Three-dimensional turbo spin-echo (TSE) MRI assessment of indirect acute muscle injuries in athletes: comparison with two-dimensional TSE MRI

OBJECTIVE

To evaluate three-dimensional (3D) turbo spin-echo (TSE) magnetic resonance imaging (MRI) for the assessment of acute muscle injuries in elite athletes in comparison with two-dimensional (2D) MRI.

METHODS

Elite athletes with clinically suspected acute muscle injury of the thigh who underwent both 2D and 3D MRI protocols on the same day were retrospectively included. Two musculoskeletal radiologists independently assessed 2D and 3D MRIs, with both techniques evaluated separately 1-month apart. Muscle injuries were evaluated using the BAMIC and the INSEP classifications. A second assessment of injuries was performed by each reader 2 months after the initial readings. Agreement was determined using weighted kappa statistics. The level of diagnostic confidence in classifying injuries was also assessed for both MRI protocols.

RESULTS

A total of 40 athletes were included. Intra-reader agreement when comparing injury grades from 2D vs. 3D for both INSEP and BAMIC classifications was almost perfect for both readers and ranged between 0.84 and 0.98. Inter-reader agreement was substantial to almost perfect and ranged from 0.78 to 0.93 for the 2D protocol, and from 0.78 to 0.95 for the 3D protocol. Intra-reader agreement for each MRI protocol separately was almost perfect to perfect for both readers and ranged between 0.84 and 1.00. Diagnostic confidence for grading injuries improved for both readers when using the 3D protocol.

CONCLUSIONS

Compared to 2D MRI, 3D TSE MRI is a reliable technique for acute muscular injury assessment, providing faster acquisition times and improving the diagnostic confidence.

KEY POINTS

• Compared to 2D MRI, 3D TSE MRI is a reliable technique for the assessment of acute muscular injuries. • 3D TSE MRI has the advantage of faster total acquisition times, thinner sections, and multiplanar reconstruction, improving the confidence for structural assessment including connective tissue involvement.

Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review

Tarsal tunnel syndrome may be idiopathic or may be caused by various conditions: bone disease, thickening of the retinaculum, hematoma, or iatrogenic nerve damage; tendinopathy or tenosynovitis; the presence of supernumerary muscles such as an accessory soleus, peroneocalcaneus internus, or accessory flexor digitorum muscle; bone or joint disorders; expansile tumors or cysts; and venous aneurysm or kinking of the tibial artery. The purpose of this article is to describe and illustrate most of the causes of tarsal tunnel syndrome, as diagnosed by ultrasound, which is a practical, inexpensive method.

Biceps femoris snapping and friction on the fibular head secondary to abnormal distal tendon insertion: 15 cases and a literature review

INTRODUCTION

Abnormal biceps femoris distal tendon insertion can cause tendon snapping, as is well-known in the literature. The presenting symptom is lateral knee pain, often during sports activities and cycling in particular. The present study tested two hypotheses: abnormal biceps femoris insertion on the fibular head may cause painful friction without clinical snapping, whether visible, audible or palpable; surgical correction achieves good results for pain and return to sport, regarding both snapping and friction.

MATERIAL AND METHODS

Between 2006 and 2017, 11 patients were managed for pain secondary to abnormal biceps femoris insertion. In 4 cases, pain was bilateral, resulting in a total of 15 knees: 9 with snapping (in 6 patients), and 6 with friction syndrome without snapping (in 5 patients). All 6 patients with snapping were male, with a mean age of 29 years. Friction without snapping concerned 3 female and 2 male patients, with a mean age of 30 years. Study data included type and level of sport, clinical signs, imaging, type and results of treatment, and type of abnormality.

RESULTS

The insertion abnormality consisted in excessively anterior insertion in the fibular arm in 6 cases, in predominantly tibial insertion in 2 cases, and in isolated tibial insertion in 4 cases. Surgery mainly consisted inrelease and reinsertion of the distal biceps femoris tendon (in 7 cases). All patients were able to return to sport. The mechanism underlying snapping and friction was the same: distal biceps tendon friction on the fibular head secondary to unduly anterior fibular or predominantly or exclusively tibial insertion.

DISCUSSION

The literature reports 24 cases, all of snapping, with between 1 and 3 cases per author. These findings were compared with the present results. With or without snap, symptoms are secondary to abnormal tendon insertion and to activity or sport requiring repeated knee flexion greater than 90°.

CONCLUSIONS

(1) Case studies show that lateral knee pain by friction on the fibular head is not systematically accompanied by snapping. (2) In all reports and in the present series, surgery was highly effective on snapping and pain, and patients returned to sport at their previous level.

LEVEL OF EVIDENCE

IV.

Ultrasound-detected connective tissue involvement in acute muscle injuries in elite athletes and return to play: The French National Institute of Sports (INSEP) study

OBJECTIVES

Previous MRI studies showed that involvement of connective tissue in muscle injuries may prolong recovery times. The relevance of ultrasound assessment of connective tissue involvement as a prognostic factor is unknown. The aim was to test the hypothesis that ultrasound-detected connective tissue involvement in acute muscle injuries are related to longer recovery times.

DESIGN

Cohort study.

METHODS

Seventy consecutive elite athletes from the French National Institute of Sports (INSEP) sustaining an acute muscle injury showing positive findings on ultrasound at baseline were included. Ultrasound was systematically performed within 7days after the injury for the assessment of severity (grades 1-4) and type of injury in regard to the absence (M injuries) or presence (C injuries) of connective tissue involvement. The differences in the mean time needed to return to play (RTP) between the different grades and types of injury were assessed using multiple non-parametric tests.

RESULTS

When considering the overall grades independently of the type of injury (M or C), an increase in the mean time needed to RTP was observed with the increase of grades (p<0.0001). The same relationship was found when considering grades from M and C injuries separately, with higher grades of injuries exhibiting longer times needed to RTP (p<0.0001). Longer times needed to RTP were observed in athletes demonstrating C injuries in comparison to the ones exhibiting M injuries overall (p=0.002).

CONCLUSIONS

Ultrasound-detected connective tissue involvement in acute muscle injuries are related to longer times needed to RTP, especially when disruption is detected.

Unknown Tendons, Muscles and Nerves of the Shoulder: Proposal for a Standardized Ultrasound-guided Examination, a "mini GEL" Experience

Thanks to its excellent spatial resolution and dynamic aspect, ultrasound of the shoulder allows an optimal evaluation of tendon, muscle and nerve' structures in shoulder pain. Through this article and owing to inter-observer reproducibility, we will describe an ultrasound standardized protocol (posterior, anterior, global plane) in basic first ultrasounds (ie without tendon abnormality of the supra/infra spinatus, the biceps and subscapularis).

Elastography Study of Hamstring Behaviors during Passive Stretching

INTRODUCTION

The mechanical properties of hamstring muscles are usually inferred from global passive torque/angle relationships, in combination with adjoining tissues crossing the joint investigated. Shear modulus measurement provides an estimate of changes in muscle-tendon stiffness and passive tension. This study aimed to assess the passive individual behavior of each hamstring muscle in different stretching positions using shear wave elastography.

METHODS/RESULTS

The muscle shear modulus of each hamstring muscle was measured during a standardized slow passive knee extension (PKE, 80% of maximal range of motion) on eighteen healthy male volunteers. Firstly, we assessed the reliability of the measurements. Results were good for semitendinosus (ST, CV: 8.9%-13.4%), semimembranosus (SM, CV: 10.3%-11.2%) and biceps femoris long-head (BF-lh, CV: 8.6%-13.3%), but not for biceps femoris short-head (BF-sh, CV: 20.3%-44.9%). Secondly, we investigated each reliable muscle in three stretch positions: 70°, 90° and 110° of hip flexion. The results showed different values of shear modulus for the same amount of perceived stretch, with the highest measurements in the high-flexed hip situation. Moreover, individual muscles displayed different values, with values increasing or BF-lh, SM and ST, respectively. The inter-subject variability was 35.3% for ST, 27.4% for SM and 30.2% for BF-lh.

CONCLUSION

This study showed that the hip needs to be high-flexed to efficiently tension the hamstrings, and reports a higher muscle-tendon stress tolerance at 110° of hip angle. In addition muscles have different passive behaviors, and future works will clarify if it can be linked with rate of injury.

The biceps tendons: From the top and from the bottom

The biceps brachii muscle, which inserts proximally onto the scapula and distally onto the forearm, has several tendons with numerous anatomic peculiarities, which render their sonographic examination highly variable. Proximally, the tendon of the short head of the biceps inserts onto the coracoid process and that of the long head on the superior aspect of the glenoid. The distal biceps tendon is bifurcated, and it generally inserts on the radial tuberosity, around which it rolls during pronation/supination. There is a third distal structure, the Lacertus fibrosus, an aponeurosis that branches off from the medial aspect of the tendon, crossing the median artery and median nerve, and inserting on the superficial aponeurosis of the flexor muscles. The sonographic examination of these tendons focuses on nine separate zones of interest: the glenoid insertion of the long head, its extension to the upper pole of the humeral head, the rotator interval, the reflection to the upper bicipital groove, the bicipital groove, the upper myotendinous junction, the lower myotendinous junction, the distal tendon(s), and the inferior enthesis. Because of their morphological and topographical characteristics, the biceps tendons are subject to a variety of lesions, some of which are frequently misdiagnosed on the basis of clinical findings. Ultrasound plays an important role in detecting and characterizing these lesions. Proper examination of the biceps (the distal portion in particular) is a difficult task that cannot be improvised.

[Ultrasonography of the tendons: from image to pathology]

Radiology allows to define etiologies of tendon injuries and authorize a most suitable treatment. For that reason, the use of the sonography has been developed from several years and has four main purposes to define the type of injury and to orient the treatment: to confirm the real existence of the tendon tear, to need the exact location the same one, to determine the gravity of the lesion, and finally, to evaluate its acute or chronic character. In this paper, we will try to define the normal pattern of the tendon and describe the more frequent lesions of the shoulder or the ankle: complete or partial tear, tendinopathy, dislocation and enthesopathy.

[Impingement and kinesiology]

During physical activity, especially in sport, repeated and/or exaggerated movements may lead to different impingements. Rupture, luxation, and tendon insertion injuries are seen after mobilization in the acute phase, but the goal of this paper is to analyze chronic impingements. It is possible to see the consequences of these impingements in all the musculoskeletal structures but, in relation to movement, three groups can be described. In the first, there is chronic compression and percussion between two structures; in the second there is entrapment and friction, and in the third, there is distraction. These impingements are frequent and are seen in all people, but particular movements during sport can increase their frequency.

Extensor carpi ulnaris injuries in tennis players: a study of 28 cases

Pain on the ulnar side of the wrist is common among elite tennis players. Ten years of experience has allowed identification of a pathology involving the extensor carpi ulnaris (ECU) tendon. On the basis of 28 clinical cases seen over the last five years, three clinical patterns are described: (a) acute instability of the ECU; (b) tendinopathy; (c) ECU rupture. Each of these clinical entities requires a different therapeutic approach. A review of the relevant anatomy is provided.

Échographie dynamique

The ability to perform dynamic evaluation is a great advantage of ultrasound especially for musculoskeletal evaluation. Different manoeuvres are routinely used. The importance of the mobility of a structure or an articulation, but also the grade of compression of the lesion, can provide useful diagnostic information. For ligaments, the tension of each band is important and mobilisation is often able to depict some conflicts between the tendons and others structures. Muscle contraction is also an important element for making the diagnosis and, similar to a Valsalva manoeuvre for the diagnosis of a hernia. Interventional procedures are also facilitated by this dynamic evaluation. On the other hand, this great advantage requires the presence of a physician during the examination.

[Ultrasound of acute disorders of the shoulder]

Acute pain of the shoulder, with or without associated injury shows specific features that enable differentiation from chronic lesions. Osteo-articular injuries, tendinous lesions, bursitis and moving calcification may produce acute pain. Examination of the acromio-clavicular joint is also essential as acromial lesions are often overlooked in emergency radiology. Along with X-ray radiography, sonography, if adequately performed, is able to determine the etiology of acute pain and to establish lesion staging.

Sonoanatomy of the ulnar nerve in the cubital tunnel: a multicentre study by the GEL

The objective is to determine the normal appearance of the ulnar nerve on a posterior axial sonogram section of the elbow through the medial epicondyle and the humeroulnar joint space. Ultrasound evaluation was carried out on 400 elbows with measurement of the ulnar nerve cross-sectional area and ulnar nerve-cortex distance, as well as recording of apparent ulnar nerve division. Factors that significantly influenced the study variables were sought by statistical analysis. Mean cross-sectional area of the ulnar nerve at the elbow was 7.9 +/- 3.1 mm2 overall. Values were lower in females than in males and increased between 40 and 60 years of age. The ulnar nerve-cortex distance was 0.8 +/- 0.4 mm and varied widely across individuals. Apparent ulnar nerve division at the elbow was noted in about one-fifth of individuals, with no difference between females and males or between the right and left elbows. When present, apparent division was often bilateral and was not associated with changes in cross-sectional area or in distance from the medial epicondyle cortex. This study provides normative data on ulnar nerve sonoanatomy at the elbow and establishes that apparent ulnar nerve division at the elbow is a normal variant.

Ultrasonographic rotator-cuff changes in veteran tennis players: the effect of hand dominance and comparison with clinical findings

The aim of this study was to correlate sonographic abnormalities of the rotator cuff with clinical findings in veteran tennis players. One hundred fifty individuals playing competition-level tennis, aged from 35 to 77 years (mean age 55 years), underwent physical and US examinations of their shoulders. The US abnormalities found in the dominant shoulder were compared with those observed in the non-dominant shoulder and in different subsets of players defined by the absence or presence of former and/or current pain. Tears of the long head of the biceps tendon were seen only in dominant shoulders ( n=8), and tears (23 complete and 20 partial) of the supraspinatus tendon were observed in 43 dominant vs 16 (3 complete and 13 partial) contralateral shoulders ( p<0.001). Subscapularis tendon calcifications were depicted in 23 dominant vs 12 contralateral shoulders ( p<0.05). Seventy players had no pain, 49 had former-but-not-current pain, and 31 had current pain. Abnormal thickening (>2 mm) and effusion of the subacromial-subdeltoid bursa and complete tear of the supraspinatus tendon were more frequent in the latter two groups ( p<0.001 and p<0.05), respectively. Although 90% of the players with a complete supraspinatus tear had experienced former pain, no relationship was found between current pain and the presence of a supraspinatus tear or tendon calcification. The rotator cuff may present important asymptomatic lesions, such as complete tears of the supraspinatus tendon or calcifications, that do not prevent the playing competitive tennis. The only US abnormality associated with pain was subacromial-subdeltoid bursa effusion.

[Ligament pathology of the ankle joint]

Recent advances in ultrasound technology and the development of high-resolution ultrasound transducers have enabled detailed depiction of superficial musculoskeletal structures. The advantages of ultrasound include wide availability and dynamic evaluation. The main disadvantage is the uneasiness of performing ultrasonography, especially for foot and ankle. In addition, diagnostic accuracy requires time, knowledge, and meticulous attention to technical parameters. Ultrasound can be used to evaluate joints, ligaments, tendons, plantar fascias, fore-foot diseases and to look for foreign bodies. Power Doppler can be used to evaluate blood flow. The standardisation of the procedure and the production of normal reference images seem to guarantee a global increase in quality of the sonographic examinations. The diagnostic and therapeutic impact is very important regarding the low cost of this technique, especially in ankle sprain.

Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study

OBJECTIVE

To assess the prevalence and severity of peripheral enthesitis among the different subtypes of spondylarthropathy (SpA) by using ultrasonography (US) in B mode with power Doppler.

METHODS

One hundred sixty-four consecutive patients with SpA (according to the criteria of the European Spondylarthropathy Study Group) and 64 control patients (34 with mechanical low back pain [MBP] and 30 with rheumatoid arthritis [RA]) underwent US examination of major entheses of their limbs. Particular attention was given to the detection of vascularization at the following sites: cortical bone insertion of entheses, junction between tendon and entheses, body of tendon, and bursa.

RESULTS

Abnormal US findings consistent with at least one enthesitis were observed in 161 of 164 SpA patients (98%), affecting 1,131 of 2,952 entheses examined (38%). In contrast, only 132 of 1,152 entheses (11%) were found to be abnormal in 33 of 64 control patients (52%). US enthesitis was most commonly distributed in the distal portion of the lower limbs, irrespective of SpA subtype and of skeletal distribution of clinical symptoms. None of the abnormal entheses in control patients showed vascularization, compared with 916 of 1,131 abnormal entheses in SpA patients (81%), where it was always detected at the cortical bone insertion and sometimes also in the bursa. In SpA patients, the US pattern depended on the clinical presentation, with a higher prevalence of the most severe stages in those with peripheral forms.

CONCLUSION

US in B mode combined with power Doppler allowed the detection of peripheral enthesitis in a majority of SpA patients, but not in MBP or RA patients. The presence of entheseal involvement was independent of SpA subtype, but its degree of severity appeared to be greater in peripheral forms. US could be very useful for both the diagnosis and the assessment of SpA activity.

Epithelioid sarcoma mimicking abscess: review of the MRI appearances

A case of epithelioid sarcoma involving the soft tissues of the ankle is presented. The tumor was a hemorrhagic, fluid-filled, multiloculated lesion with inflammatory changes in the surrounding planes. Tuberculous abscess was diagnosed on the basis of the clinical picture, ultrasound and MRI findings. Surgical exploration of the ankle mass was carried out because of lack of local healing while the patient's general and pulmonary status improved on antituberculosis treatment. This was an unusual case of epithelioid sarcoma mimicking a multilocular abscess.

MR arthrography of the hip: normal intra-articular structures and common disorders

This pictorial review illustrates the anatomical features of normal intra-articular components of the hip and their common disorders on MR arthrography. On T1-weighted MR arthrograms, the normal contrast-filled joint cavity shows a homogeneous high signal intensity. Normal acetabular labrum appears as a well-delineated triangle showing a low signal intensity, surrounded by contrast material in the perilabral recess. Intra-articular paramagnetic contrast outlines labral tears, loose bodies, communicating labral cysts and cartilage lesions (traumatic tears, focal defects, degenerative fissures and thinning), and improves their detection. Overall, MR arthrography enables accurate detection and staging of hip intra-articular structure abnormalities.

[Accurate use of imaging in ankle sprain]

Imaging ankle trauma has two goals: to evaluate bone lesions and to appreciate the capsulo-ligamentous tears. Concerning bone lesions, Ottawa's criteria specify the clinical characteristics to perform radiography in the emergency conditions. These recommendations negate the need for nearly 30% of unnecessary radiographs initially performed. Four views of the tarsis have been selected: anteroposterior, lateral, internal rotation, external oblique. Immediate screening of the ligament is very accurately performed with ultrasound, which depicts the number of bundle concerned and the extent of the lesions. This requires an experienced operator and a high quality sonograph. Stress radiography should not be performed anymore as sensitivity is around 50%. Arthrography and CT arthrography are very accurate when performed immediately but are more expensive. This report highlights the complementary role of radiography and ultrasound to evaluate ankle sprain.

[Normal and pathological MRI aspects of the posterolateral corner of the knee]

The purpose of the study is to compare normal PLC anatomy and its MRI appearance, with the various lesions observed in MRI, from the simple popliteus tendinous contusion to the complete PLC rupture. For this specific work on PLC lesions, we selected 61 examinations among the traumatic knees explored during the last 3 years. Surgical correlation is obtained for the 61 patients. MRI examinations are performed on a 0.5 T. unit with gradient echo T1, T1 and T1 GD-DOTA IV. Normal PLC anatomy is compared to the dissection of 4 anatomic subjects. Normal MRI slices are evaluated with this reference analysis. The principle anatomical structures of the PLC include the lateral collateral ligament, the popliteus tendon, the arcuate ligament, the fabello fibular ligament, the posterolateral condylar capsule, and the posterior horn of the lateral meniscus. Surgical findings confirm PLC lesion for 58 patients with 3 false positive. Diagnosis of these lesions is important because chronical posterolateral laxity is secondary to the destabilisation of lateral condyle. Unrecognised and untreated posterolateral instability may result in failure of ACL reconstruction. When clinical tests are doubtful or complex, or the examination very painful, MRI evaluates completely the traumatic knee and particularly the PLC.

Ultrasono-anatomy of the ankle ligaments

The ligaments of the ankle are superficial and easily accessible at ultrasonography. Surprisingly, the reliability of this technique has never been proven. With this goal in mind, ten ankles were subjected to a ultrasono-anatomic comparison. The five principle ligamentous fascicles (three on the lateral side and two on the medial side) measured at ultrasonography and the values verified after dissection. This study shows that the ligaments of the ankle are analyzed with ultrasonography and that the measures done are valid and have a precision of 2 mm for the anterior fascicle and the lateral fascicle of the lateral ligamentous plane Due to its simplicity and its low price, ultrasonography appears to be an important method in evaluating the ligaments and the degree of seriousness of ankle sprains.

[The sign of the fibular head. An indication of torsion?]

The head of the fibula is posteriorly located on a lateral view of the knee. This location varies according to the rotation of the limb when the knee is positioned for the radiograph. Our study shows that the location of fibular head is an indirect sign of torsion disorder of the inferior limb.