Dynamic Ultrasonography of the Deep External Rotator Musculature of the Hip: A Descriptive Study.

BACKGROUND: No detailed reports exist describing the methodology of ultrasound image acquisition of the deep external rotator muscles of the hip. Because gluteal pain and sciatica are common, ultrasound may be a useful dynamic imaging adjunct in the evaluation of these patients. OBJECTIVE: To describe dynamic ultrasonography of the deep external rotator muscles of the hip for diagnostic purposes. DESIGN: Descriptive. SETTING: University radiology department. PARTICIPANTS: Participants (n = 25; 14 male) without gluteal pain or sciatica were enrolled (mean age 27.6 ± 4.7 years; mean body mass index 26.0 ± 4.1 kg/m(2)). METHODS: Ultrasonographic cine clips oriented to the long axis of each deep external rotator muscle were captured. In addition, cine clips of the piriformis tendon and obturator internus tendon were obtained. Cine clips were analyzed approximately 1 week after completion of image acquisition independently by 2 blinded raters. MAIN OUTCOME MEASURES: A 5-point Likert scale to evaluate the diagnostic utility of the ultrasound image. RESULTS: The modal Likert scores for rater 1 were as follows: piriformis muscle = 4; piriformis tendon = 4; superior gemellus muscle = 3; obturator internus muscle = 4; obturator internus tendon = 4; inferior gemellus muscle = 4; quadratus femoris muscle = 4. The modal scores for rater 2 were: piriformis muscle = 4; piriformis tendon = 3; superior gemellus muscle = 4; obturator internus muscle = 3; obturator internus tendon = 4; inferior gemellus muscle = 3; quadratus femoris muscle = 4. CONCLUSION: Dynamic ultrasonography may be useful to image the hip deep external rotator musculature for diagnostic purposes and therefore aid in the evaluation of gluteal pain and sciatica. Future work should investigate the reliability and validity of ultrasonography in the evaluation of pathology of these muscles.

Reference Values for the Scalene Interval Width During Varying Degrees of Glenohumeral Abduction Using Ultrasonography.

OBJECTIVE: The aim of this study was to establish reference values for the width of the interval between the anterior and middle scalene muscles using ultrasonography during varying degrees of glenohumeral joint (GH) abduction. Reliability and body mass index (BMI) data were also assessed. METHODS: Interscalene triangles of asymptomatic participants were scanned bilaterally in the transverse plane. Images were obtained at 0°, 90°, and 150° of GH abduction with the participant seated. Width measurements were taken between the anterior and middle scalene muscle borders by bisecting the C6 nerve root as it passed superficial to the posterior tubercle of the C7 transverse process. Intra- and interexaminer reliability and BMI correlation were studied. Statistical significance was defined as P ≤ .05. RESULTS: Images of 42 scalene intervals were included from 21 participants (11 female). Mean participant age was 25.3 ± 3.9 years; mean BMI was 25.4 ± 2.7 kg/m2. Scalene interval measurements at 0°, 90°, and 150° of GH abduction were 4.5 ± 0.5 mm, 4.6 ± 0.5 mm, and 4.4 ± 0.7 mm, respectively, without a significant difference (P = .07). Intraexaminer reliability was excellent (0°: intraclass correlation coefficient [ICC] = 0.82; 90°: ICC = 0.89; 150°: ICC = 0.90). Interexaminer reliability was good to excellent (0°: ICC = 0.59; 90°: ICC = 0.85; 150°: ICC = 0.89). Body mass index was positively correlated only at 0° of GH abduction. CONCLUSIONS: This study establishes previously unreported reference ultrasonography values for the width of the scalene interval. Intraexaminer reliability was excellent at all glenohumeral positions, and interexaminer reliability was determined to be good to excellent. Body mass index was positively correlated only at 0° of GH abduction.

Use of high-resolution ultrasound to measure changes in plantar fascia thickness resulting from tissue creep in runners and walkers.

OBJECTIVE: This study sought to use high-resolution ultrasound to measure changes in plantar fascia thickness as a result of tissue creep generated by walking and running. METHODS: Independent samples of participants were obtained. Thirty-six walkers and 25 runners walked on a treadmill for 10 minutes or ran for 30 minutes, respectively. Standardized measures of the thickness of the plantar fascia were obtained in both groups using high-resolution ultrasound. RESULTS: The mean thickness of the plantar fascia was measured immediately before and after participation. The mean plantar fascia thickness was decreased by 0.06 ± 0.33 mm SD after running and 0.03 ± 0.22 mm SD after walking. The difference between groups was not significant. CONCLUSION: Although the parameters of this study did not produce significant changes in the plantar fascia thickness, a slightly higher change in the mean thickness of the plantar fascia in the running group deserves further investigation.

Ultrasound measurements of lumbar multifidus and abdominal muscle size in firefighters.

BACKGROUND: Firefighters have a high incidence of low back pain and injury. OBJECTIVE: To describe lumbar multifidus and abdominal muscle size characteristics in firefighters and to compare these characteristics to normative reference ranges. METHODS: In career firefighters without current low back pain (62 males, 7 females), ultrasonography was used to assess: L4 and L5 lumbar multifidus cross-sectional area (CSA), asymmetry, and thicknesses; and external oblique, internal oblique, and transverse abdominal thicknesses. Comparisons of mean values in firefighters were made to the normative 95% reference ranges for the general population and soldiers. RESULTS: Mean values for lumbar multifidus and abdominal muscle size in firefighters fell within the 95% reference ranges for the general population and soldiers for all measurements, except L4 multifidus CSA in males and L5 multifidus CSA in females, which were larger in firefighters than the general population. CONCLUSIONS: The majority of lumbar multifidus and abdominal muscle size measurements in firefighters are similar to the general population and soldiers. The larger lumbar multifidus CSA in firefighters compared with the general population warrants further study. These data provide a basis for future research using ultrasonography to assess muscle size in firefighters and other workers in physically-demanding occupations.

Sonographic measurement of the normal suprascapular nerve and omohyoid muscle.

The aim of this study was to obtain normative ultrasonography (US) data on the suprascapular nerve (SSN) and omohyoid muscle (OM) in the lateral cervical region. The SSN and OM are known to be related throughout the nerve's course, yet little imaging data exists on these structures at areas more proximal than the suprascapular foramen. US data from a convenience sample of 33 asymptomatic subjects between 21 and 42 years of age were collected. Cross sectional area (CSA) of the SSN, distances from the OM to the SSN, and long-axis diameter of the OM at three reference points were obtained. The mean CSA of the SSN at both its origin and over the first rib was 1.9 mm2 and at the distal clavicle was 2.0 mm2. The mean distance of the OM to the SSN at these locations was 7.6 mm, 4.2 mm and 2.8 mm respectively. The mean long axis diameter of the OM was 2.4 mm at the SSN origin, 3.4 mm at the first rib, and 4.1 mm at the distal clavicle. We present US data from asymptomatic subjects on the SSN and OM. Our results show that the SSN nerve CSA is consistent throughout the nerves proximal course. Furthermore, the OM and SSN tend to approximate as they course distally. Future studies with larger samples will better characterize the normal sonoanatomy of these structures between genders and across different ages.

Sonographic evaluation of the greater occipital nerve in unilateral occipital neuralgia.

OBJECTIVES: Occipital neuralgia is a headache that may result from greater occipital nerve entrapment. Entrapped peripheral nerves typically have an increase in cross-sectional area. The purpose of this study was to measure the cross-sectional area and circumference of symptomatic and asymptomatic greater occipital nerves in patients with unilateral occipital neuralgia and to correlate the greater occipital nerve cross-sectional area with headache severity, sex, and body mass index. METHODS: Both symptomatic and contralateral asymptomatic greater occipital nerve cross-sectional areas and circumferences were measured by a single examiner using sonography in 17 patients. The Wilcoxon signed rank test and Spearman rank order correlation coefficient were used to analyze the data. RESULTS: Significant differences between the cross-sectional areas and circumferences of the symptomatic and asymptomatic greater occipital nerves were noted (P < .001). No difference existed in cross-sectional area (P = .40) or circumference (P = .10) measurements of the nerves between male and female patients. A significant correlation existed between the body mass index and symptomatic (r = 0.424; P = .045) and asymptomatic (r = 0.443; P = .037) cross-sectional areas. There was no correlation shown between the cross-sectional area of the symptomatic nerve and the severity of Headache Impact Test 6 scores (r = -0.342; P = .179). CONCLUSIONS: We report sonographic evidence showing an increased cross-sectional area and circumference of the symptomatic greater occipital nerve in patients with unilateral occipital neuralgia.

Symptomatic plantar fibroma with a unique sonographic appearance.

We present a case of a solitary plantar fibroma with unique sonographic features with MRI and pathologic correlation. A 25-year-old woman presented with a left foot mass that interfered with her gait. Sonography demonstrated a well-circumscribed, 32 mm × 27 mm × 14 mm subcutaneous mass with heterogeneous echogenicity. Unique sonographic characteristics included posterior acoustic enhancement, cystic components, and mild intratumoral hypervascularity. MRI confirmed the sonographic findings. Surgical excision was performed without complication. A pathologic diagnosis of fibroma with myxoid degeneration and cyst formation was made.

Normative cross-sectional area of the C5-C8 nerve roots using ultrasonography.

This study will define a normal range of values for the cross-sectional area (CSA) of the C5-C8 ventral rami in normal subjects and will assess the interexaminer reliability of the CSA measurements. We also describe the normal sonoanatomy of the C5-C8 ventral rami. Thirty-three normal subjects (20 female) were scanned bilaterally. The mean CSA and reference ranges for the C5, C6, C7 and C8 ventral rami were 7.1 +/- 4.1 mm(2), 10.6 +/- 4.3 mm(2), 12.1 +/- 4.1 mm(2) and 10.7 +/- 4.8 mm(2), respectively. The intraclass correlation coefficient (ICC) demonstrated good reliability with a coefficient of 0.76 overall, with individual level coefficients at C5, C6, C7 and C8 of 0.69, 0.71, 0.76 and 0.72, respectively. This is the first study to obtain normative CSA measurements of the C5-C8 ventral rami.

Sonography of the normal greater occipital nerve and obliquus capitis inferior muscle.

BACKGROUND: To use sonography to measure the cross-sectional area (CSA) of the greater occipital nerve (GON) and the adjacent obliquus capitis inferior muscle (OCI) in normal subjects. METHODS: Data from 30 asymptomatic subjects between the ages of 22 and 35 were collected. CSA and circumference of the GON and CSA of OCI were measured using sonography. Interexaminer reliability analysis was performed using the intraclass correlation coefficient. RESULTS: The CSA of the GON and OCI were 2 mm2 +/- 1 mm2 and 1.86 cm2 +/- 0.51 cm2, respectively. The average circumference of the GON was 4.8 mm +/- 1.3 mm. The interexaminer reliability of the measurements was excellent with intraclass correlation coefficient coefficients of 0.91, 0.84, and 0.73 for the GON CSA, GON circumference, and OCI CSA, respectively. CONCLUSION: We report the normal values of the CSA of the GON and OCI. Knowledge of these normal values may facilitate the diagnosis of GON entrapment and provide outcome measures in therapeutic interventions.

Patellar dislocation in a 16-year-old athlete with femoral trochlear dysplasia.

OBJECTIVE: This case report discusses the diagnosis and conservative management of a patient with femoral trochlear dysplasia (FTD) and subacute patellar dislocation. Femoral trochlear dysplasia is characterized by an abnormally shallow trochlear groove. Disengagement of the patella from the shallow femoral trochlea is common in FTD and is a predisposing risk factor to recurrent patellar dislocation and subsequent premature osteoarthrosis. Accurate diagnosis is necessary to prevent recurrent patellar dislocations and damage of the patellofemoral joint cartilage and supporting structures. CLINICAL FEATURES: A 16-year-old male adolescent presented with pain, ecchymosis, and swelling about the right anterior knee approximately one month after a self-described dislocating event. Clinical and imaging findings, including magnetic resonance imaging and ultrasonography, demonstrated evidence of patellar dislocation with previously undiagnosed FTD. INTERVENTION AND OUTCOME: After drainage of the knee effusion at a local hospital, the patient underwent a chiropractic treatment protocol consisting of stabilization with patellar tracking orthosis, customized orthotic support, and various muscular stabilization and strengthening exercises. After 6 weeks of treatment, the swelling and ecchymosis resolved. The knee ranges of motion were full without pain. Although the hypermobility of the patella demonstrated no interval change, the patient reported improved strength and stability of the right knee. CONCLUSION: This case highlights a young athlete with subacute patellar dislocation and FTD who responded successfully to conservative management. Conservative stabilization and strengthening protocols improved patient outcome without surgical repair of the underlying FTD. Conservative management of FTD has not been reported and it makes the current case unique. However, the long-term outcome of conservative management is unknown at this point and further studies are necessary to evaluate treatment protocols.

Normative cross-sectional area of the brachial plexus and subclavian artery using ultrasonography.

OBJECTIVE: Ultrasonography has been used to measure the cross-sectional area (CSA) of peripheral nerves, but the CSA of the brachial plexus has not previously been reported. The purpose of this study was to establish a reference range of values for the CSA of the brachial plexus, subclavian artery, and peak systolic velocity (PSV) of the subclavian artery in healthy subjects using ultrasonography. METHODS: Thirty-two asymptomatic subjects (19 men, 13 women) from a chiropractic college with an average age of 29.5 +/- 9.6 participated in the study. The brachial plexus and subclavian artery CSA were measured at 3 locations: interscalene, first rib, and infraclavicular. The PSV of the subclavian artery was measured in both supraclavicular and infraclavicular locations. Each subject was imaged bilaterally. Means and 95% confidence intervals were calculated. Interexaminer reliability was evaluated between 2 examiners on 15 randomly selected subjects. RESULTS: The average CSA for the brachial plexus at the interscalene space, first rib, and infraclavicular location was 0.75 +/- 0.05, 0.96 +/- 0.07, and 0.98 +/- 0.07 cm(2), respectively. The average CSA for the subclavian artery at the same locations was 0.35 +/- 0.03, 0.38 +/- 0.03, 0.35 +/- 0.03 cm(2), respectively. The average subclavian artery PSV in supraclavicular and infraclavicular locations was 98 +/- 8 and 93 +/- 7 cm/s, respectively. The overall interexaminer reliability was poor at 0.39 (0.20-0.55). CONCLUSIONS: This is the first study to obtain normative CSA measurements of the brachial plexus and subclavian artery in multiple locations of the thoracic outlet as well as interexaminer reliability data. These data may be beneficial in future studies designed to assess the brachial plexus and subclavian artery in patients with thoracic outlet syndrome.

Sacral fatigue fracture in a female runner: a case report.

OBJECTIVE: This case report describes and discusses the clinical presentation, diagnosis, and management of a patient with a sacral fatigue fracture. CLINICAL FEATURES: A 26-year-old female long-distance runner presented with nonspecific low-back and buttock pain that prevented her from training. INTERVENTION AND OUTCOME: Radiographic findings on the patient's lumbar spine and pelvis were interpreted as normal. Single-photon emission computed tomography and magnetic resonance imaging were performed, revealing a fatigue fracture of the left sacral ala. The patient discontinued training for 6 months and gradually returned to running. CONCLUSIONS: A high index of suspicion should prompt investigation with skeletal scintigraphy, computed tomography, or magnetic resonance imaging. Sacral stress fractures may respond well to conservative measures if diagnosed in a timely fashion.

Stress-induced spiculated periosteal reaction appearing as a malignant bone tumor: a case report.

OBJECTIVE: The aim of this study was to describe the appearance of a rare occurrence of a spiculated periosteal reaction caused by stress injury and the subsequent diagnostic assessments. A proposed mechanism for the etiology of stress-induced periosteal reactions in this case is offered. CLINICAL FEATURES: A 54-year-old female had ankle pain for 1 year. Radiographs revealed a spiculated periosteal reaction of the distal fibula. In light of the clinical history of prior breast carcinoma, the possibility of metastatic disease was entertained. INTERVENTION AND OUTCOME: Scintigraphy and magnetic resonance imaging were used in the diagnostic evaluation of this patient. Malignancy was ruled out on the basis of the magnetic resonance imaging findings, and an etiology of a stress reaction was proposed based on the scintigraphic findings. CONCLUSION: Stress-induced spiculated periosteal reactions are a rare occurrence. This case illustrates the role that advanced imaging plays in the assessment of a suspicious periosteal reaction.

Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management.

OBJECTIVE: To review current literature regarding the etiology, diagnosis, and conservative treatment of spondylolysis and spondylolytic spondylolisthesis. METHODS: The PubMed database was searched for articles on spondylolysis and/or spondylolisthesis and their incidence, diagnosis, imaging, treatment, and prognosis. The bibliographies of articles determined to be relevant were also reviewed. RESULTS: A PubMed search of spondylolysis or spondylolis-thesis yielded over 800 citations. Sixty-eight articles were selected based on an opinion of perceived relevance to the subjects of spondylolysis and spondylolisthesis. CONCLUSIONS: Spondylolysis affects approximately 6% of the population. The lesion likely represents a stress fracture and the typical age of onset is early childhood and adolescence. Most individuals are asymptomatic. Adolescents with low back pain may have an impending or new pars defect. A high index of suspicion for a new pars defect should prompt utilization of physiologic imaging to determine the likelihood of pars union in young patients. Restrictive bracing may lead to healing of the fracture and cessation of pain. Spondylolisthesis is a common complication of spondylolysis. Spondylolisthesis progression is typically small and most likely in young individuals. Significant progression in adults is rare. The finding of spondylolysis and spondylolisthesis in an adult patient is usually incidental and not likely to be a direct source of pain unless there is concurrent instability.