MRI classification of calf injuries - a reliability study and correlation with return to play in professional rugby players.

OBJECTIVE: To assess the validity and reliability of the calf injury classification system proposed by the Olympic Park group which focuses on connective tissue structure integrity on MRI. MATERIALS AND METHODS: A retrospective study analysing calf muscle group injuries in an English Premiership professional rugby union club using the MRI classification proposed by the Olympic Park group. Classification on MRI examinations of 28 calf injuries sustained over a 6-year period was performed by three independent musculoskeletal radiologists to determine the inter-observer variability and correlation of the grade of injury with return-to-full-training (RTFT) time. RESULTS: RTFT time ranged from 5 to 110 days (mean = 40.1, SD = 26.4) following calf muscle injury. The Olympic Park classification injury grade demonstrated moderate to strong correlation with RTFT time (Spearman's rank correlation coefficient, 0.661-0.715, p < 0.01). RTFT time was statistically different between different injury grades (one-way ANOVA, p < 0.01). Inter-observer agreement of the overall grade between radiologist pairs was fair to moderate (weighted kappa 0.406-0.583). CONCLUSION: The Olympic Park classification system demonstrates moderate to strong correlation with time to RTFT following calf injury. Inter-observer reliability is fair to moderate.

Shoulder Pain, Function, and Ultrasound-Determined Structure in Elite Wheelchair-Using Para Athletes: An Observational Study.

PURPOSE: This study aimed to determine the relationship between shoulder pain, physical examination, and tissue pathology in manual wheelchair users competing in elite sport. METHODS: Eighty elite para athletes who used a manual wheelchair for daily mobility were recruited from international track (n = 40), field (n = 19), and powerlifting (n = 21) competitions. Athletes were surveyed regarding shoulder pain history and symptoms (Wheelchair User's Shoulder Pain Index (WUSPI)), whereas independent blind observers measured signs (Physical Examination of the Shoulder Scale (PESS)) and tissue pathology (Ultrasound Shoulder Pathology Rating Scale (USPRS)). Relationships between measures for the total cohort and for subgroups defined by sporting discipline were calculated. RESULTS: A large proportion of athletes reported a history of upper limb pain (39% dominant and 35% nondominant). For the total cohort, WUSPI score was 22.3 ± 26.9, PESS score was 7.4 ± 6.7, and USPRS score was 5.2 ± 4.0. There were no USPRS score differences between athlete subgroups; however, track athletes had lower WUSPI and PESS scores, especially compared with field athletes. The first principal component explained most of the variance in the WUSPI and PESS, which were strongly correlated (r = 0.71), and the second orthogonal component explained the USPRS, which did not correlate with either the PESS (r = 0.21) or WUSPI (r = 0.20). Subgroup analysis showed that track athletes had lower symptom scores for a given physical examination score. CONCLUSIONS: Elite para athletes who use manual wheelchairs for daily mobility have a high prevalence of shoulder symptoms, positive signs on physical examination, and ultrasound-determined tissue pathology. Ultrasound-determined tissue pathology does not correlate with symptoms or signs. This information can help to guide clinicians in managing shoulder problems in this athlete population at high risk of injury.

Navigating the complexity of calf injuries in athletes: a review of MRI findings.

The calf muscle group is a common area for injury within the professional athlete population. Anatomical and biomechanical differences between the different component muscles vary their individual predispositions to and patterns of injury. However, there is a common unifying factor: injuries involving tendinous components have greater clinical implications with regards to rehabilitation, potential intervention, length of time to return to play, and re-injury rates. As such, accurate understanding of the underlying anatomy and subsequent interpretation of the injury patterns carry significant clinical ramifications. Ultrasound is a useful tool but has limitations, particularly when assessing soleus. As such, magnetic resonance imaging remains the workhorse in calf injury investigation.

The frondiform ligament sling: a sonographic landmark for injection into the sinus tarsi.

Localisation and injection of the sinus tarsi can be challenging, particularly for the less experienced musculoskeletal sonographer/practitioner. The inferior extensor retinaculum arises from the sinus tarsi in the form of three roots (medial, intermediate and lateral) which are collectively termed the frondiform ligament. This is readily identified on ultrasound and can be used as a reference point to aid the safe delivery of injectate material into the sinus tarsi. This article describes the technique and its anatomical basis.

Chronic Wear-Induced Bearing Dislocation in a Fixed-Bearing Unicompartmental Knee Arthroplasty: A Case Report.

Case: We present a case of late onset, bearing wear-induced failure of locking mechanism, resulting in bearing dislocation and rapidly progressive severe metallosis in a medial fixed-bearing (FB) unicompartmental knee arthroplasty (UKA). Conclusion: Bearing dislocation is a rare complication of chronic wear in FB UKA, and early recognition is essential to prevent metallic component articulation-induced metallosis and catastrophic failure.

Case report: Primary bone lymphoma presenting as a painful supraclavicular lump.

Primary bone lymphoma is a rare type of non-Hodgkin's lymphoma. It commonly arises from long bones such as the femur in the appendicular skeleton. The authors present a case of primary bone lymphoma of the clavicle, an uncommon location for this pathology, presenting as a painful supraclavicular lump in a 76-year-old woman. Magnetic resonance imaging and ultrasound examinations showed the typical feature of preservation of the bony cortex, and PET-CT revealed no alternative primary site of malignancy. This case highlights the importance of considering typical imaging characteristics of a lesion, even if it presents in an unusual site, as well as the value of completion imaging in clinical practice to secure a diagnosis.

A Case of Bilateral Baxter's Neuropathy Secondary to Plantar Fasciitis.

Heel pain is 1 of the most common presentations to the foot surgeon, and its causes are multifactorial. Baxter's neuropathy is caused by an impingement of the inferior calcaneal nerve and has been reported to be responsible for up to 20% of heel pain. The diagnostic imaging features are striking, with inflammation or atrophy of the abductor digiti minimi muscle. Multiple studies have found that the prevalence of this finding is much greater than initially thought. However, it is more unusual to find bilateral and symmetrical features. The possible causes of this condition lie along the course of the inferior calcaneal nerve. Management is focused on treating the underlying condition, with conservative therapy and steroid injection as the mainstay. Refractory cases may require surgical release. We present the case of a 56-year-old female presenting with bilateral foot pain. Imaging reveals symmetrical abductor digiti minimi atrophy associated with bilateral plantar fasciitis. These appearances are well demonstrated on both magnetic resonance imaging and ultrasound.

Time to return to full training is delayed and recurrence rate is higher in intratendinous ('c') acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification.

BACKGROUND: The British Athletics Muscle Injury Classification describes acute muscle injuries and their anatomical site within muscle based on MRI parameters of injury extent. It grades injuries from 0 to 4 and classifies location based on a myofascial (a), musculotendinous (b) or intratendinous (c) description. This is a retrospective cohort study that assessed time to return to full training (TRFT) and injury recurrence in the different British Athletics classifications for hamstring injuries sustained by elite track and field (T&F) athletes over a 4-year period. METHODS: The electronic medical records (EMRs) of 230 elite British T&F athletes were reviewed. Athletes who sustained an acute hamstring injury, with MRI investigation within 7 days of injury, were included. MRI were graded by two musculoskeletal radiologists using the British Athletics Muscle Injury Classification. The EMRs were reviewed by 2 sports physicians, blinded to the new classification; TRFT and injury recurrence were recorded. RESULTS: There were 65 hamstring injuries in 44 athletes (24±4.4 years; 28 male, 16 female). TRFT differed among grades (p<0.001). Grade 3 injuries and 'c' injuries took significantly longer and grade 0 injuries took less TRFT. There were 12 re-injuries; the injury recurrence rate was significantly higher in intratendinous (c) injuries (p<0.001). There was no difference in re-injury rate between number grades 1-3, hamstring muscle affected, location (proximal vs central vs distal), age or sex. CONCLUSIONS: This study describes the clinical application of the British Athletics Muscle Injury Classification. Different categories of hamstring injuries had different TRFT and recurrence rate. Hamstring injuries that extend into the tendon ('c') are more prone to re-injury and delay TRFT.

Osteoid osteoma of the cuboid managed by percutaneous radiofrequency ablation.

We present details of a case of osteoid osteoma of the tarsal cuboid bone. Osteoid osteoma arising in the foot is not very common, and localization in the cuboid is rare. To our knowledge, this is the first case of osteoid osteoma of the cuboid bone treated successfully by percutaneous radiofrequency ablation.

Femoroacetabular impingement: presence of FAI-like features on conventional radiography in young patients presenting to primary care with hip pain.

BACKGROUND: Femoroacetabular impingement (FAI) is a recognized major cause of early osteoarthritis in the hip and tends to present in young and active patients. The presence of morphological parameters associated with, or predisposing to FAI on radiographs can guide referral to a hip specialist for further assessment. PURPOSE: To determine the presence of radiographic findings with a known association with FAI in young patients presenting to primary care with hip pain. MATERIAL AND METHODS: Retrospective review of 223 consecutive patients presenting with hip pain (age range, 20-40 years) who underwent a pelvic radiograph in a 6-month period. Patients with pre-existing hip disease and/or technically inadequate radiographs were excluded from the study. Radiographs were analyzed for the presence of radiographic signs associated with FAI: acetabular cross-over sign; prominent posterior wall sign; coxa profunda; protrusio acetabula; acetabular index; lateral center edge angle; pistol grip deformity; and herniation pits. RESULTS: Of the initial 223 patients, 33 (17 women, 16 men; age range, 21-40 years; mean age, 33 years) were included in the study after strict application of exclusion criteria. Sixty-four of 66 joints (33/34 [97%] female joints and 31/32 [97%] male joints) had at least one abnormal finding associated with FAI. Forty-three of 66 joints (23/34 [68%] female joints and 20/32 [63%] male joints) had two or more parameters associated with FAI. All of these abnormal radiographs had initially been reported as normal. CONCLUSION: Our study demonstrates a high presence of FAI-like radiographic features in a young symptomatic population; these are often not mentioned in the radiology report.

Cam and pincer femoroacetabular impingement: CT findings of features resembling femoroacetabular impingement in a young population without symptoms.

OBJECTIVE: The purpose of this study was to use CT to determine the presence of radiologic parameters associated with cam and pincer femoroacetabular impingement (FAI) in a young population without symptoms. MATERIALS AND METHODS: A retrospective review of 50 patients (age range, 20-40 years) with no current or previous hip disorder who underwent CT of the abdomen and pelvis was conducted. Multiplanar images were reformatted with a soft-tissue and bone algorithm and assessed for the presence of parameters associated with FAI; alpha angle greater than 55°, femoral head-neck offset less than 8 mm, angle of acetabular version less than 15°, lateral center edge angle greater than 40°, acetabular index less than 0°, pistol-grip deformity, acetabular crossover, and prominent posterior wall signs. RESULTS: At least one abnormal parameter was present in 66% of joints, and two or more abnormal parameters were present in 29% of joints. In seven patients the findings were bilateral. Parameters of mixed morphologic characteristics (cam and pincer) were found in 22% of joints. In side-by-side comparison, high alpha angles were seen in 36 joints measured in the radial plane compared with only three joints measured in the axial oblique plane. CONCLUSION: The CT finding of FAI-like features was made with high frequency in a young symptom-free population. Cutoff values for defining morphologic abnormalities associated with FAI may have been set too low in the current literature. Alpha angle measurements in the radial plane may be a more accurate quantitative assessment of asphericity of the femoral head-neck junction than are measurements in the axial oblique plane.

Spinal cord injury following chiropractic manipulation to the neck.

Spinal cord injury is a rare complication of chiropractic treatment. This case report describes a 50-year-old man who developed neurological symptoms a few hours after manipulation (high velocity low amplitude [HVLA] technique) of the cervical spine. Magnetic resonance (MR) imaging of the cervical spine revealed intramedullary high signal at the C2/3 level of the right side of the cervical cord on the T2-weighted images. The potential mechanism of injury and causes of the radiological appearance are discussed.

Surgical management of tibial tubercle fractures in association with tibial plateau fractures fixed by direct wiring to a locking plate.

Tibial tubercle fractures disrupting the extensor mechanism of the knee can occur in association with complex tibial plateau fractures (AO type 41A, B, C). The management of these fractures can be difficult; a stable repair of the tibial tubercle fragment is essential if the extensor mechanism is to be reconstituted. There are few reported techniques described to manage tibial tubercle fractures in conjunction with complex proximal tibial injuries. Traditionally, tibial tubercle fractures have been repaired by lagging the tubercle fragment to the posterior cortex of the tibia using 1 or more screws. However, the cortex of the posterior tibia does not always offer good purchase for screw fixation, particularly in osteopenic bone. Additionally, in complex proximal tibial fractures, comminution often extends posteriorly, further complicating stable lag screw fixation. Placement of an anteroposterior lag screw can also be complicated by "screw traffic" if there are a large number of screws fixing the primary fracture. In this article, we report a novel surgical approach for the management of tibial tubercle fracture fragments occurring in association with complex proximal tibial fractures. Using this technique, the tibial tubercle fragment is stabilized by wiring it directly to the screws of a locking plate. It allows for reduction and fixation of the tibial tubercle fragment that is stable enough to allow immediate full active range of motion. Over the past 5 years, we have applied this technique in 16 patients. Our preliminary results using this new technique have demonstrated a high rate of clinical and radiographic union with near normal return of extensor mechanism function.