Faculty Bibliography

OBJECTIVES: (1) Assess the association between the B-mode morphologic appearance and elasticity in the rotator cuff tendon using shear wave elastography (SWE). (2) Assess the association between SWE and symptoms. METHODS: Institutional Review Board approval and informed consent were obtained. A retrospective review identified 21 studies in 19 eligible patients for whom SWE was performed during routine sonographic evaluations for shoulder pain. Evaluations were compared with 55 studies from 16 asymptomatic volunteers and 6 patients with asymptomatic contralateral shoulders. Repeated studies were accounted for by resampling. Proximal and distal tendon morphologic characteristics were graded from 1 to 4 (normal to full-thickness tear), and average shear wave velocity (SWV) measurements were obtained at both locations. In 68 examinations, deltoid muscle SWV measurements were available for post hoc analysis. RESULTS: The morphologic grade and SWV showed weak-to-moderate negative correlations in the proximal (P < .001) and distal (P = .002) rotator cuff tendon. A weakly significant SWV decrease was found in the proximal tendon in symptomatic patients (P = .049); no significant difference was seen in the distal tendon. The deltoid muscle SWV showed weak-to-moderate negative correlations with the morphologic grade in the proximal (P = .004) and distal (P = .007) tendon; the deltoid SWV was also significantly lower in symptomatic shoulders (P = .001). CONCLUSIONS: Shear wave elastography shows tendon softening in rotator cuff disease. It captures information not obtained by a morphologic evaluation alone; however, a poor correlation with symptoms suggests that SWE will be less useful in workups for shoulder pain than for preoperative assessments of tendon quality. Deltoid muscle softening seen in morphologically abnormal and symptomatic patients requires further exploration.

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.

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.

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

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.

Purpose: To demonstrate that sonographic morphologic properties of the supraspinatus tendon correlate with mechanical properties, as assessed quantitatively by shear-wave ultrasound elastography.
Material(s) and Method(s): This retrospective study included 36 patients who underwent sonographic evaluation of one or both shoulders on one or multiple dates from June 2013 through October 2014. A shoulder was excluded if the supraspinatus tendon contained calcifications or had undergone surgical repair for a tear. Each sonographic evaluation of each shoulder was regarded as a separate data point, totaling 76 sonographic evaluations of 36 patients. For each sonographic evaluation, the morphologic appearance of the proximal and distal supraspinatus tendon was graded (1 = normal or mild tendinosis without a tear, 2 = moderate or severe tendinosis without a tear, 3 = partial tear, 4 = full-thickness tear) by consensus of 2 musculoskeletal radiologists. In addition, for each sonographic evaluation, sample volumes were randomly placed within the proximal and distal supraspinatus tendon, viewed in the longitudinal dimension, to obtain shear-wave ultrasound elastography measurements. Finally, for 68 of the sonographic evaluations, on the same image used for sample volumes of the supraspinatus tendon, sample volumes were randomly placed within the deltoid muscle to obtain shear-wave ultrasound elastography measurements. Spearman rank correlations assessed the association between tendonmorphology grade and elastographymeasurements. Mann-Whitney tests compared elastography measurements between scans grouped by symptomatology or morphology grade. Bootstrap re-sampling procedures accounted for lack of statistical independence among scans of the same patient.
Result(s): Of the 36 patients, there were 21 males and 15 females (mean age 46, range 23-74). Of the 76 sonographic evaluations, there were 38 males and 38 females (mean age 44, range 23-74), 36 right and 40 left shoulders, and 21 symptomatic and 55 asymptomatic shoulders. The tendon morphology grade and elastography measurements were correlated in both the proximal (p < 0.001) and distal (p = 0.002) supraspinatus tendon. Comparing between grade 1 and grade >= 2 morphology, the elastography measurements differed significantly in both the proximal (p = 0.001) and distal (p = 0.012) supraspinatus tendon. Comparing between grade <= 2 and grade > 2 morphology, the elastography measurements also differed significantly in both the proximal (p = 0.002) and distal (p = 0.004) supraspinatus tendon. Interestingly, deltoid muscle elastography measurements also were associated with the morphology grade of the proximal (p = 0.004) and distal (p = 0.007) supraspinatus tendon; this measurement also differed significantly between asymptomatic and symptomatic scans (p = 0.001).
Conclusion(s): The sonographic morphologic properties of the supraspinatus tendon correlate with mechanical properties, as assessed by shear-wave ultrasound elastography. These findings indicate that shear-wave ultrasound elastography - a non-invasive, relatively inexpensive, and simple examination - can provide an objective measurement of tendon elasticity. Correlation of deltoid muscle elasticity with supraspinatus tendon morphology and symptomatology may be related to the two muscles being a force couple. Further research is needed to assess whether tendon elastography measurements correlate with the MRI morphologic appearance of the tendon and with intraoperative evaluation of tendon quality

Purpose: A previous study has suggested that sonographic assessment of the acetabular labrum following intra-articular injection demonstrated concordance between sonographic and non-contrast MRI findings of labral pathology. However, the time interval between sonographic imaging andMRI varied significantly, and non-contrastMRI is less accurate in diagnosing labral tears than MR arthrography. We wish to verify whether such concordance exists when systematically compared to MRA performed on the same day. Material andMethods: Imaging from 26 patients who were referred for hip directMR arthrography with ultrasound guidance were retrospectively reviewed for this study. US-guided hip injection was performed with a 6 MHz curved transducer and a 3.5 inch, 22-gauge needle according to the department's standard protocol. A dilute gadolinium mixture of 10 cc of normal saline and 0.1 cc of gadolinium contrast and 2 cc of 1% lidocaine was administered in all cases. Routine post-injection ultrasound imaging examination of the anterosuperior labrum was performed from the iliopsoas tendon to the rectus femoris tendon using a linear 9 MHz transducer by an experienced MSK radiologist. Subsequently, patients proceeded directly to MR imaging. Same-day ultrasound and MRA images were retrospectively and blindly reviewed in random order by two experienced MSK radiologists after the studies were anonymized. The labrum for each study was divided into three anatomical zones: adjacent to iliopsoas tendon, adjacent to rectus femoris tendon, and between the two tendons. For each modality and anatomic zone, the labrum was given three binary numerical scores denoting the presence or absence of the following: intrasubstance labral cleft, chondrolabral junction cleft, and abnormal labrum morphology. The values for each labrum anatomical zone and pathology were then compared. MRA was considered the gold standard for diagnosing labral tears.
Result(s): The patient population consisted of 11 males and 15 females, mean age 33.5 years (standard deviation of 9.1 years). 11 injections were performed in the left hip and 15 were performed in the right hip. The mean body mass index (BMI) was 23.7 (standard deviation of 4.1). 4 patients were eventually taken to arthroscopy and theMRAfindings were confirmed. Given that the presence or absence of labral cleft, chondrolabral junction cleft, and abnormal morphology was included for each labrum anatomical zone, 234 data points were obtained for US and MRevaluation. US and MR showedmatching analysis in 124/234 (53%) of the data points. 3/26 (11.5%) patients had normal labrumMRA examinations. On a zonal basis, US was most accurate in detecting abnormal morphology (LR+ 1.59, LR- 0.388). US was also moderately accurate detecting labral clefts on a zone basis (LR+ 1.35, LR- 0.58). US called some form of pathology near the rectus femoris and between the tendons in all patients, with PPVof 0.577 and 0.692 in each zone respectively

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.