High resolution ultrasound for imaging complications of muscle injury: Is there an additional role for elastography?

Ultrasound Imaging in Diagnosis and Management of Lower Limb Injuries: A Comprehensive Review

Medical imaging tests are widely used to diagnose a broad spectrum of lower-limb injuries. Among these modalities, ultrasound (US) imaging has gained significant traction as a valuable diagnostic instrument for assessing conditions primarily affecting muscles, tendons, ligaments, and other soft tissues. However, there are important dilemmas related to the indications and possibilities of US in lower-limb injuries. Conflicting findings and approaches raise questions regarding the validity, accuracy, and usefulness of the US in that area. This narrative review attempts to summarize the current state of knowledge regarding US imaging of lower-limb injuries. The study provides a detailed discussion of the existing literature and contemporary insights on the diagnosis of lower-limb injuries using US examination, and draws attention to the role of the US in interventional procedures and monitoring of the healing process. The characteristics of normal muscles, tendons, and ligaments in US imaging are presented, along with the most commonly documented conditions affecting these tissues. Furthermore, the benefits and justifications for employing US in interventional procedures are discussed, ranging from platelet-rich plasma injections to physiotherapeutic treatments like percutaneous electrolysis. The study was further augmented with US pictures depicting various lower-limb injuries, mainly affecting young athletes. This article aims to review the role of US imaging in the diagnosis and management of common lower-limb injuries.

The feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients using Quantitative Muscle Ultrasound (QMUS)

PURPOSE

Quantitative muscle ultrasound (QMUS) is a patient friendly tool for examining orofacial muscles. Resection of tissue can have an effect on the architecture and function of these muscles. The aim of this study is to investigate the feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients and to relate the findings to tumor and patient characteristics.

METHODS

Adult patients with a resected first primary pT1 or T2 oral squamous cell carcinoma, at least one year post operatively, where included. Ultrasound data were collected of the geniohyoid muscle, digastric muscles, masseter muscle, transverse muscle and genioglossus muscle. Ultrasound images were labeled as clearly visible, questionable or unclear. Of the clear muscles, echogenicity and muscle thickness were measured.

RESULTS

37 patients were included. The masseter muscle was clearly visible in all ultrasound images, both intrinsic tongue muscles had the lowest visibility (45.9%). There was a significant correlation between visibility and tumor localization for the genioglossus (p = 0.029). Age correlated with the visibility of the genioglossus muscle, BMI with the genioglossus and transverse muscles. Echogenicity and muscle thickness of the clearly identified muscles did not differ from normative values.

CONCLUSION

QMUS of orofacial muscles is feasible in postoperative oral cancer patients with relatively small tumor sizes. Tongue resections negatively affected the visibility of the two intrinsic tongue muscles. These preliminary results for particular muscles indicate that the use of ultrasound might be promising in oral cancer patients to help determine targeted goals in post-operative rehabilitation.

[Muscle injuries: the importance of high-resolution dynamic sonography in diagnostics, treatment and monitoring]

BACKGROUND

Muscle injuries are common in football. Imaging diagnostics have a major role in establishing a diagnosis. The main diagnostic procedures are MRI and ultrasound. Both diagnostics have advantages and disadvantages, which should be balanced against each other.

NEW ULTRASONIC TECHNIQUES

The role of MRI as the gold standard is increasingly being replaced by high-resolution ultrasound techniques, and MRI imaging is not always useful. To detect complications in the early stages it is advised to perform regular ultrasound-imaging check-ups. The healing process can be monitored, and it offers additional options for ultrasound-guided interventions such as hematoma punctures and targeted infiltrations.

ADVANTAGES AND DISADVANTAGES

However, ultrasound imaging is highly user dependent. Experienced operators can eliminate this disadvantage, which makes ultrasound a superior imaging system in many areas, especially for dynamic examinations. Nevertheless, MRI imaging remains a necessary imaging method in certain areas.

Imaging of muscle injuries in soccer

Accurate diagnosis of muscle injuries is a challenge in everyday clinical practice and may have profound impact on the recovery and return-to-play decisions of professional athletes particularly in soccer. Imaging techniques such as ultrasound and magnetic resonance imaging (MRI), in addition to the medical history and clinical examination, make a significant contribution to the timely structural assessment of muscle injuries. The severity of a muscle injury determined by imaging findings has a decisive influence on therapy planning and affects prognosis. Imaging is of high importance when the diagnosis or grade of injury is unclear, when recovery is taking longer than expected, and when interventional or surgical management may be needed. This narrative review will discuss ultrasound and MRI for the assessment of sports-related muscle injuries in the context of soccer, including advanced imaging techniques, with the focus on the clinical relevance of imaging findings for the prediction of return to play.

Emerging Quantitative Imaging Techniques in Sports Medicine

This article describes recent advances in quantitative imaging of musculoskeletal extremity sports injuries, citing the existing literature evidence and what additional evidence is needed to make such techniques applicable to clinical practice. Compositional and functional MRI techniques including T2 mapping, diffusion tensor imaging, and sodium imaging as well as contrast-enhanced US have been applied to quantify pathophysiologic processes and biochemical compositions of muscles, tendons, ligaments, and cartilage. Dual-energy and/or spectral CT has shown potential, particularly for the evaluation of osseous and ligamentous injury (eg, creation of quantitative bone marrow edema maps), which is not possible with standard single-energy CT. Recent advances in US technology such as shear-wave elastography or US tissue characterization as well as MR elastography enable the quantification of mechanical, elastic, and physical properties of tissues in muscle and tendon injuries. The future role of novel imaging techniques such as photon-counting CT remains to be established. Eventual prediction of return to play (ie, the time needed for the injury to heal sufficiently so that the athlete can get back to playing their sport) and estimation of risk of repeat injury is desirable to help guide sports physicians in the treatment of their patients. Additional values of quantitative analyses, as opposed to routine qualitative analyses, still must be established using prospective longitudinal studies with larger sample sizes.

[Imaging of muscle injuries in sports medicine]

BACKGROUND

Early diagnosis of muscle injuries is indispensable in order to initiate appropriate treatment and to facilitate optimal healing.

PURPOSE

The aim of this review is to provide an update on imaging of muscle injuries in sports medicine with a focus on ultrasound and magnetic resonance imaging (MRI) and to present experimental approaches in addition to routine diagnostic procedures.

MATERIALS AND METHODS

A PubMed literature search for the years 2012-2022 using the following keywords was performed: muscle, muscle injury, muscle imaging, muscle injury classification, delayed onset muscle soreness, ultrasound, MRI, sodium MRI, potassium MRI, ultra-high-field MRI, injuries of athletes.

RESULTS

Imaging is crucial to confirm and assess the extent of sports-related muscle injuries and may help establishing treatment decisions, which directly affect the prognosis. This is of importance when the diagnosis or grade of injury is unclear, when recovery is taking longer than expected, and when interventional or surgical management may be necessary. In addition to established methods such as B‑mode ultrasound and ¹H‑MRI, individual studies show promising approaches to further improve the imaging of muscle injuries in the future. Prior to the integration of contrast-enhanced ultrasound and X‑nuclei into clinical routine, additional studies are needed to validate these techniques further.

CONCLUSION

B‑mode ultrasound represents an easily available, cost-effective modality for the initial diagnosis of muscle injuries. MRI is still considered the reference standard and enables an accurate morphological assessment of the extent of the injury. There are still no imaging approaches available for the objective determination of the optimal point of return to play.

[CME-Sonography 105: Ultrasound in Sports Injuries]

CME-Sonography 105: Ultrasound in Sports Injuries Abstract. Muscle injuries are frequent in athletes and in the general population. For therapy and prognosis, it is important to understand the total extent of the injury and to be aware of possible complications. In most cases ultrasound is a useful tool for diagnostics of muscle injuries. However, muscle ultrasound is not as common as joint ultrasound; this article discusses the possibilities of high-resolution dynamic ultrasound in diagnostics and its limitations.

Value of strain-wave sonoelastography as an imaging modality in assessment of benign acute myositis in children

Background/aim

Although sonoelastography is applied in assessment of many organs, studies for evaluation of muscles are very few in number and are mostly limited to adults. With this prospective study, we aimed to evaluate the value of sonoelastography in assessment of influenza related benign acute myositis in children.

Materials and methods

This study enrolled 25 patients with a clinical diagnosis of benign acute childhood myositis (BACM) and 25 age and sex-matched healthy controls. All patients presented to our emergency department with the complaint of inability to walk and had increased serum creatine kinase (CK) levels. All patients underwent strain elastography of the gastrocnemius muscle, and an elastography score was assigned to each patient by using a previously published 5 point-color scoring system. The findings were compared with those of the control group.

Results

No statistically significant difference was detected regarding age, weight, height, or body mass index (BMI) between patient and control groups. A statistically significant difference was found between the final elastography scores of the patient and control groups, mean values being 4.16 ± 0.75 versus 3.08 ±0.40, respectively (p < 0.001). Sonoelastography yielded a sensitivity of 80%, positive predictive value of 87%, specificity 88%, negative predictive value of 81.5%, and an overall accuracy of 84 %.

Conclusion

Sonoelastography proves to be a valuable tool for diagnosis of BACM. It is one of the available ultrasound techniques in a radiology department and may particularly evolve to become a useful routine ancillary technique for investigation and follow-up in these cases.

Diagnosis and Simultaneous Treatment of Musculoskeletal Injury Using H2O2-Triggered Echogenic Antioxidant Polymer Nanoparticles in a Rat Model of Contusion Injury

Ultrasound is clinically used for diagnosis and interventions for musculoskeletal injuries like muscle contusion, but contrast of ultrasonography still remains a challenge in the field of the musculoskeletal system. A level of hydrogen peroxide (H₂O₂) is known to be elevated during mechanical tissue damage and therefore H₂O₂ can be exploited as a diagnostic and therapeutic marker for mechanical injuries in the musculoskeletal system. We previously developed poly(vanillin-oxalate) (PVO) as an inflammation-responsive polymeric prodrug of vanillin, which is designed to rapidly respond to H₂O₂ and exert antioxidant and anti-inflammatory activities. The primary aim of this study is to verify whether PVO nanoparticles could serve as contrast agents as well as therapeutic agents for musculoskeletal injuries simultaneously. In a rat model of contusion-induced muscle injury, PVO nanoparticles generated CO₂ bubbles to enhance the ultrasound contrast in the injury site. A single intramuscular injection of PVO nanoparticles also suppressed contusion-induced muscle damages by inhibiting the expression of pro-inflammatory cytokines and inflammatory cell infiltration. We, therefore, anticipate that PVO nanoparticles have great translational potential as not only ultrasound imaging agents but also therapeutic agents for the musculoskeletal disorders such as contusion.

Ultrasound Imaging in Sport-Related Muscle Injuries: Pitfalls and Opportunities

Muscle injuries occur frequently in athletes, accounting for more than one-third of sport-related trauma. Athletes most affected by these injuries are those practicing football and track and field, with hamstrings and gastrocnemius-soleus as the mainly involved sites. Muscle injuries lead to loss of competitions, long recovery times and risk of re-injury with a consequent increase of the management costs. It is therefore advisable to make an accurate and timely diagnosis to establish appropriate interventions for proper healing in the shortest time. In this context, ultrasound imaging is widely used for diagnosis of musculoskeletal disorders because of several advantages including absence of radiation, portability, good spatial resolution, and the ability to perform dynamic tests. The aim of this review is to address the role of US in the evaluation of athletes with muscle injuries. US may play a pivotal role for the management of sport-related muscle injuries because it is fast and relatively cheap, allowing dynamic muscle assessment and time series evaluation of the healing process.

The repeatability of measurements of male pelvic floor anatomy and function made from transperineal ultrasound images of healthy men and those before and after prostatectomy

AIMS

To investigate the inter- and intratester repeatability of measurement of the location and displacement of five pelvic landmarks related to pelvic floor muscles with transperineal ultrasound (TPUS) imaging recorded from healthy men and men before and after prostatectomy.

METHODS

TPUS images were selected from four different participant groups: healthy men, men awaiting prostatectomy, men 2 weeks after prostatectomy, and men 12 months after prostatectomy. On two separate occasions, two assessors with different levels of experience performed analysis of location and displacement of five pelvic landmarks in images made at rest and during voluntary contraction. A two-way mixed effects, single measurement, absolute agreement intraclass correlation coefficient (ICC) was used to investigate the repeatability.

RESULTS

Intertester reliability of all locations at rest for all groups was excellent (ICCs > 0.8) except for the craniocaudal coordinate of the ventral urethrovesical junction for men 2 weeks postprostatectomy and the anorectal junction for men with a cancerous prostate. Intertester reliability of the measurement of landmark displacement was acceptable (>0.5) for the dorsoventral axis of motion but not for the craniocaudal axis of motion for all landmarks across all groups. The more experienced assessor was consistently more repeatable. More deeply placed landmarks were more often excluded from analysis and had poorer reliability.

CONCLUSIONS

Analysis of TPUS images across clinical groups is repeatable for both location and displacement of pelvic landmarks related to pelvic floor muscles when measures are made twice. Analysis experience, landmark depth and optimization of ultrasound settings appear to be important factors in reliability.

AGEs accumulation is related to muscle degeneration and vascular calcification in peritoneal dialysis patients

BACKGROUND

Patients with chronic kidney disease (CKD) are affected by dynapenia, sarcopenia, and vascular calcification. Advanced glycation end products (AGEs) may accumulate in peritoneal dialysis (PD) patients and favor sarcopenia via changes in collagen cross-linking, muscle protein breakdown, and the calcification of arterial smooth muscle cells via p38-MAPK activation. The aim of this study is to explore the relationships between AGEs, muscle degeneration, and coronary artery calcification.

METHODS

This was a clinical observational study in patients with CKD undergoing PD, in which serum and skin AGEs (AGEs-sAF), cumulative glucose load, muscle strength and functional tests, muscle ultrasounds with elastography, coronary artery calcium (CAC) quantification, and muscle density by multislice computed tomography were measured.

RESULTS

27 patients aged 48±16 years, dialysis vintage of 27±17 months, had AGEs-sAF levels of 3.09±0.65 AU (elevated in 13 [87%] patients), grip strength levels of 26.2±9.2 kg (11 [42%] patients with dynapenia), gait speed of 1.04±0.3 m/s (abnormal in 14 [58%] patients) and "timed-up-and-go test" (TUG) of 10.5±2.2s (abnormal in 7 [26%] patients). Correlations between AGEs-sAF levels and femoral rectus elastography (R=-0.74; p=0.02), anterior-tibialis elastography (R= -0.68; p=0.04) and CAC (R=0.64; p=0.04) were detected. Cumulative glucose load correlated with femoral rectal elastography (R=-0.6; p=0.02), and serum glycated hemoglobin concentrations correlated with psoas muscle density (R= -0.58; p=0.04) and CAC correlated with psoas muscle density (R=0.57; p=0.01) and lumbar square muscle density (R=-0.63; p=0.005).

CONCLUSIONS

The study revealed associations between AGEs accumulation and lower muscle stiffness/density. Associations that linked muscle degeneration parameters with vascular calcification were observed.

Isolated partial tear of extensor digitorum longus tendon with overlying muscle herniation in acute ankle sports injury: role of high resolution musculoskeletal ultrasound

Lateral Ankle sprain is a common sports-related trauma with the mechanism of injury ranging from inversion to plantar flexion. These injuries commonly affect the ligaments but can also affect the associated soft tissue structures like the eversion muscles and tendons. Prompt and accurate diagnosis of such injuries is warranted so as to ensure early return to play and prevent long-term complications. Lateral ankle sprain injuries in sports may not always be associated with ligament injuries. We report a never before reported case of lateral ankle sprain injury in a soccer player with the unusual finding of isolated partial tear of Extensor digitorum longus muscle and its fascia leading to myo-fascial herniation. The lateral ankle ligaments were intact. The diagnosis was clinched on a high-frequency ultrasound scan supported by dynamic maneuvers which in fact proved to be superior to MRI as the latter failed to demonstrate the myo-fascial herniation in our case. We therefore propose that real-time ultrasound scanning with dynamic maneuvers should be the first line of investigation to assess sports injuries in anatomically complex joints like the ankle.

Pearls and Pitfalls in the Imaging of Soft-Tissue Masses in Children

There is a broad spectrum of soft-tissue masses in children that can be challenging to diagnose clinically and on imaging. This article reviews the typical clinical and imaging findings of the most common and relevant benign, intermediate and malignant pediatric soft-tissue tumors in the following categories of the 2013 World Health Organization (WHO) classification: adipocytic tumors (lipoma, lipoblastoma, and liposarcoma), fibroblastic/myofibroblastic tumors (nodular fasciitis, myositis ossificans, fibrous hamartoma of infancy, fibromatosis colli, desmoid-type fibromatosis, lipofibromatosis, and infantile fibrosarcoma), pericytic tumors (myofibroma/myofibromatosis), skeletal muscle tumor (rhabdomyosarcoma), nerve sheath tumors (neurofibroma, malignant peripheral nerve sheath tumor), and uncertain differentiation (synovial sarcoma). In general, ultrasound and magnetic resonance imaging are used as first- and second-line imaging modalities, with limited roles for plain radiographs, computed tomography, and fluorodeoxyglucose-positron emission tomography. Many of these tumors have nonspecific imaging findings although there are some key imaging clues that in conjunction with the clinical information allow a specific diagnosis or a narrow differential diagnosis. However, in many instances, histology is required for final diagnosis.

Novel Muscle Imaging in Inflammatory Rheumatic Diseases-A Focus on Ultrasound Shear Wave Elastography and Quantitative MRI

In recent years, imaging has played an increasing role in the clinical management of patients with rheumatic diseases with respect to aiding diagnosis, guiding therapy and monitoring disease progression. These roles have been underpinned by research which has enhanced our understanding of disease pathogenesis and pathophysiology of rheumatology conditions, in addition to their key role in outcome measurement in clinical trials. However, compared to joints, imaging research of muscles is less established, despite the fact that muscle symptoms are very common and debilitating in many rheumatic diseases. Recently, it has been shown that even though patients with rheumatoid arthritis may achieve clinical remission, defined by asymptomatic joints, many remain affected by lingering constitutional systemic symptoms like fatigue, tiredness, weakness and myalgia, which may be attributed to changes in the muscles. Recent improvements in imaging technology, coupled with an increasing clinical interest, has started to ignite new interest in the area. This perspective discusses the rationale for using imaging, particularly ultrasound and MRI, for investigating muscle pathology involved in common inflammatory rheumatic diseases. The muscles associated with rheumatic diseases can be affected in many ways, including myositis-an inflammatory muscle condition, and myopathy secondary to medications, such as glucocorticoids. In addition to non-invasive visual assessment of muscles in these conditions, novel imaging techniques like shear wave elastography and quantitative MRI can provide further useful information regarding the physiological and biomechanical status of the muscle.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.