Musculoskeletal colour/power Doppler in sports medicine: image parameters, artefacts, image interpretation and therapy.

This review article discusses the aspects of sports medicine where musculoskeletal Doppler ultrasound has valuable contribution in diagnosis and/or treatment of some of the typical musculoskeletal sports injuries. Also, conditions where the Doppler ultrasound has no value are discussed. Some guidelines and recommendations are based on personal experience since no evidence in literature exists. The basic technical background of Doppler ultrasound and typical artefacts will be discussed, in order to understand and interpret the Doppler result. Recommendations for the Doppler settings are given in relevant sections. Ultrasound guided treatments where the Doppler result is used as a guide are mentioned and discussed.

Doppler ultrasonography of the anterior knee tendons in elite badminton players: colour fraction before and after match.

BACKGROUND: Anterior knee tendon problems are seldom reported in badminton players although the game is obviously stressful to the lower extremities. HYPOTHESES: Painful anterior knee tendons are common among elite badminton players. The anterior knee tendons exhibit colour Doppler activity. This activity increases after a match. Painful tendons have more Doppler activity than tendons without pain. STUDY DESIGN: Cohort study. METHODS: 72 elite badminton players were interviewed about training, pain and injuries. The participants were scanned with high-end ultrasound equipment. Colour Doppler was used to examine the tendons of 64 players before a match and 46 players after a match. Intratendinous colour Doppler flow was measured as colour fraction (CF). The tendon complex was divided into three loci: the quadriceps tendon, the proximal patellar tendon and the insertion on the tibial tuberosity. RESULTS: Interview: Of the 72 players, 62 players had problems with 86 tendons in the lower extremity. Of these 86 tendons, 48 were the anterior knee tendons. Ultrasound: At baseline, the majority of players (87%) had colour Doppler flow in at least one scanning position. After a match, the percentage of the knee complexes involved did not change. CF increased significantly in the dominant leg at the tibial tuberosity; single players had a significantly higher CF after a match at the tibial tuberosity and in the patellar tendon both before and after a match. Painful tendons had the highest colour Doppler activity. CONCLUSIONS: Most elite badminton players had pain in the anterior knee tendons and intratendinous Doppler activity both before and after match. High levels of Doppler activity were associated with self-reported ongoing pain.

Effect of knee position on ultrasound Doppler findings in patients with patellar tendon hyperaemia (jumper's knee).

PURPOSE: The purpose of this study is to see if changes in patient positioning result in significant changes in Doppler findings. MATERIALS AND METHODS: 30 consecutive patients with jumper's knee in the proximal portion of the patellar tendon formed the study group. The patellar tendon was scanned in the longitudinal plane with colour and spectral Doppler with the knee fully extended as well as, flexed at 15 degrees and 20 degrees . All subjects were randomised to either extension or 20 degrees flexion as the initial position. The amount of colour Doppler activity inside the tendon was expressed with the colour fraction (colour pixels/total pixels) in the proximal portion of the tendon. With spectral Doppler, the resistive index was measured ((peak systolic velocity--end-diastolic velocity)/ peak systolic velocity). RESULTS: The mean (+/- SE) colour fraction in the fully extended position and 20 degrees flexion was 36.7 +/- 3.4% and 13.3 +/- 3.4%, respectively (p<0.0001). The mean resistive index was 0.607 +/- 0.036 with full extension and 0.914 +/- 0.036 with 20 degrees flexion (p<0.0001). On an individual patient basis, a decrease in colour fraction was observed in all 30 patients (100%), whereas an increase in resistive index was observed in 29 patients (97%). Maximum perfusion was seen in all positions when flexion was the initial position. CONCLUSION: We advocate that for the examination of the patellar tendon by Doppler sonography, the patients should have fully extended and relaxed knees. Otherwise, the colour Doppler findings will underestimate the flow, and the spectral Doppler will overestimate peripheral vascular resistance.

Ultrasound Doppler of the Achilles tendon before and after injection of an ultrasound contrast agent--findings in asymptomatic subjects.

UNLABELLED: The sensitivity of ultrasound Doppler has now reached a level at which perfusion can be detected even in normal, resting musculoskeletal tissues. To be able to distinguish normal from abnormal flow, the resistive index (RI) determined by spectral Doppler may be of value. Inflammation is associated with low RI values and a value of 1.00 is normal. PURPOSE: In tissues with no detectable flow, it has been assumed that RI may be defined as 1.00. This study was performed to test if normal tendinous vessels could be visualised with a contrast agent, and if such vessels had normal RI. MATERIALS AND METHODS: Ultrasound (US) was performed with a 14 MHz linear transducer. 22 asymptomatic tendons in 12 subjects were scanned, and only 5 ultrasonically normal tendons in 5 subjects were identified. In these 5 normal tendons, SonoVue was used to make vessels visible. The Achilles tendons and the peritendinous tissues were evaluated clinically. RESULTS: In all 5 ultrasonically normal tendons, arteries could be detected with Doppler after contrast injection and in all cases with normal RI values. All vessels were located in the mid-portion of the tendon. 18 tendons were categorised as normal by the clinician. CONCLUSION: After administration of a contrast agent, all Achilles tendons could be demonstrated to have arteries present in the mid-portion. The flow profile of these arteries was fully normal without diastolic component and with an RI of 1.00. This finding has implications for criteria of normality of tendons, which cannot be based exclusively on the presence or absence of Doppler activity. The majority of the tendons in this study had ultrasound abnormalities both on gray-scale and colour Doppler. It can be speculated that the abnormalities may be age-related degenerative changes and that age-stratified normal materials are needed to define normality. There was no consistency between US and clinical diagnosis.

Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise.

BACKGROUND: Intratendinous Doppler activity has been interpreted as an equivalent of neovessels in the Achilles tendon and as a sign of tendinosis (AT). AIM: To evaluate the vascular response as indicated by color Doppler activity after repeated loading of both symptomatic and non-symptomatic Achilles tendons. MATERIAL AND METHODS: Ten non-trained, healthy subjects ran 5 km. Ultrasound (US) Doppler activity was determined before and after the exercise. Eleven patients with chronic AT performed 3 x 15 heavy-load eccentric exercise. The Achilles tendons were scanned before and immediately after the exercise. RESULTS: Non-symptomatic: six Achilles tendons in five subjects had intratendinous Doppler activity before the exercise. All but two subjects (80%) had intratendinous Doppler activity after running. Symptomatic: all patients had Doppler activity in the tendons, with a median color fraction before eccentric exercise of 0.05 (range 0.01-0.33). The Doppler activity did not disappear after exercise. Tendons with a color fraction below the median at baseline increased significantly after the exercise (P=0.02). CONCLUSION: The mere presence of Doppler in the Achilles tendon does not per se indicate disease. Eccentric exercise does not extinguish the flow during or after one training session in patients with chronic AT.

Intra-tendinous ossification with concomitant tendonitis and bursitis--ultrasound grey-scale and colour Doppler findings.

A case report of a 62-year-old man with a 20-year history of tendon problems, who presented with a swollen and tender left Achilles tendon. Ultrasound (US) revealed a 2 x 1 x 0.9 cm intra-tendinous substance with acoustic shadowing. On a radiogram, ossification was found. Colour Doppler activity was present in both the bursa and the tendon. A US-guided injection of 40 mg Depomedrol was applied into the retrocalcaneal bursa. On follow-up two months later, the patient had no symptoms and US showed total regression of Doppler activity. The ossification was unchanged. US colour Doppler may be recommended for guidance and monitoring of treatment.

Doppler ultrasound findings in healthy wrists and finger joints before and after use of two different contrast agents.

OBJECTIVE: To examine the effect of contrast agents on Doppler ultrasound findings in the synovial membrane in the wrist and fingers of healthy volunteers. MATERIALS AND METHODS: Eleven healthy subjects were included in the study (5 women and 6 men, mean age 38 years, range (20-60)). They had no clinical signs of inflammatory or degenerative joint diseases. A total of 66 joints were examined-6 joints for each subject: wrist and metacarpophalangeal (MCP) joints 1-5-before contrast injection and after Levovist and SonoVue injection with a 30 minute interval. RESULTS: Colour Doppler activity was detected in 10/55 (18%) MCP joints before contrast injection and in 29/55 (53%) and 28/55 (51%) joints after Levovist (p<0.0001) and SonoVue injection (p = 0.0001), respectively. A significant increase in Doppler activity in the radial (p<0.05) and ulnar (p = 0.01) parts of the wrist joint was detected only after SonoVue injections. With spectral Doppler no difference was found in the resistive index (RI) in the vessels measured before as compared with those only detected after contrast injection. CONCLUSION: The number of joints with colour Doppler activity in healthy volunteers was increased by the use of contrast agents. No changes in RI were detected. The value of contrast agents remains to be demonstrated in inflammatory diagnostics.

Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients.

BACKGROUND: It is debated as to whether Achilles tendonitis (AT) has an inflammatory component. The intratendinous hyperaemia demonstrated with colour Doppler has been interpreted as neovascularisation. Glucocorticoid injection around the tendon is a common therapeutic procedure. HYPOTHESES: The intratendinous hyperaemia seen with ultrasound (US) colour Doppler represents an inflammatory background. Glucocorticoid injections will be effective if administered inside the tendon where the inflammation seems to be. STUDY DESIGN: An uncontrolled, prospective study with a minimum follow-up of 3 months. METHODS: Six tendons in five patients were evaluated with grey-scale US and colour Doppler before and after US-guided intratendinous glucocorticoid injection. Pain at rest and at activity was evaluated on a visual analogue scale. RESULTS: With colour Doppler all tendons had intratendinous flow. Pain and colour Doppler activity decreased during a mean follow-up of 182 days (range 92-309 days). One tendon relapsed after 199 days. CONCLUSION: Intratendinous glucocorticoid injections seem to have a marked effect on both symptoms and colour Doppler findings, which may be taken as an indication of an inflammatory component in the disease. Colour Doppler adds significant information to grey-scale US with regard to diagnosis, location and follow-up of AT.

Protection of chymotrypsin from inactivation by a N-mustard analog.

Chymotrypsin activity is rapidly inactivated by the N-mustard anti-tumor drug, chlorambucil. Since mustards react with thiols, amines, carboxyls, imidazoles, and sulfide sites on proteins, N-acetylcysteine, 2 proprietary protein hydrolyzates, beta-mercaptoethanol, ethanolamine, and sodium lactate were tested for their capacity to protect chymotrypsin from inactivation by the mustard. In each instance, protection was afforded to chymotrypsin. In as much as N-acetylcysteine protected chymotrypsin from inactivation by chlorambucil, it is suggested that this thiol compound may serve as a detoxication agent and may not require prior transformation into glutathione by cells in order to reduce mustard levels within the cells, as suggested by Smith and Gross (Proceedings of the NATO Panel VIII meeting, Grenoble, France, 1991.) It is further suggested that amino acids present as biosynthetic and degradative components of cells may detoxify mustards.