Muscle shear wave elastography, conventional B mode and power doppler ultrasonography in healthy adults and patients with autoimmune inflammatory myopathies: a pilot cross-sectional study.

BACKGROUND: Before the role of shear wave elastography (SWE) and B mode ultrasound (US) in the diagnosis of different forms of idiopathic inflammatory myopathies (IIM) can be investigated, normative data is required. This study aimed to describe and then compare normative SWE and B mode ultrasound metrics of muscles in healthy controls and patients with IIM. METHODS: Twenty nine healthy adult controls and 10 IIM patients (5 with inclusion body myositis and 5 with necrotising autoimmune myopathy) underwent a full clinical examination, laboratory investigations, SWE and US measurements of selected proximal and distal limb muscles. Shear wave speed (SWS) and multiple US domains [echogenicity, fascial thickness, muscle bulk and power Doppler (PD)] were measured in both groups. RESULTS: In healthy controls (n = 29; mean age 46.60 ± 16.10; 44.8 % female), age was inversely correlated with SWS at the deltoid (stretch) (Rs. -0.40, p = 0.030) and PD score at the deltoid (rest) (Rs. -0.40, P = 0.032). Those ≥ 50 years old had a lower SWS at the deltoid (stretch) compared to the < 50 year group (2.92 m/s vs. 2.40 m/s, P = 0.032). Age correlated with increased echogenicity in the flexor digitorum profundus (Rs. 0.38, P = 0.045). Females had a smaller muscle bulk in the deltoid (P = 0.022). Body mass index (BMI) was inversely associated with SWS in the deltoid (stretch) (Rs - 0.45, P = 0.026), and positively correlated with echogenicity in the deltoid (Rs. 0.69, P = 0.026). In patients ≥50 years of age, patients with IIM (mean age 61.00 ± 8.18; females 20.0 %) had a higher proportion of abnormal echogenicity scores at the flexor digitorum profundus (FDP) (40.00 % vs. 14.30 %, P = 0.022) and tibialis anterior (TA) (80.00 % vs. 28.60 %, P = 0.004). Fascial thickness was lower in the FDP (0.63mm vs. 0.50mm, p = 0.012) and TA (0.58mm vs. 0.45mm, P = 0.001). CONCLUSIONS: Our findings suggest there is scope for US techniques to be useful for diagnostic screening of affected muscles in patients with IIM, especially in those with suspected inclusion body myositis or necrotising autoimmune myopathy. We provide normative data for future studies into SWE and US techniques in skeletal muscle. The differences between IIM patients and controls warrant further study in a broader IIM patient cohort.

Cortical desmoid of the humerus: radiographic and MRI correlation.

Cortical desmoids are self-limiting fibro-osseous lesions commonly occurring at the medial supracondylar femur in active adolescents, at either the origin of the medial head of the gastrocnemius or at the insertion of the adductor magnus aponeurosis. Less commonly, in a similar demographic, cortical desmoids may occur in the proximal humerus medially at the insertion of the pectoralis major muscle or laterally at the insertion of the deltoid. The radiographic appearance of the proximal humerus cortical desmoid has been described previously, but not the MRI appearance. We present the radiographic and MRI appearances of a proximal humerus cortical desmoid in a young adolescent who presented for investigation of right shoulder pain.

Plexiform neurofibroma causing an ossifying subperiosteal haematoma: a rare case in the tibia of an 11-year-old girl.

Ossifying subperiosteal haematoma is an exceedingly rare manifestation of Neurofibromatosis type 1 (NF-1). We report an interesting case of plexiform neurofibroma causing a rapidly growing tibial mass as a result of subperiosteal haemorrhage, in an 11-year-old girl with previously undiagnosed NF-1. This reflects a precursor of the more mature periosteal ossification seen in cases traditionally termed "subperiosteal cysts". A previously well young girl was referred by her general practitioner with an increasingly large, mildly tender, soft lump on the anterior aspect of her right tibia. Plain radiographs demonstrated soft tissue thickening overlying the anterior tibia, without appreciable periosteal ossification. Magnetic resonance imaging (MRI) illustrated a single central fluid-fluid level and periosteal elevation with saucerisation of the anterior tibial cortex and mild surrounding oedema. Histopathology revealed a large plexiform neurofibroma. Interestingly, this was associated with haemorrhagic change and a peripheral rim of florid reactive new bone formation. This unusual presentation was discussed at a multidisciplinary bone and soft tissue tumour meeting, where in combination with the clinical history of café au lait spots and positive family history, a consensus diagnosis of NF-1 was made. To date, there have only been limited case reports of this rare pathological process. In summary, this case report accounts an acute presentation of this rare osseous manifestation of NF-1, being the first to clearly demonstrate a timeline of subperiosteal haematoma with subsequent subperiosteal bone proliferation. The clinical reasoning and radiological features for such a presentation are also described.

Ultrasound-Guided Radiofrequency Denervation of the Medial Calcaneal Nerve.

OBJECTIVE: Plantar fasciosis is a common complaint of athletes, particularly for runners. The medial calcaneal nerve (MCN) may play a role in the pain syndrome, and radiofrequency (RF) denervation has been previously reported. The hypothesis is that ultrasound-guided denervation of the MCN results in symptomatic improvement. DESIGN: Retrospective cohort. SETTING: Private practice. PATIENTS: Twenty-nine patients previously receiving ultrasound-guided RF denervation of the MCN, having failed conservative therapy, were assessed in 2 groups, those more than (group 1, n = 16) or less than (group 2, n = 13) 6 months since the procedure. INTERVENTIONS: Ultrasound-guided RF denervation of the MCN. MAIN OUTCOME MEASURES: Pain scores before denervation, as well as at maximal pain relief and the time of the interview. Levels of satisfaction and attitudes toward surgery were also assessed. RESULTS: Pain scores decreased significantly in both groups, for both best and residual pain scores. Group 1 mean pain scores were 8.56 before procedure, 2.81 (P < 0.001 compared to baseline) at best pain score, and 3.75 (P < 0.01) residual pain score. Group 2 mean pain scores were 7.23 before procedure, 3.77 (P < 0.01) at best pain score and 4.92 (P < 0.01) residual pain score. Levels of satisfaction were predominantly positive (69% of group 1% and 54% of group 2 were either somewhat or very satisfied), with attitudes toward surgery unchanged. CONCLUSIONS: For patients with refractory plantar heel pain, ultrasound-guided denervation of the MCN can potentially improve symptoms, although efficacy needs assessing in comparative studies. CLINICAL RELEVANCE: Ultrasound-guided denervation of the MCN provides a further management option for patients with refractory plantar fasciosis.

Muscle injuries of the lower leg.

Muscle injuries of the lower leg are a common cause for time off from sports, and may also be a cause of disability in nonathletes who have a running or "pushing off" injury as part of their activities of daily living. Most injuries can be managed without imaging, but in selected cases advanced imaging techniques can demonstrate the exact site and extent of the injury and potentially modify rehabilitation and return to sports. In experienced hands ultrasonography can identify the location of muscle injuries as well as aid in hematoma aspiration. It is useful for excluding differential diagnoses such as deep vein thrombosis or Baker's cyst and may be superior for investigating certain conditions such as muscle hernia. Magnetic resonance imaging is more sensitive for injury to deeper muscles and dual injuries and is generally the modality of choice in elite athletes.

Imaging in the diagnosis of idiopathic inflammatory myopathies; indications and utility.

INTRODUCTION: Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of muscle diseases that carry a significant morbidity and mortality risk. The utilization of imaging in the diagnostic pathway of IIM is therefore important to obtain early diagnosis and even monitor patients over time. Areas covered: Magnetic resonance imaging (MRI) has been the main imaging modality used to detect myositis but limitations include cost and accessibility, leading to delays in time to scan, and patient contraindications. This has led to the exploration of other imaging techniques to diagnose and monitor response to therapy. This article is based primarily on a literature search via PubMed using Boolean terms 'myositis' and the various imaging modalities. Expert opinion: Imaging is sensitive to pathology in IIM and may contribute to the diagnostic process. Learning how specific imaging features can distinguish different forms of IIM may allow more rapid diagnosis of myositis subtype and treatment planning, and to monitor disease activity particularly in patients who respond poorly to treatment. However, more work is needed to investigate the validity and relative utility of these imaging modalities.

Normative MRI, ultrasound and muscle functional MRI findings in the forearms of asymptomatic elite rowers.

OBJECTIVES: Forearm injuries are common and debilitating to elite rowers. Chronic exertional compartment syndrome, intersection syndrome and proximal radial bone stress injuries have been documented in this population. This paper explores the imaging findings related to these conditions in asymptomatic elite rowers. DESIGN: Observational study. METHODS: 19 asymptomatic senior elite and under-23 rowers currently competing at National level or above underwent ultrasound (US), Magnetic Resonance Imaging (MRI) and muscle functional MRI evaluation of their forearms. A comprehensive evaluation sheet identifying characteristics of bone stress, intersection syndrome and chronic exertional compartment syndrome was utilised based on a literature search and review by senior clinicians working with this population. RESULTS: Peritendinous fluid of Extensor Carpi Radialis Longus (n=10, 53%) or Extensor Carpi Radialis Brevis (n=6, 32%) was a common finding on US. MRI had a higher rate of identification than US. Extensor Digitorum (Coeff=-1.76, 95%CI -3.04 to -0.49), Flexor Carpi Radialis (Coeff=-2.86, 95%CI -5.35 to -0.38) and Flexor Carpi Ulnaris (Coeff=-3.31, 95%CI -5.30 to -1.32), Pronator Teres (Coeff=-3.94, 95%CI -6.89 to -0.99), and Supinator (Coeff=-168, 95%CI -3.28 to -0.02) showed statistically significant changes immediately post-exercise. Mild proximal radial marrow hyperintensity was present (n=15, 78.9%) with three participants (15.8%) also having mild periosteal oedema of the radius. CONCLUSIONS: Imaging findings commonly seen in symptomatic populations are observed in elite, asymptomatic rowers. Care should be taken when diagnosing bone stress injuries, intersection syndrome and compartment syndrome on imaging findings alone. Data presented can be utilised as a normative dataset for future case studies.

Pattern of Fascicular Involvement in Midportion Achilles Tendinopathy at Ultrasound.

BACKGROUND: The Achilles tendon is composed of fascicles from the soleus and gastrocnemius muscles, which are identifiable as discrete components at anatomical dissection. HYPOTHESIS: The pattern of fascicular involvement in Achilles tendinopathy may be characterized at ultrasound, and this characterization is reliable between different observers. STUDY DESIGN: Cross-sectional diagnostic study. LEVEL OF EVIDENCE: Level 3. METHODS: One hundred cases of Achilles tendinopathy were retrospectively evaluated by 2 blinded musculoskeletal radiologists. Using a short-axis anatomical map, each case was categorized as involving the fascicular territories of the medial head of gastrocnemius, lateral head of gastrocnemius, soleus, or combinations of these, or as indeterminate. RESULTS: Both radiologists agreed on the fascicular involvement pattern in 93 of 100 cases; 20 involved only medial gastrocnemius territories, 8 lateral gastrocnemius, 15 soleus, 3 medial and lateral gastrocnemius, 21 medial gastrocnemius and soleus, 9 soleus and lateral gastrocnemius, and 16 the entire tendon, and 1 case was classified as indeterminate. In 7 cases, the interpretations were discordant. The kappa value was calculated as 0.92 (95% CI, 0.86-0.98) in keeping with a high level of interobserver agreement. CONCLUSION: As assessed at ultrasound, most cases of Achilles tendinopathy involve the medial head of gastrocnemius and/or soleus fascicles. CLINICAL RELEVANCE: The provided observational data will increase understanding of patterns of Achilles tendinopathy.

Cell therapy in joint disorders.

CONTEXT: Articular cartilage possesses poor natural healing mechanisms, and a variety of non-cell-based and cell-based treatments aim to promote regeneration of hyaline cartilage. DATA SOURCES: A review of the literature to December 2013 using PubMed with search criteria including the keywords stem cell, cell therapy, cell transplantation, cartilage, chondral, and chondrogenic. STUDY SELECTION: Forty-five articles were identified that employed local mesenchymal stem cell (MSC) therapy for joint disorders in humans. Nine comparative studies were identified, consisting of 3 randomized trials, 5 cohort studies, and 1 case-control study. STUDY TYPE: Clinical review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Studies were assessed for stem cell source, method of implantation, comparison groups, and concurrent surgical techniques. RESULTS: Two studies comparing MSC treatment to autologous chondrocyte implantation found similar efficacy. Three studies reported clinical benefits with intra-articular MSC injection over non-MSC controls for cases undergoing debridement with or without marrow stimulation, although a randomized study found no significant clinical difference at 2-year follow-up but reported better 18-month magnetic resonance imaging and histologic scores in the MSC group. No human studies have compared intra-articular MSC therapy to non-MSC techniques for osteoarthritis in the absence of surgery. CONCLUSION: Mesenchymal stem cell-based therapies appear safe and effective for joint disorders in large animal preclinical models. Evidence for use in humans, particularly, comparison with more established treatments such as autologous chondrocyte implantation and microfracture, is limited.