Jonathan T. Finnoff

Intrarater and Interrater Reliability of the Balance Error Scoring System (BESS)

The purpose of this study was to determine the intrarater and interrater reliability of the Balance Error Scoring System (BESS).

Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection.

To determine whether ultrasound (US)‐guided percutaneous needle tenotomy followed by a platelet‐rich plasma (PRP) injection would result in pain reduction, functional improvement, or structural alterations in patients with chronic, recalcitrant tendinopathy.

Diagnostic and Interventional Musculoskeletal Ultrasound: Part 1. Fundamentals

Musculoskeletal ultrasound involves the use of high‐frequency sound waves to image soft tissues and bony structures in the body for the purposes of diagnosing pathology or guiding real‐time interventional procedures. Recently, an increasing number of physicians have integrated musculoskeletal ultrasound into their practices to facilitate patient care. Technological advancements, improved portability, and reduced costs continue to drive the proliferation of ultrasound in clinical medicine. This increased interest creates a need for education pertaining to all aspects of musculoskeletal ultrasound. The primary purpose of this article is to review diagnostic ultrasound technology and its potential clinical applications in the evaluation and treatment of patients with neurologic and musculoskeletal disorders. After reviewing this article, physicians should be able to (1) list the advantages and disadvantages of ultrasound compared with other available imaging modalities, (2) describe how ultrasound machines produce images using sound waves, (3) discuss the steps necessary to acquire and optimize an ultrasound image, (4) understand the different ultrasound appearances of tendons, nerves, muscles, ligaments, blood vessels, and bones, and (5) identify multiple applications for diagnostic and interventional musculoskeletal ultrasound in musculoskeletal practice. Part 1 of this 2‐part article reviews the fundamentals of clinical ultrasonographic imaging, including relevant physics, equipment, training, image optimization, and scanning principles for diagnostic and interventional purposes.

Diagnostic and Interventional Musculoskeletal Ultrasound: Part 2. Clinical Applications

Musculoskeletal ultrasound involves the use of high‐frequency sound waves to image soft tissues and bony structures in the body for the purposes of diagnosing pathology or guiding real‐time interventional procedures. Recently, an increasing number of physicians have integrated musculoskeletal ultrasound into their practices to facilitate patient care. Technological advancements, improved portability, and reduced costs continue to drive the proliferation of ultrasound in clinical medicine. This increased interest creates a need for education pertaining to all aspects of musculoskeletal ultrasound. The primary purpose of this article is to review diagnostic ultrasound technology and its potential clinical applications in the evaluation and treatment of patients with neurological and musculoskeletal disorders. After reviewing this article, physicians should be able to (1) list the advantages and disadvantages of ultrasound compared to other available imaging modalities; (2) describe how ultrasound machines produce images using sound waves; (3) discuss the steps necessary to acquire and optimize an ultrasound image; (4) understand the difference ultrasound appearances of tendons, nerves, muscles, ligaments, blood vessels, and bones; and (5) identify multiple applications for diagnostic and interventional musculoskeletal ultrasound. Part 2 of this 2‐part article will focus on the clinical applications of musculoskeletal ultrasound in clinical practice, including the ultrasonographic appearance of normal and abnormal tissues as well as specific diagnostic and interventional applications in major body regions.

Sonographically guided carpal tunnel injections: the ulnar approach.

Objective. The purpose of this report is to describe a new sonographically guided technique for carpal tunnel injections using an ulnar approach. Methods. Previously published sonographically guided techniques for carpal tunnel injections were reviewed. Described approaches were noted to be technically challenging because of the need to perform long‐axis imaging of the carpal tunnel, short‐axis (out‐of‐plane) imaging of the needle, or both. Results. We developed and herein describe the ulnar approach for sonographically guided carpal tunnel injections. Advantages of this approach include transverse imaging of the carpal tunnel, long‐axis (in‐plane) imaging of the needle, and versatility in targeting structures within the carpal tunnel. Conclusions. Clinicians should consider the ulnar‐sided approach when performing sonographically guided carpal tunnel injections.

Accuracy of Ultrasound-Guided Versus Fluoroscopically Guided Contrast-Controlled Piriformis Injections A Cadaveric Study

Objective. The purpose of this study was to compare the accuracy of ultrasound‐guided piriformis injections with fluoroscopically guided contrast‐controlled piriformis injections in a cadaveric model. Methods. Twenty piriformis muscles in 10 unembalmed cadavers were injected with liquid latex using both fluoroscopically guided contrast‐controlled and US‐guided injection techniques. All injections were performed by the same experienced individual. Two different colors of liquid latex were used to differentiate injection placement for each procedure, and the injection order was randomized. The gluteal regions were subsequently dissected by an individual blinded to the injection technique. Colored latex seen within the piriformis muscle, sheath, or both was considered an accurate injection. Results. Nineteen of 20 ultrasound‐guided injections (95%) correctly placed the liquid latex within the piriformis muscle, whereas only 6 of the 20 fluoroscopically guided contrast‐controlled injections (30%) were accurate (P = .001). The liquid latex in 13 of the 14 missed fluoroscopically guided contrast‐controlled piriformis injections and the single missed ultrasound‐guided injection was found within the gluteus maximus muscle. In the single remaining missed fluoroscopically guided contrast‐controlled piriformis injection, the liquid latex was found within the sciatic nerve. Conclusions. In this cadaveric model, ultrasound‐guided piriformis injections were significantly more accurate than fluoroscopically guided contrast‐controlled injections. Despite the use of bony landmarks and contrast, most of the fluoroscopically attempted piriformis injections were placed superficially within the gluteus maximus. Clinicians performing piriformis injections should be aware of the potential pitfalls of fluoroscopically guided contrast‐controlled piriformis injections and consider using ultrasound guidance to ensure correct needle placement.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

Background The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections. Objective Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues. Design Systematic review of the literature. Results USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C). Conclusions The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: a cadaveric study.

To evaluate the accuracy of ultrasound (US)‐guided and palpation‐guided knee injections by an experienced and a less‐experienced clinician with use of a superolateral approach.

Hip strength and knee pain in high school runners: a prospective study.

To the Editor, It was with great interest that we read the article by Finnoff et al, “Hip Strength and Knee Pain in High School Runners: A Prospective Study,” published in the September 2011 issue of PM&R [1]. The article addresses an important clinical problem, and we applaud the authors for contributing a prospective study to the literature. Although we agree with the authors that hip strength may be a contributing factor to lower extremity injuries (ie, patellofemoral pain), we raise several questions in the following commentary in an effort to clarify the clinical relevance of the findings. Our first comment pertains to the between-group comparisons at baseline. The lack of a detailed description of the statistical analyses used for such comparisons makes it difficult to interpret the reported results. For example, according to Table 2 in the article, the only significant between-group difference was found in the external/internal rotation ratio; however, this variable had the smallest effect size (effect size 0.77). Using the data presented (means, SD, and sample sizes), we performed independent t-tests to estimate the between-group differences and found a discrepancy between our results and 3 of the variables reported in Table 2 of the article: external/internal rotation strength ratio, hip abduction strength, and abduction/adduction strength ratio. This finding is of concern because these 3 hip strength variables appeared in their subsequent logistic regression analysis and were the main emphasis of the manuscript. Our t-test results (Table 1) indicated no significant difference in

Accuracy of Sonographically Guided Posterior Subtalar Joint Injections: Comparison of 3 Techniques

Objective. The primary purpose of this investigation was to determine the accuracy of 3 different sonographically guided posterior subtalar joint (PSTJ) injection techniques in an unembalmed cadaveric model. Methods. A single experienced examiner injected the PSTJs of 12 unembalmed cadaveric ankle‐foot specimens using the anterolateral, posterolateral, and posteromedial approaches. The injection order for each specimen was randomized, and each technique was completed with a different‐color diluted latex solution. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the PSTJ), accurate with overflow (within the PSTJ but also in other regions), or inaccurate (no latex in the joint). Results. All 3 sonographically guided PSTJ injection approaches accurately placed latex into the PSTJ (100% accuracy). Latex was also found in adjacent regions in 19.4% (7 of 36) of injections: 8.3% (3 of 36) within the tibiotalar joint, 8.3% (3 of 36) in the peroneal (fibularis) tendon sheath, and 2.8% (1 of 36) in the flexor hallucis longus tendon sheath. The anterolateral approach placed latex outside the PSTJ 25% of the time (3 of 12 injections: 1 tibiotalar and 2 peroneal [fibularis] sheath), the posterolateral approach 25% of the time (3 of 12 injections: 1 tibiotalar, 1 peroneal [fibularis] sheath, and 1 flexor hallucis longus tendon sheath), and the posteromedial approach 8.3% of the time (1 tibiotalar). Conclusions. This cadaveric investigation suggests that all 3 sonographically guided PSTJ techniques may be used to access the PSTJ with a high degree of accuracy. Clinicians should consider sonographically guided PSTJ injections as a favorable alternative to fluoroscopy and computed tomographic guidance when diagnostic or therapeutic image‐guided PSTJ injections are indicated.