Faculty Bibliography

OBJECTIVE:To compare the efficacy of ultrasound-guided hyaluronic acid (HA) versus leukocyte-poor platelet-rich plasma (LP-PRP) injection in the treatment of glenohumeral osteoarthritis. DESIGN/METHODS:Double-blind randomized controlled trial. SETTING/METHODS:Academic institution. PATIENTS/METHODS:Seventy patients with chronic glenohumeral osteoarthritis were randomly assigned to receive a single injection of HA (n = 36) or LP-PRP (n = 34). INTERVENTIONS/METHODS:Leukocyte-poor platelet-rich plasma was processed using Harvest/TerumoBCT Clear PRP kits. Ultrasound-guided injections of 6 mL HA or 6 mL LP-PRP into the glenohumeral joint were performed. Patients, the injecting physician, and outcomes assessor were blinded to treatment assignments. MAIN OUTCOME MEASURES/METHODS:Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) score, current/average numerical rating scale (NRS) pain scores, satisfaction, and side effects were assessed at the 5 follow-up time points over 12 months. RESULTS:Baseline characteristics were similar between groups. There were no significant between-group differences regarding SPADI, ASES, and current/average NRS pain scores at any time point up to 12 months postinjection (P > 0.05). However, significant improvements in SPADI, ASES, and current/average NRS pain scores were observed in both groups starting at 1 or 2 months (P < 0.01, P < 0.01, P < 0.001, and P < 0.01, respectively). These improvements were observed regardless of osteoarthritis severity. For patients who received LP-PRP, there was no effect of platelet yield on outcomes. Side effect and satisfaction rates were similar between groups. CONCLUSIONS:There were no differences in pain and functional outcomes after a single injection of LP-PRP versus HA. However, significant improvements in pain and function were observed after both treatments in patients with glenohumeral osteoarthritis.

BACKGROUND:Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone vs. PNT with intratendinous LR-PRP for multiple tendon types in a single study. OBJECTIVE:To assess the efficacy of PNT vs. PNT+LR-PRP to treat chronic tendinosis. STUDY DESIGN/METHODS:Double-blind, randomized, controlled comparative treatment study SETTING: Primary academic institution PARTICIPANTS: A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses. INTERVENTIONS/METHODS:Participants were randomly assigned to PNT (n=19) or PNT+LR-PRP (n=21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60mL) and injected into the affected tendon using the same PNT technique. MAIN OUTCOME MEASURES/METHODS:Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks. RESULTS:Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (p>0.05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT+LR-PRP at 6 weeks (estimated-mean[SE]: 3.1[0.4] vs. 4.6[0.6], p=0.04; 3.4[0.4] vs. 4.9[0.5], p=0.03) only. Adverse event rates were low (PNT-3.9%; PNT+LR-PRP-5.0%) and related primarily to post-procedural pain and inflammation. CONCLUSION/CONCLUSIONS:Although pain scores were lower after PNT compared to PNT+LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks. This article is protected by copyright. All rights reserved.

PURPOSE/OBJECTIVE:To assess the utility of a 2D dynamic HASTE sequence in assessment of cervical spine flexion-extension, specifically (1) comparing dynamic spondylolisthesis to radiographs and (2) assessing dynamic contact upon or deformity of the cord. METHODS:Patients with a dynamic flexion-extension sagittal 2D HASTE sequence in addition to routine cervical spine sequences were identified. Static and dynamic listhesis was first determined on flexion-extension radiographs reviewed in consensus. Blinded assessment of the dynamic HASTE sequence was independently performed by 2 radiologists for (1) listhesis and translation during flexion-extension and (2) dynamic spinal cord impingement (cord contact or deformity between neutral, flexion and extension). RESULTS:32 scans in 32 patients (9 males, 23 females) met inclusion criteria acquired on 1.5 T (n = 15) and 3 T (n = 17) scanners. The mean acquisition time was 51.8 s (range 20-95 seconds). Dynamic translation was seen in 14 patients on flexion-extension radiographs compared to 12 (reader 1) and 13 (reader 2) patients on HASTE, with 90.6 % agreement (K = 0.83; p = 0.789). In all cases dynamic listhesis was ≤3 mm translation with one patient showing dynamic listhesis in the range 4-6 mm. Four cases (13 %) demonstrated deformity of the cord between flexion-extension, not present in the neutral position. For cord impingement there was strong inter-reader agreement (K = 0.93) and the paired sample Wilcoxon signed rank test found no significant difference between the impingement scores of the two readers (p = 0.787). CONCLUSIONS:A sagittal dynamic flexion-extension HASTE sequence provides a rapid addition to standard MRI cervical spine protocols, which may useful for assessment of dynamic spondylolisthesis and cord deformity.

History: A 37 year-old healthy female with no relevant past medical history presented with 2 years of atraumatic left knee pain. She described intermittent, sharp, non-radiating pain located in the anterior infrapatellar region. The patient reported the pain worsened with knee flexion, walking and sometimes after prolonged sitting. The pain was intermittently relieved with Tylenol. The patient previously was regularly participating in cycling, but had to decrease her activity because of the pain. She denied gait difficulty, leg numbness, tingling or weakness. Physical Exam: On exam, there was no valgus or varus deformity and gait was normal. There was full range of motion of the knee joint and no swelling was seen. There was no tenderness along medial or lateral joint lines, iliotibial band insertion or quadriceps tendon; however, there was tenderness to palpation at the proximal patellar tendon. There was no varus or valgus laxity, no anterior or posterior drawer laxity and no medial or lateral patellar laxity. Patient demonstrated full strength in flexion and extension of the left knee without pain. Differential Diagnosis: 86. Patellar tendinopathy 87. Patellofemoral syndrome 88. Patellar instability 89. Chondromalacia patellae 90. Hoffa's disease Test Results: Point of care ultrasound showed a 1x1x1 cm cystic, hypoechoic, heterogenous, non-compressible mass with marked hyperemia within the cystic walls, which was tender to sonopalpation. Knee MRI with IV contrast showed a T2 hyperintense, homogenously enhancing, wellcircumscribed mass within the medial patellofemoral ligament at its insertion on the inferomedial patella. Oncologic Orthopedic Surgery excised an intra-articular mass and surgical pathology revealed an angioleiomyoma. Final Diagnosis: Intra-articular angioleiomyoma.
Discussion(s): Instead of identifying changes at the patellar tendon, ultrasound revealed a hyperemic, non-compressible mass diagnosed as angioleiomyoma. These are rare, benign tumors that arise from the smooth muscle of blood vessels. They usually present as painful swelling in the lower extremities of middle-aged females, favoring subcutaneous fat and fascia. They rarely occur within the knee joint and only few cases are reported in the literature. Excision is usually curative. This case highlights the importance of point of care ultrasound in sports medicine to expedite diagnosis. Angioleiomyoma should be considered in patients with refractory knee pain and a tender mass on physical or sonographic exam.
Outcome(s): At 2 weeks post-op, patient reported her left knee pain had significantly improved and there was no tenderness to palpation on exam. Follow-Up/Return to Play: At 2 months post-op, patient reported only mild incisional sensitivity, but otherwise reported no knee pain and was slowly returning to her regular activities. In the 6 months after the operation, no recurrence has been detected

Case Description: The patient initially presented with acute left shoulder weakness that started during an overhead press 2 weeks earlier. He reported weakness worsened with external rotation movements. Denied neck pain, numbness, tingling, or distal weakness. On exam of the left shoulder, there was no atrophy or asymmetry, and no tenderness to palpation. Patient had full range of motion in all planes. Strength testing was significant for 4/5 left external rotation, with 5/5 abduction, flexion, and internal rotation. Hornblower's and O'Brien's tests were positive. Ultrasound of the left shoulder revealed a paralabral cyst extending from the glenohumeral joint to the spinoglenoid notch.
Setting(s): Outpatient sports practice Patient: 40-year-old right handed male physical therapist with 2 weeks of left shoulder weakness. Assessment/Results: Patient underwent left shoulder MRI without contrast which showed small nondisplaced type 2 superior labral anterior to posterior (SLAP) tear and associated 2.4-cm paralabral cyst with suggestion of minimal infraspinatus muscle edema. One month later, patient returned to the office after completing a strengthening program targeting the infraspinatus with no improvement in symptoms. He underwent uncomplicated ultrasound-guided percutaneous aspiration of the cyst. Two weeks later, patient reported his strength had returned to baseline and exam demonstrated 5/5 strength in external rotation. Patient was referred to Orthopedics for evaluation of his SLAP tear.
Discussion(s): Paralabral cysts are commonly associated with type 2 SLAP lesions, and in rare circumstances, they cause compression of the suprascapular nerve at the spinoglenoid notch. Traditional management includes arthroscopic decompression of the cyst with SLAP lesion repair. To our knowledge, this is the first documented case report of infraspinatus weakness that improved after ultrasound-sound guided aspiration of a paralabral cyst.
Conclusion(s): In patients with compressive suprascapular neuropathy from a paralabral cyst at the spinoglenoid notch, ultrasound-guided aspiration may be considered as part of the treatment plan for rapid symptom relief

Description: A 37-year-old man presented to clinic with a 1-year history of left thigh pain. He denied any specific eliciting event or injury and described an insidiously progressive pain over his left upper thigh. Prior to symptoms, he was running and participating in yoga regularly. He reported pain worse with hip flexion but denied any radiating pain, numbness, tingling, or weakness down the leg. After seeing an orthopedic surgeon several months prior, he was diagnosed with a left hip flexor strain after x-ray was unremarkable. He completed a course of physical therapy with no symptomatic relief. Physical examination revealed no asymmetry/deformities and passive range of motion was not restricted or painful. Focal tenderness to palpation was noted on the upper-third of the left thigh, slightly laterally. FABER and FADIR tests didn't reproduce/exacerbate symptoms. Bedside ultrasonography was performed showing a cystic mass just above the focal area of pain prompting an MRI for further evaluation of the cystic mass.
Setting(s): Outpatient Sports Medicine Clinic Results: MRI revealed a 1.4-cm ovoid circumscribed lesion within the anterolateral aspect of the vastus intermedius. As a result, the patient was referred to a surgical oncologist where he was suspected to have a nerve related tumor. The patient was recommended to have a biopsy but declined and is scheduled to have a repeat MRI in 6 months.
Discussion(s): Although the patient's clinical history and physical examination were not suggestive of the diagnosis, the use of ultraso-nography allowed for further evaluation with bedside clinical examination and provided a look at the associated anatomy prompting further workup of an undiagnosed cystic lesion.
Conclusion(s): Experience in ultrasonography provides clinicians with an added tool to their clinical assessment of musculoskeletal pathologies. This tool is essential, as basic x-rays will not pick up much soft tissue, nerve, muscle, or tendon pathologies ultimately leaving them undiagnosed

Description: This is a 46-year-old man with a past medical history of gout who presented with a 1-week history of right knee pain and swelling. He reported he was unable to fully extend or flex the knee. He noted similar pain 1 month prior that resolved spontaneously after several days. He reports his previous gout attacks typically occurred in his right hallux.
Setting(s): Sports medicine clinic.
Result(s): Ultrasound of the knee showed large suprapatellar recess effusion. This was aspirated and he was also given intra articular steroid injection. Synovial fluid was sent for analysis. No crystals were noted. There were 1200 nucleated cells seen. Enzyme-linked immu-nosorbent assay for Lyme was indeterminate, however western blot was positive.
Discussion(s): Workup for patients with monoarticular arthritis should include arthrocentesis with synovial fluid analysis evaluating the gross appearance, crystal analysis, cell count and differential, as well as gram stain and culture. A sterile inflammatory joint without crystals should raise suspicion for systemic diseases including Lyme disease. 60% of patients with untreated Lyme disease will develop Lyme arthritis, which is characterized by intermittent or persistent arthritis. The knee is the most common site of involvement. Large joint effusion is common and often recurs after aspiration. Pain is typically only present when the joint capsule is sufficiently stretched. It is common for patients to have associated fatigue with the arthritis.
Conclusion(s): Patient reported 50% improvement of pain after injection. He denied known tick bite, but did note a rash that he thought was tinea cruris several months prior. He reported increasing fatigue. He was referred to infectious disease and started on doxycycline for 30 days for diagnosis of Lyme arthritis