Kentaro Onishi

Neuromuscular Ultrasound Application to the Electrodiagnostic Evaluation of Quadrilateral Space Syndrome

Quadrilateral space syndrome (QSS) is a rare neurovascular compression syndrome that results from the compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. Electromyography often is used to evaluate for the presence of neuropathic changes in the deltoid and teres minor in cases of suspected QSS. Needle examination of the teres minor may be challenging because of the muscles small size and proximity to the infraspinatus. In cases in which patients are overweight or have significant teres minor atrophy, localization of the muscle through conventional methods may be extremely difficult. We present a case of an overweight man with posterior shoulder pain who was diagnosed with QSS via the use of a combination of ultrasound and electromyography.

Effect of home exercise program performance in patients with osteoarthritis of the knee or the spine on the visual analog scale after discharge from physical therapy.

The aim of our study was to assess the effect of the frequency of home exercise program (HEP) performance on pain [10-point visual analog scale (VAS)] in patients with osteoarthritis of the spine or knee after more than 6 months discharge from physical therapy (PT). We performed a retrospective chart review of 48 adult patients with a clinical diagnosis of knee or spine osteoarthritis and had been discharged from PT of the spine or the knee for at least 6 months with provision of HEP from a physical therapist. Adult patients who were younger than 50 years of age, taking more than one medication to control pain, participating in worker’s compensation, or had a history of drug abuse were excluded from the study. We recorded patient demographics, pain level (10-point VAS scale), and the number of days that a HEP was performed per week. The mean VAS score of patients who performed 0 days of HEP per week was 6.90. The mean VAS score of patients who performed HEP 1–3 times per week was 6.36. The mean VAS score of patients who performed HEP 4–7 times per week was 5.00. Single-factor analysis of variance analysis indicated a P-value of less than 0.01. Post-hoc comparison of the mean VAS using Fisher’s least significant difference test showed a significant difference between the mean VAS score of 4–7 days per week of HEP versus 0 days per week (P<0.01) and 1–3 days per week (P<0.01) of HEP. There was no significant difference in the mean VAS score between 0 days of HEP and 1–3 days of HEP (P>0.05). Patients who performed 4–7 days per week of HEP had statistically significant lower mean VAS scores than patients who performed 0 days per week of HEP and 1–3 days per week of HEP. Therefore, after 6 months of discharge from PT, patients should be encouraged to perform at least 4 days of HEP per week.

Advanced Ultrasound-Guided Interventions for Tendinopathy

Tendinopathy is increasingly recognized as an important cause of musculoskeletal pain and disability. Tendinopathy is thought to be principally a degenerative process, rather than inflammatory as was traditionally believed. Consequently, traditional tendinopathy treatments focused solely on decreasing inflammation have often been ineffective or even harmful. The advancement of ultrasonography as for guidance of outpatient musculoskeletal procedures has facilitated the development of novel percutaneous procedures for the treatment of tendinopathy, mostly by using mechanical intervention to stimulate regeneration. Several of these techniques, including percutaneous needle tenotomy, percutaneous ultrasonic tenotomy, high-volume injection, and percutaneous needle scraping, are reviewed in this article.

Sonographically Guided Semimembranosus Bursa Injection: Technique and Validation

To describe and validate a sonographically guided (SG) semimembranosus (SM) bursa injection technique in an unembalmed cadaveric model.

Human Adipose-Derived Mesenchymal Stromal/Stem Cells Remain Viable and Metabolically Active Following Needle Passage

To assess the biological effects of passage through clinically relevant needles on the viability and metabolic activity of culture‐expanded, human adipose tissue–derived mesenchymal stromal/stem cells (AMSCs).

Dynamic Sonographic Visualization of an Occult Posterior Lateral Meniscocapsular Separation: A Case Report

Meniscocapsular separation describes detachment of the meniscus from the knee joint capsule. Diagnosis is challenging with conventional examination and imaging methods. We report a case of an 18‐year‐old female softball catcher with unrevealing magnetic resonance imaging despite continued left knee locking and discomfort with deep squatting. Meniscocapsular separation was revealed only on dynamic sonographic examination, where knee flexion revealed a 3.1‐mm gap that developed between the capsule and peripheral meniscus. Arthroscopy confirmed the sonographic findings, and repair resulted in complete resolution of symptoms. This case highlights the utility of dynamic diagnostic sonography in a rare case of posterior lateral meniscocapsular separation.

Poster 189: Sonographically-Identified Distal Thoracolumbar Fascia Sprain Treated with Autologous Conditioned Plasma (ACP): A Case Report

Disclosures: Allison Schroeder: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 40-year-old mother of two and previous recreational runner presented with left posterior hip pain. She had a 5-year history of intermittent stabbing pain in that region with running and daily activities, especially when sitting (worse on soft surfaces). Multiple physical therapy (PT) sessions, two sacroiliac (SI) joint injections (over a 2-year period), SI brace and oral pain medication did not offer lasting relief. Examination was notable for tenderness to palpation over the SI joint and medial iliac crest with positive Yaomen, Ganselen’s, and SI compression tests. Sacral x-rays and MRI indicated mild bilateral SI joint arthritis. HLA-B27, ANA, rheumatoid factory, and anti-CCP were all normal. She was referred to our clinic for further evaluation with diagnostic ultrasound. Setting: Outpatient musculoskeletal/sports ultrasound clinic. Results: Diagnostic sonographic evaluation revealed a hypoechoic, thickened lateral thoracolumbar fascia near its insertion on the medial iliac crest with bony irregularities and tenderness on sonopalpation. Less tenderness was observed with sonopalpation over posterior sacroiliac ligament. We proceeded with autologous conditioned plasma (ACP) injection of the left thoracolumbar fascia under sonographic guidance from a medial to lateral approach. Injection resulted in 80% sustained improvement in pain with increased activity level at 6-week follow-up. Relief was longer lasting than previous steroid injections. Discussion: Our case highlights the utility of ultrasound-assisted evaluation to elucidate the pain generator in patients with SI area pain. Furthermore, ACP injection can be considered to treat a presumed sprain of thoracolumbar fascia insertion. Conclusions: Patients presenting with SI region pain may be symptomatic from thoracolumbar fascia sprain in the right clinical context and thoracolumbar fascia should be considered as a pain generator that can mimic SI arthropathy or SI ligamentous injuries. Level of Evidence: Level V

Poster 204: Sonographic Evaluation of Dorsally Located Intra-Articular Metatarsophalangeal Joint Loose Body in an Avid Runner: A Case Report

Case/Program Description: A 40-year-old woman presented to an outpatient clinic for diagnostic ultrasound with a 3-month history of pain and swelling along the medial aspect of her left wrist. She reported occasional paresthesias involving the dorsal ulnar aspect of her hand and small finger. She denied any trauma or precipitating events. Setting: Outpatient Clinic Results: A diagnostic ultrasound was performed of her left wrist which revealed an anechoic 1.1 0.4 0.7 cm mass with smooth borders near the ulnar styloid. The dorsal branch of the ulnar nerve extended into the area of the mass, presumed to be a ganglion, and crossed directly superficial to it. Thevisible compressionandproximityof thedorsal branch of theulnar nerve to theganglioncystwasbelieved tobe thecauseof her neuritic symptoms. She returned for electrodiagnostic testing which revealed an abnormally low sensory nerve action potential of the left dorsal branch of the ulnar nerve compared to the right. The main trunk of the ulnar nerve was normal with both sensory and motor testing. Discussion: This case demonstrates the value of combined ultrasound and electrodiagnostic testing for unusual focal neuropathies. Routine electrodiagnostic testing of the main ulnar trunk would not have found any abnormalities without the guidance of prior ultrasound which revealed compression of the dorsal cutaneous branch and need for testing of less commonly performed nerve studies. Conclusions: Ultrasound and electrodiagnosis when used concomitantly provide greater diagnostic acuity for unusual focal neuropathies. Level of Evidence: Level V

Return to Play After PRP and Rehabilitation of 3 Elite Ice Hockey Players With Ulnar Collateral Ligament Injuries of the Elbow

Background: Ulnar collateral ligament (UCL) injury is a well-described etiology of pain and decreased performance for the overhead athlete. Despite a growing volume of literature regarding the treatment of these injuries for overhead athletes, there is a paucity of such data regarding stickhandling collision sport athletes, such as ice hockey players. Purpose/Hypothesis: The purpose of this study was to characterize this injury among 3 elite ice hockey players and to describe the ability of these athletes to return to play, as well as to review the unique sport-specific implications of this injury, evaluation, nonsurgical management, and considerations for return to play. The authors hypothesized that elite ice hockey players will be able to return to play at the same level following nonoperative treatment of UCL injury. Study Design: Case series; Level of evidence, 4. Methods: Data from 3 elite professional ice hockey players who sustained a high-grade injury to the UCL were retrospectively reviewed. All athletes underwent 2 autologous conditioned plasma injections as part of their treatment and were evaluated with ultrasonography and magnetic resonance imaging. Results: Three consecutive elite ice hockey players were included in this study, and no patients were excluded. Players were cleared to full return to play at a mean 36 days postinjury. Follow-up examination at this time point demonstrated full range of motion of the elbow for all athletes, without tenderness to palpation over the UCL, including no tenderness over the humeral insertion site. Stability examination improved as well, demonstrating a soft to moderate endpoint with valgus stress, although this was not symmetric to the contralateral side. All athletes were able to continue to play at the same level of competition as before the injury occurred, without any complaints. No players had repeat injury during the same or following seasons. Conclusion: The authors present 3 elite-level ice hockey players who sustained a high-grade injury to the UCL. Successful return to play was possible after nonoperative treatment with injection of autologous conditioned plasma at a mean 36 days following injury. Athletes who injure either the top or bottom hand can return to play at the same elite level following this injury.

Ultrasound elastography and ultrasound tissue characterisation for tendon evaluation

Ultrasound elastography (UE) and ultrasound tissue characterisation (UTC) are two newer modes of ultrasound (US) which have begun to attract scientific interests as ways to improve tendon characterisation. These modes of US show early promise in improved diagnostic accuracy, prediction of at-risk tendons and prognostication capability beyond conventional grey-scale US. Here, we provide a review of the literature on UE and UTC for Achilles, patellar and rotator cuff tendons. The translational potential of this article: The present literature indicates that UE and UTC could potentially increase the clinicians ability to accurately diagnose the extent of tendon pathology, including preclinical injury.