheath corticosteroid injection are commonly used to treat shoulder pain associated with arthritic shoulder conditions, but effectiveness in the stroke population is unclear. This study aimed to investigate the clinical effectiveness of ultrasound-guided SASD bursa combined with LHBT sheath corticosteroid injection for hemiplegic shoulder pain (HSP) compared with SASD bursa injection alone.

Methods

60 patients with HSP were randomly allocated to the dual-target group (n = 30) and single-target group (n = 30). The single-target group received SASD bursa corticosteroid injection alone, and the dual-target group received SASD bursa and LHBT sheath corticosteroid injection. The primary endpoint was pain intensity measured on a visual analog scale (VAS). The secondary endpoint was passive range of motion (PROM) of the shoulder, Upper Extremity Fugl-Meyer assessment (UEFMA) score, and Modified Barthel Index (MBI) score. PROM and pain intensity VAS were assessed at baseline and weeks 1, 4, and 12 post-treatment. UEFMA and MBI were recorded at baseline and weeks 4 and 12 post-treatment.

Results

A total of 141 patients with HSP were screened, and 60 patients were included. Significant differences in the VAS, PROM, UEFMA and MBI were observed at all follow-ups in both groups. The dual-target group showed a significant difference in VAS score compared with the single-target group (3.3 vs. 3.7, p = 0.01) at week 4 and week 12 (2.5 vs. 3.2, p < 0.001). Moreover, the dual-target group showed statistically significant differences in flexion (p < 0.001) at week 12, extension rotation (p < 0.001) at week 12, and abduction at week 1 (p = 0.003) and weeks 4 and 12 (p < 0.001) compared with the single-target group. There were significant differences in FMA and MBI scores in the two groups before and after treatment (p < 0.001), with a more significant increase in the dual-target group compared with the single-target group (p < 0.001) at week 12.

Conclusion

The combination of SASD bursa and LHBT sheath corticosteroid injection is superior to SASD bursa injection alone in reducing shoulder pain and improving functional activities in patients with HSP.

Clinical Trial Registration

www.chictr.org.cn, Unique identifier: ChiCTR2100047125.

Comparative Analysis of Real-Time Dynamic Ultrasound and Magnetic Resonance Imaging in the Diagnosis of Rotator Cuff Tear Injury

Objective

To explore the value of real-time dynamic ultrasound and magnetic resonance imaging (MRI) in the diagnosis of rotator cuff injury.

Methods

From January 2020 to June 2021, the clinical data of 55 patients with rotator cuff injury were collected. All patients were examined by real-time dynamic ultrasound and MRI at the same time within two weeks before surgery, which was confirmed by arthroscopy. The value of real-time dynamic ultrasound, MRI, and the real-time dynamic ultrasound combined with MRI in the diagnosis of rotator cuff injury was evaluated.

Results

Among the 55 patients with rotator cuff injury, real-time dynamic ultrasound showed full-thickness rotator cuff tear in 12 patients (21.82%), including type I in 2 patients (3.64%), type II in 6 patients (10.91%), and type III in 4 patients (7.27%), and partial rotator cuff tear in 31 patients (56.36%), including type IV in 16 patients (29.00%), type V in 5 patients (9.09%), and type VI in 10 patients (18.18%). MRI showed full-thickness rotator cuff tear in 12 patients (21.82%), including type I in 2 patients (3.64%), type II in 6 patients (10.91%), and type III in 4 patients (7.27%), and partial rotator cuff tear in 37 patients (67.27%), including type IV in 20 patients (36.36%), type V in 7 patients (12.73%), and type VI in 10 patients (18.18%). The combined examination showed full-thickness rotator cuff tear in 12 patients (21.82%), including type I in 2 patients (3.64%), type II in 6 patients (10.91%), and type III in 4 patients (7.27%), and partial rotator cuff tear in 39 cases (70.91%), including type IV in 21 cases (38.12%), type V in 7 patients (12.73%), and type VI in 12 patients (21.82%). The diagnostic accuracy of real-time dynamic ultrasound in complete tearing, partial tearing and the overall accuracy were 92.31%, 73.81% and 78.18%, respectively. The diagnostic accuracy of complete tear, partial tear and the overall accuracy of MRI were 92.31%, 88.00% and 89.09%, respectively. The diagnostic accuracy of complete tear and partial tear and overall accuracy in the real-time dynamic ultrasound combined with MRI were 92.31%, 95.24%, and 94.55%, respectively. The diagnostic accuracy and overall diagnostic accuracy of the combined examination of partial tears were higher than those of the real-time dynamic ultrasound and MRI examinations alone.

Conclusion

Real-time dynamic ultrasound and MRI have high application value in the diagnosis of rotator cuff injury, and the combined diagnosis is conducive to improving the diagnostic accuracy of patients with partial tear.

Validity of skeletal muscle ultrasound as a screening tool in the assessment of patients with suspected limb-girdle muscular dystrophy

This cross-sectional study measured the sensitivity and specificity of muscle ultrasound (MUS) in the assessment of patients with suspected limb-girdle muscular dystrophy (LGMD). Sixty patients with suspected LGMD from the Neuromuscular Unit, Myology Clinic, Ain Shams University Hospital, Cairo, Egypt, and a series of healthy subjects were included. The patients underwent real-time B-mode ultrasonography performed using a General Electric ultrasound machine (GE Logiq P7) and a General Electric 7.5 MHz linear array ultrasound probe (USA). All images were obtained and scored by a single examiner, and muscle echo intensity was visually graded semiquantitatively using Heckmatt's scale. The examiner was blinded to the clinical evaluations and patients' investigations. Statistical analysis using receiver operating characteristic (ROC) curve analysis revealed that the total upper-limb (UL) Heckmatt's US score at a cutoff point >1 predicted patients with dystrophy, with good (88%) accuracy and with sensitivity and specificity of 100% and 75%, respectively (p < 0.01). Moreover, the total lower-limbs (LL) Heckmatt's US score at a cutoff point >1 predicted patients with dystrophy, with excellent (91%) accuracy and with sensitivity and specificity of 100% and 75%, respectively (p < 0.01). Finally, the total Heckmatt's US score at a cutoff point >2 predicted patients with dystrophy, with good (89%) accuracy and with sensitivity and specificity of 100% and 75%, respectively (p < 0.01). Thus, MUS can be considered a valid screening tool in the assessment of patients with suspected LGMD.

Effect of Electroacupuncture on Shoulder Subluxation in Poststroke Patients with Hemiplegic Shoulder Pain: A Sham-Controlled Study Using Multidimensional Musculoskeletal Ultrasound Assessment

OBJECTIVE

This study aimed to use multidimensional musculoskeletal ultrasound imaging technique to investigate the effect of electroacupuncture (EA) on shoulder subluxation in poststroke patients with hemiplegic shoulder pain.

METHODS

In this prospective single-blind, randomized, sham-controlled study, thirty-four patients with shoulder subluxation and hemiplegic shoulder pain were recruited and randomly assigned into the EA group or the sham EA (SEA) group. In the EA group, EA was applied to the Jian yu (LI15), Bi nao (LI14), Jian zhen (SI9), and Jian liao (TE14) acupoints. In the SEA group, the EA was applied 15 mm away from the Lou gu (SP7), Di ji (SP8), Jiao xin (KI8), and Zhu bin (KI9) acupoints. Both groups underwent treatment 30 minutes/day, five days a week, for two weeks using dense waves with a frequency of 2/100 Hz. A Visual Analogue Scale (VAS) was used to evaluate the effectiveness of treatment in reducing shoulder pain. Musculoskeletal ultrasound was used to evaluate the changes of measures of shoulder subluxation in multidimensions (i.e., the acromiohumeral distance, AHD; acromion-greater tuberosity, AGT; and acromion-lesser tuberosity, ALT). Both the within- and between-groups treatment effects were assessed.

RESULTS

The pain intensity measured by VAS and shoulder subluxation measured by musculoskeletal ultrasound (i.e., AHD, AGT, and ALT) showed significant (p < 0.05) within-group difference in both groups. The between-group difference appeared in the pain intensity (p < 0.05), while it disappeared in the three measures of shoulder subluxation (p > 0.05).

CONCLUSIONS

Using VAS for measuring pain intensity and multidimensional musculoskeletal ultrasound imaging technique for measuring shoulder subluxation, this study finds that the hemiplegic shoulder pain can be improved significantly by the EA while the shoulder subluxation cannot be. Our findings further reveal the analgesic mechanism of EA on hemiplegic shoulder pain following stroke.

Factors affecting the onset and progression of rotator cuff tears in the general population

While previous studies have revealed factors affecting the progression of rotator cuff tear (RCT), none have yet described factors affecting its onset. The purpose of this longitudinal observational study was to analyze factors affecting the RCT onset and progression in the general population. The present study included 185 shoulders from 93 participants who completed all the examinations in both 2012 and 2017. Participants received a questionnaire with age, gender, arm dominance, and presence of pain at rest, in motion, and at night. The range of motion (ROM), simple shoulder test (SST) were also examined. Anteroposterior radiograph of the shoulder joint was performed to evaluate the degree of osteoarthritic changes by the Samilson-Prieto (S-P) classification. The degree of RCT was examined by ultrasonography. There were 132 shoulders without RCT and 53 with RCT in 2012. RCT occurred in 21 of 132 shoulders, and the factor affecting the RCT onset was S-P grade 2 osteoarthritic change in 2012 (odds ratio [OR] 10.10). RCT progressed in 22 of 53 shoulders, and the factor affecting RCT progression was the presence of motion pain in 2012 (OR 13.76). These results added new knowledge regarding the natural course of RCT onset and progression.

Ultrasonographic evaluation of chronic shoulder pain after breast cancer surgery: single center, cross-sectional study

Chronic shoulder pain is a common complication in breast cancer patients after surgery. Chronic shoulder pain after breast cancer surgery was formerly considered as neuropathic pain, however the pathophysiology including structural damages has not been assessed comprehensively. We hypothesized that the structural change could be one of the cause of shoulder pain after breast cancer surgery and evaluated various ultrasonography findings of the shoulder in breast cancer patients with chronic shoulder pain. Patients who were suffering from chronic shoulder pain on unilateral side for at least 3 months after breast cancer surgery were enrolled from a single tertiary hospital. Demographic and clinical data were collected at the baseline. Articular and adjacent structures of both shoulders (painful and contralateral side) were evaluated by ultrasonography. The ultrasonography findings were compared between painful and contralateral sides. Logistic regression analysis was performed to determine the factors associated with abnormal ultrasonography findings. Fifty-two female patients (average age of 55) were enrolled. Significantly more abnormal ultrasonography findings were observed in the painful side than in the contralateral side [39 (75.0%) vs 11 (21.2%), P < 0.001]. The coracohumeral ligament was significantly thicker in the painful side than in the contralateral side (2.48 ± 0.69 vs 1.54 ± 1.25 mm, P < 0.001); adhesive capsulitis was also more frequent in the painful side [14 (26.9%) vs 0, P < 0.001]. Furthermore, patients with a history of breast cancer surgery on the ipsilateral side were associated with abnormal ultrasonography findings and adhesive capsulitis. This study is the first to evaluate ultrasonography in patients with chronic shoulder pain after breast cancer surgery. The results showed that ultrasonography could reveal several structural problems in these patients.

Musculoskeletal ultrasound for traumatic and torsional alterations

The sonographic appearance of soft tissue can be altered by trauma and positional change with torsional stress. This creates challenges for ultrasonographic interpretation, because most descriptive literature and standard instructional references are displayed in anatomically neutral or other conventional positions. Knowledge of anatomic alteration and changes in sonographic appearance with torsional stress is essential for accurately assessing soft tissue abnormalities in conditions of spasticity, traumatic and post-surgical changes, and other conditions that distort musculoskeletal relationships. A systematic scanning approach to these alterations is needed for accurate diagnostic interpretation, optimizing electrode placement for electrodiagnostic techniques, effective needle placement for therapeutic ultrasound-guided procedures, and even planning for restorative surgery. This review describes expected positional changes of normal structures with torsional alteration, as well as sonographic recognition of scars, burns, hematomas, fat layer fracture, Morel-Lavallee lesions, abscesses, foreign bodies, myotendinous lesions, muscle injury and denervation, and traumatic peripheral nerve injury.