Clinical Utility of High-Frequency Musculoskeletal Ultrasonography in Foot and Ankle Pathology: How Ultrasound Imaging Influences Diagnosis and Management

Non-surgical management of posterior tibial tendon dysfunction- a UK survey

BACKGROUND

Posterior Tibial Tendon Dysfunction (PTTD) is commonly seen within musculoskeletal care. The condition's prevalence and management is poorly understood. This study aims to demonstrate current practice by multi-professional clinicians across the United Kingdom within the National Health Service.

METHODS

A national (UK) cross-sectional online survey was conducted among multi-professionals who treat PTTD within their NHS practice. The survey covered assessment, management and evaluation. This was shared via social media and professional groups.

RESULTS

Two hundred thirteen surveys were completed, with 153 matching the eligibility criteria. The main respondents were Physiotherapists (48%) and Podiatrists (38%). Ultrasound scanning was used most frequently when considering initial imaging (67%). Many different treatment modalities were used, but a core set of education/advice, foot orthoses, and foot specific as well as general exercise were most commonly chosen. Outcome measures routinely used were pain scale (96/269) and single leg heel raise (84/269), but patient reported outcome measures were not routinely used. The most frequent reason to escalate care was failure to manage symptoms with conservative management (106/123; 86.2%), followed by fixed deformity (10/123; 8.2%).

CONCLUSIONS

This survey provides evidence on current non-surgical management for PTTD from UK NHS practice. It provides a valuable marker for clinicians to use to compare their own practice and can be used in further research as a comparator.

Musculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a "white book", 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.

Case report: Flexor carpi ulnaris tendinopathy in a lure-coursing dog treated with three platelet-rich plasma and platelet lysate injections

In the present case report a 7-year-old male Whippet competing in lure-coursing presented with third-degree recurrent lameness of the right forelimb, pain on palpation of the caudal aspect of the carpus and swelling of the forearm proximally to the accessory carpal bone. Clinical, radiographic, and ultrasonographic evaluation diagnosed a flexor carpi ulnaris (FCU) chronic tendinopathy unresponsive to previously attempted conservative treatments such as oral non-steroidal anti-inflammatory drugs (NSAIDs) administration along with padded palmar splint application and rest. The dog was subjected to one injection of autologous platelet-rich plasma (PRP) obtained using a double centrifugation tube method, followed by two platelet lysate (PL) injections. Treatment was administered at three-week intervals. The healing process was assessed through clinical and ultrasonographic imaging (US) on the day of the first injection (T0), and at week three (T1), six (T2), twelve (T3), fifty-two (T4), and one-hundred-and-four (T5). Fiber alignment score (FAS) and echogenicity score (ES) were developed by modifying a previously published US assessment scale. At T1, ES, and FAS improvement was detected, and at T2, further improvements in ES and FAS were observed. Ultrasonographic results were clinically consistent with the improvement in lameness: lameness grade 3/4 was detected at T0 and grade 2/4 at T1. A lameness grade of 1/4 was detected at T2, and grade 0/4 was observed at T3, T4, and T5. Moreover, at T5, the dog returned to competition, and no history of re-injury was reported. Our results suggest that the treatment of FCU tendinopathy in lure-coursing dogs with a combination of consecutive injections of autologous PRP and PL could be feasible. Additionally, no adverse reactions were observed.

The Utility of Ultrasound in the Evaluation of Traumatic Hallux Valgus

Isolated disruption of the medial collateral ligament of the great toe is rare and often misdiagnosed as turf toe. It may progress to acquired traumatic hallux valgus, often requiring operative intervention and a longer return to play. This case of a grade II medial collateral ligament injury highlights the importance of a thorough physical examination and consideration of the mechanism of injury. It demonstrates the utility of diagnostic musculoskeletal ultrasound in establishing a specific diagnosis upon initial patient presentation with great toe pain. It is an example of the use of ultrasound in guiding treatment and monitoring interval healing. In this case, differentiation of the injury from the classic "turf toe" led to proper stabilization with a toe spacer and activity modification, thus preventing progression of traumatic hallux valgus and leading to successful nonoperative treatment with full return to sport.

LEVEL OF EVIDENCE

Level V.

A problem-based approach in musculoskeletal ultrasonography: central metatarsalgia

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot, dynamic capability of US, and the ability to perform direct real-time evaluations of the pain site are also strong advantages of US as a modality for examining the foot. Moreover, knowing the possible pain sources to investigate when a patient has a specific site of pain will enhance the diagnostic quality of US, and will help radiologists to perform US efficiently and effectively. The purpose of this article is to review the common etiologies of metatarsalgia including Morton’s neuroma, plantar plate injury, synovitis, tenosynovitis, bursitis, and metatarsal fractures, and to discuss their US features.

Strain Ultrasound Elastography in the Achilles Tendon of Ankylosing Spondylitis Patients Treated With Anti-TNF-α: A Preliminary Study

BACKGROUND/AIM

To compare patients affected by ankylosing spondylitis (AS) treated with anti-TNF-α for two years with controls in terms of Achilles tendon stiffness, ultrasound structure and thickness.

PATIENTS AND METHODS

B-mode ultrasound evaluation and strain ultrasound elastography were performed in longitudinal and transverse planes on 22 Achilles tendons of 11 AS patients and 26 of 13 controls.

RESULTS

There were no significant differences in thickness and stiffness of the Achilles tendon between AS patients and controls, except for an increased thickness in the middle third of the tendon in the AS patients (p=0.04). The Achilles tendon stiffness ratio of AS patients was 1.02±0.36 vs. 1.14±0.38 in the controls (p=0.2).

CONCLUSION

AS patients had an Achilles tendon thickness greater than controls at the middle third, but no difference in the stiffness was found among them. Strain ultrasound elastography may be useful to exclude early changes in mechanical properties of tendons.

Update on Investigation Methods for Lower Extremity Biomechanics

Imaging with biomechanical analysis augments the clinical examination and improves outcomes by correlating imaging findings with the examination. Plain film radiographs are the gold standard to assess osseous alignment. The biomechanical examination provides information to formulate an accurate assessment. Weightbearing computed tomography scanning is a potentially valuable for functional information about joint biomechanics. True alignment of the lower extremity can be appreciated on weightbearing computed tomography scanning. Soft tissue structures can be assessed with diagnostic ultrasound examination. Acute and chronic injuries that compromise joint stability can be identified.

The application of musculoskeletal ultrasonography in sports injuries of lower limbs in Chongqing Marathon competition

BACKGROUND

High incidence of sports injury occurring during marathon competitions urges a pressing demand for a convenient and accurate diagnostic tool of such injuries. However, contemporary information on the application of musculoskeletal ultrasonography (MSUS) in sports injury is not sufficient.

METHODS

A repeated measures study was used to describe the distribution of lower limb injuries in the Chongqing marathon and the application of MSUS in assessing these sports injuries. To verify the diagnostic accuracy of MSUS for sports injury, participants were assigned to group A (MSUS group) or group B (Sports medicine physician, i.e. SMP group), each group had an independent procedure of making a diagnosis. That is, ultrasound physicians in group A made a diagnosis from the ultrasonographic images while sports medicine physicians in group B synthesizing symptoms and signs of patients to identify the exact injury.

RESULTS

No statistically significant difference was found in the participants of the baseline characteristics between the two groups (P>0.05). In both groups, the knee was accounted as the vast majority of running injury sites, followed by the ankle (P=0.152). Tendons and ligaments injuries (χ2=48.437 and P=0.000) were the most common types of injury. Visual Analog Scale (VAS), a higher score of which indicates severer pain (0 to 10), was used to evaluate the severity of pain from injuries. VAS scores decreased significantly (P<0.05) in both groups after immediate treatment and the decrease in group A was significantly greater than group B (P=0.007). For athletes with pain sustained or exacerbated, further MRI exam showed a concordance rate of approximately 100% between MSUS and MRI diagnosis.

CONCLUSIONS

Musculoskeletal ultrasonography could be applied as an efficient method for the diagnosis of sports injuries in the athletic competition field.