Faculty Bibliography

BACKGROUND: Shoulder pain is a common problem in competitive swimmers, but the structural alterations in elite-level competitive swimmers are not well known. HYPOTHESIS: Adaptive changes are common in the rotator cuff, bursa, labrum, and capsule in elite swimmers, and such abnormalities are related to factors concerning training and correlate with symptoms. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The study population was the 2008 United States Olympic swimming team. All athletes completed standardized scales on shoulder pain and function and provided data on their training history and history of shoulder pain or injuries. Each athlete also underwent a comprehensive physical examination of both shoulders, followed by an evaluation of the rotator cuff, biceps, and bursa using ultrasound with dynamic images to assess for subcoracoid impingement and subacromial impingement. RESULTS: A history of shoulder pain was reported by 29 of 42 (66%) athletes. Morphological changes consistent with tendinosis were common in the biceps (33/46 shoulders; 72%) and supraspinatus/infraspinatus (44/46 shoulders; 96%). Subcoracoid impingement was seen in 17 of 46 shoulders (37%), with subacromial impingement seen in 34 of 41 shoulders (83%). There was an increased odds ratio (OR) for biceps tendinosis in older swimmers (OR, 1.92; 95% CI, 1.23-3.00; P = .004) and in swimmers who had missed a competition because of shoulder pain (OR, 9.76; 95% CI, 1.13-84.3; P = .038). There was an increased OR for rotator cuff tendinosis in swimmers who reported worse scores for pain with activities (OR, 0.10; 95% CI, 0.01-0.78; P = .028) and in those with a positive sulcus sign (OR, 33.2; 95% CI, 3.09-355; P = .004). There was an increased OR for impingement in swimmers with a positive sulcus sign (OR, 5.40; 95% CI, 0.80-36.3; P = .083), worse pain scores (OR, 0.44; 95% CI, 0.22-0.87; P = .019), and a partial rotator cuff tear (OR, 31.2; 95% CI, 3.58-272; P = .002). CONCLUSION: We found a high prevalence of rotator cuff and biceps tendinopathy, which was associated with increased symptoms. Tendinosis was also more common in swimmers with a positive sulcus sign, suggesting a role for shoulder laxity.

The real-time nature of ultrasound makes it ideally suited to provide guidance for a variety of musculoskeletal interventional procedures involving peripheral nerves. Continuous observation of the needle ensures proper placement and allows continuous monitoring when performing localized ablative therapy and therefore more accurate positioning of a cryoprobe, use of smaller needles, as well as access to small structures. We describe our experience performing cryoablative procedures. Patients undergoing cryoneurolysis have largely reported varying degrees of long-term pain relief and improvement in function; no serious complications have yet been identified. Ultrasound-guided cryoneurolysis can provide a useful, safe alternative to other ablative techniques to achieve long-term analgesia from painful peripheral nerve lesions.

OBJECTIVE: The purpose of this article is to review currently available tendon treatments, especially those performed with sonographic guidance. CONCLUSION: Treatments of tendon disease have continued to develop and expand, and multiple therapeutic options have become available, all with varying levels of supportive clinical evidence of their efficacy. The use of ultrasound to direct these treatments improves accuracy and performance by facilitating visualization of the target and relevant adjacent structures.

This retrospective study evaluated the technical success rate of a novel injection into the long head of the biceps tendon sheath by a rotator interval approach in 26 patients. A 25-gauge, 1.5-in needle was positioned into the rotator interval from a lateral approach, where a therapeutic injection was performed. Postinjection sonograms images were reviewed to assess for fluid within the sheath to calculate the technical success rate. Fluid distention of the biceps tendon sheath was shown in all 26 cases, corresponding to a 100% technical success rate. In addition, postinjection ultrasound imaging of the anterior shoulder provided additional diagnostic findings in 6 of 26 patients (23%).

Purpose To determine whether quantitative differences in shear-wave velocity (SWV) exist between normal skeletal muscle and those affected by GNE-related myopathy and to examine the effects of muscle anisotropy, depth, and axial preload on SWV in a healthy control group. Materials and Methods This study was approved by the institutional review board and compliant with HIPAA. Informed consent was obtained from all study volunteers. Eight patients (four women and four men aged 30-50 years) with genetically and biopsy-proved GNE-related myopathy and five healthy volunteers (three women and two men aged 27-33 years) underwent SWV imaging with use of a 9-MHz linear transducer. The gastrocnemius muscles were evaluated in the patients with GNE-related myopathy, and the gastrocnemius, vastus lateralis, and rectus femoris muscles were evaluated in the healthy cohort. The effect of muscle anisotropy, axial preload, and sample volume depth were examined in the healthy cohort. The effect of anisotropy at a fixed depth and preload were examined in the patients with GNE-related myopathy. Results Irrespective of the muscle, the mean SWV was significantly higher with the transverse orientation than with the longitudinal orientation (P < .001). In the healthy cohort, the mean SWV for superficial measurements was significantly lower than that for deep measurements (P < .02). The mean SWV with preload was significantly higher with compression (P < .001) for the rectus femoris only. The mean SWV was significantly lower in patients with GNE-related myopathy than in control subjects (P < .02). Conclusion SWV parametric imaging may provide a useful quantitative adjunct in the assessment of disease activity in patients with GNE-related myopathy. There is diminished SWV and muscle anisotropy in GNE-related myopathy. ((c)) RSNA, 2015.

BACKGROUND: Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands. QUESTIONS/PURPOSES: The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases. METHODS: Online searches were performed using the search criteria of "ballet biomechanics" and "ballet injuries." The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals. RESULTS: Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who "time is money". CONCLUSION: Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.

OBJECTIVE: The purpose of this article is to review the normal anatomy and pathologic conditions of the shoulder on the basis of the appearance on MR and ultrasound images obtained during performance of abduction external rotation and flexion adduction internal rotation positional maneuvers. CONCLUSION: Positional MRI and ultrasound are highly useful in evaluation of the shoulder. Knowledge of the normal appearance of anatomic structures and pathologic changes in nontraditional imaging planes is necessary to avoid pitfalls in interpretation.

Purpose: To evaluate whether there is a correlation between T2/T2* mapping and ultrasound elastography measurements in the supraspinatus tendon. Materials and Methods: Seven shoulders in 6 patients (2 males/4 females; mean age 60.7 years/range 44-72 years) clinically suspected of having rotator cuff pathology underwent shoulder MR imaging, including coronal, sagittal, and axial fat suppressed T2W and sagittal T1W sequences, with the addition of T2 and T2* mapping sequences. The T2 mapping sequence consisted of 2D multi-echo SE sequence with 5 echoes (TR/TE =1000/9.9 ms/DELTATE = 9.9 ms/FA 180degree/b andwidth = 337 Hz/px/ FOV= 128 mm/resolution = 0.5 x 0.5 x 3.0 mm³), while the T2* mapping sequence consisted of 2D multi-echo spoiled GRE sequence with 6 echoes (TR/TE = 428/3.01 ms/DELTATE = 6.33 ms/FA 60degree/bandwidth = 480 Hz/px/ resolution = 0.5 x 0.5 x 3.0 mm3). SNR was estimated using the background ROI method and corrected with the background Rayleigh distribution. T2/T2* maps were constructed inline by using pixelwise monoexponential fit with nonnegative least squares provided by the vendor (MapIt). The anteroposterior (AP) extent, degree of retraction, and percent thickness of tendon tearing, as well as the Goutallier grade of fatty degeneration of the supraspinatus/infraspinatus musculature were measured on the conventional MRI sequences. Each shoulder then underwent ultrasound that included elastography (USE), derived from acoustic radiation force impulse pulses produced by a 9 MHz transducer. Ultrasound shear-wave-velocities (SWV) were obtained in multiple ROIs drawn within the insertional 1-2 cm of the supraspinatus tendon at the mid-portion of the greater tuberosity superior facet using specialized built-in software. ROIs were organized, and averaged when necessary, into three equidistant groups, medial, middle, and lateral, corresponding to their location relative to the tendon insertion. T2 and T2* values were calculated from the T2 and T2* maps using three equidistant ROIs corresponding to the same medial, middle, and lateral locations as on the USE. Statistical analysis included Pearson correlation coefficients (r). Results: Average SNR in the supraspinatus tendon was 26.8 in the T2W images and 59.2 in the T2*W images. Five shoulders had full-thickness supraspinatus tendon tears with mean retraction of 26 mm and AP extent of 21.4 mm, one shoulder had a non-retracted partial-thickness tear involving less than 50 % of the tendon thickness, and one had tendinosis without a tear. All shoulders had Goutallier grade 1-2 fatty degeneration of the supraspinatus/infraspinatus musculature. The mean +/- standard deviation of the values across all ROIs were 9.4 +/- 2.8 m/s for the SWVon USE, 35.2 +/- 9.3 ms on T2 maps, and 21.3 +/- 3.9 ms on T2* maps. There was strong negative correlation between T2* and SWV values when comparing both lateral ROI's (r=-0.92/p = 0.03) and mean of all three ROI locations (r = -0.90/p = 0.04). There was also strong correlation between T2 values and degree of supraspinatus tendon retraction when comparing the mean of all three ROIs (r = 0.79/p=0.03). Conclusion: There may be an association between T2* values measured on MRI and shear wave velocities measured on ultrasound in the degenerated supraspinatus tendon. This has the potential to provide more quantitative information on tendon quality in terms of elasticity on MRI, and, in turn,more clinically useful information to the orthopaedic surgeon planning rotator cuff repair

OBJECTIVES: To compare the effects of ultrasound-guided platelet-rich plasma (PRP) and whole blood (WB) injections in patients with chronic hamstring tendinopathy. METHODS: In a prospective double-blind randomized controlled trial, PRP or WB was injected under ultrasound guidance into the proximal hamstring tendon in a cohort of patients with clinically suspected hamstring tendinosis. Questionnaires were administered before injection and 2, 6, and 12 weeks and 6 months after injection. Pain and function outcomes were measured via the Modified Harris Hip Score (MHHS), Hip Outcome Scores for activities of daily living (ADL) and sport-specific function, and International Hip Outcome Tool 33 (IHOT-33). Diagnostic ultrasound was used to compare preinjection and 6-month postinjection tendon appearances. RESULTS: The WB group showed greater improvements in pain and function over the PRP group before 12 weeks, whereas the PRP group showed improved outcomes over WB at 6 months. None of these between-group outcome measures, except 6-week IHOT-33, showed statistical significance. Comparing preinjection and 6-month scores, the PRP group showed significant improvements in ADL (P = .018) and IHOT-33 (P = .28) scores, whereas the WB group showed no significant improvements from baseline. The WB group showed significantly decreased pain with 15-minute sitting (P= .008) at 6 months. Ultrasound imaging showed no significant differences between PRP and WB group tendon appearances. CONCLUSIONS: Both PRP and WB groups showed improvements in all outcome measures at 6 months. The PRP group showed significant improvements in 6-month ADL and IHOT-33 scores. The WB group reached significance in 15-minute sitting pain. No significant between-group differences were observed at any time point.

BACKGROUND: One of the most common causes of heel pain is plantar fasciitis; however, there are other pathologic disorders that can mimic the symptoms and clinical presentation of this disorder. The purpose of this study was to retrospectively review the prevalence of various pathologic disorders on ultrasound in patients with proximal plantar heel pain. METHODS: The medical records and diagnostic ultrasound reports of patients presenting with plantar heel pain between March 1, 2006, and March 31, 2007, were reviewed retrospectively, and the prevalence of various etiologies was collected. The inclusion criteria were based on their clinical presentation of plantar fasciitis or previous diagnosis of plantar fasciitis from an unknown source. Ultrasound evaluation was then performed to confirm the clinical diagnosis. RESULTS: We examined 175 feet of 143 patients (62 males and 81 females; age range, 16-79 years). Plantar fibromas were present in 90 feet (51%). Plantar fasciitis was diagnosed in 128 feet (73%). Coexistent plantar fibroma and plantar fascial thickening was found in 63 feet (36%). Of the 47 feet that were negative for plantar fasciitis on ultrasound, 27 (57%) revealed the presence of plantar fibroma. CONCLUSIONS: Diagnostic ultrasound can effectively and safely identify the prevalence of various etiologies of heel pain. The high prevalence of plantar fibromas and plantar fascial tears cannot be determined by clinical examination alone, and, therefore, ultrasound evaluation should be performed for confirmation of diagnosis.