[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION. The fabella is a sesamoid bone in the posterolateral knee which may present itself as an etiologic cause of pain. In close proximity to the common fibular (peroneal) nerve (CFN), the fabella may impinge upon the nerve to cause fibular nerve palsies. While anatomical studies have established a relationship between the fabella and CFN, we present cases where sonography was able to determine the source of the pain secondary to CFN compression by an adjacent fabella in posterolateral knee pain that radiates into the anterolateral leg pain.
METHODS. Four patients presented with complaints of posterolateral knee pain radiating into the anterolateral leg pain. All patients underwent diagnostic and interventional ultrasound (US) in the evaluation of posterolateral knee pain.
SUMMARY. Two female and two male patients presented with complaints of posterolateral knee pain radiating into the anterolateral leg pain. Diagnostic and interventional ultrasound was able to determine the source of the pain was secondary to CFN compression by an adjacent fabella. In three cases, pain symptoms were resolved with US-guided CFN block. One patient had temporarily relief with CFN block and required surgical treatment with fabellectomy for complete resolution of symptoms.
CONCLUSIONS. Dynamic sonography plays a role in providing convincing in vivo evidence to establish a causal relationship between fabella and fibular neuropathy in posterolateral knee pain.
32nd Annual Meeting of the American Association of Clinical Anatomy, Henderson, NV; 06/2015
[Show abstract][Hide abstract] ABSTRACT: The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based on the evidence, the official AMSSM position relevant to each subject is made.
Clinical Journal of Sport Medicine 01/2015; 25(1):6-22. DOI:10.1097/JSM.0000000000000175 · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Heel pain is the most common type of foot pain. The differential diagnosis for pain in this region is vast, but plantar fasciopathy is thought to be the most common cause for pain in this region. This article will review the anatomy, biomechanics, pathophysiology, his-tory, physical examination, diagnostic imaging, and treat-ment options available for plantar fasciopathy.
[Show abstract][Hide abstract] ABSTRACT: The American Medical Society for Sports Medicine (AMSSM) developed a musculoskeletal ultrasound curriculum for sports medicine fellowships in 2010. As the use of diagnostic and interventional ultrasound in sports medicine has evolved, it became clear that the curriculum needed to be updated. Furthermore, the name 'musculoskeletal ultrasound' was changed to 'sports ultrasound' (SPORTS US) to reflect the broad range of diagnostic and interventional applications of ultrasound in sports medicine. This document was created to outline the core competencies of SPORTS US and to provide sports medicine fellowship directors and others interested in SPORTS US education with a guide to create a SPORTS US curriculum. By completing this SPORTS US curriculum, sports medicine fellows and physicians can attain proficiency in the core competencies of SPORTS US required for the practice of sports medicine.
British Journal of Sports Medicine 10/2014; 7(2). DOI:10.1136/bjsports-2014-094220 · 5.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To estimate the prevalence of perceived and International Committee of Medical Journal Editors (ICMJE) defined honorary authorship, and identify factors affecting each rate in the physical medicine and rehabilitation literature.
First authors of papers published in three major physical medicine and rehabilitation journals between January 2009 and December 2011 were surveyed in June and July of 2012.
The reported prevalence of perceived and ICMJE defined honorary authorship were the primary outcome measures, and multiple factors were analyzed to determine if they were associated with these measures.Results: The response rate was 27.3% (248/908). The prevalence of perceived and ICMJE defined honorary authorship were 18.0% (44/244) and 55.2% (137/248), respectively. Factors associated with perceived honorary authorship in the multivariate analysis included the suggestion that an honorary author should be included (P<.0001), being a medical resident or fellow (P=.0019), listing "reviewed manuscript" as one of the non-authorship tasks (P=.0013), and the most senior author deciding the authorship order (P=.0469). Living outside of North America was independently associated with ICMJE defined honorary authorship (P=.0079) in the multivariate analysis. In the univariate analysis, indicating that the most senior author decided authorship order was significantly associated with ICMJE defined honorary authorship (P=.0003).
Our results suggest honorary authorship does occur in a significant proportion of the physical medicine and rehabilitation literature. Additionally, we found several factors associated with perceived and ICMJE defined honorary authorship and a discrepancy between the two rates. Further studies with larger response rates are recommended to further explore this topic.
Archives of physical medicine and rehabilitation 11/2013; 95(3). DOI:10.1016/j.apmr.2013.09.024 · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The first purpose of this investigation was to describe and validate an ultrasound-guided ischial bursa injection technique in an unembalmed cadaveric model. The second purpose was to compare the distance between the ischial tuberosity and the sciatic nerve in a hip neutral versus 90 degree flexed hip position in asymptomatic volunteers.
The first part was a single blind, prospective study. The second part was a prospective cohort study.
Academic institution procedural skills laboratory and outpatient clinic.
The first part of the study involved one cadaveric specimen. The second part of the study involved 20 asymptomatic subjects. The mean age of the subjects was 28 years, and the mean BMI was 23.2 kg/m(2) +/- 2.8 (minimum 18.3, maximum 29.5).
In the first part of the study, a single operator completed bilateral ultrasound-guided ischial bursa injections in an unembalmed cadaveric specimen using diluted colored latex. In the second part of the study, ultrasound was used in 20 asymptomatic volunteer subjects (10 males and 10 females) to measure the distance from the lateral edge of the ischial tuberosity to the sciatic nerve.
The injections were graded for accuracy as follows: accurate (all injectate contained within the ischial bursa), accurate with overflow (injectate within the ischial bursa, but also located in adjacent structures other than the needle track), or inaccurate (injectate not within the ischial bursa). The second part of the study measured the distance from the ischial tuberosity to the sciatic nerve with subjects in two different positions (prone, and side-lying with the tested hip flexed to 90 degrees). Results: Post-injection cadaveric dissections revealed that both ultrasound-guided injections accurately placed liquid latex within the ischial bursae. There was no evidence of injury to surrounding neurovascular structures. Among asymptomatic volunteers, the average distance between the ischial tuberosity and the sciatic nerve increased from 28.4 mm (range 20.5-38.9 mm) in the neutral position to 41.9 mm (range 30.9-66.0 mm) with the hip flexed to 90 degrees (average change 13.5 mm away from the ischial tuberosity, p = .0001).
Ultrasound-guided ischial bursa injections are technically feasible. Flexing the hip to 90 degrees increases the distance between the ischial tuberosity and the sciatic nerve in asymptomatic volunteers, thus potentially resulting in a safer needle trajectory when ischial bursa injections are clinically indicated. Further investigation in clinical settings is warranted to validate these findings.
[Show abstract][Hide abstract] ABSTRACT: Objective
To determine whether there is a consistent extension of the lateral synovial recess under the iliotibial band (ITB) in an unembalmed cadaveric model.
A prospective laboratory investigation.
A procedural skills laboratory of a tertiary medical center.
Twelve unembalmed cadaveric knee specimens.
The suprapatellar recess, ITB, and region deep to the ITB were examined sonographically to document the absence of fluid in each knee. Thereafter, 60 mL of normal saline solution was injected into each knee to distend the joint recesses. Postinjection sonographic examination of the ITB at the level of the lateral femoral epicondyle was repeated at 0°, 25°, and 45° of knee flexion to detect and characterize any fluid visualized in the region of the ITB. The location of fluid in relation to the ITB was recorded as anterior, deep, posterior, or a combination of these positions.
Fluid was observed anterior and deep to the ITB in 100% of 12 specimens. In 2 specimens, fluid also was noted posterior to the ITB. The presence and location of the fluid did not appear to change as a function of knee position. Using dynamic sonographic evaluation, we could track the fluid deep to the ITB back to the knee joint.
The lateral synovial recess appears to regularly extend beneath the anterior ITB. Fluid deep to the ITB should precipitate further evaluation of the knee joint when clinically indicated. Although distention of the lateral synovial recess is not always symptomatic, synovial irritation may be a pathoetiologic factor in the production of lateral knee pain syndromes, including ITB syndrome.
[Show abstract][Hide abstract] ABSTRACT: Many ultrasound educational products and ultrasound researchers present diagnostic and interventional ultrasound information using picture-in-picture videos, which simultaneously show the ultrasound image and transducer and patient positions. Traditional techniques for creating picture-in-picture videos are expensive, nonportable, or time-consuming. This article describes an inexpensive, simple, and portable way of creating picture-in-picture ultrasound videos. This technique uses a laptop computer with a video capture device to acquire the ultrasound feed. Simultaneously, a webcam captures a live video feed of the transducer and patient position and live audio. Both sources are streamed onto the computer screen and recorded by screen capture software. This technique makes the process of recording picture-in-picture ultrasound videos more accessible for ultrasound educators and researchers for use in their presentations or publications.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2013; 32(8):1493-7. DOI:10.7863/ultra.32.8.1493 · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives- The purpose of this study was to determine whether the iliotibial band (ITB) moves relative to the lateral femoral epicondyle (LFE) as a function of knee flexion in both non-weight-bearing and weight-bearing positions in asymptomatic recreational runners. Methods- Five male and 15 female asymptomatic recreational runners (10-30 miles/wk) aged 18 to 40 years were examined with sonography to assess the distance between the anterior fibers of the ITB and the LFE in full extension, 30° of knee flexion, and 45° of knee flexion. Measurements were obtained on both knees in the supine (non-weight-bearing) and standing (weight-bearing) positions. Results- The distance between the anterior fibers of the ITB and the LFE decreased significantly from full extension to 45° of knee flexion in both supine (0.38-cm average decrease; P < .001) and standing (0.71-cm average decrease; P < .001) positions. These changes reflect posterior translation of the ITB during the 0° to 45° flexion arc of motion in both the supine and standing positions. Conclusions- Sonographic evaluation of the ITB in our study population clearly revealed anteroposterior motion of the ITB relative to the LFE during knee flexion-extension. Our results indicate that the ITB does in fact move relative to the femur during the functional ranges of knee motion. Future investigations examining ITB motion in symptomatic populations may provide further insight into the pathophysiologic mechanisms of ITB syndrome and facilitate the development of more effective treatment strategies.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 07/2013; 32(7):1199-1206. DOI:10.7863/ultra.32.7.1199 · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To evaluate the prevalence and distribution of fluid associated with the iliotibial band (ITB) in asymptomatic recreational runners. DESIGN: Prospective cohort study. SETTING: Sports medicine center at a tertiary medical center. PATIENTS: Five male and fifteen female asymptomatic recreational runners (10-30 miles per week) ages 18-40 years. METHODS: Participants were examined using ultrasonography to assess for the presence of fluid at the level of the lateral femoral epicondyle and determine its relationship to the ITB at 0 and 30 degrees of knee flexion in both supine (non-weightbearing) and standing (weightbearing) positions. RESULTS: Fluid was associated with the ITB in 100% of asymptomatic recreational runners, and was bilateral in 90%. When examined in full extension, fluid was seen in 67.5% of knees (n= 40) when supine, compared to 95% of the knees when standing. When examined in 30 degrees of flexion, the presence of fluid decreased to 30% when supine and 22.5% when standing. With the knee in full extension in a supine/standing position, fluid was located anterior and deep 70/74% of the time and anterior only 11/0% of the time. With the knee flexed to 30 degrees in a supine/standing position, fluid was located anterior and deep 50/33% of the time and anterior only 33/67% of the time. CONCLUSION: The prevalence of fluid associated with the ITB varied with body and knee position, was most common in the standing position with the knee extended, and was generally located anterior or anterior and deep to the ITB. The clinical significance of our findings are twofold: (1) body position should be considered when searching for fluid in the vicinity of the ITB, and (2) clinicians and imagers should exercise caution when interpreting the clinical significance of fluid associated with the ITB during ultrasonographic evaluation of runners with lateral knee pain.
[Show abstract][Hide abstract] ABSTRACT: Exertional leg pain is a common condition seen in athletes and the general population. Although the differential diagnosis of exertional leg pain is broad, this article focuses on the incidence, anatomy, pathophysiology, clinical presentation, diagnostic evaluation, management, and return-to-play guidelines of chronic exertional compartment syndrome and vascular and nerve entrapment etiologies.
[Show abstract][Hide abstract] ABSTRACT: Sports injuries are common and can result in significant problems, such as pain, social isolation, depression, disability (temporary or permanent), loss of income, or loss of scholarship. Further, sports injuries can predispose the athlete to future injury or degenerative disorders, for example, osteoarthritis. Therefore, a preventive approach is paramount, and exercise can be used as an effective tool to prevent sports-related injuries. This article describes the process by which successful injury prevention programs can be developed and implemented by using noncontact anterior cruciate ligament injury programs as an example. The knowledge gained from this information can be used in the future to assist in the creation of new injury prevention programs for other common sports injuries.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To validate the diagnostic performance of an in-scanner exercise-based magnetic resonance imaging (MRI) examination used to screen for chronic exertional compartment syndrome (CECS). Final clinical impression and intracompartmental needle manometry (INM) served as the reference standards. MATERIALS AND METHODS: Consecutive patients, referred by a sports medicine physician or orthopedic surgeon, underwent the MRI examination for lower extremity pain over the past 4 years and 9 months. Utilizing a diagnostic T2-weighted intensity ratio threshold of 1.54, established by a prior cohort of patients, sensitivity, specificity, predictive value, and diagnostic odds ratio were calculated for the anterior compartments. The means of the T2-weighted intensity ratios were compared using the Wilcoxon rank sum test. RESULTS: A total of 79 patients were identified, and 76 met the inclusion criteria and were evaluated. Of these, 23 met clinical diagnostic criteria. Sensitivity and specificity were 96% (95% CI: 79-99%) and 87% (95% CI: 75-94%) using the established threshold of 1.54. T2-weighted intensity ratio provided excellent discrimination with a concordance statistic of 0.96 (95% CI: 0.91-1.00). In the subset of 36 patients with INM results, 23 patients met criteria for CECS, although only 19 patients met both INM and clinical criteria. The sensitivity and specificity of the MRI examination relative to INM results were 87% (95%: 70-96%) and 62% (95% CI: 36-82%) respectively. CONCLUSION: In-scanner exercise-based MRI demonstrated reliability and reproducibility as a non-invasive screening test for CECS, thus reducing the need for invasive INM.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
To introduce axial balanced steady state free precession (bSSFP) MR imaging with provocative maneuvers as an adjunct test for popliteal artery entrapment syndrome (PAES).
METHOD AND MATERIALS
All scans were performed on a 1.5 T scanner. An axial 2D bSSFP, non-fat saturated imaging technique was performed through both knees simultaneously with the following parameters: TR 3.2-8.2 ms, minimum TE (1.3-1.8 ms), flip angle 45º, field of view to include both knees (30-40 cm), 5 mm slice thickness with 0 skip, 224 pixel × 256 pixel matrix, and number of excitations 1. An 8 channel torso phased array coil was used in association with a Plexiglas footplate. bSSFP was performed in the neutral position and then in resisted plantar and dorsiflexion (Figure). All scans were performed and analyzed by a single fellowship trained musculoskeletal radiologist. A retrospective chart review was performed to identify patients who underwent additional diagnostic evaluation with provocative ultrasound (US) and/or conventional angiography.
One hundred and twenty legs were evaluated in 60 patients. A total of 22 extremities (11 patients) underwent conventional diagnostic angiography and/or subsequent surgical intervention. The positive predictive value (PPV) of provocative bSSFP was 100% with 14 true positives and no false positives. The negative predictive value (NPV) of bSSFP was 50% with 4 true negatives and 4 false negatives. Arterial US exams with provocative measures were evaluated independently with a PPV of 64% (7 true positives and 4 false positives.) There were no true negatives and 7 false negatives for arterial US. Eighteen extremities underwent both provocative bSSFP and arterial US prior to conventional provocative diagnostic angiography. The PPV of provocative bSSFP and US were 100% and 64%, respectively. The NPV of bSSFP was 67% in this subset of patients. There were 7 false negatives and no true negatives with US.
The bSSFP PPV in our study group was 100% compared with 64% for provocative arterial US. The bSSFP NPV was only 50%, but this was superior to provocative arterial US in our study group.
bSSFP may simplify the evaluation of patients with chronic exertional leg pain by identifying patients who may benefit from conventional diagnostic angiography to exclude PAES.
Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 11/2011
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model.
A clinician with 6 years of experience performing sonographically guided procedures injected 1.0 mL of a diluted latex solution into the STT joints of 20 unembalmed cadaveric wrist specimens using a palmar approach. At a minimum of 24 hours after injection, an experienced clinician specializing in hand care completed palpation guided injections in the same specimens using a dorsal approach and 1 mL of a different-colored latex. A fellowship-trained hand surgeon blinded to the injection technique then dissected each specimen to assess injection accuracy. Injections were graded as accurate if the colored latex was found in the STT joint, whereas inaccurate injections resulted in no latex being found in the joint.
All sonographically guided injections were accurate (100%; 95% confidence interval, 81%-100%), whereas only 80% of palpation guided injections were accurate (95% confidence interval, 61%-99%). Sonographically guided injections were significantly more accurate than palpation guided injections, as determined by the ability to deliver latex into the joint (P < .05).
Sonographic guidance can be used to inject the STT joint with a high degree of accuracy and is more accurate than palpation guidance within the limits of this study design. Clinicians should consider using sonographic guidance to perform STT joint injections when precise intra-articular placement is desired. Further clinical investigation examining the role of sonographically guided STT joint injections in the treatment of patients with radial wrist pain syndromes is warranted.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 11/2011; 30(11):1509-15. · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar-sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ-related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship-trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 11/2011; 30(11):1587-92. · 1.53 Impact Factor