Ayşe Merve Ata

Ischiofemoral impingement revisited: what physiatrists need to know in short.

A 53-yr-old female patient was seen because of low back, right hip, and buttock pain radiating to the right lower extremity for the last 2 yrs. On detailed questioning, she declared that her pain got worse during walking or other daily activities and that she was better during rest. She denied any trauma, and her medical history was unremarkable except for diabetes mellitus (for 3 yrs) and total colectomy due to ulcerative colitis (7 yrs ago). With the same complaints, she had visited another center where she had been diagnosed with enteropathic spondyloarthropathy and started on a combination treatment of sulphasalazine and acemetacin for 2 mos. On physical examination, low back and hip range of motion were normal. However, she experienced pain during resistive right hip adduction and external rotation. Neurologic evaluation of the lower limbs was otherwise noncontributory. Complete blood count, erythrocyte sedimentation rate, C-reactive protein, and liver/renal/thyroid function tests were unremarkable. Because the aforementioned diagnosis of spondyloarthropathy was considered to be unlikely, pelvic magnetic resonance imaging was performed and revealed bilateral ischiofemoral impingement (Fig. 1). Accordingly, she was treated with a 3-wk physical therapy program, which was composed of moist heat, ultrasound, transcutaneous electrical nerve stimulation, and hip stretching exercises. On the control visit, her complaints were found to have improved significantly. Ischiofemoral impingement is described as one of the uncommon sources of hip pain that ensues because of entrapment of the quadratus femoris muscle between the lesser trochanter and the ischium. Although its etiology remains unclear, several congenital or acquired conditions (e.g., intertrochanteric fractures/osteotomy, hip osteoarthritis, hamstring insertion problems) have been speculated to cause this clinical scenario. Eventually, the pertinent complaints of the patients occur secondary to the narrowing of the ischiofemoral space (compressing the quadratus femoris muscle) and, in case of radiating pain, as a result of irritation of the ipsilateral sciatic nerve. Presenting this case report, we aimed to draw the attention of physiatrists to this potentially underestimated syndrome whereby prompt physical examination as well as radiologic imaging and initial conservative treatment are crucial for its management.

Ultrasonographic Evaluation of the Radial Nerves in Patients with Unilateral Refractory Lateral Epicondylitis

Objective To evaluate the possible radial nerve entrapment of patients with unilateral refractory lateral epicondylitis (LE) by using ultrasound (US) and electroneuromyography. Design Cross-sectional study. Setting Three physical medicine and rehabilitation departments. Subjects Consecutive 44 patients (15 M, 29 F) with unilateral refractory LE. Methods All patients underwent detailed clinical, electrophysiological and ultrasonographic evaluations. Ultrasound imaging was used to evaluate thickness and presence of abnormal findings of the common extensor tendon (CET) and cross-sectional area (CSA) of the radial nerve (at spiral groove and before bifurcation) bilaterally. Unaffected sides of the patients were taken as controls. Results When compared with the unaffected sides, CET thickness and radial nerve CSAs (at both levels) were higher, and abnormal US findings regarding LE (47.7% vs. 6.8%) were more common on the affected sides than nonaffected sides (all P  < 0.001). Grip strength values were lower on the affected sides ( P  < 0.001). Electrophysiological studies were all normal, and similar between the two sides (all P  > 0.05). When subgroup analyses were performed after taking into account the hand dominance, affected and dominant sides were found to be the same in 31 and different in 13 patients. In subgroups, CETs and radial nerve CSAs at both levels were higher on the affected sides (all P  < 0.01). Conclusions Radial nerves and the CETs seem to be swollen on the affected sides, independent from the hand dominance of the patients with refractory LE. These results morphologically support the previous literature that attributes some of the chronic complaints of these patients actually to radial nerve entrapment.

Sonographic quantification of the forearm muscles in relation with handgrip strength

Dear Editor, We have taken interest in the recently published article in your journal by Abe et al. (2017). We congratulate the authors for once again demonstrating the usefulness of ultrasound (US) imaging as regards the measurements of anterior forearm muscles. Of note, they have already shown the usefulness of US measurements for predicting body composition (Abe et al., 1994) and validated them in comparison with magnetic resonance imaging (Sanada et al., 2006). Herein, we have some important comments as regards precise sonographic muscle scanning and quantification. First, in their Table 1, the authors show ‘major muscles at 30% of forearm length’. First, it is noteworthy that flexor pollicis longus muscle just originates at this level, and that the origins of extensor pollicis longus/brevis and extensor indicis proprius muscles are even more distal (Fig. 1). Second, muscle thickness measurements on the radial side (MT-radial) also include extensor forearm muscles, namely brachioradialis, extensor carpi radialis longus and brevis and supinator. Although this measurement (MT-radial) can be used for skeletal muscle mass estimation (Sanada et al., 2006), discussing its relationship with handgrip strength (which is much more related with extrinsic finger flexor muscles) may be a little indirect or irrelevant (Lieber et al., 1992). Third, the authors

Shall We Inject Superficial or Deep to the Plantar Fascia? An Ultrasound Study of the Treatment of Chronic Plantar Fasciitis

ABSTRACT We compared the effectiveness of ultrasound (US)‐guided corticosteroid, injected superficial or deep to the fascia, in patients with plantar fasciitis. Thirty patients (24 females [75%] and 6 males [25%]) with unilateral chronic plantar fasciitis were divided into 2 groups according to the corticosteroid injection site: superficial (n = 15) or deep (n = 15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the Foot Ankle Outcome Scale (FAOS) for foot disability, evaluated at baseline and repeated in the first and sixth weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender, and body mass index (p > .05 for all). Compared with the baseline values, the Likert pain scale (p < .001 for all) and FAOS subscale (p < .01 for all) scores had improved at the first and sixth week follow‐up visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the sixth week (p < .001 for both), the heel pad thickness remained unchanged (p > .05 for both). The difference in the FAOS subscales (pain, p = .002; activities of daily living, p = .003; sports/recreational activities, p = .008; quality of life, p = .009) and plantar fascia thickness (p = .049) showed better improvement in the deep than in the superficial injection group. US‐guided corticosteroid injections are safe and effective in the short‐term therapeutic outcome of chronic plantar fasciitis. Additionally, injection of corticosteroid deep to the fascia might result in greater reduction in plantar fascia thickness, pain, and disability and improved foot‐related quality of life. &NA; Level of Clinical Evidence: 2

Ultrasound imaging for diagnosis and follow‐up of persistent median artery thrombosis

Neurological Societies/Peripheral Nerve Society Guideline on management of chronic inflammatory demyelinating polyradiculoneuropathy: report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society--First Revision. J Peripher Nerv Syst 2010;15:1–9. 2. Jain S, Cigler T. Eribulin mesylate in the treatment of metastatic breast cancer. Biologics 2012;6:21–29. 3. Dybdal-Hargreaves NF, Risinger AL, Mooberry SL. Eribulin mesylate: mechanism of action of a unique microtubule-targeting agent. Clin Cancer Res 2015;21:2445–2452. 4. Cortes J, O’Shaughnessy J, Loesch D, Blum JL, Vahdat LT, Petrakova K, et al; EMBRACE (Eisai Metastatic Breast Cancer Study Assessing Physician’s Choice Versus E7389) investigators. Eribulin monotherapy versus treatment of physician’s choice in patients with metastatic breast cancer (EMBRACE): a phase 3 open-label randomised study. Lancet 2011;377:914–923. 5. Gutmann L. AAEM minimonograph #37: facial and limb myokymia. Muscle Nerve 1991;14:1043–1049. 6. Varela H, Rubin DI. Facial and trigeminal neuropathies as the initial manifestation of chronic inflammatory demyelinating polyradiculopathy. J Clin Neuromuscul Dis 2009;10:194–198.

Ultrasonographic Evaluation of the Femoral Cartilage, Achilles Tendon and Plantar Fascia in Young Women Wearing High-heeled Shoes

Specific attention on the musculoskeletal impact of wearing high‐heeled shoes (HHS) has mainly focused on knee osteoarthritis and the literature is limited to biomechanical changes. The distal femoral cartilage has not been morphologically studied. Additionally, although heel elevation is coupled with a shear stress at the heel and overloaded calf muscles, Achilles tendon (AT) and plantar fascia (PF) thicknesses have not been assessed either.

Ultrasound Imaging in the Management of a Rare Superficial Fibular Nerve Injury.

A 50-year-old man was seen for pain, numbness, and tingling on the lateral side of his left leg and dorsum of the foot. His complaints have started after excision of a local fibrolipoma 2 months ago. He received a diagnosis of nonHodgkin lymphoma the previous year (currently in remission); otherwise, his medical history was unremarkable. On physical examination, there was a positive Tinel sign on the scar area (14 cm proximal to the lateral malleolus). Neurological examination was normal, but there was hypesthesia on the left superficial fibular nerve (SFN) innervated region. With a likely diagnosis of SFN injury, ultrasound (US) evaluation was performed. When compared with the asymptomatic side, US showed significantly swollen left SFN with intrafascicular edema nearby the scar (Fig. 1). Sono-Tinel was also positive on the same area. As he received a diagnosis of SFN injury, a US-guided injection with a combination of corticosteroid and local anesthetic was done (video, http://links.lww.com/PHM/A225). Immediately after the injection, the patient_s complaints decreased, and his condition further improved in the follow up. Superficial fibular nerve is a branch of the common fibular nerve. It innervates the fibularis longus and brevis muscles before it penetrates the deep fascia in the lower leg (where the nerve is purely sensory). It supplies the skin on the anterolateral leg and dorsum of the foot and toes (except

Ultrasound Imaging of a Partial Flexor Digitorum Profundus Tear Due to a Bony Spur

A 37-year-old man was referred from the plastic surgery department for an ultrasound (US) evaluation of the flexor tendons in his right index finger. The patient was unable to actively flex his finger at the distal interphalangeal joint, and the surgeons wanted to evaluate for a possible flexor digitorum profundus (FDP) rupture, and if positive, to localize the ruptured end of the tendon to plan surgery. The patient reported that his weakness had progressed gradually over 1 year, after forcefully opening a glass bottle. He added that his middle phalanx had sustained a superficial laceration,

Letter to the Editor: Does the Use of Ultrasound Affect Contamination of Musculoskeletal Injections Sites?

To the Editor, We read the study by Sherman and colleagues [2] and congratulate the authors for their effort in drawing attention to the expanding use of ultrasound imaging in musculoskeletal practice. Their concern related with local contamination after ultrasound-guided interventions is also noteworthy. While their findings (especially increased contamination with sterile gel use but not with nonsterile gel use) might be intriguing, they can only be considered partially clinically relevant. Their methodology of simulation for ultrasound-guided injections failed to reflect the actual clinical scenario. During such an intervention, depending on various factors (such as the size/nature of the target, nearby structures, injection material), the physician may prefer to use the direct or the indirect method [1]. In the latter one, as the intervention is not performed under real-time imaging, any risk of ultrasound gel-related contamination is not likely. This is important since many injections can readily be done using this indirect method. On the other hand, even if the clinician prefers to use the direct method, it is usually suggested that the injection needle does not have any contact with the gel (or the sterile covering of the probe with a glove/condom). The only exception would be an injection close to a bony prominence where the injection needle needs to be guided through the sterile gel. Overall, ultrasound-guided interventions still need to be evaluated, not only for therapeutic efficacy, but also with concern for infectious complications. The study models should better simulate the prompt interventional techniques.