Michael Y. Lee

Diagnostic Value of Ultrasonography for Clinical Medial Epicondylitis

OBJECTIVES To assess the ultrasonographic findings and to evaluate the value of ultrasonography as a diagnostic method for detecting clinical medial epicondylitis. DESIGN A prospective, single-blind study. SETTING An outpatient rehabilitation clinic in a tertiary university hospital. PARTICIPANTS Twenty-one elbows from 18 patients with clinical medial epicondylitis and 25 elbows without medial epicondylitis were evaluated. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The clinical diagnosis of medial epicondylitis was based on the patients symptoms and clinical signs in a physical examination performed by a physiatrist. An experienced radiologist made the real-time ultrasonographic diagnosis based on the detection of at least one of the following abnormal findings: a focal hypoechoic or anechoic area, tendon nonvisualization, intratendinous calcifications, and cortical irregularity. RESULTS Ultrasonography revealed positive findings in 20 of 21 elbows with medial epicondylitis and was negative in 23 of 25 without medial epicondylitis. Ultrasonography showed sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for clinical medial epicondylitis of 95.2%, 92%, 93.5%, 90.9%, and 95.8%, respectively. Tendinosis was observed in 15 elbows, and a partial-thickness tear, including 1 intrasubstance tear, was detected in 5 elbows. The most common ultrasonographic abnormality was a focal echogenic abnormality (15 hypoechoic, 5 anechoic) of the tendons. CONCLUSIONS Our results indicate that ultrasonography is informative and accurate for the detection of clinical medial epicondylitis. Therefore, ultrasonography should be considered as an initial imaging method for evaluating medial epicondylitis.

Ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia.

OBJECTIVE To evaluate the ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia. DESIGN Prospective, single blind study. PATIENTS A total of 41 patients with post-stroke hemiplegia were included (24 men and 17 women, mean age 56 years (standard deviation 11), age range 34-78 years). METHODS Clinical evaluation of the affected shoulder was assessed using the Motricity Index scores and the Modified Ashworth Scale. Two ultrasonographic measurements were taken to check intra-rater reliability. The shoulder subluxation ratio was determined as the ratio of the radiographic vertical and horizontal distance, and the ultrasonographic lateral and anterior distances in the affected shoulder divided by that in the unaffected shoulder. RESULTS Intraclass correlation coefficients of the repeated ultrasonographic lateral/anterior distance measurements in the unaffected and affected shoulders were 0.979/0.969 and 0.950/0.947, respectively. Ultrasonographic lateral/anterior distance ratios were negatively correlated with Motricity Index scores of the affected shoulder abduction (r = -0.490, p < 0.001/ r = -0.671, p < 0.001). Ultrasonographic anterior distance ratio was negatively correlated with Modified Ashworth Scale score of the affected shoulder (r = -0.374, p < 0.05). However, there was no correlation between radiographic distance ratios and clinical evaluation scores. CONCLUSION We strongly recommend ultrasonography as a diagnostic tool to measure the degree of shoulder subluxation in patients with post-stroke hemiplegia.

Causative factors affecting peripheral neuropathy in burn patients

Peripheral neuropathy in burn patients may be frequently missed in clinical settings. Although its incidence has been reported, little is known regarding the factors that cause burn-related peripheral neuropathy. A retrospective chart review of the demographic and clinical characteristics of patients admitted to a university hospital based burn center was conducted to explore the characteristics of burn-related neuropathy and factors affecting its types or extent. The variables collected were gender, age, length of hospital stay, site and surface area of burn, type of burn, and electrodiagnostic findings. We found that flame injuries, and third degree injuries were the most common in patients with peripheral neuropathy. Axonotmesis was more common than demyelinating injury and polyneuropathy was more common than mononeuropathy. Higher degree and larger area burns were more frequently associated with axonotmesis than with demyelination. Length of hospital stay was significantly longer in patients with axonotmesis. Overall, more severe burns showed a significant association with axonotmesis and a tendency to be related to polyneuropathy.

The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging

Park G-Y, Kim J-M, Lee S-M, Lee MY: The value of ultrasonography in the detection of meniscal tears diagnosed by magnetic resonance imaging. Am J Phys Med Rehabil 2008;87:14–20. Objective:To evaluate the diagnostic value of ultrasonography in meniscal tears that were diagnosed by magnetic resonance imaging (MRI). Design:Twenty-seven knees with meniscal tears and 14 knees without tears on MRI were prospectively evaluated. A radiologist performed the ultrasonography and evaluated the presence and locations of the meniscal tears. MRI was used as the reference standard. Results:Twenty-nine menisci with tears and 53 menisci without tears were identified by MRI. Twenty-two tears were in the medial menisci, and seven tears were in the lateral menisci. In the 29 meniscal tears, the ultrasonographic diagnosis was correct in 25 (86.2%) and incorrect in 4 (13.8%) menisci. In the 53 menisci without tears, the ultrasonographic diagnosis was correct in 45 (84.9%) and incorrect in 8 (15.1%) menisci. Ultrasonography showed a sensitivity, specificity, accuracy, and positive and negative predictive values for meniscal tears of 86.2%, 84.9%, 85.4%, 75.8%, and 91.8%, respectively. Of the four intracapsular injuries observed by MRI in injured knees, an osteochondritis dessecans was only observed by ultrasonography. Conclusions:Ultrasonography is an accurate imaging study for diagnosing meniscal tears. The results correlated with those obtained by MRI; this suggests that ultrasonography can be a useful imaging modality in uninjured knees.

Heterotopic ossification in the residual lower limb in an adult nontraumatic amputee patient

Atkinson GJ, Lee MY, Mehta MK: Heterotopic ossification in the residual lower limb in an adult nontraumatic amputee patient. Heterotopic ossification usually occurs in association with various neurologic injuries, trauma, and burns. There have been few reports in the literature of heterotopic bone formation at the distal residual limb in the adult amputee population. All previous cases with a documented cause have involved traumatic amputations. An adult diabetic patient who underwent left below-the-knee amputation for progressive Charcot foot is presented. The patient began to experience residual limb pain and decline in functional mobility 4–5 mos after surgery. Radiographs demonstrated heterotopic bone around the distal tibial and fibular remnant with extension into adjacent soft tissue. Triple-phase bone scan testing and tissue biopsy verified active heterotopic ossification. The patient was treated with etidronate and eventually was able to ambulate with a prosthesis on a regular basis. This case demonstrates that heterotopic ossification may occur and be a source of residual limb pain in the adult nontraumatic amputee population.

Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial

OBJECTIVE To determine whether capsule-preserved hydrodilatation with corticosteroid improves pain and function in patients with refractory adhesive capsulitis (AC) better than intra-articular corticosteroid injection (IACI) alone. DESIGN Prospective randomized controlled study. SETTING University-affiliated tertiary care hospital. PARTICIPANTS Subjects with primary AC (N=64) with shoulder pain level of visual analog scale (VAS) score ≥5, even after the initial administration of IACI alone. INTERVENTIONS Participants randomly received ultrasound-guided IACI alone with 1mL of 40mg/mL triamcinolone acetonide and 3mL of 1% lidocaine (n=32) or ultrasound-guided capsule-preserved hydrodilatation with corticosteroid with a mixture of 1mL of 40mg/mL triamcinolone acetonide, 6mL of 1% lidocaine, and normative saline (n=32). MAIN OUTCOME MEASURES The primary outcome measure was the Shoulder Pain and Disability Index score. Secondary outcomes were the VAS of shoulder pain level and angles of shoulder passive range of motion, including flexion, abduction, extension, external rotation, and internal rotation at pretreatment and weeks 3, 6, and 12 of posttreatment. RESULTS There were no significant differences between the 2 groups in terms of demographic characteristics (age, sex, duration of symptoms, shoulder affected, and body mass index) at baseline. Repeated-measures analysis of variance showed significant effect of time in all outcome measurements in both groups. However, group-by-time interactions were not significantly different for any of the outcomes between groups. CONCLUSIONS This study shows that compared with pretreatment, all outcome measures improved significantly in both groups by time; however, there was no significant difference between the 2 groups. Therefore, we recommend IACI alone over capsule-preserved hydrodilatation with corticosteroid when considering the corticosteroid injection as a secondary option after the initial IACI fails to improve symptoms for patients with refractory AC.

Early Intra-articular Corticosteroid Injection Improves Pain and Function in Adhesive Capsulitis of the Shoulder: 1-Year Retrospective Longitudinal Study

Intra‐articular corticosteroid injection is a commonly used therapy for adhesive capsulitis, but not enough studies exist on the optimal timing of the injection.

Effect of adductor canal block on medial compartment knee pain in patients with knee osteoarthritis: Retrospective comparative study

Abstract Knee osteoarthritis (KOA) is a common disease in middle-aged and elderly people. Pain is the chief complaint of symptomatic KOA and a leading cause of chronic disability, which is most often found in medial knees. The aim of this study is to evaluate the efficacy of pain relief and functional improvement in KOA patients treated with ultrasound-guided adductor canal block (ACB). This is a 3-month retrospective case-controlled comparative study. Two hundred patients with anteromedial knee pain owing to KOA that was unresponsive to 3-month long conservative treatments. Ninety-two patients received ACB with 9 mL of 1% of lidocaine and 1 mL of 10 mg triamcinolone acetonide (ACB group), and 108 continued conservative treatments (control group). The main outcome measure was visual analog scale (VAS) of the average knee pain level for the past one week. Secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the timed up and go test, numbers of analgesic ingestion per day, and opioid consumption per day. During the 3-month follow-up, 86 patients in ACB group and 92 in control group were analyzed. There was no significant difference, with the exception of the duration of symptoms, between the 2 groups in age, sex, body mass index, and Kellgren-Lawrence grade. Repeated-measures analysis of variance and post hoc tests showed improvement of VAS (at month 1), WOMAC (at month 1), and opioid consumption per day (at month 1 and 2) in ACB group. No adverse events were reported. To our knowledge, this is the first study to assess the efficacy of ACB for patients with KOA. ACB is an effective and safe treatment and can be an option for patients who are either unresponsive or unable to take analgesics.

Poster 156: Relief of Piriformis Syndrome with Repeated Botulinum Toxin Injections: A Case Report

underwent radiologic imaging of her spine as well as an EMG/NCV. Her lumbar spine radiographs showed lumbarisation of her sacral spine revealing a sixth lumbar vertebra and a Grade I spondylolisthesis of L4 on L5. Electrodiagnostic testing showed bilateral delayed H-reflexes. There were also positive sharp waves and fibrillations found on needle electromyography in the paraspinal muscles corresponding to the L6 level bilaterally. Setting: Outpatient musculoskeletal office. Results: The patient was diagnosed with an L6 radiculopathy, spondylolisthesis, and an L6 lumbar vertebra. The patient received anti-inflammatory medication, a lumbar corset, and the appropriate physical therapy. Discussion: Lumbosacral transitional vertebrae (LSTV) are common congenital abnormalities with an incidence of 12%. There is evidence that there is a relationship with early disk degeneration and LSTV. LSTV may cause a relative hypermobility in the intervertebral spaces above the anomaly. There is also an inability to disperse load equally and an increase in local stresses that result in lumbar instability. There is also evidence of relationships with anatomical abnormalities such as cervical ribs, altered nerve root functioning, facet joint arthrosis, and spinal canal or foraminal stenosis. LSTV may be part of a clinical picture in which genetic factors that affect the axial skeleton may contribute to multiple anatomical derangements causing a predisposition to pain syndromes. Conclusions: This case suggests a relationship between LSTV and a spondylolisthesis with resultant radiculopathy. Further studies need to be performed to investigate the relationship so that patients with increased risk for degenerative spondylolisthesis and resultant pain syndromes can be identified and properly treated.

Poster 190: Autonomic dysreflexia caused by an imbedded intrauterine device in a tetraplegic woman: a case report.1

Abstract Setting: Tertiary care university medical center. Patient: A 46-year-old woman with traumatic right C5, left C6 incomplete tetraplegia (American Spinal Injury Association class C) for 14 years. Case Description: The patient presented to the clinic with a 1-month history of constant and sharp low back pain (LBP), which was exacerbated by sitting up and with onset of symptoms of headache, piloerection, diaphoresis, increased spasticity, and increased blood pressure. Her blood pressure would increase up to 140/90mmHg (baseline blood pressure, 110/60mmHg). Extensive work-up, including magnetic resonance imaging of the spine, ruled out compression fracture of the spine, lower-extremity fracture, urinary tract infection, and fecal impaction. Computerized tomography scan of the pelvis suggested a partially extrauterine intrauterine device (IUD) beyond the confines of the posterior uterine wall. Diagnostic and operative hysteroscopy was performed with the removal of the imbedded IUD. Assessment/Results: Patients LBP and symptoms of autonomic dysreflexia (AD), including spasticity and diaphoresis, immediately improved on removal of the imbedded IUD. She was able to sit in a wheelchair for a prolonged period and returned to her usual activities. Discussion: This is the first reported case, to our knowledge, of an imbedded IUD in a tetraplegic woman causing AD. Several etiologies of positionally induced AD have been suggested, including lesions of the lower spine and hips where AD symptoms were induced by sitting up. Conclusion: Complications with an IUD, including embedment, should be considered in the evaluation of SCI woman with AD.