Musculoskeletal Ultrasound as a Motivator for Selecting a Physical Medicine and Rehabilitation Residency Program in the United States: A Multicenter Survey Study.

ABSTRACT: This study aimed to determine the influence of musculoskeletal ultrasound (MSKUS) curriculum on applicants during the residency-selection process. A survey of 666 applicants for the Johns Hopkins University, Mayo Clinic, and Harvard/Spaulding Rehabilitation Physical Medicine and Rehabilitation programs was conducted in June 2020. A total of 180 respondents scored the influence of a MSKUS curriculum on their decision making for residency selection. In addition, applicants were asked to rank specific areas of physical medicine and rehabilitation that influenced their decision making. Participants most commonly included MSKUS in their top three areas of interest when constructing their rank order list. When asked whether MSKUS presence within a program had an effect during the interview-selection process, 71% responded with "very important" or "absolutely essential" (P < 0.001). For 74% of applicants, exposure to MSKUS in residency was an important factor when creating their rank order list (P < 0.001). More than 92% of applicants stated that they are "likely" or "very likely" to use MSKUS in their future practice and 83% would recommend a program with MSKUS to future candidates (P < 0.001). Based on these results, a large percentage of physical medicine and rehabilitation applicants intend on using MSKUS in their future practice. Therefore, MSKUS may be an important factor for residency selection.

Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study.

BACKGROUND: Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited. OBJECTIVE: To determine whether ultrasound can improve the ability of physicians in training (residents) to palpate the long head of the biceps tendon (LHBT) in the bicipital groove. DESIGN: Prospective study design. SETTING: Tertiary care center. PARTICIPANTS: Ten physical medicine and rehabilitation residents served as subjects. Exclusion criteria included the presence of any condition that precluded their ability to palpate. Three volunteers were used as models. Model exclusion criteria included anything that distorted normal shoulder anatomy or inhibited examiner palpation. Three investigators with experience performing diagnostic musculoskeletal ultrasound were used to confirm palpation attempts. METHODS: Subjects attempted to palpate the LHBT bilaterally in the bicipital groove of each model. Investigators assessed the accuracy of the palpation attempt using real-time ultrasonography. Subjects participated in a 30-minute ultrasound-assisted training session learning how to palpate the LHBT in the bicipital groove with ultrasound confirmation. After the ultrasound training session, subjects again attempted to palpate the LHBT in the bicipital groove of each model with investigator confirmation. MAIN OUTCOME MEASUREMENTS: LHBT palpation accuracy rates preintervention versus postintervention. RESULTS: Pretraining LHBT palpation accuracy was 20% (12/60 attempts). Post-ultrasound training session accuracy was 51.7% (31/60 attempts; P ≤ .001). CONCLUSIONS: Our findings demonstrate that palpation accuracy improves after ultrasound assisted LHBT palpation training. These data suggest that the use of ultrasound may be beneficial when teaching musculoskeletal palpation skills to health care professionals. LEVEL OF EVIDENCE: II.

Sonographic evaluation of the extensor carpi ulnaris in asymptomatic tennis players.

OBJECTIVE: To determine the prevalence of structural abnormalities and instability affecting the extensor carpi ulnaris (ECU) tendons of asymptomatic recreational tennis players by the use of high-resolution ultrasonography. DESIGN: Cross-sectional observational study. SETTING: Academic sports medicine center. PARTICIPANTS: Twenty-six asymptomatic, recreational male and female tennis players. METHODS: A single, experienced operator completed bilateral static and dynamic ultrasound examinations of the ECU tendons of 26 asymptomatic, long-term, recreational tennis players ages 26-61 years (11 male, 15 female, average 24.4 ± 14.2 years of tennis participation). Tendons were evaluated for tendinosis and tearing, tendon sheath effusion and tenosynovitis, and instability via a standardized scanning protocol and predetermined diagnostic criteria. MAIN OUTCOME MEASUREMENTS: The prevalence of static structural ECU tendon abnormalities (eg, tendinosis, tenosynovitis, tears) and dynamic ECU instability (eg, subluxation, dislocation). RESULTS: Thirty-nine of 52 wrists (75%) demonstrated static ECU tendon abnormalities, the most common finding being a partial-thickness tear located just distal to the ulnar groove. Overall, 92% (24/26) of players exhibited tendinosis or tearing in at least one wrist. Dynamic ECU instability was detected in 42% of wrists (22/52) and 91% (20/22) of the time manifested as subluxation. Only 2 ECU tendon dislocations were observed, both occurring in the same individual. Overall, 73% (19/26) of players exhibited ECU instability in at least one wrist. There was no relationship between static and dynamic ECU tendon abnormalities within the methodological limits of the investigation. Complete ECU tearing, tendon sheath effusion, tenosynovitis, and static dislocation were not seen in any wrist. CONCLUSION: Sonographic evidence of ECU tendinosis, partial-thickness tearing, full-thickness tearing, and subluxation can be seen in long-term, asymptomatic, recreational tennis players, whereas tendon sheath effusions, tenosynovitis, and tendon dislocation are uncommon. Further research is warranted to determine the clinical significance of asymptomatic ECU tendon abnormalities among long-term tennis players at multiple skill levels.

Distribution pattern of sonographically guided iliopsoas injections: cadaveric investigation using coned beam computed tomography.

OBJECTIVES: To investigate the distribution pattern of sonographically guided iliopsoas (IP) injections in an unembalmed cadaveric model. METHODS: A single experienced operator completed 10 sonographically guided IP injections in 5 unembalmed cadaveric pelvic specimens (4 male and 1 female; ages 55-95 years; body mass indices, 15.5-27.5 kg/m(2)) using a previously described in-plane, lateral-to-medial approach short axis to the tendon. Each injection consisted of 7 mL of a 20% dilution of contrast material injected between the IP tendon and the acetabular rim using a 22-gauge, 87.5-mm (3½-in) needle. To facilitate interpretation of contrast patterns, 2 additional injections were performed on single hips: sonographically guided 14 mL contrast-latex IP injection and sonographically guided superficial IP "peritendinous" injection with 7 mL of contrast-latex. Immediately before and after each injection, fluoroscopic images were obtained with a fixed C-arm equipped with coned beam computed tomography. After each injection, radiographic images were evaluated by a board-certified, fellowship-trained musculoskeletal radiologist to determine injectate distribution. Specimens receiving contrast-latex injections were dissected 48 hours after injection to determine the anatomic location of the injectate. RESULTS: Nine of 10 IP injections (90%) produced characteristic "U-shaped" flow patterns covering 50% to nearly 100% of the IP tendon circumference and resembling previously published IP bursograms. One injection was excluded because the majority of the latex was within the pectineus muscle, likely due to technical factors. Latex flowed an average of 5.3 cm (range, 0.3-7.9 cm) cephalad and 5.2 cm (range, 1.0-7.5 cm) caudad to the acetabular rim. The large-volume (14-mL) IP injection produced a similar flow pattern to the 7 mL injections, whereas the superficial peritendinous injection produced a contrast pattern consistent with intramuscular flow. Subsequent dissection confirmed bursal flow for the 14-mL injection, whereas the superficial peritendinous injection placed latex within the superficial portion of the IP muscle (ie, intramuscular). CONCLUSIONS: Sonographically guided IP injections using an in-plane, lateral-to-medial technique place injectate into the IP bursa between the IP tendon and the acetabular rim. Within the limits of this cadaveric investigation, this sonographically guided 7-mL IP "bursa" injection may provide a minimum of 50% circumferential IP tendon coverage and approximately 5 cm of cephalad and caudad flow. There does not appear to be a peritendinous space deep to the IP tendon at the acetabular rim that is both outside the bursa and amenable to sonographically guided injection. Injections into the superficial aspect of the IP using 7-mL volumes may not deliver injectate deep to the IP tendon and therefore may represent a fundamentally different injection.

Posttraumatic fat necrosis presenting as prepatellar loose bodies in an adolescent football player.

A 16-year-old high school football player presented with 4 months of anterior knee pain and small, mobile, prepatellar "lumps" after falling onto an opponent's cleat. He reported knee pain primarily during knee flexion and direct pressure during squatting and kneeling. Knee radiographs were unremarkable. Ultrasonography revealed multiple, freely mobile, subcutaneous nodules of variable size and echogenicity in the prepatellar region. Analysis of magnetic resonance imaging suggested possible fat necrosis but was nondiagnostic. The patient opted for surgical exploration, at which time multiple, opalescent subcutaneous nodules were removed. Pathology was consistent with encapsulated fat necrosis. After surgery, his symptoms resolved, and he returned to sports without restrictions.

Ultrasound-guided ischial bursa injection: technique and positioning considerations.

OBJECTIVES: To 1) describe and validate an ultrasound-guided ischial bursa injection technique in an unembalmed cadaveric model and 2) to compare the distance between the ischial tuberosity and the sciatic nerve in a hip neutral versus 90° flexed hip position in asymptomatic volunteers. DESIGN: The first part was a single-blind prospective study. The second part was a prospective cohort study. SETTING: An academic institution procedural skills laboratory and outpatient clinic. PARTICIPANTS: The first part of the study involved 1 cadaveric specimen. The second part of the study involved 20 asymptomatic subjects. The mean age of the subjects was 28 years, and the mean (standard deviation) body mass index was 23.2 ± 2.8 kg/m(2) (minimum, 18.3 kg/m(2); maximum, 29.5 kg/m(2)). METHODS: In the first part of the study, a single operator completed bilateral ultrasound-guided ischial bursa injections in an unembalmed cadaveric specimen by using diluted colored latex. In the second part of the study, ultrasound was used in 20 asymptomatic volunteer subjects (10 men and 10 women) to measure the distance from the lateral edge of the ischial tuberosity to the sciatic nerve. MAIN OUTCOME MEASUREMENTS: The injections were graded for accuracy as follows: accurate (all injectate contained within the ischial bursa), accurate with overflow (injectate within the ischial bursa but also located in adjacent structures other than the needle track), or inaccurate (injectate not within the ischial bursa). The second part of the study measured the distance from the ischial tuberosity to the sciatic nerve with subjects in 2 different positions (prone and side lying with the tested hip flexed to 90°). RESULTS: Postinjection cadaveric dissections revealed that both ultrasound-guided injections accurately placed liquid latex within the ischial bursae. There was no evidence of injury to surrounding neurovascular structures. Among asymptomatic volunteers, the average distance between the ischial tuberosity and the sciatic nerve increased from 28.4 mm (range, 20.5-38.9 mm) in the neutral position to 41.9 mm (range, 30.9-66.0 mm) with the hip flexed to 90° (average change, 13.5 mm away from the ischial tuberosity; P = .0001). CONCLUSIONS: Ultrasound-guided ischial bursa injections are technically feasible. Flexing the hip to 90° increases the distance between the ischial tuberosity and the sciatic nerve in asymptomatic volunteers, thus potentially resulting in a safer needle trajectory when ischial bursa injections are clinically indicated. Further investigation in clinical settings is warranted to validate these findings.

Sonographically guided obturator internus injections: techniques and validation.

OBJECTIVES: The primary purpose of this investigation was to describe and validate sonographically guided techniques for injecting the obturator internus (OI) muscle or bursa using a cadaveric model. METHODS: A single experienced operator completed 10 sonographically guided OI injections in 5 unembalmed cadaveric pelvis specimens (4 female and 1 male, ages 71-89 years with body mass indices of 15.5-24.2 kg/m2). Four different techniques were used: (1) OI tendon sheath (4 injections), (2) OI intramuscular (2 injections), (3) OI bursa trans-tendinous (2 injections), and (4) OI bursa short-axis (2 injections). In each case, the operator injected 1.5 mL of diluted yellow latex using direct sonographic guidance and a 22-gauge, 87.5-mm (3½-in) needle. Seventy-two hours later, study coinvestigators dissected each specimen to assess injectate placement. RESULTS: All 10 OI region injections accurately placed latex into the primary target site. Two of the 4 OI tendon sheath injections produced overflow into the underlying OI bursa. Both OI intramuscular injections delivered 100% of the latex within the OI. All 4 OI bursa injections (2 trans-tendinous and 2 short-axis) delivered 100% of the latex into the OI bursa, with the exception that 1 OI bursa trans-tendinous injection produced minimal overflow into the OI itself. No injection resulted in injury to the sciatic nerve or gluteal arteries, and no injectate overflow occurred outside the confines of the OI or its bursa. CONCLUSIONS: The results of this investigation demonstrate that sonographically guided injections into the OI or its bursa are feasible and, therefore, may play a role in the diagnosis and management of patients presenting with gluteal and "retrotrochanteric" pain syndromes.

Ultrasound-guided intra-articular knee injection in an obese patient.

A 35-yr-old woman was referred to our outpatient clinic for a right intra-articular knee aspiration and injection. She had a medical history notable for lymphedema and morbid obesity (Fig. 1). Her body mass index was recently calculated at greater than 60 kg/m(2). She had a history of four previous nonguided knee joint injections performed elsewhere that provided no significant improvement in pain. On physical examination, it was difficult to localize common knee joint bony landmarks, including the medial and lateral borders of the patella (Fig. 2). Consequently we opted to utilize ultrasound guidance for the knee joint injection via the technique described herein.

Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: a cadaveric study.

OBJECTIVE: To compare the relative accuracy rates of ultrasound (US)-guided versus nonguided ankle (tibiotalar) joint and sinus tarsi injections in a cadaveric model. DESIGN: Prospective human cadaveric study with injection technique randomized and accuracy assessed by skilled observers blinded to injection technique. SETTING: Procedural skills laboratory in a tertiary care academic medical center. METHODS: Twelve embalmed and 8 unembalmed cadavers (40 ankles) were used for this investigation. Using a predetermined randomization process, 1 ankle of each cadaver was injected with US guidance and the other without. Tibiotalar joint injections were performed via an anterior approach and sinus tarsi injections performed via an anterolateral approach. All injections were performed by the senior author using a 22-gauge, 1.5-inch needle to place 3 mL of 50% diluted blue latex solution into the target area. Two anatomists blinded to the injection technique dissected each ankle and determined injection accuracy based on previously agreed upon criteria. MAIN OUTCOME MEASUREMENTS: Injection accuracy, where an accurate injection delivered injectate within the tibiotalar joint or into the mid-portion of the sinus tarsi. RESULTS: The accuracy rate for US-guided tibiotalar joint injections was 100% (20/20) versus 85% (17/20) for nonguided injections. The accuracy rate for US-guided sinus tarsi injections was 90% (18/20) versus 35% (7/20) for nonguided injections. CONCLUSIONS: In this cadaveric study, US guidance produced superior accuracy compared with nonguided injections with respect to both the tibiotalar joint and sinus tarsi. Although further research is warranted, clinicians should consider US guidance to optimize injectate placement into these areas when optimal accuracy is necessary for diagnostic or therapeutic purposes.

Sonographically guided carpal tunnel injections: the ulnar approach.

OBJECTIVE: The purpose of this report is to describe a new sonographically guided technique for carpal tunnel injections using an ulnar approach. METHODS: Previously published sonographically guided techniques for carpal tunnel injections were reviewed. Described approaches were noted to be technically challenging because of the need to perform long-axis imaging of the carpal tunnel, short-axis (out-of-plane) imaging of the needle, or both. RESULTS: We developed and herein describe the ulnar approach for sonographically guided carpal tunnel injections. Advantages of this approach include transverse imaging of the carpal tunnel, long-axis (in-plane) imaging of the needle, and versatility in targeting structures within the carpal tunnel. CONCLUSIONS: Clinicians should consider the ulnar-sided approach when performing sonographically guided carpal tunnel injections.

Femoroacetabular impingement: an overlooked cause of hip pain.

Femoroacetabular impingement is a cause of hip pain arising from abnormal contact between the proximal femur and the acetabulum during terminal hip motion. This is caused by a structural abnormality at the femoral head/neck junction or the acetabulum. The problem usually presents in young adults and can often go undiagnosed for years. Failure to identify and properly restore the biomechanics has been hypothesized to lead to the early onset of hip osteoarthritis; thus, early recognition is important. In this case study, we report on a 31-yr-old patient with many years of bilateral hip pain who underwent successful treatment of bilateral femoroacetabular impingement.

Intramuscular hemangioma of the foot: a diagnostic dilemma.

Intramuscular hemangioma is a rare but important cause of pain and potentially decreased performance in athletes. These benign tumors occur more often in the lower extremity and usually present during the first three decades of life. Symptomatic intramuscular hemangiomas usually present with pain and swelling, which often worsen with activity. Diagnosis can be difficult, resulting in frustration and prolonged activity limitations for these patients. Magnetic resonance imaging and clinical findings can often suggest the diagnosis. Recommended treatment is usually wide total excision, but there are certain cases in which excision is not possible. In difficult areas such as the hands or feet, a sclerosing agent can be injected into the hemangioma to reduce the size of the hemangioma, decrease pain, and improve function.