Yusef A. Sayeed

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.

Accuracy of Sonographically Guided and Palpation Guided Scaphotrapeziotrapezoid Joint Injections

The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model.

Accuracy of Palpating the Long Head of the Biceps Tendon: An Ultrasonographic Study

To determine the accuracy of palpating the long head of the biceps tendon (LHBT) within the intertubercular groove with the use of ultrasonographic localization as a gold standard.

Sonographically guided distal radioulnar joint injection: technique and validation in a cadaveric model.

Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar‐sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ‐related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship‐trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.

The risk of subsequent joint arthroplasty after primary unilateral total knee arthroplasty, a 10-year study.

The purposes of this study were to determine the probabilities of subsequent lower extremity arthroplasty after index knee arthroplasty for osteoarthritis and to evaluate the demographic as well as radiographic factors that may predict progression to arthroplasty in the contralateral knee. Between 1984 and 1994, 646 patients, aged 40 to 75 years, with a primary cruciate-retaining knee were identified. The 10-year probability of having a contralateral knee after index knee was 36%. When grade 4 radiographic changes were present, the probability increased to 70%. Demographic factors played no role in the risk of future contralateral knee. The radiographic grade of the contralateral knee at the time of index surgery was found to correlate strongly with the future risk of contralateral total knee.

Sonographic Appearance of the Posterior Interosseous Nerve at the Wrist

The purpose of this study was to determine whether sonography can identify the distal posterior interosseous nerve at the wrist.

Atypical Anomalous Peroneal (Fibularis) Tendon: Potential Pitfall in Musculoskeletal Sonography

The role of musculoskeletal sonography in the evaluation of patients presenting with peroneal (fibularis) tendon disorders is well established.1 When 3 tendinous structures are visualized in the retromalleolar region, the differential diagnosis is generally limited to a longitudinal split tear of the peroneus brevis, resulting in 2 hemitendons, or a peroneus quartus.2,3 The sonographic differentiation of these 2 entities has been previously described.2,3 A key feature suggesting the presence of a peroneus quartus is its typical location posterior and medial to the peroneus longus and brevis tendons, whereas the split brevis hemitendons are located anteriorly in the retromalleolar groove, directly adjacent to the fibula.2–4 This report describes an atypical anomalous peroneal tendon variant encountered while scanning an unembalmed cadaveric specimen during an educational session. The location of the anomalous tendon was atypical for the traditionally described peroneus quartus and therefore would present a potential diagnostic pitfall if encountered during the sonographic evaluation of a patient presenting with posterolateral ankle pain. During an educational scanning session on an unembalmed cadaveric specimen (88-year-old female without foot and ankle deformity or a history of foot and ankle disorders on medical record review), the authors encountered 3 tendons in the right retromalleolar region (Figures 1, A and B). The peroneus longus and brevis tendons appeared normal in size, echo texture, origin, and insertion. The third tendinous structure was located just posterior to the fibula, adjacent and lateral to the peroneus brevis and anterior to the peroneus longus. This third tendon had a normal tendinous echo texture, was smaller than the peroneus brevis and longus, and when traced proximally and distally appeared to represent an anomalous muscle-tendon unit. When scanned proximally, the tendon was seen to originate from the upper half of the leg, adjacent to the proximal musculotendinous junction of the peroneus longus (Figure 1C and Video 1). Distally, the tendon’s course was complex. After passing the fibular tip, the tendon bifurcated, sending a small slip to a normal-sized retrotrochlear eminence and a larger slip toward the inferior peroneal retinaculum.5 Sonographically, this latter slip appeared to blend into the retinaculum itself. These sonographic observations were confirmed on subsequent dissection, which further clarified the intimate relationship of the anomalous muscle-tendon’s origin with the peroneus longus (Figure 1, D–G). Contralateral left limb scanning revealed normal anatomy. This report represents the first sonographic description of this atypical anomalous peroneal tendon variant. Multiple anomalous peroneal tendons have been described in the literature based on anatomic data derived from dissections and intraoperative observations.1–9 The most common anomalous peroneal tendon is the peroneus quartus, which is present in up to 22% of the population and is classically described as arising from the peroneus brevis, coursing posterior and medial to the longus and brevis tendons, and inserting into an often enlarged retrotrochlear eminence posterior to the peroneal tubercle.2,4–8 Multiple other peroneal tendon variations have been described arising from the peroneus brevis, peroneus longus, and/or interosseous membrane and having one or more insertions into the retrotrochlear eminence, peroneal tubercle, peroneus brevis, peroneus longus, inferior peroneal retinaculum, cuboid, fifth metatarsal, and/or fifth digit.2,4–10 The nomenclature applied to these variations is confusing and at times controversial, resulting in the recommendation of Sobel et al6 to refer to all such anomalous tendons as “peroneus quartus” tendons. Regardless of nomenclature, a common theme of these variant peroneal tendons appears to be their location in the posteromedial aspect of the retromalleolar groove. On the contrary, the anomaly we observed clearly coursed anterior in the retromalleolar groove, directly adjacent to the fibula. A literature review failed to reveal a detailed anatomic or sonographic description of the variant observed in this report. In the most in-depth anatomic study to date, Sobel et al6 depicted a peroneus quartus variant occurring in 1.6% of specimens, which arose from the peroneus longus and had a single insertion into the retrotrochlear eminence. Although the figures of Sobel et al6 suggested the possibility that the tendon was located anteriorly in the retromalleolar groove, a precise anatomic description of this variant’s course was not provided in the report. In his classic text, Saraffian9 mentioned an observation of a duplicated peroneus longus tendon but did not provide a written description or a figure of this variant. Whether considered an atypical peroneus quartus or perhaps a bifid peroneus longus, the variant observed in this report has important clinical implications. When 3 tendinous structures are encountered in the retromalleolar groove, the differential diagnosis is typically limited to a split peroneus brevis tear with 2 hemitendons, or a peroneus quartus.2,3 The peroneus quartus is usually easily identified by its posteromedial position within the retroClinical Letters

The Bifurcating Distal Biceps Femoris Tendon: Potential Pitfall in Musculoskeletal Sonography

Posterolateral knee pain is a relatively uncommon but clinically challenging problem.1–3 The differential diagnosis is broad and includes lateral meniscal disorders, iliotibial band syndrome, fibular collateral ligament sprains, fibular collateral ligament–biceps femoris bursopathy, popliteus tendinopathy, proximal tibiofibular joint disorders, common peroneal neuropathy, posterolateral corner injuries, and distal biceps femoris tendinopathy.1–6 Because of the complex and variable anatomy of this region, clinicians often rely on advanced diagnostic imaging to assist in the evaluation of patients presenting with posterolateral knee pain.1,7 Although the role of magnetic resonance imaging (MRI) is well established, recent publications have increasingly emphasized the potential role of musculoskeletal sonography to evaluate posterolateral knee disorders.1,3,5,6,8,9 As requests for posterolateral knee sonography have increased, we have commonly recognized thickening and hypoechogenicity of the distal biceps femoris tendon when imaged in the long axis at the fibular head. Although these sonographic findings would suggest the presence of biceps femoris tendinosis, they have been observed in individuals without any clinical or MRI evidence of biceps femoris tendon injury.6,8 Further sonographic evaluation of the distal biceps femoris tendon and closely associated fibular collateral ligament in patients presenting for knee sonography revealed a common anatomic arrangement in which the distal biceps femoris tendon bifurcated into two limbs (superficial and deep), which enveloped the distal fibular collateral ligament at the level of the fibula. This anatomic arrangement was sonographically visible in both longand short-axis views. During long-axis imaging, the divergent superficial and deep heads of the biceps femoris simulated Clinical Letters

Sonographic Evaluation of the Plantar Heel in Asymptomatic Endurance Runners

The primary purpose of this investigation was to determine the prevalence and spectrum of asymptomatic sonographically determined structural changes in the plantar fascia and plantar heel pad among experienced runners without a history of heel pain.

Poster 422: Successful Treatment of Cervical Facet Joint Pain using Platelet Rich Plasma—A Novel Case Report

Disclosures: Teresa Bianchi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old woman with history of cervical spine surgery (C5-C7 in 2008) complained of intermittent neck pain with radiating symptoms from her left shoulder to hand for several months. An MRI of the cervical spine was ordered by Neurology which showed multilevel degenerative changes with limited evaluation of C5-C7 due to hardware. The patient was then referred to Physiatry for pre-surgical workup for cervical radiculopathy. Physical examination showed limited range of motion of the cervical spine. Spurling’s Test was equivocal on the left. On palpation along the distribution of pain, a soft, rubbery, palpable mass was identified in the middle of her left forearm dorsally. Deep palpation of the mass reproduced her radiating symptoms. Per patient, the severity and exact location of her symptoms varied based on the degree of swelling in the middle of her forearm. Electrodiagnostic studies were within normal limits. Setting: Tertiary care veterans affairs medical center. Results: Ultrasound imaging of the mass site showed a ganglion cyst within the flexor digitorum superficialis. Among the various treatment options discussed, the patient opted to monitor the cyst without further intervention. On 6 week follow up, the patient had fewer symptoms which coincided with reduced nodular size. Discussion: Our case demonstrates the importance of considering extraspinal pathologies among the differential diagnoses when working up radiculopathy. An understanding of anatomy, detailed patient history, and careful physical examination are essential to identify extraspinal causes of radiating symptoms. In very rare cases, intramuscular ganglion cysts have been reported, which can be detected with ultrasound imaging. These points will be discussed further. Conclusions: Extraspinal pathologies may mimic cervical radiculopathy, which is important to uncover early in the workup for efficient use of time and resources, improved management, and overall patient satisfaction and well-being. Level of Evidence: Level V