Quantitative Ultrasonographic Analysis of Changes of the Suprascapular Nerve in the Aging Population With Shoulder Pain

Ultrasound Diagnosis of Upper Extremity Peripheral Entrapment Neuropathies: A Narrative Review

» Diagnostic ultrasound evaluation has become an important adjunct to electrodiagnostic studies in the diagnosis of upper extremity entrapment neuropathy. » For the common median and ulnar entrapment neuropathies, published normative values for nerve cross-sectional area at the wrist and elbow have demonstrated a high degree of diagnostic validity of diagnostic ultrasound. » Expert consensus on best practice for the clinical use of these reference is lacking and should be a logical next step in the deployment of ultrasound for upper extremity neuropathy evaluation.

[Research progress of ultrasound in diagnosis and treatment of shoulder joint diseases]

Objective

To review the research progress of ultrasound in the diagnosis and treatment of shoulder diseases, in order to provide a theoretical basis for the further development of ultrasound in shoulder surgery.

Methods

The recent literature on the application of ultrasound in the shoulder joint was extensively reviewed. The application of ultrasound in the diagnosis and treatment of shoulder joint diseases, and the advantages and disadvantages of ultrasound were analysed, and the development trend of ultrasound technology in the shoulder joint area was prospected.

Results

At present, the diagnosis of shoulder joint diseases mainly relies on MRI, however, with the development of ultrasound technology, ultrasound with the characteristics of convenient, reliable, and real-time dynamic evaluation is more and more recognized in the diagnosis process of shoulder joint diseases, combined with three-dimensional ultrasound, ultrasound intervention, and elastography can improve the accuracy, sensitivity, and specificity of the diagnosis, and is suitable for the diagnosis and treatment of various shoulder joint diseases, which is expected to carry out early prevention of shoulder joint diseases in the future and achieve more refined and minimally invasive treatment.

Conclusion

Ultrasound technology has wide application prospect in shoulder joint diseases, but it is still in the developing stage, and the subjective dependence needs to be solved further.

Structural and Functional Changes in Supraspinatus Tendinopathy through Percutaneous Electrolysis, Percutaneous Peripheral Nerve Stimulation and Eccentric Exercise Combined Therapy: A Single-Blinded Randomized Clinical Trial

Shoulder tendinopathies produce pain and reduce functionality. The aim of this randomized clinical trial was to analyze the effects of Percutaneous electrolysis (PE), Percutaneous peripheral Nerve Stimulation (PNS) and eccentric exercise (EE) on pain (NPRS), strength, electromyographic activity, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and functionality (DASH and SPADI) in individuals with supraspinatus tendinopathy. Participants (n = 50) were divided into two groups; they received 4 treatment sessions, 1 per week, of PE and PNS (n = 25) or 10 treatment sessions of TENS and US (n = 25). Both groups performed the EE program consisting of 3 sets of 10 repetitions of each of the 3 exercises, twice a day, during the 4 weeks. Follow-up was carried out at 4, 12 and 24 weeks after the start of the intervention. There are statistically significant differences in the analysis between groups (p < 0.001) in the post-treatment and follow-up measurements favorable to the PE+PNS+EE treatment on pain (NPRS), strength, supraspinatus electromyographic amplitude, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and DASH and SPADI questionnaires. The combined treatment with PE, PNS and EE is an effective option in the clinical management of tendinopathies, with positive results in the short and long term on the variables studied.

Ultrasound-guided pulsed radiofrequency for chronic shoulder pain: a prospective study

BACKGROUND AND OBJECTIVES

Chronic shoulder pain is a frequent cause of suffering and impaired quality of life. Treatment includes non-pharmacological and pharmacological therapies, and interventional procedures such as suprascapular nerve blocks and radiofrequency. This prospective study aims to evaluate the efficacy of ultrasound-guided pulsed radiofrequency of suprascapular nerve for chronic shoulder pain in a clinical setting.

METHODS

Therapeutic efficacy was evaluated through pain intensity using numeric pain rating scale at baseline, immediately, 3, and 6 months after, and patient...s motor function improvement. The secondary outcome was patient satisfaction.

RESULTS

A total of 34 patients were enrolled and all patients presented a reduction in the numeric pain rating scale immediately after treatment. Pain reduction from baseline to 6 months after the procedure was 34.4% and 36.9% static and dynamic, respectively. The median percentage reduction was statistically significant immediately, 3 and 6 months after. There was also an improvement in range of motion, 39.6% in abduction, 24.1% in flexion, and 29.5% in extension. Ninety percent of patients reported patient...s global impression of change superior to six.

CONCLUSION

This study concludes that ultrasound-guided pulsed radiofrequency of suprascapular nerve reduces pain intensity for at least 6 months, accompanied by improvement of motor function and higher levels of patients... satisfaction. Therefore, this technique represents a valid analgesic approach to chronic shoulder pain.

The impact of shoulder pathologies on job discontinuation and return to work: a pilot ultrasonographic investigation

BACKGROUND

Ultrasound imaging has emerged as one of the most useful tools for evaluating shoulder disorders. To date, the association between shoulder ultrasonography and a patient's work status has rarely been explored by antecedent studies.

AIM

This study aimed to investigate the association between sonographically diagnosed shoulder pathologies and job discontinuation and return to work.

DESIGN

A cross-sectional study.

SETTING

Outpatient clinic in the university hospital.

POPULATION

Fifty-nine patients who were older than 20 years of age and had worked in a full-time job within the past three years.

METHODS

All participants underwent clinical evaluation using the visual analog scale (for pain), Shoulder Pain and Disability Index, Pittsburgh Sleep Quality Index, and shoulder ultrasound examination. The work-related ergonomic risks, including dealing with heavy objects, repeated use and requiring forceful motion of the affected upper extremity, were assessed. The ultrasound-identified shoulder pathologies associated with job discontinuation, that is, sick leave due to painful shoulder for more than two consecutive months, were considered as the primary outcome. In the job discontinuation subgroup, we further investigated the association between return to work and the clinical/sonographic findings.

RESULTS

Univariate analysis revealed a positive association between job discontinuation and shoulder surgery or work types requiring forceful upper-limb movements. Multivariate analysis demonstrated that job discontinuation was positively associated with supraspinatus tendon full-thickness tears (risk ratio, 8.80; 95% CI, 1.77-10.56; P=0.018). Of the patients who received shoulder surgery, 46.6% had recurrent rotator cuff tears. Return to work was likely to be related to pain scores during overhead activities and shoulder function impairment but not to sonographic findings.

CONCLUSIONS

Job discontinuation is associated with shoulder surgery, work that necessitates forceful upper-extremity movements and supraspinatus tendon full-thickness tears detected by ultrasound.

CLINICAL REHABILITATION IMPACT

Sonographic findings should not be used as the only standard for evaluating the patient's work capability.

Nora Lesion (Bizarre Parosteal Osteochondromatous Proliferation): An Ultrasound Diagnosis with Magnetic Resonance Imaging Correlation

Advanced cross-sectional imaging techniques are firmly established as a means of evaluating musculoskeletal disease, and ultrasound (US) is increasingly being used for the assessment of a diversity of tendon, joint, and soft-tissue abnormalities. A benign condition - bizarre parosteal osteochondromatous proliferation (BPOP) - arises from the periosteum, typically in the small bones of the hands and feet, and grows as a surface bone lesion in the surrounding soft tissue. Proliferations can become symptomatic, exercising mass effect on adjacent structures that may require operative management. As a bone-forming process, BPOP may occasionally assume worrisome histologic features that mimic sarcoma, and a pronounced tendency to recur after primary excision. A solitary mass was growing in the middle finger of a young woman that curtailed proper hand function. With US, a partially ossified formation was revealed in the proximal phalanx situated on the outer surface of the bone. There was faint acoustic shadowing distal to the lesion, and a hypoechoic halo was seen covering part of the abnormal tissue growth. Importantly, the lesion caused significant limitation of motion of the finger, on the dynamic flexion US images with the displacement of the flexor tendon and compression of a digital nerve. To restore the range of motion in the finger, surgical excision of the juxtacortical mass was performed and histology yielded a diagnosis of BPOP. We describe the US features of digital BPOP, which were found to correspond closely to those of computed tomography and magnetic resonance imaging.

Ultrasound-based radiomic analysis of the peripheral nerves for differentiation between CIDP and POEMS syndrome

BACKGROUND

Demyelinating peripheral neuropathy is characteristic of both polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome and chronic inflammatory demyelinating polyneuropathy (CIDP). We hypothesized that the different pathogeneses underlying these entities would affect the sonographic imaging features.

PURPOSE

To investigate whether ultrasound (US)-based radiomic analysis could extract features to describe the differences between CIDP and POEMS syndrome.

MATERIAL AND METHODS

In this retrospective study, we evaluated nerve US images from 26 with typical CIDP and 34 patients with POEMS syndrome. Cross-sectional area (CSA) and echogenicity of the median and ulnar nerves were evaluated in each US image of the wrist, forearm, elbow, and mid-arm. Radiomic analysis was performed on these US images. All radiomic features were examined using receiver operating characteristic analysis. Optimal features were selected using a three-step feature selection method and were inputted into XGBoost to build predictive machine-learning models.

RESULTS

The CSAs were more enlarged in patients with CIDP than in those with POEMS syndrome without significant differences, except for that of the ulnar nerve at the wrist. Nerve echogenicity was significantly more heterogeneous in patients with CIDP than in those with POEMS syndrome. The radiomic analysis yielded four features with the highest area under the curve (AUC) value of 0.83. The machine-learning model showed an AUC of 0.90.

CONCLUSION

US-based radiomic analysis has high AUC values in differentiating POEM syndrome from CIDP. Machine-learning algorithms further improved the discriminative ability.

Efficacy of acupuncture versus rehabilitation therapy on post-stroke shoulder pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture and rehabilitation therapy (RT) have been widely used for post-stroke shoulder pain (PSSP), but the efficacy of acupuncture versus RT remains unclear. Our aim was to assess the efficacy of acupuncture versus RT for PSSP.

METHODS

Six databases including PubMed, Cochrane Library, China National Knowledge Infrastructure, Chinese biological medicine database, Chinese Scientific Journal Database, and WAN FANG were searched from their inception to March 2022. Randomized controlled trials (RCTs) comparing acupuncture with RT on PSSP were included. Primary outcome was shoulder pain. Secondary outcomes were upper limb motor function, activities of daily living (ADL), and adverse events (AEs). We used RevMan Version 5.3 to pool data. We conducted data synthesis of all outcomes using the random effects model. The methodological quality of all studies was assessed by 2 independent reviewers using the risk of bias (ROB) assessment tool. We also performed subgroup analysis and sensitivity analysis. We assessed the publication bias using the Egger test and funnel plots.

RESULTS

Eighteen studies were included in qualitative synthesis, fifteen (83%) studies with 978 patients were included in meta-analysis (MA) because of the outcomes of 3 studies were inappropriate. Nine (50%) studies were considered as moderate to high quality according to ROB assessment tool. The effectiveness of acupuncture for patients with PSSP was similar to that of RT on shoulder pain alleviation (standardized mean difference [SMD]: -0.41, 95% confidence interval [CI]: -0.91 to 0.08, P = .10), improvement of upper limb motor function (weighted mean difference [WMD]: 0.80, 95% CI: -1.19 to 2.79, P = .43), and ADL (WMD: -0.83, 95% CI: -3.17 to 1.51, P = .49). Two (11%) studied reported no acupuncture-related AEs, and fourteen (78%) studies did not mention AEs resulting from acupuncture.

CONCLUSIONS

Acupuncture is similar to RT in relieving shoulder pain, improving upper limb motor function and ADL in patients with PSSP. Either acupuncture or RT might be the optimal treatment of PSSP. More well-designed RCTs of this topic are needed in the future.

Analgesic Efficacy and Outcomes of Ultrasound-guided Erector Spinae Plane Block in Patients Undergoing Bariatric and Metabolic Surgeries: A Systematic Review

Erector spinae plane block (ESPB) has been used as an intervention for providing postoperative analgesia in patients undergoing bariatric and metabolic surgeries. After registering the protocol in PROSPERO, randomized controlled trials and nonrandomized observational studies were searched in various databases till July 2022. The primary outcome was 24-h opioid consumption; the secondary outcomes were intraoperative opioid use, pain scores, time to rescue analgesia, and complications. The risk of bias and Newcastle-Ottawa scale were used to assess the quality of evidence. From the 695 studies identified, 6 studies were selected for analysis. The 24-h opioid consumption was significantly lesser in ESPB group when compared to control (mean difference [MD]: -10.67; 95% confidence interval [CI]: -21.03, -0.31, I² = 99%). The intraoperative opioid consumption was significantly less in the ESPB group (MD: -17.75; 95% CI: -20.36, -15.13, I² = 31%). The time to rescue analgesia was significantly more in the ESPB group (MD: 114.36; CI: 90.42, 138.30, I² = 99%). Although pain scores were significantly less at 6 and 24 h in ESPB group (MD: -2.00, 95% CI: -2.49, -1.51; I² = 0% and MD: -0.48; 95% CI: -0.72, -0.24; I² = 48%), at zero and 12 h, the pain scores were comparable (MD: -1.53, 95% CI: -3.06, -0.00, I² = 97% and MD: -0.80; 95% CI: -1.80, 0.20, I² = 88%). Bilateral ESPB provides opioid-sparing analgesia and better pain scores when compared to control. These results should be interpreted with caution due to high heterogeneity among the included studies.

Ultrasound Imaging and Guidance for Distal Peripheral Nerve Pathologies at the Wrist/Hand

Ultrasound has emerged as a highly valuable tool in imaging peripheral nerve lesions in the wrist region, particularly for common pathologies such as carpal tunnel and Guyon's canal syndromes. Extensive research has demonstrated nerve swelling proximal to the entrapment site, an unclear border, and flattening as features of nerve entrapments. However, there is a dearth of information regarding small or terminal nerves in the wrist and hand. This article aims to bridge this knowledge gap by providing a comprehensive overview concerning scanning techniques, pathology, and guided-injection methods for those nerve entrapments. The median nerve (main trunk, palmar cutaneous branch, and recurrent motor branch), ulnar nerve (main trunk, superficial branch, deep branch, palmar ulnar cutaneous branch, and dorsal ulnar cutaneous branch), superficial radial nerve, posterior interosseous nerve, palmar common/proper digital nerves, and dorsal common/proper digital nerves are elaborated in this review. A series of ultrasound images are used to illustrate these techniques in detail. Finally, sonographic findings complement electrodiagnostic studies, providing better insight into understanding the whole clinical scenario, while ultrasound-guided interventions are safe and effective for treating relevant nerve pathologies.

HaTU-Net: Harmonic Attention Network for Automated Ovarian Ultrasound Quantification in Assisted Pregnancy

Antral follicle Count (AFC) is a non-invasive biomarker used to assess ovarian reserves through transvaginal ultrasound (TVUS) imaging. Antral follicles' diameter is usually in the range of 2-10 mm. The primary aim of ovarian reserve monitoring is to measure the size of ovarian follicles and the number of antral follicles. Manual follicle measurement is inhibited by operator time, expertise and the subjectivity of delineating the two axes of the follicles. This necessitates an automated framework capable of quantifying follicle size and count in a clinical setting. This paper proposes a novel Harmonic Attention-based U-Net network, HaTU-Net, to precisely segment the ovary and follicles in ultrasound images. We replace the standard convolution operation with a harmonic block that convolves the features with a window-based discrete cosine transform (DCT). Additionally, we proposed a harmonic attention mechanism that helps to promote the extraction of rich features. The suggested technique allows for capturing the most relevant features, such as boundaries, shape, and textural patterns, in the presence of various noise sources (i.e., shadows, poor contrast between tissues, and speckle noise). We evaluated the proposed model on our in-house private dataset of 197 patients undergoing TransVaginal UltraSound (TVUS) exam. The experimental results on an independent test set confirm that HaTU-Net achieved a Dice coefficient score of 90% for ovaries and 81% for antral follicles, an improvement of 2% and 10%, respectively, when compared to a standard U-Net. Further, we accurately measure the follicle size, yielding the recall, and precision rates of 91.01% and 76.49%, respectively.

Diagnostic accuracy of S-Detect to breast cancer on ultrasonography: A meta-analysis (PRISMA)

BACKGROUND

Computer-aided diagnosis (CAD) systems have shown great potential as an effective auxiliary diagnostic tool in breast imaging. Previous studies have shown that S-Detect technology has a high accuracy in the differential diagnosis of breast masses. However, the application of S-Detect in clinical practice remains controversial, and the results vary among different clinical trials. This meta-analysis aimed to determine the diagnostic accuracy of S-Detect for distinguishing between benign and malignant breast masses.

METHODS

We searched PubMed, Cochrane Library, and CBM databases from inception to April 1, 2021. Meta-analysis was conducted using STATA version 14.0 and Meta-Disc version 1.4 softwares. We calculated the summary statistics for sensitivity (Sen), specificity (Spe), positive, and negative likelihood ratio (LR+/LR-), diagnostic odds ratio(DOR), and summary receiver operating characteristic (SROC) curves. Cochran Q-statistic and I2 test were used to evaluate the potential heterogeneity between studies. Sensitivity analysis was performed to evaluate the influence of single studies on the overall estimate. We also performed meta-regression analyses to investigate potential sources of heterogeneity.

RESULTS

Eleven studies that met all the inclusion criteria were included in the meta-analysis. A total of 951 malignant and 1866 benign breast masses were assessed. All breast masses were histologically confirmed using S-Detect. The pooled Sen was 0.82 (95% confidence interval(CI) = 0.74-0.88); the pooled Spe was 0.83 (95%CI = 0.78-0.88). The pooled LR + was 4.91 (95%CI = 3.75-6.41); the pooled negative LR - was 0.21 (95%CI = 0.15-0.31). The pooled DOR of S-Detect in the diagnosis of breast nodules was 23.12 (95% CI = 14.53-36.77). The area under the SROC curve was 0.90 (SE = 0.0166). No evidence of publication bias was found (t = 0.54, P = .61).

CONCLUSIONS

Our meta-analysis indicates that S-Detect may have high diagnostic accuracy in distinguishing benign and malignant breast masses.

Effectiveness of Ultrasonography Visual Biofeedback of the Diaphragm in Conjunction with Inspiratory Muscle Training on Muscle Thickness, Respiratory Pressures, Pain, Disability, Quality of Life and Pulmonary Function in Athletes with Non-Specific Low Back Pain: A Randomized Clinical Trial

Diaphragmatic weakness and thickness reduction have been detected in athletes with lumbopelvic pain (LPP). Strength training of inspiratory muscles may be necessary for athletes with LPP. Inspiratory muscle training (IMT) and visual biofeedback by rehabilitative ultrasound imaging (RUSI) have been proposed as possible interventions. Here, we determine the effectiveness of visual biofeedback by RUSI with a proposed novel thoracic orthotic device to facilitate diaphragmatic contraction in conjunction with high-intensity IMT in athletes with non-specific LPP. A single-blinded, parallel-group, randomized clinical trial was performed (NCT04097873). Of 86 participants assessed for eligibility, 64 athletes with non-specific LPP (39 males and 25 females; mean age, 33.15 ± 7.79 years) were recruited, randomized, analyzed and received diaphragm visual biofeedback by RUSI in conjunction with high-intensity IMT (RUSI+IMT; n = 32) or isolated high-intensity IMT (IMT; n = 32) interventions for 8 weeks. Diaphragmatic thickness during normal breathing, maximum respiratory pressures, pain intensity, pressure pain threshold on lumbar musculature, disability by the Roland−Morris questionnaire, quality of life by the SF-12 questionnaire and spirometry respiratory parameters were assessed at baseline and after the 8-week intervention. There were significant differences (p = 0.015), within a medium effect size (Cohen’s d = 0.62) for the forced expiratory volume in 1-s (FEV1), which was increased in the RUSI+IMT intervention group relative to the IMT alone group. Adverse effects were not observed. The rest of the outcomes did not show significant differences (p > 0.05). Diaphragm visual biofeedback by RUSI with the proposed novel thoracic orthotic device in conjunction with high-intensity IMT improved lung function by increasing FEV1 in athletes with non-specific LPP.

Suprascapular nerve release does not provide additional benefits in arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis

PURPOSE

To investigate the effect of suprascapular nerve release in arthroscopic rotator cuff repair surgery.

METHODS

This systematic review was performed to include randomized controlled trials (RCTs) and non-RCTs that compared the outcomes of patients who did and did not receive suprascapular nerve release (SSNR) during arthroscopic rotator cuff repair surgery. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant studies. Methodological Index for Non-randomized Studies (MINORS) was used for cohort study assessment. The Cochrane risk of bias assessment tool (version 1.0) was used to assess the risk of bias in randomized trials. The primary outcomes were pain and shoulder function. The secondary outcome was the re-tear rate.

RESULTS

Two RCTs and three non-RCTs with a total of 187 patients (90 patients received SSNR and 97 patients did not receive SSNR) were included in this systematic review. The meta-analysis revealed that the SSNR group did not had a more pain reduction, assessed by visual analogue scale, compared to the non-SSNR group. Also, the SSNR group did not have a significantly more improvement in the UCLA score, compared to the non-SSNR group. In addition, there was no significant difference between the two groups in terms of Constant score and re-tear rate.

CONCLUSIONS

The result of this study showed that additional suprascapular nerve release did not provide additional benefit in arthroscopic rotator cuff repair surgery. Routine arthroscopic SSNR is not recommended when treating patients with rotator cuff tear.

LEVEL OF EVIDENCE

Level III.

The Prevalence of Shoulder Disorders among Professional Bullfighters: A Cross-Sectional Ultrasonography Study

We aimed to investigate clinical and ultrasound signs of shoulder overuse injuries in professional bullfighters; side-to-side differences (dominant vs. non-dominant); and to determine potential differences according to bullfighters’ categories. An observational cross-sectional study was conducted. Thirty professional and active bullfighters were assessed. A bilateral ultrasound assessment of the subacromial bursa, long biceps head tendon (LHBT), and rotator cuff was performed to determine the presence of bursitis, subluxation, partial or total tendon rupture, tenosynovitis, or calcification. Supraspinatus tendon thickness was measured. Finally, a battery of clinical orthopedic tests (Yergason, Jobe, infraspinatus, Gerber, and bursa tests) were also performed. Most identified ultrasound findings were located in the dominant side, being the presence of bursitis (n = 9; 30%), LHBT tenosynovitis (n = 8; 26.7%), and subscapularis tendon calcification (n = 5; 16.7%) the most prevalent. No side-to-side or between-categories differences were found for supraspinatus tendon thickness (all, p > 0.05). The most frequent positive signs were the infraspinatus test (40.0%), Gerber lift-off test (33.3%), and bursitis, Jobe, and Yergason tests (all, 26.7%). Ultrasound signs were commonly found at LHBT, subacromial bursa, and rotator cuff in professional bullfighters without difference between categories and sides. No side-to-side or between-categories differences were found. Positive clinical test signs suggestive of bursitis, LHBT, and rotator cuff tendinopathy were frequently observed.

Quantitative Analysis of Dynamic Subacromial Ultrasonography: Reliability and Influencing Factors

Objective: Current imaging methods used to examine patients with subacromial impingement syndrome (SIS) are limited by their semi-quantitative nature and their capability of capturing dynamic movements. This study aimed to develop a quantitative analytic model to assess subacromial motions using dynamic ultrasound and to examine their reliability and potential influencing factors.

Method: We included 48 healthy volunteers and examined their subacromial motions with dynamic ultrasound imaging. The parameters were the minimal vertical acromiohumeral distance, rotation radius, and degrees of the humeral head. The generalized estimating equation (GEE) was used to investigate the impact of different shoulder laterality, postures, and motion phases on the outcome.

Result: Using the data of the minimal vertical acromiohumeral distance, the intra-rater and inter-rater reliabilities (intra-class correlation coefficient) were determined as 0.94 and 0.88, respectively. In the GEE analysis, a decrease in the minimal vertical acromiohumeral distance was associated with the abduction phase and full-can posture, with a beta coefficient of −0.02 cm [95% confidence interval (CI), −0.03 to −0.01] and −0.07 cm (95% CI, −0.11 to −0.02), respectively. The abduction phase led to a decrease in the radius of humeral rotation and an increase in the angle of humeral rotation, with a beta coefficient of −1.28 cm (95% CI, −2.16 to −0.40) and 6.60° (95% CI, 3.54–9.67), respectively. A significant negative correlation was observed between the rotation angle and radius of the humeral head and between the rotation angle and the minimal vertical acromiohumeral distance.

Conclusion: Quantitative analysis of dynamic ultrasound imaging enables the delineation of subacromial motion with good reliability. The vertical acromiohumeral distance is the lowest in the abduction phase and full-can posture, and the rotation angle of the humeral head has the potential to serve as a new parameter for the evaluation of SIS.

Ultrasonographic morphological characteristics determined using a deep learning-based computer-aided diagnostic system of breast cancer

To investigate the correlations between ultrasonographic morphological characteristics quantitatively assessed using a deep learning-based computer-aided diagnostic system (DL-CAD) and histopathologic features of breast cancer.This retrospective study included 282 women with invasive breast cancer (<5 cm; mean age, 54.4 [range, 29-85] years) who underwent surgery between February 2016 and April 2017. The morphological characteristics of breast cancer on B-mode ultrasonography were analyzed using DL-CAD, and quantitative scores (0-1) were obtained. Associations between quantitative scores and tumor histologic type, grade, size, subtype, and lymph node status were compared.Two-hundred and thirty-six (83.7%) tumors were invasive ductal carcinoma, 18 (6.4%) invasive lobular carcinoma, and 28 (9.9%) micropapillary, apocrine, and mucinous. The mean size was 1.8 ± 1.0 (standard deviation) cm, and 108 (38.3%) cases were node positive. Irregular shape score was associated with tumor size (P < .001), lymph nodes status (P = .001), and estrogen receptor status (P = .016). Not-circumscribed margin (P < .001) and hypoechogenicity (P = .003) scores correlated with tumor size, and non-parallel orientation score correlated with histologic grade (P = .024). Luminal A tumors exhibited more irregular features (P = .048) with no parallel orientation (P = .002), whereas triple-negative breast cancer showed a rounder/more oval and parallel orientation.Quantitative morphological characteristics of breast cancers determined using DL-CAD correlated with histopathologic features and could provide useful information about breast cancer phenotypes.

Ultrasound Features of Adhesive Capsulitis

Introduction

Adhesive capsulitis (AC), which is characterised by shoulder pain and a limited range of motion (ROM), is usually diagnosed on the basis of clinical suspicion, with imaging only being used to exclude other causes of similar symptoms. The aim of this study was to identify and describe the typical ultrasound (US) features of AC in a group of patients with shoulder pain and stiffness.

Methods

This was a cross-sectional study of 1486 patients with AC in which two experienced US specialists examined the axillary pouch (AP), the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), and the long head of the biceps tendon (LHBT), and dynamically visualised the infraspinatus tendon during passive external rotation (PER) during a US evaluation of shoulder ROM.

Results

AC was confirmed in 106 patients (7.1%). Thickening of the AP of more than 4 mm was observed in 93.4% of the patients, whereas 6.6% showed AP thickening of less than 4 mm but more than 60% of the thickening in the contralateral shoulder. Effusion within the LHBT sheath was detected in 71% of the patients, and thickening of the CHL or SGHL in 88%. The dynamic study of the infraspinatus tendon showed reduced sliding with folding towards the joint capsule in 73% of cases, thus changing the tendon’s profile from flat to concave during PER. The reduced tendon sliding was associated with a bouncing movement that returned the tendon to its baseline resting position in 41.5% of cases.

Conclusions

We believe a sufficiently experienced US specialist can confirm a clinical diagnosis of AC by carrying out a comparative study of APs, evaluating the thickness of the CHL and SGHL, and detecting reduced sliding of the infraspinatus tendon.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00413-w.

Ultrasound Imaging of Head/Neck Muscles and Their Fasciae: An Observational Study

Background: Masticatory muscle thickness provides objective measurements of the temporomandibular motor function, which may change in patients with oral myofascial pain. Moreover, they are considered as being part of the craniocervical unit by a crucial relationship with cervical muscles and their fasciae. In this study, we aimed to assess by ultrasound (US) imaging the fasciae of the masseter, temporal, and sternocleidomastoid muscles to understand their mean thickness and eventual variation in relationship with the muscles, sides, and sex.

Methods: We studied 16 healthy volunteers without temporomandibular joint dysfunction. Concerning each subject were evaluated the range of motion of the temporomandibular joint and of the neck, the thickness of muscles and their fasciae of both sides, and the delta of muscle thickness.

Results: All the motor evaluations of the subjects showed normal ranges. The US results showed that the fasciae have a mean thickness of 0.50 ± 0.1 mm, which did not change during muscle contraction. The evaluated muscles presented a symmetry between right and left (p > 0.05), even if the delta of muscle (US) thickness had a huge range between different subjects, for example in the masseter muscle from 0.7 to 4.2 mm.

Conclusions: Ultrasound imaging is a suitable and reliable tool to study the muscles and fasciae of the head and neck region, permitting also the evaluation of the ability of the muscles to contract. Finally, identifying functional asymmetry that could become symptomatic, US imaging could allow an early rehabilitation treatment.

Bilateral suprascapular notches are asymmetrically shaped in a third of the Asian population

PURPOSE

The side-to-side differences within an individual's suprascapular notch (SSN) and the clinical characteristics of an ossified superior transverse scapular ligament are unclear. Therefore, the morphological asymmetry of the SSN was investigated, and the factors associated with the ossification of the superior transverse scapular ligament were analyzed.

METHODS

Two hundred and seventy-six computed tomography images were retrospectively analyzed, which included those of both scapulae of Asian patients (mean age, 62.1 ± 19.1 years; males, 197) with high-energy injuries or respiratory diseases. Variations in the SSN were classified into six types based on Rengachary's classification using reconstructed three-dimensional computed tomography. The group with a type VI SSN (completely ossified superior transverse scapular ligament) in at least one scapula was compared with the other group for age, sex, and chronic comorbidities.

RESULTS

Among 276 patients, 95 (34.4%) had asymmetric SSNs and 15 (5.4%) had type VI SSNs. There were no significant differences in age, sex, or comorbidities between both the groups. However, on comparing age groups, the prevalence of type VI SSN was higher in patients aged > 70 years than in those aged < 70 years. Fifteen patients had type VI SSNs, which were unilateral in 10 patients.

CONCLUSION

Asymmetric SSNs were observed in a third of the Asian patients. There were variations in SSNs between individuals and also within an individual. In the cases with suprascapular nerve paralysis, the difference in SSN morphology compared to a healthy side should be considered.

LEVEL OF EVIDENCE

III.

Retrospective study of the clinical effect of incobotulinumtoxinA for the management of myofascial pain syndrome in refractory patients

The aim was to evaluate the effectiveness and safety of IncobotulinumtoxinA (IncoA) for the management of myofascial pain syndrome (MPS) in refractory patients. This single-center, observational, retrospective study includes 37 patients. The pain reduction was 4.7 points (95%CI: 5.6 to -3.8) from baseline to one-month post-injection (using a 10-point visual analogue scale). Only 18.9% experienced mild adverse events. In conclusion, IncoA is an effective and safe alternative for the treatment of MPS in refractory patients.

Ultrasound-Guided Measurement of Piriformis Muscle Thickness to Diagnose Piriformis Syndrome

Background: Piriformis syndrome (PS) is a neuromuscular condition caused by the entrapment of the sciatic nerve at the level of the piriformis muscle (PM). Diagnosing PS remains challenging despite recent invasive and non-invasive diagnostic methods. Response to invasive nerve block is still one of the most reliable diagnostic modalities because there is no gold standard test for PS. As early diagnosis may prevent delayed diagnosis that results in chronic somatic dysfunction and muscle weakness, a screening test with high sensitivity could guide clinicians in performing the next appropriate step in diagnosing PS.

Aim: The purpose of this study is to determine the sensitivity, specificity, and best cut-off point of ultrasound-guided PM thickness in PS.

Method: This case-control study was conducted in a general hospital in Tangerang during a 3-month period. We recruited 58 patients clinically diagnosed with PS and 58 healthy patients (without a history of hip and buttock pain) during their visits to the outpatient clinic. All patients underwent ultrasound assessment to measure bilateral PM thickness. Sex, age, body mass index, history of micro-/macro-trauma, and prolonged sitting duration were recorded. Statistical analyses were performed using the Statistical Package for the Social Sciences version 25.

Result: The PS and control groups predominantly comprised female subjects, with mean ages of 51.79 ± 14.10 and 50.09 ± 13.26 years on PS and healthy subjects, respectively. The mean ultrasound-guided PM thickness was higher in PS subjects compared to healthy subjects with mean thicknesses of 1.16 ± 0.13 and 0.85 ± 0.11 cm, respectively (p < 0.05). The area under the receiver operating characteristic curve of the PM was 0.970 (95% confidence interval 0.943–0.998, p < 0.05). The best cut-off point defined by Youden's J index was 0.9950 cm for all PS subjects.

Conclusion: We propose 0.9950 cm as the cut-off point for diagnosing PS by ultrasound, which has the sensitivity and specificity of 94.8 and 87.9%, respectively.

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach

To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ± 3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ± 3.92°, a mean PA of 7.43 ± 2.68°, and a mean Rasmussen radiological score of 16.00 ± 2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ± 3.51°, a mean PA of 9.68 ± 4.01°, and a mean Rasmussen radiological score of 15.33 ± 2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ± 10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ± 10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.

Value of shear wave elastography combined with the Toronto clinical scoring system in diagnosis of diabetic peripheral neuropathy

To evaluate the diagnostic values of shear wave elastography (SWE) alone and in combination with the Toronto clinical scoring system (TCSS) on diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM).The study included 41 DPN patients, 42 non-DPN patients, and 21 healthy volunteers. Conventional ultrasonography and SWE were performed on the 2 sides of the tibial nerves, and cross-sectional area (CSA) and nerve stiffness were measured. TCSS was applied to all patients. A receiver operating characteristic curve analysis was performed.The stiffness of the tibial nerve, as measured as mean, minimum or maximum elasticity, was significantly higher in patients in the DPN group than the other groups (P < .05). The tibial nerve of subjects in the non-DPN group was significantly stiffer compared to the control group (P < .05). There was no significant difference of the tibial nerve CSA among the 3 groups (P > .05). Mean elasticity of the tibial nerve with a cutoff of 71.3 kPa was the most sensitive (68.3%) and had a higher area under the curve (0.712; 0.602-0.806) among the 3 shear elasticity indices for diagnosing DPN when used alone. When combining SWE with TCSS in diagnosing DPN, the most effective parameter was the EMax, which yielded a sensitivity of 100.00% and a specificity of 95.24%.SWE is a better diagnostic tool for DPN than the conventional ultrasonic parameter CSA, and a higher diagnostic value is attained when combining SWE with TCSS.

Peripheral neuropathy in systemic lupus erythematosus: what can neuromuscular ultrasonography (NMUS) tell us? A cross-sectional study

OBJECTIVE

To evaluate peripheral nerve involvement in patients with SLE with neuromuscular ultrasonography (NMUS) and understand its role in investigating SLE-related peripheral neuropathy.

METHODS

This is an observational cross-sectional study on patients with SLE and healthy controls. Five nerves in each patient were examined bilaterally with NMUS, and the cross-sectional area (CSA) of each nerve at certain sites was estimated. The mean CSA at each site, for each nerve, in each group was statistically analysed and compared between groups.

RESULTS

370 nerves were evaluated in 37 patients. By nerve conduction study (NCS), 36 patients had polyneuropathy (80.6% mixed type, 19.4% sensory). Significant mean CSA enlargement was present among the ulnar nerve at the Guyon's canal and mid-humerus (both p=0.001); tibial nerve at the distal leg and proximal to the tarsal tunnel (p=0.003 and p=0.001, respectively); and peroneal nerve at the popliteal fossa (p=0.042). The mean CSA showed high specificity compared with NCS.

CONCLUSION

Our study shows that CSA could be a complementary tool to NCS for studying peripheral neuropathy in SLE. Furthermore, NMUS provides data on the different pathophysiological aspects of nerve involvement in SLE. Future studies using more than one sonographic parameter in combination with NCS and nerve histopathology are recommended to further investigate SLE-related neuropathy.Trial registration number NCT04527172.

Concurrent Validity and Reliability of Manual Versus Specific Device Transcostal Measurements for Breathing Diaphragm Thickness by Ultrasonography in Lumbopelvic Pain Athletes

The use of rehabilitative ultrasound imaging (RUSI) to evaluate diaphragm thickness during breathing in athletes who suffer from non-specific lumbopelvic pain presents some measurement errors. The purpose of this study was to evaluate intra- and inter-sessions, intra- and inter-rater reliabilities, and concurrent validity of diaphragm thickness measurements during breathing using transcostal RUSI with a novel thoracic orthotic device that was used to fix the US probe versus those measurements obtained using manual fixation. A total of 37 athletes with non-specific lumbopelvic pain were recruited. Intra- (same examiner) and inter-rater (two examiners) and intra- (same day) and inter-session (alternate days) reliabilities were analyzed. All measurements were obtained after manual probe fixation and after positioning the thoracic orthotic device to fix the US probe in order to correctly correlate both measurement methods. Both left and right hemi-diaphragm thickness measurements were performed by transcostal RUSI at maximum inspiration, expiration, and the difference between the two parameters during relaxed breathing. Intra-class correlation coefficients (ICC), standard errors of measurement (SEM), minimum detectable changes (MCD), systematic errors, and correlations (r) were assessed. Orthotic device probe fixation showed excellent reliability (ICC = 0.852-0.996, SEM = 0.0002-0.054, and MDC = 0.002-0.072), and most measurements did not show significant systematic errors (p > 0.05). Despite manual probe fixation with a reliability ranging from good to excellent (ICC = 0.714-0.997, SEM = 0.003-0.023, and MDC = 0.008-0.064 cm), several significant systematic measurement errors (p < 0.05) were found. Most significant correlations between both orthotic device and manual probe fixation methods were moderate (r = 0.486-0.718; p < 0.05). Bland-Altman plots indicated adequate agreement between both measurement methods according to the agreement limits. The proposed novel thoracic orthotic device may allow ultrasound probe fixation to provide valid and reliable transcostal RUSI measurements of diaphragmatic thickness during relaxed breathing thus reducing some measurement errors and avoiding systematic measurement errors. It may be advisable to measure diaphragm thickness and facilitate visual biofeedback with respect to diaphragm re-education during normal breathing in athletes with non-specific lumbopelvic pain.

A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway.

Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators.

Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.

Sciatic nerve excursion during neural mobilization with ankle movement using dynamic ultrasound imaging: a cross-sectional study

PURPOSE

Ankle movement is used as a sensitizing maneuver for sciatica during neurodynamic techniques. In vivo studies on the sciatic nerve biomechanics associated with ankle movement during different positions of neighboring joints are scarce. The aim of this study was to investigate sciatic nerve excursion during ankle dorsiflexion in different positions in a healthy population.

METHODS

This is a cross-sectional study. High-resolution dynamic ultrasound imaging was used to measure longitudinal excursion of the sciatic nerve in the posterior thigh of 27 healthy participants during ankle dorsiflexion in six positions of the neck, hip, and knee. Both the long and short distance of the nerve excursion were measured. Wilcoxon signed-rank tests were used for data analysis, and Eta squared (r) was used to quantify the effect size.

RESULTS

Ankle dorsiflexion resulted in distal sciatic nerve excursion that was significantly higher in positions in which the knee was extended (median 0.7-1.6 mm) than in positions in which the knee was flexed (median 0.5-1.4 mm) (P ≤ 0.049, r ≥ 0.379). There were no significant differences in nerve excursion between positions where the neck was neutral compared with positions where the neck was flexed (P ≥ 0.710, r ≤ 0.072) or between positions where the hip was neutral compared with positions where the hip was flexed (P ≥ 0.456, r ≤ 0.143).

CONCLUSION

The positions of adjacent joints, particularly the knee, had an impact on the excursion of the sciatic nerve in the thigh during ankle movement.

Sarcopenia Is Associated With Increased Risks of Rotator Cuff Tendon Diseases Among Community-Dwelling Elders: A Cross-Sectional Quantitative Ultrasound Study

Backgrounds: Recently, the association between sarcopenia and various musculoskeletal disorders, such as lumbar spine stenosis and fibromyalgia, has been highlighted. However, the relationship between sarcopenia and rotator cuff tendon diseases has rarely been investigated. This study aimed to evaluate whether sarcopenia was associated with shoulder pain and to determine whether rotator cuff tendons differed in echotexture between the sarcopenic and non-sarcopenic populations.

Methods: The thickness and echogenicity ratio of the tendon vs. the overlying muscle (ER_TM) or subcutaneous tissue (ER_TT) were measured using high-resolution ultrasonography in 56 sarcopenic patients and 56 sex- and age- matched controls. The association between ultrasound measurements of the rotator cuff tendon complex and sarcopenia was investigated using the generalized estimating equation (GEE).

Results: The sarcopenic group had an increased prevalence of shoulder pain. Based on the GEE analysis, sarcopenia was significantly associated with an increase in supraspinatus tendon thickness (β coefficient = 0.447, p < 0.001) and a decrease in the ER_TM for the biceps long head and rotator cuff tendons. A negative trend of association was observed between sarcopenia and ER_TT in the supraspinatus tendons (β coefficient = −0.097, p = 0.070). Nevertheless, sarcopenia was not associated with an increased risk of rotator cuff tendon tears.

Conclusions: Patients with sarcopenia have a higher risk of shoulder pain. A consistent tendinopathic change develops in the supraspinatus tendons in sarcopenic patients. However, sarcopenia is less likely to be associated with serious rotator cuff pathology, such as tendon tears. Prospective cohort studies are warranted to explore the causal relationship between sarcopenia and shoulder disorders.