Ming-Yen Hsiao

Reduced Patellar Tendon Elasticity with Aging: In Vivo Assessment by Shear Wave Elastography

How aging affects the elasticity of tendons has long been debated, partly because of the limited methods for in vivo evaluation, which differ vastly from those for in vitro animal studies. In this study, we tested the reliability of shear wave elastography (SWE) in the evaluation of patellar tendons and their change in elasticity with age. We recruited 62 healthy participants in three age groups: 20-30 years (group 1), 40-50 years (group 2) and 60-70 years (group 3). Shear wave velocity and elastic modulus were measured at the proximal, middle and distal areas of the patellar tendon. Reliability was excellent at the middle area and fair to good at both ends. Compared with the other groups, group 3 had significantly decreased elastic modulus and shear wave velocity values (p ≤ 0.001 vs. group 1 or 2), with significant increased side-to-side differences. SWE may be valuable in detecting aging tendons before visible abnormalities are observed on B-mode ultrasonography.

Sonographic Tracking of the Lower Limb Peripheral Nerves: A Pictorial Essay and Video Demonstration.

ABSTRACTCompared with the upper limbs, sonographic tracking of peripheral nerves in the lower limbs is more challenging. The overlying muscles are larger, hindering visualization of the deeply embedded nerves by using a linear transducer. The use of a curvilinear transducer—providing an extended view with better penetration for the field of interest—may be useful for scanning the nerves in the hip and thigh. Application of the Doppler mode helps localization of the target nerve by identifying the accompanying vessels. Aiming to demonstrate the relevant tracking techniques, the present article comprises a series of ultrasound images and videos showing how to scan the nerves in the lower limb, that is, femoral, obturator, pudendal, lateral femoral cutaneous, sciatic, saphenous, sural, tibial, and peroneal nerves.

Comparative effectiveness of autologous blood-derived products, shock-wave therapy and corticosteroids for treatment of plantar fasciitis: a network meta-analysis

OBJECTIVE To compare the efficacy of autologous blood-derived products (ABPs), CSs and shock-wave (SW) therapy in the treatment of plantar fasciitis. METHODS Electronic databases were searched for studies that compared ABPs, CSs and SW therapy for the treatment of plantar fasciitis, published up to June 2014. The primary and secondary outcomes were reduction in visual analogue scale (VAS) score at 3 and 6 months and odds ratio of treatment success, respectively. Groups were compared by traditional pair-wise meta-analysis and by network meta-analysis. RESULTS Seven randomized controlled trials and three quasi-experimental studies that included 604 patients were enrolled. Pair-wise meta-analysis indicated a trend favouring ABPs over CSs regarding VAS reduction at 3 months; this benefit was significant in a subgroup analysis of platelet-rich plasma (PRP) vs CSs. There were no significant between-group differences in VAS reduction at 6 months and in treatment success. Network meta-analysis showed that ABPs had the highest probability of being the best treatment at 3 months, but ABPs were slightly inferior to SW for VAS reduction at 6 months. Although SW therapy had the highest likelihood of treatment success, the between-group differences in probabilities were less remarkable than those for pain reduction at 3 and 6 months. CONCLUSION ABPs, followed by CSs, were best in providing relief from pain at 3 months. SW therapy and ABPs had similar probabilities of providing pain relief at 6 months, and were better than CSs at that time. Subgroup analysis indicated that an ABP regimen consisting of platelet-rich plasma improves treatment efficacy.

Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis

Background Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales. Methods PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection. Results Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14–1.17), 0.84 (95% CI, 0.40–1.27), 0.85 (95% CI, 0.60–1.10), and 0.87 (95% CI, 0.53–1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10–0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07–0.70) and exercise (effect size, 0.71; 95% CI, 0.30–1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, –0.18 to 0.80) which was only estimated from one study. Conclusion Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose–response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.

Dynamic Ultrasound Imaging for Ulnar Nerve Subluxation and Snapping Triceps Syndrome.

A 32-year-old man was seen for pain at the right posteromedial elbow for more than 3 months. He declared that forceful elbow extension aggravated the pain while he felt an intermittent popping sensation during elbow flexion. There was no paresthesia at his ipsilateral forearm or hand. He also denied any antecedent injury. On further questioning, it was learned that he was a postman who repetitively flexed and extended that elbow when delivering mails. Physical examination showed focal tenderness posterior to the right medial epicondyle. A band-like structure sliding abruptly anteriorly over the medial epicondyle during active elbow flexion (toward the end of motion range) could be felt. There was no weakness or sensory impairment. Static ultrasonography (US) showed a swollen and hypoechoic ulnar nerve at and immediately proximal to the cubital tunnel (Fig. 1A). Dynamic ultrasound imaging clearly showed that the ulnar nerve and triceps muscle were subluxating during active elbow flexion over 100 degrees (Fig. 1B) and that they were relocated posteriorly during elbow extension (Video). The patient received a diagnosis of ulnar nerve subluxation and snapping triceps syndrome causing neuropathy of the ulnar nerve. Surgical consultation was suggested, but the patient declined. His complaints partially improved after nonsteroidal anti-inflammatory medications and instructions to reduce repetitive elbow flexion. The ulnar nerve courses behind the medial epicondyle along the medial border of the triceps and enters the cubital tunnel bordered by the medial epicondyle, olecranon, and 2 heads of the flexor carpi ulnaris muscle. Besides entrapment at the cubital tunnel, ulnar neuropathy at the elbow could result from ulnar nerve subluxation, snapping triceps syndrome, or, less commonly, by anconeus epitrochlearis. With regard to elbow snapping, it could be intra-articular or extra-articular. The differential diagnosis of extra-articular medial elbow snapping includes ulnar nerve subluxation,

Intracellular triggered release of DNA-quaternary ammonium polyplex by ultrasound

2-Methacryloyloxy ethyl trimethyl ammonium chloride (TMA) is a potent polymeric plasma DNA (pDNA) carrier. The present study shows that TMA/pDNA polyplexes could be internalized into cells efficiently, but could not mediate gene transfection on its own. The transfection process of TMA/pDNA polyplexes is turned on only when ultrasound (US) was applied 4-8h after incubating TMA/pDNA polyplexes with target cells (with a gene expression 1000 times that of the immediate US group). US is a widely used physical method for gene delivery; its transfection efficiency can be significantly enhanced when combined with cationic polymer vectors. Traditionally, US is given simultaneously with genetic materials, carriers and microbubbles to exert maximal efficacy. The unique on-off phenomenon of TMA/pDNA polyplexes, controlled by US exposure, was found to relate to the endosomal escape effect of US since the polyplexes colocalized well with the lysosome marker if no US was given or was given at inappropriate times. The proposed delivery system using US and TMA carriers has potential in many pharmaceutical applications requiring precise temporal and spatial release control.

Dynamic ultrasound imaging for type A intrasheath subluxation of the peroneal tendons.

From the Department of Physical Medicine and Rehabilitation,National Taiwan University Hospital Bei-Hu Branch, College ofMedicine, National Taiwan University, Taipei, Taiwan (M-YH);Department of Physical Medicine and Rehabilitation, NationalTaiwan University Hospital, College of Medicine, National TaiwanUniversity, Taipei, Taiwan (S-GS, C-HW); and Department ofPhysical Medicine and Rehabilitation, Hacettepe UniversityMedical School, Ankara, Turkey (LO¨).Financial disclosure statements have been obtained, and noconflicts of interest have been reported by the authors or by anyindividuals in control of the content of this article.Supplemental digital content is available for this article. DirectURL citations appear in the printed text and are provided in theHTML and PDF versions of this article on the journal_s Web site(www.ajpmr.com).0894-9115/15/0000-0000American Journal of Physical Medicine & RehabilitationCopyright *2015 Wolters Kluwer Health, Inc. All rights reserved.

Delayed diagnosis of vertebral osteomyelitis in a paraplegic patient

Study design:Case report.Objective:Vertebral osteomyelitis, usually presented with back pain and local tenderness, can pose a great challenge of early diagnosis among spinal cord injury (SCI) patients who lost sensation below the injured level. We reported a paraplegic patient who had recurrent febrile episodes after being treated as urinary tract infection initially and was discovered later to have vertebral osteomyelitis.Case report:A 41-year-old man, completely paralyzed at the T11 level and with Foley catheterization for 9 years, was re-admitted within 2 weeks for recurrent fever, turbid urine, bacteriuria and bacteremia with Escherichia coli. Spine X-ray and renal, cardiac and abdominal ultrasonography showed no definite lesions related to infection in a previous admission. Intermittently febrile episodes continued despite treatment with antibiotics for 1 week. He had no pressure sores or other wounds. Computerized tomography and magnetic resonance imaging showed lumbosacral osteomyelitis and bilateral paravertebral abscess. The patient underwent debridement of paravertebral tissue. Fever subsided soon after surgery and the patient continued antibiotics and remained free of fever at a 1-year follow-up.Conclusion:It can be challenging to diagnose vertebral osteomyelitis below injury levels in SCI patients. Vertebral osteomyelitis should be considered in febrile SCI patients even with known infectious foci, as classic symptoms of osteomyelitis are lacking in this population.

Pulsed Wave Doppler Ultrasonography for the Assessment of Peripheral Vasomotor Response in an Elderly Population

To assess sympathetic vasomotor activity and its changes with age, using pulsed wave Doppler ultrasound.

Dynamic Ultrasonography of the Intra-Articular Long Head Biceps Tendon and Superior Labrum.

This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this new feature will change and enhance the learning experience.URL: http://journals.l