Sonographic measures and sensory threshold of the normal sciatic nerve and hamstring muscles

PURPOSE

The sciatic nerve innervates the hamstring muscles. Occasionally, the sciatic nerve is injured along with a hamstring muscle. Detailed biomechanical and sensory thresholds of these structures are not well-characterized. Therefore, we designed a prospective study that explored high-resolution ultrasound (US) at multiple sites to evaluate properties of the sciatic nerve, including cross-sectional area (CSA) and shear-wave elastography (SWE). We also assessed SWE of each hamstring muscle at multiple sites. Mechanical algometry was obtained from the sciatic nerve and hamstring muscles to assess multi-site pressure pain threshold (PPT).

METHODS

Seventy-nine asymptomatic sciatic nerves and 147 hamstring muscles (25 males, 24 females) aged 18-50 years were evaluated. One chiropractic radiologist with 4.5 years of US experience performed the evaluations. Sciatic nerves were sampled along the posterior thigh at four sites obtaining CSA, SWE, and algometry. All three hamstring muscles were sampled at two sites utilizing SWE and algometry. Descriptive statistics, two-way ANOVA, and rater reliability were assessed for data analysis with p ≤ 0.05.

RESULTS

A significant decrease in sciatic CSA from proximal to distal was correlated with increasing BMI (p < 0.001). Intra-rater and inter-rater reliability for CSA was moderate and poor, respectively. Elastographic values significantly increased from proximal to distal with significant differences in gender and BMI (p = 0.002). Sciatic PPT significantly decreased between sites 1 and 2, 1 and 3, and 1 and 4. Significant correlation between gender and PPT was noted as well as BMI (p < 0.001). Hamstring muscle elastographic values significantly differed between biceps femoris and semitendinosus (p < 0.001) and biceps femoris and semimembranosus (p < 0.001). All three hamstring muscles demonstrated increased PPT in males compared to females (p < 0.001). In addition, PPT of the biceps femoris correlated with BMI (p = 0.02).

CONCLUSION

High-resolution US provided useful metrics of sciatic nerve size and biomechanical properties. PPT for the normal sciatic nerve and hamstring muscles was obtained for future clinical application.

Neural Arch Bone Marrow Edema and Spondylolysis in Adolescent Cheerleaders: A Case Series

Objective

Spondylolysis is 1 of the most common sources of low back pain in children and adolescents; however, there is still a great deal of confusion in regard to etiology, clinical presentation, and diagnostic imaging findings. It is imperative for clinicians to recognize that persistent low back pain is strongly indicative of spondylolysis, especially in high-performance athletes. This case series demonstrates a comprehensive diagnostic spectrum of spondylolysis and its treatment in 2 competitive adolescent cheerleaders.

Clinical Features

In case 1, a 12-year-old female competitive cheerleader presented with a gradual onset of subacute low back pain. Comprehensive clinical examination indicated imaging studies that identified bilateral L5 grade 1 stress reaction, consisting of neural arch bone marrow edema (BME). Treatment included spinal adjustments, rehabilitation, and myofascial therapy. In case 2, 15-year-old female competitive cheerleader presented with insidious chronic low back pain that was provocative with extension. Magnetic resonance imaging revealed a left L5 grade 1 pars interarticularis stress reaction. Computed tomography demonstrated right L5 pars grade 3 and left L5 healing spondylolysis. Treatment included spinal adjustments and rehabilitation exercises. She was also seen by a physical therapist who prescribed a lumbar spine flexion brace.

Intervention and Outcome

Diagnosis of BME and spondylolysis led to temporary cessation of cheerleading activities in cases 1 and 2. The individual in case 1 self-discharged with a list of rehabilitation exercises and was lost to follow-up. The individual in case 2 was able to return to sport pain free approximately 5 weeks after seeking treatment.

Conclusion

Spondylolysis is common in adolescent athletes, and the presence of BME precedes spondylolysis. Primary spine providers could consider this diagnosis in any adolescent, especially an athlete, who has persistent low back pain. Timely diagnosis will optimize treatment outcomes.

Diagnosing acetabular labral tears with hip traction sonography: a case series

PURPOSE

Three cases of acetabular labral tear (ALT) diagnosed with sonography (US) are reported. We aim to show utility for US with the addition of manual hip traction as an adjunctive modality to the current diagnostic imaging of choice, magnetic resonance arthrography (MRA), for diagnosing ALT.

METHODS

Three cases of young athletic patients with similar clinical presentations are reported. All received US examination of the hip with attention to the labrum that included a novel long-axis hip traction technique which assisted in diagnosing ALT.

RESULTS

In the first and second cases, MRA and orthopedic consult were obtained for confirmation of the diagnosis. Arthroscopy was performed to correct the ALT. The third patient declined an MRA. Conservative management consisted of McKenzie method active care, resulting in return to sport in the third case.

CONCLUSION

These three cases demonstrate the clinical and sonographic presentation of ALT. The dynamic long-axis hip traction protocol facilitated the use of US as an adjunctive modality for diagnosing ALT by increasing the visualization of the defect.

Rectus abdominis muscle tear diagnosed with sonography and its conservative management

PURPOSE

This is a rare case of a post-traumatic rectus abdominis muscle tear in an adolescent female diagnosed by ultrasonography (US). Conservative management is also described.

METHODS

A 14-year-old female presented to a chiropractic clinic with extreme pain and tenderness in the right lower quadrant (RLQ) after post-plyometric power kneel box jumps. Movement aggravated her pain and she demonstrated active abdominal guarding with RLQ palpation. Ultrasonography revealed a subacute Grade 2 right rectus abdominis muscle tear, without evidence of hyperemia or a hematoma. Following the diagnosis of a right rectus abdominis muscle tear, she was treated with spinal manipulation and a course of musculoskeletal rehabilitation directed at truncal stabilization.

RESULTS

After treatment, the patient was able to return to play 5 week post-injury without any pain or discomfort. A follow-up US at 3 months provided evidence of muscle healing without complications.

CONCLUSION

This case demonstrates the diagnosis of a rare rectus abdominis muscle tear managed conservatively. To our knowledge, less than a dozen cases are reported using US in the evaluation and diagnosis of a rectus abdominis tear.

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis

OBJECTIVE

This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis.

CLINICAL FEATURES

A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis.

INTERVENTION AND OUTCOME

The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale.

CONCLUSION

Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Chiropractic Care in the Management of Inactive Ankylosing Spondylitis: A Case Series

Objective

This report describes chiropractic management for 3 cases of inactive ankylosing spondylitis (AS).

Clinical Features

A 25-year-old woman presented with chronic, mechanical neck pain and stiffness that was ultimately diagnosed as AS. A 23-year-old man presented with chronic low back and left hip pain that was diagnosed as AS. A 31-year-old man with low back pain presented with a known diagnosis of AS. Physical examination in 2 cases failed to identify systemic findings associated with AS. In the third case, examination revealed a history of ulcerative colitis. Laboratory examination of case 2 yielded a positive HLA-B27, but cases 1 and 3 were HLA-B27 negative. The acute reactants were negative in all 3 patients, indicating an inactive phase of disease. All 3 patients underwent spinal imaging including sacroiliac joint radiography. In case 3, magnetic resonance imaging of the sacroiliac joints was performed. All 3 imaging examinations revealed bilateral, symmetric sacroiliitis.

Interventions and Outcome

Patients were managed by both a medical rheumatologist and a doctor of chiropractic. Chiropractic care ranged from instrument-assisted spinal manipulation to diversified spinal and soft tissue manipulation and Cox flexion-distraction. Patients were given home stretches and rehabilitation exercises. All 3 patients experienced some relief of their symptoms including pain reduction and improved activities of daily living.

Conclusion

These 3 patients displayed differences and commonalities in clinical, laboratory, and imaging features. Chiropractic manipulation and rehabilitation seemed to be beneficial in reducing symptomatology and improving musculoskeletal function for these 3 patients. These findings suggest the potential for collaborative or integrative management in similar cases.

Sonographic and Magnetic Resonance Imaging Examination of a Cyclops Lesion After Anterior Cruciate Ligament Reconstruction: A Case Report

OBJECTIVE

This case report describes magnetic resonance imaging (MRI) and diagnostic ultrasound (US) findings for a patient with arthrofibrosis related to a complication of anterior cruciate ligament (ACL) reconstruction.

CLINICAL FEATURES

A 25-year old man presented with right knee pain and loss of extension 5 years after ACL reconstruction. MRI and sonographic examination revealed a soft tissue mass anterolateral to the ACL graft consistent with a cyclops lesion. The lesion was surgically resected and physical therapy was followed postoperatively.

INTERVENTION AND OUTCOME

The patient reported that full range of motion was restored 6 weeks after resection and a course of physical therapy. MRI is the modality of choice for diagnosis, but US may be useful in the diagnosis of this condition.

CONCLUSION

Cyclops lesions may complicate ACL reconstruction or acute ACL injuries. The patient may present with pain and loss of extension, which can be debilitating. MRI and US can be used to diagnose this condition in a timely manner, ensuring optimal clinical outcomes.