Three-dimensional turbo spin-echo (TSE) MRI assessment of indirect acute muscle injuries in athletes: comparison with two-dimensional TSE MRI.

OBJECTIVE: To evaluate three-dimensional (3D) turbo spin-echo (TSE) magnetic resonance imaging (MRI) for the assessment of acute muscle injuries in elite athletes in comparison with two-dimensional (2D) MRI. METHODS: Elite athletes with clinically suspected acute muscle injury of the thigh who underwent both 2D and 3D MRI protocols on the same day were retrospectively included. Two musculoskeletal radiologists independently assessed 2D and 3D MRIs, with both techniques evaluated separately 1-month apart. Muscle injuries were evaluated using the BAMIC and the INSEP classifications. A second assessment of injuries was performed by each reader 2 months after the initial readings. Agreement was determined using weighted kappa statistics. The level of diagnostic confidence in classifying injuries was also assessed for both MRI protocols. RESULTS: A total of 40 athletes were included. Intra-reader agreement when comparing injury grades from 2D vs. 3D for both INSEP and BAMIC classifications was almost perfect for both readers and ranged between 0.84 and 0.98. Inter-reader agreement was substantial to almost perfect and ranged from 0.78 to 0.93 for the 2D protocol, and from 0.78 to 0.95 for the 3D protocol. Intra-reader agreement for each MRI protocol separately was almost perfect to perfect for both readers and ranged between 0.84 and 1.00. Diagnostic confidence for grading injuries improved for both readers when using the 3D protocol. CONCLUSIONS: Compared to 2D MRI, 3D TSE MRI is a reliable technique for acute muscular injury assessment, providing faster acquisition times and improving the diagnostic confidence. KEY POINTS: • Compared to 2D MRI, 3D TSE MRI is a reliable technique for the assessment of acute muscular injuries. • 3D TSE MRI has the advantage of faster total acquisition times, thinner sections, and multiplanar reconstruction, improving the confidence for structural assessment including connective tissue involvement.

Biceps femoris snapping and friction on the fibular head secondary to abnormal distal tendon insertion: 15 cases and a literature review.

INTRODUCTION: Abnormal biceps femoris distal tendon insertion can cause tendon snapping, as is well-known in the literature. The presenting symptom is lateral knee pain, often during sports activities and cycling in particular. The present study tested two hypotheses: abnormal biceps femoris insertion on the fibular head may cause painful friction without clinical snapping, whether visible, audible or palpable; surgical correction achieves good results for pain and return to sport, regarding both snapping and friction. MATERIAL AND METHODS: Between 2006 and 2017, 11 patients were managed for pain secondary to abnormal biceps femoris insertion. In 4 cases, pain was bilateral, resulting in a total of 15 knees: 9 with snapping (in 6 patients), and 6 with friction syndrome without snapping (in 5 patients). All 6 patients with snapping were male, with a mean age of 29 years. Friction without snapping concerned 3 female and 2 male patients, with a mean age of 30 years. Study data included type and level of sport, clinical signs, imaging, type and results of treatment, and type of abnormality. RESULTS: The insertion abnormality consisted in excessively anterior insertion in the fibular arm in 6 cases, in predominantly tibial insertion in 2 cases, and in isolated tibial insertion in 4 cases. Surgery mainly consisted inrelease and reinsertion of the distal biceps femoris tendon (in 7 cases). All patients were able to return to sport. The mechanism underlying snapping and friction was the same: distal biceps tendon friction on the fibular head secondary to unduly anterior fibular or predominantly or exclusively tibial insertion. DISCUSSION: The literature reports 24 cases, all of snapping, with between 1 and 3 cases per author. These findings were compared with the present results. With or without snap, symptoms are secondary to abnormal tendon insertion and to activity or sport requiring repeated knee flexion greater than 90°. CONCLUSIONS: (1) Case studies show that lateral knee pain by friction on the fibular head is not systematically accompanied by snapping. (2) In all reports and in the present series, surgery was highly effective on snapping and pain, and patients returned to sport at their previous level. LEVEL OF EVIDENCE: IV.

An oleuropein-based dietary supplement may improve joint functional capacity in older people with high knee joint pain: findings from a multicentre-RCT and post hoc analysis.

OBJECTIVES: To investigate a 6-month intervention with an olive leaf extract (OLE) on knee functionality and biomarkers of bone/cartilage metabolism and inflammation. DESIGN: This randomized, double-blind, placebo-controlled, multi-centric trial included 124 subjects with knee pain or mobility issues. Subjects received twice a day one capsule of placebo or 125 mg OLE (Bonolive™, an OLE containing 50 mg of oleuropein) for 6 months. The co-primary endpoints were Knee injury and Osteoarthritis Outcome Score (KOOS) and serum Coll2-1NO2. The secondary endpoints were the subscales of the KOOS, knee pain VAS at rest and at walking, OARSI core set of performance-based tests and multiple inflammatory and bone or cartilage remodeling serum biomarkers and concentration of oleuropein's metabolites in urine. RESULTS: At 6 months, OLE group was not efficient on global KOOS score, changes of inflammatory and cartilage remodeling biomarkers compared to placebo. Post hoc analyses demonstrated a large and significant treatment effect of OLE in a sub-group of subjects with high walking pain at baseline (p = 0.03). This was observed at 6 months for the global KOOS score, and each different subscale and for pain at walking (p = 0.02). OLE treatment was well tolerated. CONCLUSION: OLE was not effective on joint discomfort excepted in a sub-group of subjects with high pain at treatment initiation. As oleuropein is well tolerated, OLE can be used to relieve knee joint pain and enhance mobility in subjects with articular pain.

Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review.

Tarsal tunnel syndrome may be idiopathic or may be caused by various conditions: bone disease, thickening of the retinaculum, hematoma, or iatrogenic nerve damage; tendinopathy or tenosynovitis; the presence of supernumerary muscles such as an accessory soleus, peroneocalcaneus internus, or accessory flexor digitorum muscle; bone or joint disorders; expansile tumors or cysts; and venous aneurysm or kinking of the tibial artery. The purpose of this article is to describe and illustrate most of the causes of tarsal tunnel syndrome, as diagnosed by ultrasound, which is a practical, inexpensive method.

Hyaluronan derivative HYMOVIS® increases cartilage volume and type ii collagen turnover in osteoarhritic knee: data from MOKHA study.

BACKGROUND: The objective of this pilot study was to identify biological, clinical or structural biomarkers of an intra-articular hyaluronic acid injection efficacy (HYMOVIS®) for the design of a larger placebo-controlled clinical trial studying the disease-modifying activity of this treatment. METHODS: Forty six patients with symptomatic knee Osteoarthritis (OA) were enrolled in this open-label, prospective, multicenter, pilot study. Patients received two treatment cycles of intra-articular injections (3 mL) of HYMOVIS® (8 mg/mL of hyaluronic acid hexadecylamide) at 6 months interval. Each treatment cycle involved two intra-articular injections 1 week apart. All patients had Magnetic Resonance Imaging (MRI) of the target knee at baseline and 1 year, and blood samples to assess joint biomarkers. The primary outcome was the change in type II collagen-specific biomarkers (Coll2-1, Coll2-1NO2 and CTX-II) after HYMOVIS® treatment versus baseline. Secondary endpoints included levels changes in aggrecan chondroitin sulfate 846 epitope (CS-846), Cartilage Oligomeric Matrix Protein (COMP), procollagen type II N-terminal propeptide (PIIANP), Matrix Metalloprotease (MMP)-3, Myeloperoxidase (MPO) and Interleukin (IL)-6 serum biomarkers, the ratio Coll2-1/PIIANP, CTX-II/PIIANP, variation of MRI cartilage volume, and Knee injury and Osteoarthritis Outcome Score (KOOS) index. RESULTS: Coll2-1 serum levels significantly increased overtime while Coll2-1NO2 levels were only increased at D360. Serum PIIANP levels also progressively and significantly enhanced with time. In contrast, other serum biomarker levels including CTX-II, CS-846, COMP, MMP-3, MPO or IL-6 did not change significantly overtime. Interestingly, the ratios Coll2-1/PIIANP and CTX-II/PIIANP decreased, indicating a decrease of cartilage catabolism. Compared to baseline value, MRI cartilage volume and thickness increased in lateral femoral and lateral trochlea compartments and not in medial compartment. These results, in addition to an improvement of T2 mapping score suggest a positive structural effect of the product. Interestingly, WORMS effusion score, an indicator of synovitis, significantly decreased. Finally, global KOOS score and subscales significantly increased overtime while pain at rest, walking pain and patients or investigators global assessment of disease activity decreased. The safety profile was favorable with a low incidence of injection-site pain. CONCLUSION: HYMOVIS®, a well-tolerated intra-articular treatment, significantly enhanced type II collagen turnover as suggested by the increase in Coll2-1 and PIIANP levels and cartilage volume observed by MRI in lateral knee compartment. Importantly, this study provides critical information for the design of a larger phase III clinical trial investigating Disease Modifying effect of HYMOVIS®. TRIAL REGISTRATION: http://www.isrctn.com/ISRCTN12227846 11/02/2015.

Ultrasound-detected connective tissue involvement in acute muscle injuries in elite athletes and return to play: The French National Institute of Sports (INSEP) study.

OBJECTIVES: Previous MRI studies showed that involvement of connective tissue in muscle injuries may prolong recovery times. The relevance of ultrasound assessment of connective tissue involvement as a prognostic factor is unknown. The aim was to test the hypothesis that ultrasound-detected connective tissue involvement in acute muscle injuries are related to longer recovery times. DESIGN: Cohort study. METHODS: Seventy consecutive elite athletes from the French National Institute of Sports (INSEP) sustaining an acute muscle injury showing positive findings on ultrasound at baseline were included. Ultrasound was systematically performed within 7days after the injury for the assessment of severity (grades 1-4) and type of injury in regard to the absence (M injuries) or presence (C injuries) of connective tissue involvement. The differences in the mean time needed to return to play (RTP) between the different grades and types of injury were assessed using multiple non-parametric tests. RESULTS: When considering the overall grades independently of the type of injury (M or C), an increase in the mean time needed to RTP was observed with the increase of grades (p<0.0001). The same relationship was found when considering grades from M and C injuries separately, with higher grades of injuries exhibiting longer times needed to RTP (p<0.0001). Longer times needed to RTP were observed in athletes demonstrating C injuries in comparison to the ones exhibiting M injuries overall (p=0.002). CONCLUSIONS: Ultrasound-detected connective tissue involvement in acute muscle injuries are related to longer times needed to RTP, especially when disruption is detected.

Elastography Study of Hamstring Behaviors during Passive Stretching.

INTRODUCTION: The mechanical properties of hamstring muscles are usually inferred from global passive torque/angle relationships, in combination with adjoining tissues crossing the joint investigated. Shear modulus measurement provides an estimate of changes in muscle-tendon stiffness and passive tension. This study aimed to assess the passive individual behavior of each hamstring muscle in different stretching positions using shear wave elastography. METHODS/RESULTS: The muscle shear modulus of each hamstring muscle was measured during a standardized slow passive knee extension (PKE, 80% of maximal range of motion) on eighteen healthy male volunteers. Firstly, we assessed the reliability of the measurements. Results were good for semitendinosus (ST, CV: 8.9%-13.4%), semimembranosus (SM, CV: 10.3%-11.2%) and biceps femoris long-head (BF-lh, CV: 8.6%-13.3%), but not for biceps femoris short-head (BF-sh, CV: 20.3%-44.9%). Secondly, we investigated each reliable muscle in three stretch positions: 70°, 90° and 110° of hip flexion. The results showed different values of shear modulus for the same amount of perceived stretch, with the highest measurements in the high-flexed hip situation. Moreover, individual muscles displayed different values, with values increasing or BF-lh, SM and ST, respectively. The inter-subject variability was 35.3% for ST, 27.4% for SM and 30.2% for BF-lh. CONCLUSION: This study showed that the hip needs to be high-flexed to efficiently tension the hamstrings, and reports a higher muscle-tendon stress tolerance at 110° of hip angle. In addition muscles have different passive behaviors, and future works will clarify if it can be linked with rate of injury.

Unknown Tendons, Muscles and Nerves of the Shoulder: Proposal for a Standardized Ultrasound-guided Examination, a "mini GEL" Experience.

Thanks to its excellent spatial resolution and dynamic aspect, ultrasound of the shoulder allows an optimal evaluation of tendon, muscle and nerve' structures in shoulder pain. Through this article and owing to inter-observer reproducibility, we will describe an ultrasound standardized protocol (posterior, anterior, global plane) in basic first ultrasounds (ie without tendon abnormality of the supra/infra spinatus, the biceps and subscapularis).

Ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon: a non-reliable technique.

PURPOSE: To evaluate the feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon via a keyhole incision. METHODS: This was an anatomical study performed on twelve embalmed cadaveric shoulder joints. The rotator cuff and the position of the long head of the biceps tendon were explored by ultrasound prior to beginning the procedure. The biceps tenotomy was performed under ultrasound guidance by a highly experienced sonographer who was trained in shoulder tendon exploration. Arthroscopic exploration of the shoulder was performed immediately after the percutaneous biceps tenotomy to assess the quality and the location of the biceps tenotomy. RESULTS: Three out of twelve tendons (25%) were completely sectioned at the level of the glenoid insertion. More seriously, iatrogenic lesions of the cartilage of the humeral head, the supraspinatus tendon and the subscapularis tendon were observed. CONCLUSION: This study shows that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is not reliable.

Tophaceous gout of the spine: case report and review of the literature.

Tophaceous gout of the spine is rare. We report here the case of a 68-year-old man with long-standing peripheral gouty arthritis who developed a progressive and painful weakness of the lower extremities. Radiological and histopathological findings confirmed the presence of tophaceous gout of the spine. Also presented is the case history, including the radiological and histopathological findings, and a discussion of the literature.

Ultrasonographic study of wrist ligaments: review and new perspectives.

Imaging strategy for wrist injury usually begins with standard radiographs. When a ligamentous disorder is suspected clinically, the next step is arthrographic computed tomography or arthrographic magnetic resonance imaging. When the diagnosis remains unclear, magnetic resonance imaging (MRI) is the preferred examination. Ultrasonography is usually used to assess structures like tendons and bone surface, but thanks to the performances of high-frequency transducers, it can also enable visualization of the main ligaments of the wrist. Ultrasonography could thus replace MRI because of its lower cost, as recently reported in the literature. However, a good knowledge of normal and pathological wrist anatomy is required to avoid false negatives. Wrist ligaments comprise interosseous and capsular ligaments as well as the triangular fibrocartilaginous complex. All these ligaments may be involved in carpal instability. Clinical examination has a major role to play in helping radiologists orient their procedures. A few studies have reported that ultrasonography of the triangular fibrocartilaginous complex is reliable compared with arthrography or MRI, but most of these studies were limited to the radioulnar ligaments. In this article we propose a more extensive protocol.

[Evolution of musculoskeletal ultrasonography]. / L'évolution de l'échographie de l'appareil moteur.

Sonography is a safe, inexpensive and readily accessible technique which has acquired a major place in musculoskeletal imaging over the past two decades. Thanks to recent technical innovations such as high-definition multifrequency probes, compound effect, use of harmonic frequencies, power Doppler, and extended field of view, today's sonographic images are extremely precise. At the same time, based on magnetic resonance imaging (MRI) and computed tomography (CT) acquisitions, the sonographic anatomy has become broader and more detailed, and the sonographic semiology is more precise and reliable. In this article the authors evaluate current uses of diagnostic and interventional sonography in musculoskeletal disorders.

Role of alendronate in therapy for posttraumatic complex regional pain syndrome type I of the lower extremity.

OBJECTIVE: To evaluate the effects of the antiresorptive agent alendronate at a daily oral dose of 40 mg in patients with posttraumatic complex regional pain syndrome type I (CRPS I) of the lower extremity. METHODS: Forty patients were enrolled in this 8-week randomized, double-blind, placebo-controlled study of alendronate therapy for CRPS I, a condition associated with regional osteoclastic overactivity. An optional 8-week open extension of alendronate therapy (weeks 12-20) was available after a 4-week period without therapy. Clinical assessments included joint mobility, edema of the lower extremity, tolerance to pressure in the lower extremity, and levels of spontaneous pain. Urinary levels of type I collagen N-telopeptide (NTX) were assessed by enzyme-linked immunosorbent assay. Patients were examined at weeks 4, 8, 12, 16, 20, and 24. Statistical analysis included two-way factorial analysis of variance. RESULTS: In contrast to placebo-treated patients (n = 20), all of the alendronate-treated patients (n = 19) exhibited a marked and sustained improvement in levels of spontaneous pain, pressure tolerance, and joint mobility, as well as a significant reduction in urinary levels of NTX at weeks 4 and 8. The improvement was maintained at week 12. Twelve patients from each treatment group volunteered for the 8-week open trial, and all of them had a positive response to alendronate. CONCLUSION: Our findings support the use of oral alendronate in posttraumatic CRPS I. By reducing local acceleration of bone remodeling, alendronate might relieve pain by effects on nociceptive primary afferents in bone, pain-associated changes in the spinal cord, and possibly also through a central mechanism.

Ultrasonographic rotator-cuff changes in veteran tennis players: the effect of hand dominance and comparison with clinical findings.

The aim of this study was to correlate sonographic abnormalities of the rotator cuff with clinical findings in veteran tennis players. One hundred fifty individuals playing competition-level tennis, aged from 35 to 77 years (mean age 55 years), underwent physical and US examinations of their shoulders. The US abnormalities found in the dominant shoulder were compared with those observed in the non-dominant shoulder and in different subsets of players defined by the absence or presence of former and/or current pain. Tears of the long head of the biceps tendon were seen only in dominant shoulders ( n=8), and tears (23 complete and 20 partial) of the supraspinatus tendon were observed in 43 dominant vs 16 (3 complete and 13 partial) contralateral shoulders ( p<0.001). Subscapularis tendon calcifications were depicted in 23 dominant vs 12 contralateral shoulders ( p<0.05). Seventy players had no pain, 49 had former-but-not-current pain, and 31 had current pain. Abnormal thickening (>2 mm) and effusion of the subacromial-subdeltoid bursa and complete tear of the supraspinatus tendon were more frequent in the latter two groups ( p<0.001 and p<0.05), respectively. Although 90% of the players with a complete supraspinatus tear had experienced former pain, no relationship was found between current pain and the presence of a supraspinatus tear or tendon calcification. The rotator cuff may present important asymptomatic lesions, such as complete tears of the supraspinatus tendon or calcifications, that do not prevent the playing competitive tennis. The only US abnormality associated with pain was subacromial-subdeltoid bursa effusion.

Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study.

OBJECTIVE: To assess the prevalence and severity of peripheral enthesitis among the different subtypes of spondylarthropathy (SpA) by using ultrasonography (US) in B mode with power Doppler. METHODS: One hundred sixty-four consecutive patients with SpA (according to the criteria of the European Spondylarthropathy Study Group) and 64 control patients (34 with mechanical low back pain [MBP] and 30 with rheumatoid arthritis [RA]) underwent US examination of major entheses of their limbs. Particular attention was given to the detection of vascularization at the following sites: cortical bone insertion of entheses, junction between tendon and entheses, body of tendon, and bursa. RESULTS: Abnormal US findings consistent with at least one enthesitis were observed in 161 of 164 SpA patients (98%), affecting 1,131 of 2,952 entheses examined (38%). In contrast, only 132 of 1,152 entheses (11%) were found to be abnormal in 33 of 64 control patients (52%). US enthesitis was most commonly distributed in the distal portion of the lower limbs, irrespective of SpA subtype and of skeletal distribution of clinical symptoms. None of the abnormal entheses in control patients showed vascularization, compared with 916 of 1,131 abnormal entheses in SpA patients (81%), where it was always detected at the cortical bone insertion and sometimes also in the bursa. In SpA patients, the US pattern depended on the clinical presentation, with a higher prevalence of the most severe stages in those with peripheral forms. CONCLUSION: US in B mode combined with power Doppler allowed the detection of peripheral enthesitis in a majority of SpA patients, but not in MBP or RA patients. The presence of entheseal involvement was independent of SpA subtype, but its degree of severity appeared to be greater in peripheral forms. US could be very useful for both the diagnosis and the assessment of SpA activity.