Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus

Imaging of elbow entrapment neuropathies

Entrapment neuropathies at the elbow are common in clinical practice and require an accurate diagnosis for effective management. Understanding the imaging characteristics of these conditions is essential for confirming diagnoses and identifying underlying causes. Ultrasound serves as the primary imaging modality for evaluating nerve structure and movement, while MRI is superior for detecting muscle denervation. Plain radiography and CT play a minor role and can be used for the evaluation of bony structures and calcifications/ossifications. Comprehensive knowledge of anatomical landmarks, nerve pathways, and compression sites is crucial for clinicians to accurately interpret imaging and guide appropriate treatment strategies for entrapments of ulnar, median, and radial nerves, and their branches. CRITICAL RELEVANCE STATEMENT: Accurate imaging and anatomical knowledge are essential for diagnosing elbow entrapment neuropathies. Ultrasound is the preferred modality for assessing nerve structure and motion, while MRI excels in detecting muscle denervation and guiding effective management of ulnar, median, and radial nerve entrapments. KEY POINTS: Ultrasound is the primary modality for assessing nerve structure and stability. Findings include nerve structural loss, isoechogenicity, thickening, and hyper-vascularization. MRI provides a comprehensive evaluation of the elbow and accurate muscle assessment. Imaging allows the identification of compressive causes, including anatomical variants, masses, or osseous anomalies. Awareness of anatomical landmarks, nerve pathways, and compression sites is essential.

Ultrasound-guided minimally invasive thread release of carpal tunnel: a cadaveric study

PURPOSE

Thread release of the carpal tunnel is the most recent of several minimally invasive ultrasound-guided carpal tunnel release techniques. The purpose of this article is to provide a step-by-step guide for minimally invasive, ultrasound-guided thread release of the carpal tunnel focused on transecting the transverse carpal ligament with minimal damage to the palmar aponeurosis on anatomical specimens.

METHODS

Fifteen ultrasound-guided carpal tunnel thread releases were performed on the wrists of soft-embalmed anatomical specimens, which were dissected immediately after the intervention. The procedures were performed by two musculoskeletal radiologists with 25 and 8 years of experience, respectively, in interventional radiology. Ultrasound visibility, completeness of transection, and damage to surrounding structures were evaluated on a score from 1 to 3.

RESULTS

We achieved a complete transection of the transverse carpal ligament in 11 of 15 interventions (73%) and an incomplete transection in the remaining four (27%). No neural or vascular structures were harmed. In two cases (13%), there was irrelevant damage to flexor tendons. The ultrasound visibility was rough in five specimens (33.3%), moderate in five (33.3%), and optimal in five (33.3%). Essential structures were delineated in all cases.

CONCLUSION

Thread release of the carpal tunnel leads to only minimal damage to skin, as well as structures within the carpal tunnel and the palmar aponeurosis, promising a low amount of postinterventional complications.

RELEVANCE STATEMENT

Our study showed that minimally invasive ultrasound-guided thread release of the carpal tunnel is a feasible approach in the anatomical model. The results may provide a basis for further research and refinement of this technique.

Advancing high-resolution musculoskeletal ultrasound: A histology- and anatomy-driven approach for enhanced shoulder imaging. Part I: Posterior and coronal shoulder

Ultrasound is a reliable imaging modality for diagnosing and assessing musculoskeletal disorders. Recent advancements in ultrasound technology have substantially improved image resolution, enabling the visualization of anatomic structures on a near-microscopic level. However, existing guidelines for standardized shoulder ultrasound primarily rely on earlier machine models and settings that may not harness the full potential of these high-resolution imaging capabilities. This article provides a simple and systematic guide to high-resolution sonography of the shoulder using anatomical and histological images from cadavers for comparison. International standard techniques are considered, and images were obtained using modern equipment. This two-article series systematically shows the examination and normal findings, presenting first the posterior, then frontal, then further anterior, followed by lateral and, optionally, the axillary examination. In this article, the focus is on the posterior and coronal shoulder.

US of Acute Tendon Tears

US is an effective tool for appraising acute tendon injury, allowing rapid evaluation of symptoms at bedside and paving the way for prompt diagnosis and treatment selection. It offers three main advantages in the acute or emergent setting. First, it is more sensitive and specific than physical examination. This is beneficial in tendons such as the distal triceps wherein incomplete and complete tears may manifest with similar clinical presentations. Tendon injury may also be clinically innocuous because bruising or a palpable defect is not always present and swelling may mask palpation of the tendon gap. Second, US provides important descriptors that may affect treatment selection, such as injury site, injury extent, and length of retraction. Pectoralis major tears at the tendon or musculotendinous junction warrant operative referral and are readily illustrated at US. A torn distal biceps tendon with significant retraction may require additional graft augmentation rather than reattachment to the insertion alone. Soleus and gastrocnemius strains may mimic each other clinically. Although both are managed conservatively, distinction between the two facilitates formulation of a specific rehabilitation regimen. Finally, US can narrow the differential diagnosis and rule out mimics of musculoskeletal abnormalities. Nonmusculoskeletal conditions, such as deep venous thrombosis and a ruptured Baker cyst, can manifest with the same clinical presentation as acute calf injuries and must be considered in a patient presenting with sudden calf, posterior leg, or ankle pain. The authors review the anatomic features, US techniques, and imaging findings of acute tendon injuries to aid in meaningful reporting and timely treatment selection. ©RSNA, 2024 Supplemental material is available for this article.

Multiparametric Ultrasound Assessment of Carpal Tunnel Syndrome: Beyond Nerve Cross-sectional Area

Carpal tunnel syndrome (CTS), the most common mononeuropathy, results from compression of the median nerve within the fibro-osseous carpal tunnel. Diagnosis is typically based on clinical evaluation and confirmed by nerve conduction studies. However, ultrasound (US) has emerged as a valuable noninvasive adjunct for CTS confirmation, offering potential advantages over electrodiagnostic testing in terms of patient comfort and diagnostic accuracy. This review begins with a concise summary of carpal tunnel anatomy and CTS pathophysiology as a foundation for exploring the diverse applications of US in CTS evaluation. B-mode US assessment is presented with a focus on cross-sectional imaging and dynamic evaluations, including the transverse translocation and longitudinal gliding of the median nerve. We also review current methods for assessing vascularization in CTS and explore the usefulness of elastography in CTS evaluation. The advantages and limitations of each US method are elucidated, highlighting their practical utility in clinical practice.

Overview for developing Delphi-based interdisciplinary consensus statements on imaging: pros and cons

This review paper offers a concise guide on how to execute Delphi-based interdisciplinary consensus statements on imaging. Fundamental to the Delphi methodology are several core principles. First, an initial key element is the selection of experts, known as panelists. Second is the principle of anonymity among participants, ensuring that no single individual or group applies excessive influence over others. Third, the methodology involves iterative rounds where statements are presented repeatedly, allowing for controlled feedback. Lastly, after each round, participants are given insight into the collective panel's previous responses. This knowledge enables them to potentially reconsider and adjust their positions in subsequent rounds, driving towards the group consensus. These principles emphasize the critical role of statistical group responses and the structured interaction inherent in the Delphi approach. Looking at the broader process, the development of Delphi-based interdisciplinary consensus statements on imaging unfolds through several stages. It begins with identifying the research field or the consensus statements in question. This is followed by undertaking comprehensive literature research. Subsequently, pertinent questions and their corresponding statements are crafted. The process then moves on to administering anonymous, iterative questionnaire rounds. Feedback, both on an individual and collective level, is provided between the rounds. The process culminates in the summarization and reporting of the finalized Delphi-based interdisciplinary consensus statements on imaging.

Quantitative ultrasound assessment of fatty infiltration of the rotator cuff muscles using backscatter coefficient

BACKGROUND

To prospectively evaluate ultrasound backscatter coefficients (BSCs) of the supraspinatus and infraspinatus muscles and compare with Goutallier classification on magnetic resonance imaging (MRI).

METHODS

Fifty-six participants had shoulder MRI exams and ultrasound exams of the supraspinatus and infraspinatus muscles. Goutallier MRI grades were determined and BSCs were measured. Group means were compared and the strength of relationships between the measures were determined. Using binarized Goutallier groups (0-2 versus 3-4), areas under the receiver operating characteristic curves (AUROCs) were calculated. The nearest integer cutoff value was determined using Youden's index.

RESULTS

BSC values were significantly different among most Goutallier grades for the supraspinatus and infraspinatus muscles (both p < 0.001). Strong correlations were found between the BSC values and Goutallier grades for the supraspinatus (τb = 0.72, p < 0.001) and infraspinatus (τb = 0.79, p < 0.001) muscles. BSC showed excellent performance for classification of the binarized groups (0-2 versus 3-4) for both supraspinatus (AUROC = 0.98, p < 0.0001) and infraspinatus (AUROC = 0.98, p < 0.0001) muscles. Using a cutoff BSC value of -17 dB, sensitivity, specificity, and accuracy for severe fatty infiltration were 87.0%, 90.0%, and 87.5% for the supraspinatus muscle, and 93.6%, 87.5%, and 92.7% for the infraspinatus muscle.

CONCLUSION

BSC can be applied to the rotator cuff muscles for assessment of fatty infiltration. For both the supraspinatus and infraspinatus muscles, BSC values significantly increased with higher Goutallier grades and showed strong performance in distinguishing low versus high Goutallier grades.

RELEVANCE STATEMENT

Fatty infiltration of the rotator cuff muscles can be quantified using BSC values, which are higher with increasing Goutallier grades.

KEY POINTS

Ultrasound BSC measurements are reliable for the quantification of muscle fatty infiltration. BCS values increased with higher Goutallier MRI grades. BCS values demonstrated high performance for distinguishing muscle fatty infiltration groups.

[Treatment of chronic ruptures and defects of the Achilles tendon]

BACKGROUND

Achilles tendon ruptures that are older than 4-6 weeks or developed over a more extended period are chronic. Two challenges characterize the treatment. First, defect zones over a length of several centimeters must frequently be bridged. Second, a prolonged loss of function of the muscles leads to an irreversible fatty degeneration of the tissue. So that even if the tendon is restored, significant functional deficits remain. If there are doubts about the ability of the calf muscles to regenerate, regardless of the size of the defect, tendon transfers are recommended to use the power of an additional muscle to support the plantar flexion of the ankle.

TREATMENT

Established concepts are the transposition of the flexor hallucis longus or the peroneus brevis muscle. If the muscle is intact, defects of up to 2 cm can be treated with a direct suture. Defects between 2 and 5 cm can be bridged using a VY-plasty or a turndown flap. For larger defects, free tendon transplants can be considered. The technical alternative for larger defects is a tendon transfer of the flexor hallucis longus or the peroneus brevis muscle. Besides bridging the defect, another advantage of tendon transfer is that vital muscle tissue is placed in the bed of the Achilles tendon. Both tendons are covered with muscle tissue over nearly the full length, which offers advantages, especially in patients with critical soft tissue or after infection.

FOLLOW-UP TREATMENT AND PROGNOSIS

Follow-up treatment is analogous to an acute Achilles tendon rupture. However, permanent impairments are possible; 75-80% of athletes regain their original performance level.

High-resolution Ultrasound of the Foot and Ankle

High-resolution ultrasound (US) can be used to assess soft tissue abnormalities in the foot and ankle. Compared to MRI, it has lower cost, is widely available, allows portability and dynamic assessment. US is an excellent method to evaluate foot and ankle tendon injuries, ligament tears, plantar fascia, peripheral nerves, and the different causes of metatarsalgia.

Ultrasound Elastography in Temporomandibular Disorders: A Narrative Review

A class of intricate musculoskeletal diseases known as temporomandibular disorders (TMDs) affects the temporomandibular joint (TMJ) and its supporting structures. The majority of individuals will at some point in their lives experience some degree of TMD symptoms, as these diseases are highly prevalent in the general population. TMDs are multifactorial and are attributed to various physical and biopsychosocial factors. The TMD patients typically experience preauricular pain, tenderness of masticatory muscles, and joint sounds, and these in turn affect their quality of life. To carry out the appropriate course of treatment, it is critical to make an accurate and timely diagnosis. The TMDs are classified as myofascial pain, internal disc derangement, and degenerative disorders of TMJ. Myofascial pain, which is identified by palpating the affected muscles of mastication and tenderness, is one of the most common findings. The muscles in this condition become stiff due to the contraction of myofibrils and are known as trigger bands. The diagnosis of trigger bands involving the masticatory muscles commonly involving the masseter muscle in myofascial pain to date is subjective, and palpation is the only tool used for its diagnosis. An objective assessment of the masticatory muscles is desirable for accurate diagnosis and treatment planning. Various tools like electromyography and hardness meters have been for assessing muscle stiffness, but their application in TMJ muscle disorders has not yielded valuable results. A novel diagnostic method called ultrasound elastography evaluates muscle stiffness both qualitatively and quantitatively using an elastogram and the muscular elasticity index. In this paper, we will review the ultrasound elastographic techniques utilized for the diagnosis and management of TMDs.

Diagnostic accuracy of ultrasonography in acute lateral ankle ligament injury: A systematic review and meta-analysis

BACKGROUND

The gold standard diagnostic method for acute lateral ankle ligament sprain is magnetic resonance imaging (MRI). However, it is hardly accessible and is time-consuming. Therefore, additional diagnostic methods are warranted. Point-of-care ultrasound, on the other hand, is inexpensive, widely available, time-efficient testing method.

PURPOSE

Therefore, the aim of this meta-analysis is to determine the diagnostic accuracy of ultrasound for acute ankle ligament injuries compared to MRI.

METHODS

In our systematic review and meta-analysis, we followed the recommendations of the Cochrane Handbook. We searched the following databases from inception to March 31, 2022: Medline (PubMed), EMBASE, and Cochrane Library. Eligible studies investigated the diagnostic accuracy of US compared to MRI for diagnosing acute lateral ankle ligament injuries. Finally, we calculated pooled sensitivity and specificity with a 95 % confidence interval (CI).

RESULTS

Eight studies met our eligibility criteria, involving 434 patients. For anterior tibiofibular ligament (ATFL) injury, the summary sensitivity and specificity were Se = 0.97 (CI: 0.89-0.99) and Sp = 0.93 (CI: 0.84-0.97). For calcaneofibular ligament (CFL) injury, the summary sensitivity and specificity were Se.: Se = 0.81 (CI: 0.58-0.93) and Sp = 0.92 [0,81;0,97]. In addition, subgroup analysis based on US performed by different types of investigators was comparable between each other (radiologist group Se = 0.98, CI: 0.24-1, and Sp = 0.91, CI: 0.74-0.97, and the orthopedic/ emergency department group Se = 0.96, CI: 0-1, and Sp = 0.97, CI: 0-1).

CONCLUSION

Ultrasound showed high diagnostic accuracy for acute lateral ankle ligament injury, irrespective of the investigator. Therefore, based on the current available data, it could be used in primary diagnostics of acute lateral ankle ligament injury.

A Novel Ultrasound Method of Evaluating Dynamic Extrusion of Lateral Meniscus in Healthy Population: Different Patterns of Dynamic Extrusion Revealed Between Lateral and Medial Meniscus

OBJECTIVES

To establish a reliable ultrasound (US) method of evaluating dynamic extrusion of lateral meniscus in healthy population, and to investigate the pattern of dynamic meniscus extrusion (ME) in lateral meniscus under loading conditions.

METHODS

The lateral ME was examined via US method in unloaded, double-leg standing, and single-leg standing positions. Two different US measurement methods were compared to the magnetic resonance imaging (MRI) results to determine the optimal measurement methods. The US results obtained by different researchers were tested for interobserver consistency and the results obtained by the same researcher on two separate days were tested for intraobserver consistency. The patterns of dynamic extrusion were compared between medial and lateral sides.

RESULTS

A total of healthy 44 volunteers were included in the study, with 86 knees assessed by US, and 25 knees evaluated by MRI. The US evaluation of dynamic lateral ME demonstrated excellent interobserver and intraobserver reliability. The US measurements using method A were consistent with the MRI results with no significant difference (P = .861, intraclass correlation coefficient [ICC] = 0.868), while method B underestimated the lateral ME compared to MRI (P = .001, ICC = 0.649). Lateral ME decreased slightly from unloaded (1.0 ± 0.8 mm) to single-leg standing position (0.8 ± 0.8 mm), whereas medial ME increased significantly in both double-leg and single-leg standing positions (2.4 ± 0.7 mm, 2.6 ± 0.7 mm).

CONCLUSION

A novel US evaluation method of lateral ME was established with reliable and accurate results compared to the MRI. Lateral ME in healthy populations decreased slightly as the loadings increased, which was different from the pattern of dynamic extrusion in medial meniscus.

The usefulness of ultrasound in predicting outcomes in patients with shoulder pain: a prospective observational study

OBJECTIVES

Shoulder pain is common but current clinical classification has limited utility. We aimed to determine whether groups of ultrasound-based shoulder pathologies exist and to evaluate outcomes according to identified groups and individual pathologies.

METHODS

This was a prospective study of a community-based cohort with shoulder pain referred for their first ultrasound scan at a single radiology unit, with subsequent routine clinical care. Patient-reported outcomes were collected at baseline, 2 weeks and 6 months; standardized ultrasound reporting was employed. Latent class analysis (LCA) identified ultrasound pathology-based groups. Multiple linear regression analysis explored associations between baseline pathologies, subsequent treatment and Shoulder Pain and Disability Index (SPADI). Short-term response to corticosteroid injections was investigated.

RESULTS

Of 500 participants (mean age 53.6 years; 52% female), 330 completed follow-up. LCA identified four groups: bursitis with (33%) or without (27%) acromioclavicular joint degeneration, rotator cuff tear (21%) and no bursitis/tear (19%). Total SPADI was higher at baseline for cuff tears (mean 55.1 vs 49.7-51.3; overall P = 0.005), but accounting for this, groups did not differ at 6 months (43.5 vs 38.5-40.5; P = 0.379). Baseline SPADI was the only predictor of 6-month SPADI retained by penalized modelling; neither LCA-derived ultrasound groups nor individual pathologies were selected. Response to baseline injection at week 2 did not differ between groups (mean SPADI 40.1-43.8; P = 0.423).

CONCLUSION

Ultrasound-based classification (groups or individual pathologies) of shoulder pain did not predict medium-term outcomes using current treatments. The role of routine diagnostic ultrasound for shoulder pain needs consideration; it may be useful to establish evidence-based therapies for specific pathologies.

Non invasive techniques for direct muscle quality assessment after exercise intervention in older adults: a systematic review

BACKGROUND

The aging process induces neural and morphological changes in the human musculoskeletal system, leading to a decline in muscle mass, strength and quality. These alterations, coupled with shifts in muscle metabolism, underscore the essential role of physical exercise in maintaining and improving muscle quality in older adults. Muscle quality's morphological domain encompasses direct assessments of muscle microscopic and macroscopic aspects of muscle architecture and composition. Various tools exist to estimate muscle quality, each with specific technical requirements. However, due to the heterogeneity in both the studied population and study methodologies, there is a gap in the establishment of reference standards to determine which are the non-invasive and direct tools to assess muscle quality after exercise interventions. Therefore, the purpose of this review is to obtain an overview of the non-invasive tools used to measure muscle quality directly after exercise interventions in healthy older adults, as well as to assess the effects of exercise on muscle quality.

MAIN TEXT

To address the imperative of understanding and optimizing muscle quality in aging individuals, this review provides an overview of non-invasive tools employed to measure muscle quality directly after exercise interventions in healthy older adults, along with an assessment of the effects of exercise on muscle quality.

RESULTS

Thirty four studies were included. Several methods of direct muscle quality assessment were identified. Notably, 2 studies harnessed CT, 20 utilized US, 9 employed MRI, 2 opted for TMG, 2 adopted myotonometry, and 1 incorporated BIA, with several studies employing multiple tests. Exploring interventions, 26 studies focus on resistance exercise, 4 on aerobic training, and 5 on concurrent training.

CONCLUSIONS

There is significant diversity in the methods of direct assessment of muscle quality, mainly using ultrasound and magnetic resonance imaging; and a consistent positive trend in exercise interventions, indicating their efficacy in improving or preserving muscle quality. However, the lack of standardized assessment criteria poses a challenge given the diversity within the studied population and variations in methodologies.. These data emphasize the need to standardize assessment criteria and underscore the potential benefits of exercise interventions aimed at optimizing muscle quality.

Degloving intramuscular injuries of the semimembranosus and adductor longus muscles in adolescent soccer players

Degloving muscle injury was described for the rectus femoris where the inner bipennate component is dissociated from its superficial unipennate component. The semimembranosus muscle displays a distinctive dual morphology, featuring both unipennate and bipennate muscle fibers. Nevertheless, this specific tear pattern has not been previously documented. Conversely, the adductor longus muscle showcases an elongated intramuscular tendon segment, indicating a multipennate morphology. We present two separate cases of previous undescribed degloving injuries of the semimembranosus and the adductor longus in teenage soccer players with MRI and ultrasound diagnosis, ultrasound-guided hematoma aspiration, and recovery timelines for return-to-play.

US-Guided Interventional Procedures for Total Hip Arthroplasty

In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.

Dual-energy CT in musculoskeletal imaging: technical considerations and clinical applications

Dual-energy CT stands out as a robust and innovative imaging modality, which has shown impressive advancements and increasing applications in musculoskeletal imaging. It allows to obtain detailed images with novel insights that were once the exclusive prerogative of magnetic resonance imaging. Attenuation data obtained by using different energy spectra enable to provide unique information about tissue characterization in addition to the well-established strengths of CT in the evaluation of bony structures. To understand clearly the potential of this imaging modality, radiologists must be aware of the technical complexity of this imaging tool, the different ways to acquire images and the several algorithms that can be applied in daily clinical practice and for research. Concerning musculoskeletal imaging, dual-energy CT has gained more and more space for evaluating crystal arthropathy, bone marrow edema, and soft tissue structures, including tendons and ligaments. This article aims to analyze and discuss the role of dual-energy CT in musculoskeletal imaging, exploring technical aspects, applications and clinical implications and possible perspectives of this technique.

Influencing Physical Therapist's Self-efficacy for Musculoskeletal Ultrasound Through Blended Learning: A Mixed Methods Study

BACKGROUND AND PURPOSE

With the growing interest for physical therapists to incorporate musculoskeletal (MSK) ultrasound comes a need to understand how to organize training to promote the transfer of training to clinical practice. A common training strategy blends asynchronous learning through online modules and virtual simulations with synchronous practice on live simulated participants. However, few physical therapists who attend MSK ultrasound continuing education courses integrate ultrasound into clinical practice. Self-efficacy is a significant predictor of training transfer effectiveness. This study describes to what degree and how a blended learning strategy influenced participants' self-efficacy for MSK ultrasound and transfer of training to clinical practice.

SUBJECTS

Twenty-one outpatient physical therapists with no previous MSK ultrasound training.

METHODS

Twenty-one participants assessed their self-efficacy using a 26-item self-efficacy questionnaire at 3 intervals: before asynchronous, before synchronous training, and before returning to clinical practice. Participants were interviewed within 1 week of training using a semi-structured interview guide. Quantitative analysis included descriptive statistics and repeated-measures ANOVA. Thematic analysis was used to examine participants' experiences, and "following the thread" was used to integrate findings.

RESULTS

Self-efficacy questionnaire mean scores increased significantly across the 3- time points ( F [2, 40] = 172.7, P < .001, η 2 = 0.896). Thematic analysis indicated that asynchronous activities scaffolded participants' knowledge, enhanced their self-efficacy, and prepared them for synchronous learning; however, it did not replicate the challenges of MSK ultrasound. Synchronous activities further improved self-efficacy and helped participants better calibrate their self-judgments of their abilities and readiness to integrate MSK ultrasound training into clinical practice. Despite individual-level improvements in self-efficacy, interviewees recognized their limitations and a need for longitudinal training in a clinical environment.

DISCUSSION AND CONCLUSION

A blended learning approach positively affects participants' self-efficacy for MSK ultrasound; however, future training designs should provide learners with additional support during the transition phase.

[Ultrasound in sports traumatology]

Ultrasound (US) has numerous applications in sports traumatology. The technical progress of mobile US devices has led to increasing use of ultrasound as a primary diagnostic tool. New applications such as elastography and 3 D vascularization are used for special indications.The purpose of this review is to present the current status of ultrasound in the diagnosis of sports injuries and sport traumatology including established applications and new technical advances. US is presented both in its comparison to other imaging modalities and as a sole diagnostic tool.US can be used for initial diagnosis to improve the clinical examination and for intensive shortterm follow-up imaging. The main areas of application are currently the diagnosis of acute muscle and tendon injuries as well as overuse injuries. In particular, the exclusion of structural muscle injuries can be adequately ensured with US in the majority of anatomical regions. The recently published guideline on fracture ultrasound has strengthened the clinical evidence in this area, especially in comparison to conventional radiography and in the development of algorithms and standards. The increasing use of mobile ultrasound equipment with adequate image quality makes US a location-independent modality that can also be used at training sites or during road games.

Posteromedial Corner Injuries of the Knee: Imaging Findings

The posteromedial corner (PMC) of the knee is an anatomical region formed by ligamentous structures (medial collateral ligament, posterior oblique ligament, oblique popliteal ligament), the semimembranosus tendon and its expansions, the posteromedial joint capsule, and the posterior horn of the medial meniscus. Injuries to the structures of the PMC frequently occur in acute knee trauma in association with other ligamentous or meniscal tears. The correct assessment of PMC injuries is crucial because the deficiency of these supporting structures can lead to anteromedial rotation instability or the failure of cruciate ligaments grafts. This article reviews the anatomy and biomechanics of the PMC to aid radiologists in identifying injuries potentially involving PMC components.

PET/CT and SPECT/CT for Infection in Joints and Bones: An Overview and Future Directions

Infections of the bones and joints, if misdiagnosed, may result in serious morbidity and even mortality. A prompt diagnosis followed by appropriate management may reduce the socioeconomic impact of bone and joint infections. Morphologic imaging such as ultrasound and plain radiographs form the first line investigations, however, in early infections findings may be negative or nonspecific. Nuclear medicine imaging techniques play a complementary role to morphologic imaging in the diagnosis of bone and joint infections. The availability of hybrid systems (SPECT/CT, SPECT/MRI, PET/CT or PET/MRI) offers improved specificity with ability to assess the extent of infection. Bone scans are useful as a gatekeeper wherein negative scans rule out sepsis with a good accuracy, however positive scans are nondiagnostic and more specific tracers should be considered. These include the use of labeled white blood cells and antigranulocyte antibodies. Various qualitative and quantitative interpretation criteria have been suggested to improve the specificity of the scans. PET has better image resolution and 18F-FDG is the major tracer for PET imaging with applications in oncology and inflammatory/infective disorders. It has demonstrated improved sensitivity over the SPECT based tracers, however, still suffers from lack of specificity. 18F-FDG PET has been used to monitor therapy in bone and joint infections. Other less studied, noncommercialized SPECT and PET tracers such as 111In-Biotin, 99mTc-Ubiquicidin, 18F-Na-Fluoride, 18F-labeled white blood cells and 124I-Fialuridine to name a few have shown great promise, however, their role in various bone and joint infections has not been established. Hybrid imaging with PET or PET/MRI offers huge potential for improving diagnostics in infections of the joints and bones.

Ultrasound in sports traumatology

BACKGROUND

Ultrasound (US) has numerous applications in sports traumatology. The technical progress of mobile US devices has led to increasing use of ultrasound as a primary diagnostic tool. New applications such as elastography and 3 D vascularization are used for special indications.

METHOD

The purpose of this review is to present the current status of ultrasound in the diagnosis of sports injuries and sport traumatology including established applications and new technical advances. US is presented both in its comparison to other imaging modalities and as a sole diagnostic tool.

RESULTS AND CONCLUSION

US can be used for initial diagnosis to improve the clinical examination and for intensive short-term follow-up imaging. The main areas of application are currently the diagnosis of acute muscle and tendon injuries as well as overuse injuries. In particular, the exclusion of structural muscle injuries can be adequately ensured with US in the majority of anatomical regions. The recently published guideline on fracture ultrasound has strengthened the clinical evidence in this area, especially in comparison to conventional radiography and in the development of algorithms and standards. The increasing use of mobile ultrasound equipment with adequate image quality makes US a location-independent modality that can also be used at training sites or during road games.

KEY POINTS

· Typically used for quick, focused initial diagnostic assessment and short-term follow-up after injury. · Mobile US devices allow increased use in training centers and training camps. · New US applications (SWE, 3 D) increase standardization in follow-up of tendon injuries. · Targeted use of US for musculoskeletal diagnostic assessment saves money and frees up capacity.

CITATION FORMAT

· Lerchbaumer MH, Perschk M, Gwinner C. Ultrasound in sports traumatology. Fortschr Röntgenstr 2024; 196: 440 - 449.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Musculoskeletal System Expert Panel consists of musculoskeletal radiologists, a family physician, a sports and exercise medicine physician, emergency medicine physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 25 musculoskeletal clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 41 guidelines (50 publications) and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 124 recommendation statements across the 25 scenarios related to the evaluation of the musculoskeletal system. This guideline presents the methods of development and the recommendations for imaging in the context of musculoskeletal pain, infection, tumors, arthropathies, metabolic bone disease, stress injuries, orthopedic hardware, avascular necrosis/bone infarction, and complex regional pain syndrome.

Can Secondary Adhesive Capsulitis Complicate Calcific Tendinitis of the Rotator Cuff? An Ultrasound Imaging Analysis

BACKGROUND

Adhesive capsulitis (AC) of the glenohumeral joint is a recognized cause of pain associated with both active and passive restricted ranges of movement. AC can be subdivided into primary and secondary forms. Trauma, surgery, immobilization, and diabetes mellitus are the leading well-recognized causes of secondary AC. Calcific tendinitis/tendinitis (CT) of the rotator cuff is considered a possible trigger for AC, as reported in a few previous articles. However, there are no original investigations that assess the frequency and characteristics of this association. The aim of our research was to evaluate the presence of AC in a cohort of patients with a known CT condition of the rotator cuff by an ultrasound (US) examination.

MATERIALS AND METHODS

We prospectively enrolled all the patients admitted at our single institution (October 2022-June 2023) for the preoperative US evaluation of a known CT condition. In these patients, we searched for parameters related to secondary AC. An axillary pouch (AP) thickness equal to or greater than 4 mm (or greater than 60% of the contralateral AP) was considered diagnostic of AC. Moreover, rotator interval (RI) thickness and the presence of effusion within the long-head biceps tendon (LHBT) sheath was also assessed in all patients.

RESULTS

A total of 78 patients (54F, 24M-mean age = 50.0 and range = 31-71 y.o.) were enrolled in the study. In 26 of those patients (26/78-33.3%), US signs of AC were detected. Notably, the mean AP thickness in patients with AC and CT was 3.96 ± 1.37 mm (Group 1) and 2.08 ± 0.40 mm in patients with CT only (Group 2). RI thickness was significantly greater in patients with superimposed AC: 2.54 ± 0.38 mm in Group 1 and 1.81 ± 0.41 mm in Group 2 (p < 0.00001). Moreover, effusion within the LHBT was significantly more frequently detected in patients with AC: 84.61% in Group 1 versus 15.79% in Group 2-p < 0.00001.

CONCLUSION

US signs of AC are found in one-third of patients with CT of the rotator cuff, demonstrating that AC represents a frequent complication that should be routinely evaluated during US investigation to provide more personalized treatment strategies.

Exploring the integration of diagnostic musculoskeletal ultrasound imaging into clinical practice by physical therapists

BACKGROUND

Musculoskeletal ultrasound (MSK-US) use for diagnostic purposes is expanding in physical therapy practice. Identifying and describing physical therapy-specific approaches to incorporating MSK-US into the evaluation process is needed. Musculoskeletal ultrasound extends the physical exam to allow clinicians to visualize anatomy and pathophysiology both statically and dynamically. Purpose: To document 1) weekly use of diagnostic MSK-US; and 2) clinical reasoning approach used in challenging patient cases by physical therapists (PTs) registered by Inteleos in musculoskeletal sonography (RMSK-certified).

METHODS

Longitudinal, observational, cohort study using mixed methods for data collection and analysis. All 23 currently RMSK-certified PTs using MSK-US in clinical practice across the United States were contacted, and 16 participated. Data were collected using an online survey created with the Research Electronic Data Capture System. Participants documented MSK-US clinical use and significant cases using weekly, reflective, online journals for three months. Demographic data were summarized using descriptive statistics. Case data were analyzed thematically.

RESULTS

Participating RMSK-certified PTs performed 1110 MSK-US examinations over 110 weeks. Clinicians averaged 7 (range 1-25) MSK-US examinations weekly, representing 28% of an average caseload. Examinations contributed significant anatomical/ pathological information 100% of the time. The most common joints scanned were the knee (n = 281), shoulder (n = 254), and wrist (n = 228). Case data revealed three themes: 1) augmenting the clinical evaluation to extend or narrow a diagnosis; 2) outcomes guiding action; and 3) lessons learned from clinical findings.

CONCLUSION

RMSK-certified PTs regularly used MSK-US to validate and refine their clinical diagnoses and treatment. Ultrasound imaging directly influenced patient care by informing the diagnostic process, guiding treatment, and appropriately identifying referrals.

Development of Continuous Assessment of Muscle Quality and Frailty in Older Patients Using Multiparametric Combinations of Ultrasound and Blood Biomarkers: Protocol for the ECOFRAIL Study

BACKGROUND

Frailty resulting from the loss of muscle quality can potentially be delayed through early detection and physical exercise interventions. There is a demand for cost-effective tools for the objective evaluation of muscle quality, in both cross-sectional and longitudinal assessments. Literature suggests that quantitative analysis of ultrasound data captures morphometric, compositional, and microstructural muscle properties, while biological assays derived from blood samples are associated with functional information.

OBJECTIVE

This study aims to assess multiparametric combinations of ultrasound and blood-based biomarkers to offer a cross-sectional evaluation of the patient frailty phenotype and to track changes in muscle quality associated with supervised exercise programs.

METHODS

This prospective observational multicenter study will include patients aged 70 years and older who are capable of providing informed consent. We aim to recruit 100 patients from hospital environments and 100 from primary care facilities. Each patient will undergo at least two examinations (baseline and follow-up), totaling a minimum of 400 examinations. In hospital environments, 50 patients will be measured before/after a 16-week individualized and supervised exercise program, while another 50 patients will be followed up after the same period without intervention. Primary care patients will undergo a 1-year follow-up evaluation. The primary objective is to compare cross-sectional evaluations of physical performance, functional capacity, body composition, and derived scales of sarcopenia and frailty with biomarker combinations obtained from muscle ultrasound and blood-based assays. We will analyze ultrasound raw data obtained with a point-of-care device, along with a set of biomarkers previously associated with frailty, using quantitative real-time polymerase chain reaction and enzyme-linked immunosorbent assay. Additionally, we will examine the sensitivity of these biomarkers to detect short-term muscle quality changes and functional improvement after a supervised exercise intervention compared with usual care.

RESULTS

At the time of manuscript submission, the enrollment of volunteers is ongoing. Recruitment started on March 1, 2022, and ends on June 30, 2024.

CONCLUSIONS

The outlined study protocol will integrate portable technologies, using quantitative muscle ultrasound and blood biomarkers, to facilitate an objective cross-sectional assessment of muscle quality in both hospital and primary care settings. The primary objective is to generate data that can be used to explore associations between biomarker combinations and the cross-sectional clinical assessment of frailty and sarcopenia. Additionally, the study aims to investigate musculoskeletal changes following multicomponent physical exercise programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05294757; https://clinicaltrials.gov/ct2/show/NCT05294757.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50325.

Ultrasound Evaluation of Sarcopenia in Patients with Hepatocellular Carcinoma: A Faster and Easier Way to Detect Patients at Risk

The condition of sarcopenia, defined as a progressive loss of musculoskeletal mass and muscular strength, is very common in patients with hepatocellular carcinoma (HCC) and presents a remarkable association with its prognosis. Thus, the early identification of sarcopenic patients represents one of the potential new approaches in the global assessment of HCC, and there is increasing interest regarding the potential therapeutic implications of this condition. The gold standard for the quantification of muscle mass is magnetic resonance imaging (MRI) or computed tomography (CT), but these techniques are not always feasible because of the high-cost equipment needed. A new possibility in sarcopenia identification could be muscle ultrasound examination. The measurement of specific parameters such as the muscle thickness, muscular fascicles length or pennation angle has shown a good correlation with CT or MRI values and a good diagnostic accuracy in the detection of sarcopenia. Recently, these results were also confirmed specifically in patients with chronic liver disease. This review summarizes the role of imaging for the diagnosis of sarcopenia in patients with HCC, focusing on the advantages and disadvantages of the diagnostic techniques currently validated for this aim and the future perspectives for the identification of this condition.

US-guided percutaneous irrigation of extra-shoulder calcific tendinitis

OBJECTIVES

To investigate the efficacy and safety of ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) applied out of the shoulder, comparing its effectiveness to US-PICT of the rotator cuff.

METHODS

Patients subjected to US-PICT for extra-shoulder calcific tendinitis (Case Group) were compared to those subjected to US-PICT of the rotator cuff (Control Group). We had pre-procedure Visual Analogue Scale (VAS) pain score, 1- and 3-month VAS of patients of the Case Group, pre-procedure and 3-month VAS of patients of the Control Group.

RESULTS

The Case Group consisted of 41 patients (27 women; mean age: 45 ± 9years): 26 gluteus medius, 5 patellar tendon, 3 rectus femoris, 2 gluteus maximus, 2 common extensor tendon, 1 extensor carpi radialis longus, 1 pes anserinus, and 1 peroneus longus. The Control Group included 41 patients (27 women; mean age: 47 ± 11 years). The mean pre-procedure VAS of the Case Group was 8.8 ± 0.7 with a significant (P < .001) drop at 1 month (4.5 ± 0.6) and 3 months (3.6 ± 0.6). The mean pre-procedure VAS of the Control Group was 8 ± 1.4 and dropped to 3.1 ± 1.6 after 3 months (P < .001). Post-treatment VAS at 3 months was not significantly different between two Groups (P = 0.134). Similarly, the decrease of VAS from baseline to 3 months was not significantly different between the two Groups (P = 0.264).

CONCLUSIONS

US-PICT is a safe and effective procedure that can be used out of the shoulder.

ADVANCES IN KNOWLEDGE

This study demonstrated the safety and effectiveness of US-PICT as a valuable therapeutic option for extra-shoulder calcific tendinitis, with similar clinical outcome to the same procedure performed in the rotator cuff. The technique must be adapted in some deeply located calcifications by means of the use of different needles and by thoroughly planning the access point for the procedure.

Shear-wave elastography for the evaluation of tendinopathies: a systematic review and meta-analysis

PURPOSE

To compare pathologic and healthy tendons using shear-wave elastography (SWE).

METHODS

A systematic review with meta-analysis was done searching Pubmed and EMBASE up to September 2022. Prospective, retrospective and cross-sectional studies that used SWE in the assessment of pathologic tendons versus control were included. Our primary outcome were SWE velocity (m/s) and stiffness (kPa). Methodological quality was assessed by the methodological index for non-randomized studies (MINORS). We used the mean difference (MD) with corresponding 95% confidence intervals (CIs) to quantify effects between groups. We performed sensitivity analysis in case of high heterogeneity, after excluding poor quality studies according to MINORS assessment. We used Grades of Recommendation, Assessment, Development and Evaluation to evaluate the certainty of evidence (CoE).

RESULTS

Overall, 16 studies with 676 pathologic tendons (188 Achilles, 142 patellar, 96 supraspinatus, 250 mixed) and 723 control tendons (484 healthy; 239 contralateral tendon) were included. Five studies (31.3%) were judged as poor methodological quality. Shear-wave velocity and stiffness meta-analyses showed high heterogeneity. According to a sensitivity analysis, pathologic tendons had a lower shear wave velocity (MD of - 1.69 m/s; 95% CI 1.85; - 1.52; n = 274; I2 50%) compared to healthy tendons with very low CoE. Sensitivity analysis on stiffness still showed high heterogeneity.

CONCLUSION

Pathological tendons may have reduced SWE velocity compared to controls, but the evidence is very uncertain. Future robust high-quality longitudinal studies and clear technical indications on the use of this tool are needed.

PROTOCOL

PROSPERO identifier: CRD42023405410 CLINICAL RELEVANCE STATEMENT: SWE is a relatively recent modality that may increase sensitivity and diagnostic accuracy of conventional ultrasound imaging promoting early detection of tendinopathy. Non-negligible heterogeneity has been observed in included studies, so our findings may encourage the conduct of future high-quality longitudinal studies which can provide clear technical indications on the use of this promising tool in tendon imaging.

Ultrasound imaging in professional soccer: when is it adequate?

Ultrasound imaging plays an important role in the diagnosis, monitoring and treatment of injuries in professional soccer players. With the rapid increase in the availability of hand-held portable ultrasound devices and the pressure to make timely and accurate diagnosis in professional soccer where return to play time is crucial, ultrasound imaging is an essential diagnostic tool. In this article, we discuss examples of injuries that can be adequately assessed by ultrasound imaging alone and injuries where ultrasound imaging provides a useful first step to guide further investigation and management.

The development of a systematic ultrasound protocol facilitates the visualization of foreign bodies within the canine distal limb

Ultrasonography is an excellent investigative tool that can assist with the diagnosis of soft tissue conditions. In human medicine, ultrasonography is a fundamental diagnostic tool for the investigation of suspected vegetal foreign bodies (VFB), with protocol-based ultrasonography providing increased accuracy compared to lesion-focused examinations. Protocol-based ultrasonography is an emerging tool within the veterinary field, however, compared to human medicine is not routinely employed. The objective of this study was to develop a systematic ultrasound protocol to examine the distal limb for the visualization of vegetal foreign bodies (SUEDVEG). A 12 MHz linear and an 18 MHz high-frequency small-footprint linear array transducer was used on cadaver forelimbs (n = 6) and hindlimbs (n = 6) with images obtained from three common foreign body locations within the distal limb; 1; the interdigital webbing, 2; the palmar/plantar aspect of the phalanges and metacarpus and 3; the dorsal region of the phalanges and metacarpus. From these images, a 13-step systematic musculoskeletal protocol was developed and utilized on eight clinical cases or 10 limbs that had signs typical of distal limb VFB to preliminarily validate the proposed method. Vegetal foreign bodies were successfully identified and retrieved in seven (n = 8) clinical cases with method steps 9 and 11 (orthogonal views) identifying the majority of VFBs. The described ultrasound method appears highly useful for visualizing soft tissue locations of the canine distal limb known for tracking foreign bodies. Further studies are required to validate the described systematic examination method as the preferred clinical protocol over currently used lesion-focused exploration techniques.

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Assessment of short-term effect of platelet-rich plasma treatment of tendinosis using texture analysis of ultrasound images

BACKGROUND

Computer-aided diagnosis (i.e., texture analyses) tools are becoming increasingly beneficial methods to monitor subtle tissue changes. The aim of this pilot study was to investigate short-term effect of platelet rich plasma (PRP) treatment in supraspinatus and common extensor of the forearm tendinosis by using texture analysis of ultrasound (US) images as well as by clinical questionnaires.

PATIENTS AND METHODS

Thirteen patients (7 male and 6 female, age 36-60 years, mean age 51.2 ± 5.2) were followed after US guided PRP treatment for tendinosis of two tendons (9 patients with lateral epicondylitis and 4 with supraspinatus tendinosis). Clinical and US assessment was performed prior to as well as 3 months after PRP treatment with validated clinical questionnaires. Tissue response in tendons was assessed by using gray level run length matrix method (GLRLM) of US images.

RESULTS

All patients improved of tendinosis symptoms after PRP treatment according to clinical questionnaires. Almost all GLRLM features were statistically improved 3 months after PRP treatment. GLRLM-long run high gray level emphasis (LRLGLE) revealed the best moderate positive and statistically significant correlation after PRP (r = 0.4373, p = 0.0255), followed by GLRLM-low gray level run emphasis (LGLRE) (r = 0.3877, p = 0.05).

CONCLUSIONS

Texture analysis of tendinosis US images was a useful quantitative method for the assessment of tendon remodeling after minimally invasive PRP treatment. GLRLM features have the potential to become useful imaging biomarkers to monitor spatial and time limited tissue response after PRP, however larger studies with similar protocols are needed.

Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation

Adhesive capsulitis is an idiopathic and disabling disorder characterized by intense shoulder pain and progressive limitation of active and passive glenohumeral joint range of motion. Although adhesive capsulitis has been traditionally considered a diagnosis of exclusion that can be established based on a suggestive medical history and the detection of supporting findings at the physical exam, imaging studies are commonly requested to confirm the diagnostic suspicion and to exclude other causes of shoulder pain. Indeed, clinical findings may be rather unspecific, and may overlap with diseases like calcific tendinitis, rotator cuff pathology, acromioclavicular or glenohumeral arthropathy, autoimmune disorders, and subacromial/subdeltoid bursitis. Magnetic resonance imaging, magnetic resonance arthrography, and high-resolution ultrasound have shown high sensitivity and accuracy in diagnosing adhesive capsulitis through the demonstration of specific pathological findings, including thickening of the joint capsule and of the coracohumeral ligament, fibrosis of the subcoracoid fat triangle, and extravasation of gadolinium outside the joint recesses. This narrative review provides an updated analysis of the current concepts on the role of imaging modalities in patients with adhesive capsulitis, with the final aim of proposing an evidence-based imaging protocol for the radiological evaluation of this condition.

Ultrasound Use by Upper Extremity Surgeons in 2020: A Survey of ASSH Members

BACKGROUND

The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015.

METHODS

In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US.

RESULTS

A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections.

CONCLUSIONS

Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons.

High-resolution Ultrasound of the Foot and Ankle

High-resolution ultrasound (US) can be used to assess soft tissue abnormalities in the foot and ankle. Compared to MRI, it has lower cost, is widely available, allows portability and dynamic assessment. US is an excellent method to evaluate foot and ankle tendon injuries, ligament tears, plantar fascia, peripheral nerves, and the different causes of metatarsalgia.

A New Test for Achilles Tendinopathy Based on Kager's Fat Pad Clinical Assessment Predictive Values

Background This study aimed to check the diagnostic accuracy of a new test to identify Achilles tendinopathy.

STUDY DESIGN

Observational study.

METHODS

Seventy patients recruited from a private medical centre met the diagnostic criteria for unilateral Achilles tendinopathy (age, 45.1 ± 12.7 years; weight, 75.00 ± 10 kg; height, 1.75 ± 0.1 m) and were tested based on both Achilles tendons. Seventy patients with a unilateral Achilles tendinopathy ultrasound diagnosis were tested using David's test.

RESULTS

Most (86%) subjects demonstrated Kager's fat pad asymmetry in relation to the Achilles tendon in the complete passive dorsiflexion in the prone position (David's sign). No healthy tendons had David's sign.

CONCLUSIONS

The presence of asymmetry in Kager's fat pad in relation to the Achilles tendon during complete passive dorsiflexion is strongly indicative of ultrasound-diagnosed tendinopathy. David's test demonstrated a sensitivity of 85.71% (95% CI, 77.51% to 93.91%) and a specificity of 100% (95% CI, 100% to 100%), while noting the lack of blinding of the assessors and the uncertainty of the diagnostic measures (95% CI). Asymmetry of the fat pad could potentially serve as a characteristic marker for patients with Achilles tendinopathy.

Intraneural vascularity of the median, ulnar and common peroneal nerve: Microvascular ultrasound and pathophysiological implications

Objectives

Changes in the microvascular environment are considered crucial in the pathogenesis of compression neuropathies. Several studies have demonstrated elevated intraneural vascularity in severe neuropathy compared with healthy subjects, where intraneural vascularity is considered predominantly undetectable. The aim of this study was to assess and quantify intraneural vasculature by superb microvascular imaging (SMI) in healthy volunteers in the median, ulnar and common peroneal nerve.

Methods

Intraneural vascularity was quantified in 26 healthy volunteers (312 segments overall) by SMI sonography using a 22-MHz linear transducer. Individual nerve segment vascularity was compared with the mean vascularity using one-way ANOVA and Kruskal-Wallis tests, respectively. Vendor-provided quantification and manual vessel count were compared by linear regression analysis.

Results

Intraneural vascularity was detectable in all nerve segments (100.0%). Vessel density was highest in the median nerve at the wrist (1.54 ± 0.44/mm2, P < 0.0001) and lowest in the sulcal ulnar nerve (0.90 ± 0.34/mm2, P < 0.0001). Vendor-provided automated quantification severely overestimated vascular content compared with manual quantification.

Conclusion

Superb microvascular imaging can facilitate the visualisation of nerve vascularity and even detect local variations in vessel density. The pathophysiological implications for peripheral neuropathies, especially compression neuropathies, warrant further investigation, but the absence of visible intraneural vasculature as a negative finding in the diagnostic of compression neuropathies should be interpreted with caution, as the intraneural vascularity may lie beyond the 18 MHz resolution power of a transducer.

Ultrasound or MRI in the Evaluation of Anterior Talofibular Ligament (ATFL) Injuries: Systematic Review and Meta-Analysis

OBJECTIVES

Ankle sprains represent the second most common cause of emergency department access for musculoskeletal injury and lateral ankle ligament complex tears account for 850,000 cases annually in the United States with a relapse rate of 70%. Clinical examination is limited due to its subjectivity and the difficulty of identifying a specific involvement of the ligament; therefore, US and MRI are frequently requested. Therefore, the goal of this study is to analyze the available literature on the use of ultrasound (US) and magnetic resonance imaging (MRI) to diagnose injuries to the anterior talofibular ligament (ATFL) with a meta-analytic approach.

METHODS

According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, all studies regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging ATFL injuries were searched and assessed. The data were obtained from two independent reviewers with 12 and 3 years of experience in meta-analysis. A QUADAS-2 (Quality Assessment of Studies of Diagnostic Accuracy Studies) checklist was carried out to assess the risk of biases. From the selected studies, the sensitivity, specificity, and accuracy data were extracted.

RESULTS

Nine studies were included. The results of the meta-analysis demonstrate a greater sensitivity for ultrasound [96.88 (95% CI: 94-99) (fixed effects); 97 (95% CI: 94-99) (random effects)] compared to MRI [88.50 (95% CI: 85-91) (fixed effects); 86.98 (95% CI: 77-94) (random effects)], p < 0.05. The result of this meta-analysis shows that the less expensive diagnostic technique is also the most sensitive for the diagnosis of ATFL tears. Ultrasound articles resulted to have non-heterogeneity [(p = 0.2816; I° = 21.4607%)].

CONCLUSION

This meta-analysis demonstrates that US appears to be a highly sensitive diagnostic technique for diagnosing tears of the ATFL. Compared to MRI, the sensitivity of US result was higher.

Ultrasound findings in painful spastic hip. Muscle thickness in children with cerebral palsy

BACKGROUND

In cerebral palsy (CP), spasticity is the dominant symptom and hip pain is one of the most common secondary conditions. Aetiology is not clear. Musculoskeletal ultrasound (MSUS) is a low-cost, non-invasive imaging technique that allows assessment of structural status, dynamic imaging, and quick contralateral comparison.

OBJECTIVE

A retrospective case-matched-control study. To investigate associated factors with painful spastic hip and to compare ultrasound findings (focusing on muscle thickness) in children with CP vs. typically developing (TD) peers.

SETTING

Paediatric Rehabilitation Hospital in Mexico City, from August to November 2018.

PARTICIPANTS

21 children (13 male, 7 + 4.26 years) with CP, in Gross Motor Function Classification System (GMFCS) levels IV to V, with spastic hip diagnosis (cases) and 21 children age- and sex-matched (7 + 4.28 years) TD peers (controls).

CHARACTERISTICALLY DATA

Sociodemographic data, CP topography, degree of spasticity, mobility arch, contractures, Visual Analog Scale (VAS), GMFCS, measurements of the volumes of eight major muscles of the hip joint and MSUS findings of both hips.

RESULTS

All children with CP group reported chronic hip pain. Associated factors for hip pain (high VAS hip pain score) were degree of hip displacement (percentage of migration), Ashworth Level, GMFCS level V. No synovitis, bursitis or tendinopathy was found. Significant differences (p < 0.05) were found in muscle volumes in all hip muscles (right and left) except in the right and left adductor longus.

CONCLUSION

Though possibly the most important issue with diminished muscle growth in CP children is the influence on their long-term function, it is likely that training routines that build muscle size may also increase muscle strength and improve function in this population. To improve the choice of treatments in this group and maintain muscle mass, longitudinal investigations of the natural history of muscular deficits in CP as well as the impact of intervention are needed.

Adhesive capsulitis and ultrasound diagnosis, an inseparable pair: a novel review

PURPOSE

Adhesive Capsulitis (AC) is a musculoskeletal disorder initially described by Codman in 1934. The disease is characterized by pain-limited restriction in active and passive glenohumeral range of motion (ROM) despite the lack of a structural deficit. In the last decades, arthroscopy and magnetic resonance imaging (MRI) has been the only diagnostic tools able to highlight the characteristic alterations of the glenohumeral capsular-ligament apparatus in AC; nevertheless, both arthroscopy and MRI are burdened by intrinsic limitations. The aim of this narrative review is to summarize the most significant evidence supporting the use of ultrasound (US) for the diagnosis of AC.

METHODS

We extensively searched via PubMed library the terms "frozen-shoulder" and "adhesive capsulitis" each combined with "ultrasound".

RESULTS

We found 3723 papers on PubMed and selected those inherent to AC diagnosis, US imaging, correlation with arthroscopic and MRI findings. Forty papers which were strictly related to the topic of this narrative review were initially chosen, then 20 studies which described and exploited US for AC diagnosis were finally included. Coracohumeral ligament (2.65 ± 0.4 mm) and axillary pouch thickening (3.34 ± 0.8 mm), as well as an increase in vascularity at rotator interval (78/214, 36.44%), represented the commonest US signs useful for AC diagnosis and for which the most significant cut-off values were reported.

CONCLUSIONS

The evidence collected in this review testify that musculoskeletal US is as reliable as MRI for AC diagnosis, therefore we believe that in this context US should be considered a first-line imaging technique.

Effect of Anthropometric Parameters on Achilles Tendon Stiffness of Professional Athletes Measured by Shear Wave Elastography

BACKGROUND

Shear wave elastography (SWE) is currently used to detect tissue pathologies and, in the setting of preventive medicine, may have the potential to reveal structural changes before they lead to functional impairment. Hence, it would be desirable to determine the sensitivity of SWE and to investigate how Achilles tendon stiffness is affected by anthropometric variables and sport-specific locomotion.

METHODS

To investigate the influence of anthropometric parameters on Achilles tendon stiffness using SWE and examine different types of sports to develop approaches in preventive medicine for professional athletes, standardized SWE of Achilles tendon stiffness was performed in 65 healthy professional athletes (33 female, 32 male) in the longitudinal plane and relaxed tendon position. Descriptive analysis and linear regression were performed. Furthermore, subgroup analysis was performed for different sports (soccer, handball, sprint, volleyball, hammer throw).

RESULTS

In the total study population (n = 65), Achilles tendon stiffness was significantly higher in male professional athletes (p < 0.001) than in female professional athletes (10.98 m/s (10.15-11.65) vs. 12.19 m/s (11.25-14.74)). Multiple linear regression for AT stiffness did not reveal a significant impact of age or body mass index (BMI) (p > 0.05). Subgroup analysis for type of sport showed the highest AT stiffness values in sprinters (14.02 m/s (13.50-14.63)).

CONCLUSION

There are significant gender differences in AT stiffness across different types of professional athletes. The highest AT stiffness values were found in sprinters, which needs to be considered when diagnosing tendon pathologies. Future studies are needed to investigate the benefit of pre- and post-season musculoskeletal SWE examinations of professional athletes and a possible benefit of rehabilitation or preventive medicine.

Imaging of Anatomical Variants Around the Elbow

The elbow is a synovial joint able to perform flexion, extension, supination, and pronation. Knowledge of anatomical variants is crucial to avoid misinterpretation during the evaluation of the elbow joint. We address those anatomical variants simulating pathologic conditions.

London International Consensus and Delphi study on hamstring injuries part 1: classification

Muscle injury classification systems for hamstring injuries have evolved to use anatomy and imaging information to aid management and prognosis. However, classification systems lack reliability and validity data and are not specific to individual hamstring muscles, potentially missing parameters vital for sport-specific and activity-specific decision making. A narrative evidence review was conducted followed by a modified Delphi study to build an international consensus on best-practice decision-making for the classification of hamstring injuries. This comprised a digital information gathering survey to a cohort of 46 international hamstring experts (sports medicine physicians, physiotherapists, surgeons, trainers and sports scientists) who were also invited to a face-to-face consensus group meeting in London . Fifteen of these expert clinicians attended to synthesise and refine statements around the management of hamstring injury. A second digital survey was sent to a wider group of 112 international experts. Acceptance was set at 70% agreement. Rounds 1 and 2 survey response rates were 35/46 (76%) and 99/112 (88.4%) of experts responding. Most commonly, experts used the British Athletics Muscle Injury Classification (BAMIC) (58%), Munich (12%) and Barcelona (6%) classification systems for hamstring injury. Issues identified to advance imaging classifications systems include: detailing individual hamstring muscles, establishing optimal use of imaging in diagnosis and classification, and testing the validity and reliability of classification systems. The most used hamstring injury classification system is the BAMIC. This consensus panel recommends hamstring injury classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. More research is needed on surgical referral and effectiveness criteria, and validity and reliability of classification systems to guide management.

Imaging-Guided Musculoskeletal Interventions in the Lower Limb

Imaging guidance is essential for musculoskeletal interventional procedures performed in the lower limb. A strong evidence supports the use of imaging guidance to improve safety, accuracy, and effectiveness of these interventions. Joints, tendons, bursae, and nerves can be effectively approached especially with ultrasound-guided injections. Here, we discuss evidence and technique of the most common image-guided musculoskeletal interventional procedures in the lower limb.

Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications

Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.

Detection of Subchondral Bone Microcirculatory Perfusion in Adults with Early Osteonecrosis of the Femoral Head Using Contrast-Enhanced Ultrasound: A Prospective Study

The aim of this study was to quantitatively assess subchondral bone microcirculation perfusion in adults with early osteonecrosis of the femoral head (ONFH) using contrast-enhanced ultrasound (CEUS) and to evaluate its correlation with the Association Research Circulation Osseous (ARCO) stage. We investigated 97 adult patients with definite ONFH by imaging a total of 155 hips, performing CEUS, storing images of CEUS processes at different ARCO stages and generating CEUS time-intensity curves (TICs) to obtain perfusion parameters. Differences in CEUS parameters at different ARCO stages were analyzed, and correlations were explored. A logistic regression model was constructed by incorporating the meaningful CEUS indicators. The CEUS parameters time to peak (TTP), peak intensity (PI), enhanced intensity (EI), ascending slope (AS), descending slope (DS) and area under the receiver operating characteristic curve (AUC) were significantly different in ARCO stage Ⅰ compared with stage ⅢA, and the same results were obtained in stage Ⅱ compared with stage ⅢA. However, there were no significant differences between stages Ⅰ and Ⅱ. The MTT (mean transit time) assay was not significantly different between the different stages. The receiver operating characteristic curve analysis of TTP, PI, EI, AS, DS and AUC in stages Ⅰ and ⅢA had a certain diagnostic efficacy, similar to the results in stages Ⅱ and ⅢA. The diagnostic performance of DS was less accurate in stages Ⅰ and ⅢA, while the diagnostic performance of TTP was less accurate in stages Ⅱ and ⅢA. ARCO stage was independently and negatively correlated with TTP and DS and independently and positively correlated with PI, EI, AS and AUC. The MTT assay was not correlated with ARCO stage. Logistic regression models containing statistically significant TTP, EI and AUC values were constructed, and all three values were closely related to the ARCO stage. In patients with different ARCO stages of ONFH, CEUS can effectively assess subchondral bone perfusion of the femoral head and is expected to become an effective imaging method for the diagnosis of early ONFH.

Imaging of Muscle Injuries

Ultrasound (US) and MR imaging are the most common imaging modalities used to assess sports muscle injuries. The site of the muscle injury can be located at the peripheral aspect of the muscle (myofascial), within the muscle belly (musculotendinous), and with tendon involvement (intratendinous). Tears that affect the intramuscular tendon have a worse prognosis in terms of recovery time. US is an excellent method to evaluate muscle injuries, with high spatial and contrast resolution. MR imaging can be reserved for evaluation of professional athletes, surgical planning, differential diagnosis, and assessment of deep located and proximal muscle groups.

Can We Apply Snyder's Arthroscopic Classification to Ultrasound for Evaluating Rotator Cuff Tears? A Comparative Study with MR Arthrography

We aimed to demonstrate the applicability of Snyder's arthroscopic classification of rotator cuff tears (RCT) in shoulder ultrasound (US) and to compare it with MR arthrography (MRA). Forty-six patients (34 males; mean age:34 ± 14 years) underwent shoulder US and MRA. Two radiologists (R1 = 25 years of experience; R2 = 2 years of experience) assigned A1-4, B1-4, or C1-4 values depending on the extent of RCT in both US and MRA. Inter-reader intra-modality and intra-reader inter-modality agreement were calculated using Cohen's kappa coefficient. US sensitivity and specificity of both readers were calculated using MRA as the gold standard. Patients were divided into intact cuff vs. tears, mild (A1/B1) vs. moderate (A2-3/B2-3) tears, mild-moderate (A2/B2) vs. high-moderate (A3/B3) cuff tears, moderate (A2-3/B2-3) vs. advanced (A4/B4) and full-thickness (C) tears. The highest agreement values in inter-reader US evaluation were observed for mild-moderate vs. high-moderate RCT (K = 0.745), in inter-reader MRA evaluation for mild vs. moderate RCT (K = 0.821), in R1 inter-modality (US-MRA) for mild-moderate vs. high-moderate and moderate vs. advanced/full-thickness RCT (K = 1.000), in R2 inter-modality (US-MRA) for moderate vs. advanced/full-thickness RCT (K = 1.000). US sensitivity ranged from 88.89%(R1)-84.62%(R2) to 100% (both readers), while specificity from 77.78%(R1)-90.00%(R2) to 100% (both readers). Snyder's classification can be used in US to ensure the correct detection and characterization of RCT.