Sonographic measures and sensory threshold of the normal sciatic nerve and hamstring muscles.

PURPOSE: The sciatic nerve innervates the hamstring muscles. Occasionally, the sciatic nerve is injured along with a hamstring muscle. Detailed biomechanical and sensory thresholds of these structures are not well-characterized. Therefore, we designed a prospective study that explored high-resolution ultrasound (US) at multiple sites to evaluate properties of the sciatic nerve, including cross-sectional area (CSA) and shear-wave elastography (SWE). We also assessed SWE of each hamstring muscle at multiple sites. Mechanical algometry was obtained from the sciatic nerve and hamstring muscles to assess multi-site pressure pain threshold (PPT). METHODS: Seventy-nine asymptomatic sciatic nerves and 147 hamstring muscles (25 males, 24 females) aged 18-50 years were evaluated. One chiropractic radiologist with 4.5 years of US experience performed the evaluations. Sciatic nerves were sampled along the posterior thigh at four sites obtaining CSA, SWE, and algometry. All three hamstring muscles were sampled at two sites utilizing SWE and algometry. Descriptive statistics, two-way ANOVA, and rater reliability were assessed for data analysis with p ≤ 0.05. RESULTS: A significant decrease in sciatic CSA from proximal to distal was correlated with increasing BMI (p < 0.001). Intra-rater and inter-rater reliability for CSA was moderate and poor, respectively. Elastographic values significantly increased from proximal to distal with significant differences in gender and BMI (p = 0.002). Sciatic PPT significantly decreased between sites 1 and 2, 1 and 3, and 1 and 4. Significant correlation between gender and PPT was noted as well as BMI (p < 0.001). Hamstring muscle elastographic values significantly differed between biceps femoris and semitendinosus (p < 0.001) and biceps femoris and semimembranosus (p < 0.001). All three hamstring muscles demonstrated increased PPT in males compared to females (p < 0.001). In addition, PPT of the biceps femoris correlated with BMI (p = 0.02). CONCLUSION: High-resolution US provided useful metrics of sciatic nerve size and biomechanical properties. PPT for the normal sciatic nerve and hamstring muscles was obtained for future clinical application.

Baseball Injury Resulting in Type III Salter-Harris Fracture of the First Proximal Phalangeal Base: A Case Report.

Objective: The purpose of this report is to describe the clinical, radiographic, and diagnostic ultrasound findings in a patient who sustained a type III Salter-Harris fracture of the first proximal phalanx. Clinical Features: A 14-year-old male baseball player presented to a chiropractic clinic with a 2-day history of proximal thumb pain, which began following a forceful hyperabduction injury while sliding into base. Thenar swelling was evident on clinical examination, and both active and passive thumb motions were painful in all directions. Radiography revealed a type III Salter-Harris fracture of the first proximal phalangeal base. Additionally, diagnostic ultrasonography demonstrated a probable high-grade ulnar collateral ligament sprain. No further displacement of the fracture fragment was visualized with radial deviation stress. Intervention and Outcome: The patient was referred to a pediatric hand orthopedic specialist for consultation and treatment. Conclusion: Salter-Harris III fractures of the thumb base warrant special attention to various clinical and imaging features, which may affect patient outcomes. Fracture characterization with radiography is essential in determining the proper management. Ultrasonography and magnetic resonance imaging may be useful in the evaluation of concomitant soft tissue injuries, as demonstrated in this case report.

Diagnosing acetabular labral tears with hip traction sonography: a case series.

PURPOSE: Three cases of acetabular labral tear (ALT) diagnosed with sonography (US) are reported. We aim to show utility for US with the addition of manual hip traction as an adjunctive modality to the current diagnostic imaging of choice, magnetic resonance arthrography (MRA), for diagnosing ALT. METHODS: Three cases of young athletic patients with similar clinical presentations are reported. All received US examination of the hip with attention to the labrum that included a novel long-axis hip traction technique which assisted in diagnosing ALT. RESULTS: In the first and second cases, MRA and orthopedic consult were obtained for confirmation of the diagnosis. Arthroscopy was performed to correct the ALT. The third patient declined an MRA. Conservative management consisted of McKenzie method active care, resulting in return to sport in the third case. CONCLUSION: These three cases demonstrate the clinical and sonographic presentation of ALT. The dynamic long-axis hip traction protocol facilitated the use of US as an adjunctive modality for diagnosing ALT by increasing the visualization of the defect.

Sonoelastography of the trunk and lower extremity muscles in a case of Duchenne muscular dystrophy.

Duchenne muscular dystrophy (DMD) is a rare genetic disorder typically presenting with muscle weakness and reduced tone of trunk and lower extremities. The sonoelastographic properties of DMD are poorly understood. We describe sonoelastographic characteristics of a patient's trunk and lower extremity musculature. An 8-year-old male presented with a 5-year history of DMD. Sonoelastographic measures of the gluteus maximus and medius, lumbar erector spinae, rectus abdominis, rectus femoris, biceps femoris, tibialis anterior, medial and lateral gastrocnemius muscles were obtained. Sonoelastography demonstrated increased elasticity by elevated kiloPascals (kPa) across all muscles, except the lumbar erector spinae. Patient values were compared to an age-matched healthy control. These abnormal sonoelastographic findings reflected the pathological mechanical properties of DMD. Sonoelastography was valuable for characterizing the mechanical properties of normal and abnormal muscle tissue. There is limited information on the sonoelastography application to DMD. Sonoelastography may serve as a useful measure for diagnosis and monitoring clinical outcomes for DMD.

Rectus abdominis muscle tear diagnosed with sonography and its conservative management.

PURPOSE: This is a rare case of a post-traumatic rectus abdominis muscle tear in an adolescent female diagnosed by ultrasonography (US). Conservative management is also described. METHODS: A 14-year-old female presented to a chiropractic clinic with extreme pain and tenderness in the right lower quadrant (RLQ) after post-plyometric power kneel box jumps. Movement aggravated her pain and she demonstrated active abdominal guarding with RLQ palpation. Ultrasonography revealed a subacute Grade 2 right rectus abdominis muscle tear, without evidence of hyperemia or a hematoma. Following the diagnosis of a right rectus abdominis muscle tear, she was treated with spinal manipulation and a course of musculoskeletal rehabilitation directed at truncal stabilization. RESULTS: After treatment, the patient was able to return to play 5 week post-injury without any pain or discomfort. A follow-up US at 3 months provided evidence of muscle healing without complications. CONCLUSION: This case demonstrates the diagnosis of a rare rectus abdominis muscle tear managed conservatively. To our knowledge, less than a dozen cases are reported using US in the evaluation and diagnosis of a rectus abdominis tear.

Ulnar nerve instability in the cubital tunnel of asymptomatic volunteers.

PURPOSE: Ulnar nerve instability (UNI) in the cubital tunnel is defined as ulnar nerve subluxation or dislocation. It is a common disorder that may be noted in patients with neuropathy or in the asymptomatic. Our prospective, single-site study utilized high-resolution ultrasonography (US) to evaluate the ulnar nerve for cross-sectional area (CSA) and measures of shear-wave elastography (SWE). Mechanical algometry was obtained from the ulnar nerve in the cubital tunnel to assess pressure pain threshold (PPT). METHODS: Forty-two asymptomatic subjects (n = 84 elbows) (25 males, 17 females) aged 22-40 were evaluated. Two chiropractic radiologists, both with 4 years of ultrasound experience performed the evaluation. Ulnar nerves in the cubital tunnel were sampled bilaterally in three different elbow positions utilizing US, SWE, and algometry. Descriptive statistics, two-way ANOVA, and rater reliability were utilized for data analysis with p ≤ 0.05. RESULTS: Fifty-six percent of our subjects demonstrated UNI. There was a significant increase in CSA in subjects with UNI (subluxation: 0.066 mm2 ± 0.024, p = 0.027; dislocation: 0.067 mm2 ± 0.024, p = 0.003) compared to controls (0.057 mm2 ± 0.017) in all three elbow positions. There were no significant group differences in SWE or algometry. Inter- and intra-observer agreements for CSA of the ulnar nerves within the cubital tunnel were assessed using intraclass correlation coefficient (ICC) and demonstrated moderate (ICC 0.54) and excellent (ICC 0.94) reliability. CONCLUSIONS: Most of the asymptomatic volunteers demonstrated UNI. There was a significant increase in CSA associated with UNI implicating it as a risk factor for ulnar neuropathy in the cubital tunnel. There were no significant changes in ulnar nerve SWE and PPT. Intra-rater agreement was excellent for the CSA assessment of the ulnar nerve in the cubital tunnel. High-resolution US could be utilized to assess UNI and monitor for progression to ulnar neuropathy.

Neural Arch Bone Marrow Edema and Spondylolysis in Adolescent Cheerleaders: A Case Series.

OBJECTIVE: Spondylolysis is 1 of the most common sources of low back pain in children and adolescents; however, there is still a great deal of confusion in regard to etiology, clinical presentation, and diagnostic imaging findings. It is imperative for clinicians to recognize that persistent low back pain is strongly indicative of spondylolysis, especially in high-performance athletes. This case series demonstrates a comprehensive diagnostic spectrum of spondylolysis and its treatment in 2 competitive adolescent cheerleaders. CLINICAL FEATURES: In case 1, a 12-year-old female competitive cheerleader presented with a gradual onset of subacute low back pain. Comprehensive clinical examination indicated imaging studies that identified bilateral L5 grade 1 stress reaction, consisting of neural arch bone marrow edema (BME). Treatment included spinal adjustments, rehabilitation, and myofascial therapy. In case 2, 15-year-old female competitive cheerleader presented with insidious chronic low back pain that was provocative with extension. Magnetic resonance imaging revealed a left L5 grade 1 pars interarticularis stress reaction. Computed tomography demonstrated right L5 pars grade 3 and left L5 healing spondylolysis. Treatment included spinal adjustments and rehabilitation exercises. She was also seen by a physical therapist who prescribed a lumbar spine flexion brace. INTERVENTION AND OUTCOME: Diagnosis of BME and spondylolysis led to temporary cessation of cheerleading activities in cases 1 and 2. The individual in case 1 self-discharged with a list of rehabilitation exercises and was lost to follow-up. The individual in case 2 was able to return to sport pain free approximately 5 weeks after seeking treatment. CONCLUSION: Spondylolysis is common in adolescent athletes, and the presence of BME precedes spondylolysis. Primary spine providers could consider this diagnosis in any adolescent, especially an athlete, who has persistent low back pain. Timely diagnosis will optimize treatment outcomes.

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis.

OBJECTIVE: This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis. CLINICAL FEATURES: A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis. INTERVENTION AND OUTCOME: The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale. CONCLUSION: Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Chiropractic Care in the Management of Inactive Ankylosing Spondylitis: A Case Series.

OBJECTIVE: This report describes chiropractic management for 3 cases of inactive ankylosing spondylitis (AS). CLINICAL FEATURES: A 25-year-old woman presented with chronic, mechanical neck pain and stiffness that was ultimately diagnosed as AS. A 23-year-old man presented with chronic low back and left hip pain that was diagnosed as AS. A 31-year-old man with low back pain presented with a known diagnosis of AS. Physical examination in 2 cases failed to identify systemic findings associated with AS. In the third case, examination revealed a history of ulcerative colitis. Laboratory examination of case 2 yielded a positive HLA-B27, but cases 1 and 3 were HLA-B27 negative. The acute reactants were negative in all 3 patients, indicating an inactive phase of disease. All 3 patients underwent spinal imaging including sacroiliac joint radiography. In case 3, magnetic resonance imaging of the sacroiliac joints was performed. All 3 imaging examinations revealed bilateral, symmetric sacroiliitis. INTERVENTIONS AND OUTCOME: Patients were managed by both a medical rheumatologist and a doctor of chiropractic. Chiropractic care ranged from instrument-assisted spinal manipulation to diversified spinal and soft tissue manipulation and Cox flexion-distraction. Patients were given home stretches and rehabilitation exercises. All 3 patients experienced some relief of their symptoms including pain reduction and improved activities of daily living. CONCLUSION: These 3 patients displayed differences and commonalities in clinical, laboratory, and imaging features. Chiropractic manipulation and rehabilitation seemed to be beneficial in reducing symptomatology and improving musculoskeletal function for these 3 patients. These findings suggest the potential for collaborative or integrative management in similar cases.

Sonographic and Magnetic Resonance Imaging Examination of a Cyclops Lesion After Anterior Cruciate Ligament Reconstruction: A Case Report.

OBJECTIVE: This case report describes magnetic resonance imaging (MRI) and diagnostic ultrasound (US) findings for a patient with arthrofibrosis related to a complication of anterior cruciate ligament (ACL) reconstruction. CLINICAL FEATURES: A 25-year old man presented with right knee pain and loss of extension 5 years after ACL reconstruction. MRI and sonographic examination revealed a soft tissue mass anterolateral to the ACL graft consistent with a cyclops lesion. The lesion was surgically resected and physical therapy was followed postoperatively. INTERVENTION AND OUTCOME: The patient reported that full range of motion was restored 6 weeks after resection and a course of physical therapy. MRI is the modality of choice for diagnosis, but US may be useful in the diagnosis of this condition. CONCLUSION: Cyclops lesions may complicate ACL reconstruction or acute ACL injuries. The patient may present with pain and loss of extension, which can be debilitating. MRI and US can be used to diagnose this condition in a timely manner, ensuring optimal clinical outcomes.

Shoulder Internal Derangement and Osteoarthritis in a 25-Year-Old Female Softball Athlete.

OBJECTIVE: The purpose of this report is to describe osteoarthritis and internal derangement of the shoulder in a collegiate softball player. CLINICAL FEATURES: A 25-year-old female softball athlete presented with a history of chronic right shoulder pain. A thorough clinical examination and multiple imaging studies were performed. Osteoarthritis was demonstrated on radiographs, and ligamentous and rotator cuff tendon tears were displayed on magnetic resonance imaging. The patient's treatment plan included full spine manipulation, cold laser therapy, kinesiotaping, stretching, and neuromuscular reeducation of the right shoulder. INTERVENTIONS AND OUTCOMES: The patient reported a decrease in symptoms after 1 month, although treatment was sporadic because of poor patient compliance. CONCLUSION: Osteoarthritis and internal derangement may occur in overhead-throwing athletes, and correct imaging is needed for timely and accurate diagnoses. Following a timely diagnosis, the young patient in this case had a good recovery with multimodal chiropractic care.