Kenneth Mautner

Outcomes After Ultrasound-Guided Platelet-Rich Plasma Injections for Chronic Tendinopathy: A Multicenter, Retrospective Review

To determine whether ultrasound‐guided platelet‐rich plasma (PRP) injections are an effective treatment for chronic tendinopathies.

A Call for a Standard Classification System for Future Biologic Research: The Rationale for New PRP Nomenclature

Autologous cell therapies including platelet‐rich plasma (PRP) and bone marrow concentrate (BMC) are increasingly popular options for soft tissue and joint‐related diseases. Despite increased clinical application, conflicting research has been published regarding the efficacy of PRP, and few clinical publications pertaining to BMC are available. Preparations of PRP (and BMC) can vary in many areas, including platelet concentration, number of white blood cells, presence or absence of red blood cells, and activation status of the preparation. The potential effect of PRP characteristics on PRP efficacy is often not well understood by the treating clinician, and PRP characteristics, as well as the volume of PRP delivered, are unfortunately not included in the methods of many published research articles. It is essential to establish a standard reporting system for PRP that facilitates communication and the interpretation and synthesis of scientific investigations. Herein, the authors propose a new PRP classification system reflecting important PRP characteristics based on contemporary literature and recommend adoption of minimal standards for PRP reporting in scientific investigations. Widespread adoption of these recommendations will facilitate interpretation and comparison of clinical studies and promote scientifically based progress in the field of regenerative medicine.

Relationship of Attention Deficit Hyperactivity Disorder and Postconcussion Recovery in Youth Athletes.

Objective:To investigate whether attention deficit hyperactivity disorder (ADHD) influences postconcussion recovery, as measured by computerized neurocognitive testing. Design:This is a retrospective case control study. Setting:Computer laboratories across 10 high schools in the greater Atlanta, Georgia area. Participants:Immediate postconcussion assessment and cognitive testing (ImPACT) scores of 70 athletes with a self-reported diagnosis of ADHD and who sustained a sport-related concussion were compared with a randomly selected age-matched control group. Immediate postconcussion assessment and cognitive testing scores over a 5-year interval were reviewed for inclusion. Main Outcome Measures:Postconcussion recovery was defined as a return to equivalent baseline neurocognitive score on the ImPACT battery, and a concussion symptom score of ⩽7. Results:Athletes with ADHD had on average a longer time to recovery when compared with the control group (16.5 days compared with 13.5 days), although not statistically significant. The number of previous concussions did not have any effect on the rate of recovery in the ADHD or the control group. In addition, baseline neurocognitive testing did not statistically differ between the 2 groups, except in verbal memory. Conclusions:Although not statistically significant, youth athletes with ADHD took on average 3 days longer to return to baseline neurocognitive testing compared with a control group without ADHD. Clinical Relevance:Youth athletes with ADHD may have a marginally prolonged recovery as indexed by neurocognitive testing and should be considered when prognosticating time to recovery in this subset of student athletes.

Where Do Injectable Stem Cell Treatments Apply in Treatment of Muscle, Tendon, and Ligament Injuries?

Treatment options for muscle, tendon, and ligament injuries span a constantly evolving spectrum. For years, treatments focused on symptomatic relief. Closer scrutiny of symptomatic treatment suggests that the provision of transient relief of symptoms may have caused more harm than good. Cortisone injections provide a trade‐off of short‐term relief for poorer long‐term outcomes. When conventional treatment failed, patients have faced limited options including surgery, which has increased risk and limited efficacy. Regenerative injections offer a more robust option for soft tissue disease. Basic science and clinical studies show conflicting results to support the use of platelet‐rich plasma injections for soft tissue disorders, and even fewer trials have focused on injectable stem cells with limited findings. Additional studies are needed to determine the potential benefits of this regenerative therapy.

Intramuscular Vascular Malformations A Rare Cause of Exertional Leg Pain and a Novel Treatment Approach With Ultrasound-Guided Doxycycline Sclerotherapy

Intramuscular vascular malformations are a rare subset of vascular lesions and present a considerable diagnostic challenge. The majority of vascular lesions are initially misdiagnosed and are often attributed to more common musculoskeletal disorders. Sports medicine practitioners need to be familiar with intramuscular vascular malformations because up to 20% of cases have symptoms of exertional leg pain. Exertional leg pain, a common symptom seen by sports medicine practitioners, is defined as exercise-related leg pain distal to the knee and proximal to the talocrural joint. Depending on the study methodology, exertional leg pain has an incidence of 12.8% to 82.4% in athletes. Although a comprehensive review of exertional leg pain is beyond the scope of this report, the differential diagnosis is broad and includes musculoskeletal, vascular, and neurologic etiologies (Table 1). Here we present a case of intramuscular venous malformation in the flexor digitorum longus muscle in a 15-yearold female runner with exertional leg pain. Treatment options for intramuscular venous malformations include observation, sclerotherapy, or surgical resection. Although a variety of different sclerosing agents have been described in the literature, to our knowledge, this is the first report of doxycycline sclerotherapy for intramuscular venous malformations. CASE REPORT

Ultrasound-Guided Distal Bicep Tendon Injection Using a Posterior Approach

Distal biceps tendinopathy is an uncommon but increasingly diagnosed condition in persons with elbow pain. When traditional treatments are unsuccessful, practitioners have performed ultrasound (US)‐guided tendon injections in this region using an anterior approach. Although success has been reported with this technique, this approach may lead to neurovascular injury. This case report is the first in the literature to describe a US‐guided distal bicep tendon injection using a posterior approach. The patient had an excellent clinical outcome with no adverse events. This outcome suggests that a US‐guided posterior percutaneous tendon injection might be a safe, viable, nonsurgical option for recalcitrant distal biceps tendinopathy.

Ultrasound Findings of Delayed-Onset Muscle Soreness

The purpose of this series was to retrospectively characterize the ultrasound findings of delayed‐onset muscle soreness (DOMS). The Institutional Review Board approved our study, and informed consent was waived. A retrospective search of radiology reports using the key phrase “delayed‐onset muscle soreness” and key word “DOMS” from 2001 to 2015 and teaching files was completed to identify cases. The sonograms were reviewed by 3 fellowship‐trained musculoskeletal radiologists by consensus. Sonograms were retrospectively characterized with respect to echogenicity (hypoechoic, isoechoic, or hyperechoic), distribution of muscle involvement, and intramuscular pattern (focal versus diffuse and well defined versus poorly defined). Images were also reviewed for muscle enlargement, fluid collection, muscle fiber disruption, and increased flow on color or power Doppler imaging. There were a total of 6 patients identified (5 male and 1 female). The average age was 22 years (range, 7–44 years). Of the 6 patients, there were a total of 11 affected muscles in 7 extremities (1 bilateral case). The involved muscles were in the upper extremity: triceps brachii in 27% (3 of 11), biceps brachii in 18% (2 of 11), brachialis in 18% (2 of 11), brachioradialis in 18% (2 of 11), infraspinatus in 9% (1 of 11), and deltoid in 9% (1 of 11). On ultrasound imaging, the abnormal muscle was hyperechoic in 100% (11 of 11), well defined in 73% (8 of 11), poorly defined in 27% (3 of 11), diffuse in 73% (8 of 11), and focal in 27% (3 of 11). Increased muscle size was found in 82% (9 of 11) and minimal hyperemia in 87.5% (7 of 8). The ultrasound findings of DOMS include hyperechoic involvement of an upper extremity muscle, most commonly appearing well defined and diffuse with increased muscle size and minimal hyperemia.

Ultrasound-Guided Percutaneous Needle Tenotomy for Chronic Tensor Fascia Lata Tendinopathy: A Case Series and Description of Sonographic Findings

Proximal tensor fascia lata tendinopathy at its origin on the anterior superior iliac crest is one potential cause of lateral hip pain. However, there is limited literature regarding the mechanism, disease course, or management of this condition. There is growing evidence supporting the effective treatment of percutaneous needle tenotomy (PNT) for chronic tendinopathy. Only a single case series has examined the efficacy of PNT for tendinopathy about the hip and pelvis. Presented here are examples of 2 cases of chronic recalcitrant proximal ultrasound confirmed tensor fascia lata (tendinopathy effectively treated with ultrasound‐guided PNT.

Musculoskeletal and Sports Medicine Physical Medicine and Rehabilitation Curriculum Guidelines

The following Musculoskeletal and Sports Medicine Physical Medicine and Rehabilitation (PM&R) Curriculum Guidelines were developed to define a recommended training strategy for PM&R residents in the realm of musculoskeletal and sports medicine. This document has been endorsed by the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the Association of Academic Physiatrists. There are other published educational resources for sports medicine faculty that provide direction in improving the quality of sports medicine fellowship programs [1]. However, this document was developed to meet the unique needs and skills of the physiatrist. As is the case for all areas of physiatric training, the knowledge and skills in the areas of musculoskeletal and sports medicine should be attained through longitudinal experience that promotes educational competencies defined by the Accreditation Council for Graduate Medical Education (http://www.acgme.org) [2]. The curriculum guidelines recommend structured experiences in several areas unique to ambulatory physiatry training as well as structured didactic lectures, conferences, journal clubs, and workshops with an emphasis on outcomes-oriented, evidence-based studies.

Platelet-Rich Plasma Versus an Eccentric Exercise Program for Recalcitrant Lateral Elbow Tendinopathy

A 48-year-old male, left handedominant air conditioning repairman has a 3-month history of persistent pain in his left elbow. He does not report any traumatic precipitating incident. He is now having difficulty performing his work duties, especially gripping and lifting. In addition, he has had to stop playing recreational tennis and golf. His initial treatment was physical therapy, including therapeutic ultrasound, friction massage, and use of a counterforce strap. After 8 sessions and minimal improvement in his pain, he was referred to a sports medicine specialist. The pain averages 5 out of 10 on a visual analog scale (VAS) and is usually a deep ache, but at times it is sharp. Examination showed no obvious inflammation of common extensor origin. Tenderness was present over the lateral epicondyle, and gripping reproduced the pain. The Cozen test (resisted wrist extension with an extended and pronated elbow) and resisted middle finger extension were positive for pain. The patient was diagnosed with chronic lateral elbow tendinopathy. Given his lack of improvement with physical therapy, the patient is requesting a more aggressive approach. Dr Joseph Ihm will argue that an eccentric exercise strengthening program should be implemented to provide long-term relief. Drs Kenneth Mautner and Joseph Blazuk will argue that an injection of platelet-rich plasma (PRP) is warranted in this patient to optimize and restore his long-term function.