Posterior intra-articular hip injections: a pilot study investigating a new approach.

PURPOSE: The purpose of this study was to investigate a novel posterior intra-articular hip injection approach while discussing the clinical pearls for methodology, accuracy, and associated adverse events. The goal was to investigate if this approach could potentially be used in those where the typical anterior access would be challenging. MATERIALS AND METHODS: 10 adults (age > 18 years) who were referred to a tertiary outpatient clinic for hip injection due to hip osteoarthritis or femoral acetabular impingement with labral tearing to a single academic sports medicine clinic. Patients were placed in prone position. Posterior structures were identified using a curvilinear transducer. A 22 gauge 3.5-6-inch spinal needle was advanced in-plane to the transducer towards the hip capsule at the head-neck junction of the femur from inferolateral to superomedial. A fluoroscopic arthrogram was obtained to evaluate needle placement accuracy. Location of the needle, direction of contrast flow, the rate of conversion to an anterior portal, and adverse events were analyzed. RESULTS: A fluoroscopic arthrogram was obtained after the first attempt in nine patients (90%). One patient (10%) was converted to the anterior approach due to inability to obtain the expected arthrogram. Two patients (20%) demonstrated mild adverse events. CONCLUSION: Ultrasound-guided posterior approach hip injection is accurate and without serious adverse events in our study. The posterior approach can be considered as an alternative approach for patients who cannot tolerate or may have technical difficulty with an anterior approach.

Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment.

OBJECTIVE: Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. DESIGN: Retrospective chart review. SETTING: Single institution. PARTICIPANTS: Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. INDEPENDENT VARIABLES: Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. MAIN OUTCOME MEASURES: Rate of return to play (RTP) to collegiate athletics. RESULTS: Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. CONCLUSIONS: Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. CLINICAL RELEVANCE: This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.

Team's average acute:chronic workload ratio correlates with injury risk in NCAA men's soccer team.

BACKGROUND: Research in multiple sports has shown that an individual's acute:chronic workload ratio (ACWR) correlates with injury. However, tailoring team trainings to each individual's ACWR is technically challenging and has not been found to decrease injury risk. OBJECTIVE: To establish a more feasible method of utilizing the ACWR for injury prevention in soccer. In a National Collegiate Athletic Association (NCAA) men's soccer team, we assessed whether the team's average ACWR, as opposed to that of each individual, correlated with injuries sustained throughout the season. DESIGN: Injury and workload data were retrospectively evaluated for all players (n = 23) of an NCAA men's soccer team during one 18-week season. Workload data for five global positioning system (GPS)-derived workload variables (total distance, high-speed distance, accelerations, player load, and average velocity) were used to calculate the team's average daily acute and chronic workloads (accumulated load for each variable during the past 3 and 28 days, respectively), and uncoupled ACWRs (acute workload divided by chronic workload for each variable). A retrospective cohort design was used to compare the team's workloads and ACWRs on days where ≥1 injury occurred versus days where zero injuries occurred using binary logistic regression models. RESULTS: Trainings/games with injuries had higher acute workloads, lower chronic workloads, and higher ACWRs for all five workload variables. In multivariable analysis, risk factors for injury included a low chronic workload for total distance (odds ratio [OR] 7.23, p = .024) and an ACWR >1.4 for accelerations (OR 4.34, p = .029). CONCLUSIONS: The team's injury risk was greater with low distance accumulation during the chronic period and with an elevated ACWR for accelerations. Future intervention-based studies aimed at using ACWR load-management principles as a method of decreasing injury risk in soccer can consider tracking the team's average values with the goal of maintaining a consistent chronic workload for total distance and avoiding elevations in the ACWR for accelerations.

Impact of Scalene Muscle Botulinum Toxin Injection With and Without Surgery in Neurogenic Thoracic Outlet Syndrome.

OBJECTIVE: Scalene blocks are part of both the diagnostic and treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, there is a paucity of data on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the impact of BTI with and without surgery at a multidisciplinary referral center. DESIGN: Retrospective cohort study. SETTING: Single institution tertiary academic center, 2011 to 2020. PATIENTS: Seventy-seven consecutive patients. INTERVENTIONS: Scalene muscle BTI for nTOS with or without surgical decompression. MAIN OUTCOME MEASURES: Pain relief and Quick Disability of the Arm, Shoulder and Hand (QDASH) score. RESULTS: Seventy-seven patients, with a mean age of 31.4 years, had BTI for symptoms of nTOS. All patients underwent pretreatment physical therapy through the Edgelow protocol for a mean duration of 3.4 months. However, 72.7% had dynamic vascular compression on duplex ultrasound with provocative maneuvers and 85.7% had a positive physical examination finding. After BTI, 77.9% reported subjective relief, confirmed by an improved QDASH disability score. Thirty-one patients (40.3%) then went on to have further persistent symptoms and proceeded with first rib resection. After BTI + Surgery, 96.8% reported symptomatic relief and had a median QDASH score improvement of 21 (range: 10-40), with all reaching minimal clinically important differences in the QDASH score after combination therapy. CONCLUSIONS: In this reported series of chemodenervation in patients with nTOS, BTI is helpful in alleviating symptoms before definitive surgical decompression. BTI followed by first rib resection provides additional symptom improvement over BTI alone.

Ultrasound of Thumb Muscles and Grasp Strength in Early Thumb Carpometacarpal Osteoarthritis.

PURPOSE: The pathophysiology of thumb carpometacarpal (CMC) osteoarthritis (OA) involves complex interactions between the ligaments and muscles supporting the joint. Factors such as muscle volume and strength may be more relevant in early disease. We used ultrasound as a noninvasive method to explore differences in the intrinsic hand muscles of patients with early CMC OA, as determined using physical exam and radiographs, and healthy controls. We also assessed differences in grip strength. METHODS: A convenience sample of postmenopausal women with early CMC OA diagnosed using a physical examination or radiographs was recruited from an orthopedic clinic specializing in hand surgery. Healthy controls who were matched for age and hand dominance were recruited from the same clinic. We used ultrasound to determine the length of the first metacarpal and the muscle thickness of the abductor pollicis brevis, opponens pollicis (OPP), and first dorsal interosseous. Grip strength measurements were taken using a standard Jamar dynamometer and 2 custom-designed tools for cylindrical grasp and pinch strength. RESULTS: Twenty-three subjects were enrolled, with a total of 32 thumbs measured: 15 thumbs with arthritis and 17 healthy thumbs. Multivariable logistic regression models indicated that thumbs with thicker OPP had 0.85 lower odds (95% CI = 0.71-0.97) of early OA, adjusting for hand dominance and the first metacarpal length. Linear regression models indicated no association between early OA and grip strength. CONCLUSIONS: The size of OPP may have a weak association with the diagnosis of early OA. CLINICAL RELEVANCE: This study supports further exploration of the role of OPP in stabilizing the CMC joint, particularly with regard to minimizing joint subluxation. This may be clinically relevant to providers who treat patients with CMC OA early in the course of the disease, when nonsurgical treatment is the most relevant.

Effectiveness of Ultrasound-Guided Pulsed Radiofrequency Treatment in Patients with Refractory Chronic Cervical Radicular Pain.

BACKGROUND: The effect of pulsed radiofrequency (PRF) stimulation for alleviating cervical radicular pain has been demonstrated in several previous studies. OBJECTIVES: We aimed to evaluate the effectiveness of PRF with ultrasound (US) guidance in patients with chronic cervical radicular pain that was refractory to repeated transforaminal epidural steroid injections (TFESIs). STUDY DESIGN: A prospective outcome study. SETTING: The outpatient clinic of a single academic medical center. METHODS: This study included 49 patients with chronic cervical radicular pain, unresponsive to repeated TFESIs, and who underwent PRF stimulation under US guidance. Using US, a cannula was inserted toward the cervical spinal nerve. The pain intensity was evaluated using the Numeric Rating Scale (NRS-11) for cervical radicular pain at pretreatment and 1, 3, and 6 months posttreatment; and the Neck Disability Index (NDI) was used for evaluating functional disability before treatment and 6 months posttreatment. Successful pain relief was defined as >= 50% reduction in the NRS-11 score as compared with the score before treatment. RESULTS: Cervical radicular pain was significantly reduced at 1, 3, and 6 months post-PRF (P < 0.001). At 6 months post-PRF, functional disability (NDI score) had significantly reduced, and 63.3% of the patients achieved successful pain relief. LIMITATIONS: The small number of included patients and no long-term follow-up. CONCLUSIONS: PRF stimulation under the guidance of US is a potentially effective treatment method for managing refractory chronic cervical radicular pain. KEY WORDS: Ultrasound, pulsed radiofrequency, cervical radicular pain, chronic pain.

Orthobiologics for the Hip Region: A Narrative Review.

Management of hip region disorders is challenging. Orthobiologic treatments including platelet rich plasma (PRP), mesenchymal stem cells, and amniotic injectables have gained popularity as promising treatments despite a lack of robust evidence for their effectiveness. We review rationale and current evidence for orthobiologics for three common hip region conditions: hip osteoarthritis, gluteal tendinopathy, and proximal hamstring tendinopathy. Overall, the current state of evidence is extremely limited for orthobiologic treatments and is predominantly relevant to PRP injections. There is currently a lack of data to support the use of mesenchymal stem cells or amniotic injectables in these conditions of the hip.

Ultrasonographic measurement of the cross-sectional area of the axillary nerve.

INTRODUCTION: The objectives of this study were to determine normal reference values for ultrasonographic measurement of the cross-sectional area (CSA) of the axillary nerve and to standardize the measurement methods. METHODS: Sixty healthy volunteers were evaluated. Ultrasonography was performed with the shoulder positioned in 100°-120° abduction and 90° external rotation. The CSA of the axillary nerve was measured bilaterally. RESULTS: The normal CSA of the right axillary nerve was 2.9 ± 1.1 mm2 . The side-to-side discrepancy was 22.8% ± 17.8%. DISCUSSION: These reference values may be helpful for investigating pathologies involving the axillary nerve.

Golf Swing Rotational Velocity: The Essential Follow-Through.

OBJECTIVE: To evaluate if shoulder and pelvic angular velocities differ at impact or peak magnitude between professional and amateur golfers. Golf swing rotational biomechanics are a key determinant of power generation, driving distance, and injury prevention. We hypothesize that shoulder and pelvic angular velocities would be highly consistent in professionals. METHODS: Rotational velocities of the upper-torso and pelvis throughout the golf swing and in relation to phases of the golf swing were examined in 11 professionals and compared to 5 amateurs using three-dimensional motion analysis. RESULTS: Peak rotational velocities of professionals were highly consistent, demonstrating low variability (coefficient of variation [COV]), particularly upper-torso rotational velocity (COV=0.086) and pelvic rotational velocity (COV=0.079) during down swing. Peak upper-torso rotational velocity and peak X-prime, the relative rotational velocity of uppertorso versus pelvis, occurred after impact in follow-through, were reduced in amateurs compared to professionals (p=0.005 and p=0.005, respectively) and differentiated professionals from most (4/5) amateurs. In contrast, peak pelvic rotational velocity occurred in down swing. Pelvic velocity at impact was reduced in amateurs compared to professionals (p=0.019) and differentiated professionals from most (4/5) amateurs. CONCLUSION: Golf swing rotational velocity of professionals was consistent in pattern and magnitude, offering benchmarks for amateurs. Understanding golf swing rotational biomechanics can guide swing modifications to help optimize performance and prevent injury.

Use of 18F-sodium fluoride bone PET for disability evaluation in ankle trauma: a pilot study.

BACKGROUND: There are no objective and accurate rating tools for permanent impairment of traumatized ankles. The purpose of this study is to assess the role of 18F-Sodium fluoride (18F-NaF) positron emission tomography-computed tomography (PET/CT) bone scans in evaluating patients with limited ankle range of motion (ROM) after trauma. METHODS: 18F-NaF PET/CT was performed in 121 patients (75 men, 46 women; mean age: 45.8) who had ROM < 70% of normal after trauma affecting ankles. Metabolic target volume (MTV), the sum of voxels with standardized uptake value (SUV) > 2.5 was automatically obtained from the 3D volume that included the ankle joint. The maximum & mean SUV (SUVmax & SUVmean), and the total lesion activity (TLA) were measured. RESULTS: The median period from injury to performing 18F-NaF PET/CT was 290 days. The causes of injury were as follows: fracture (N = 95), Achilles tendon rupture (N = 12), and ligament injury (N = 12). Hot uptake in the ankle was seen in 113 of 121 patients. The fracture group had higher SUVmax, SUVmean, and TLA values than the non-fracture group. More limited ROM correlated with higher hot-uptake parameters (SUVmax, SUVmean, TLA). In subgroup analysis, the same correlations were present in the fracture, but not in the non-fracture group. CONCLUSIONS: 18F-NaF PET/CT can provide considerable information in impairment evaluations of limited ankle ROM, particularly in fracture around the ankle. Thus, 18F-NaF bone PET/CT may provide an additional option as an objective imaging tool in disability assessment after ankle injury.

Comparison of Muscle Onset Activation Sequences between a Golf or Tennis Swing and Common Training Exercises Using Surface Electromyography: A Pilot Study.

Aim. The purpose of this pilot study is to use surface electromyography to determine an individual athlete's typical muscle onset activation sequence when performing a golf or tennis forward swing and to use the method to assess to what degree the sequence is reproduced with common conditioning exercises and a machine designed for this purpose. Methods. Data for 18 healthy male subjects were collected for 15 muscles of the trunk and lower extremities. Data were filtered and processed to determine the average onset of muscle activation for each motion. A Spearman correlation estimated congruence of activation order between the swing and each exercise. Correlations of each group were pooled with 95% confidence intervals using a random effects meta-analytic strategy. Results. The averaged sequences differed among each athlete tested, but pooled correlations demonstrated a positive association between each exercise and the participants' natural muscle onset activation sequence. Conclusion. The selected training exercises and Turning Point™ device all partially reproduced our athletes' averaged muscle onset activation sequences for both sports. The results support consideration of a larger, adequately powered study using this method to quantify to what degree each of the selected exercises is appropriate for use in both golf and tennis.

Basic appearance of ultrasound structures and pitfalls.

The role of ultrasound in musculoskeletal imaging is expanding as technology advances and clinicians become better educated about its clinical applications. The main use of musculoskeletal ultrasound to physiatrists is to examine the soft tissues of the body and to diagnose pathologic changes. Ultrasound can be used to assist clinicians in performing interventional procedures. However, to successfully integrate this technology into their clinical practices, physicians must be familiar with the normal and abnormal appearance of tissues. They also must recognize the clinically relevant limitations and pitfalls associated with the use of ultrasound.