Visualization During Endoscopic Versus Open Cubital Tunnel Decompression: A Cadaveric Study.

PURPOSE: To determine the minimum incision size needed using an open cubital tunnel technique to obtain equivalent visualization comparable with an endoscopic technique. METHODS: Visualization was assessed in 10 fresh-frozen cadavers with a 2-cm incision, using percutaneous needle localization with the endoscopic system. The most proximal and distal extent of the field of view was marked. Next, an open cubital tunnel release was performed on each cadaver specimen. The incision size was increased incrementally, and the most proximal and distal extents of visualization were recorded for each incision size. The mean visualization distance and standard deviation for each incisional length were calculated. RESULTS: The mean proximal field of view with the endoscopic technique was 8.1 cm. The mean distal field of view was 8.3 cm. Using the open technique, a 2-cm incision allowed 5.9 cm visualization proximally and 5.2 cm distally, which was significantly less than the endoscopic view. A 4-cm open incision provided similar visualization as the endoscopic technique. A 6-cm open incision was required to obtain statistically significant improvements in visualization compared with an endoscopic technique. CONCLUSIONS: A 4-cm open incision allowed visualization of approximately 9 cm proximal and 9 cm distal to the medial epicondyle, which was equivalent to the 2-cm endoscopic technique for cubital tunnel release. CLINICAL RELEVANCE: Although the endoscopic release allows greater visualization of the ulnar nerve with a smaller incision, it is unclear whether this improvement in visualization improves the surgeon's ability to decompress the ulnar nerve.

The Utility of MRI in Evaluating Ruptures of the Patellar Tendon.

Background: Although the identification of patellar tendon rupture is a clinical diagnosis aided by standard radiography, magnetic resonance imaging (MRI) may aid in identifying the location of the rupture and concomitant pathology. Purpose: To evaluate the characteristics of patellar tendon tears needing surgical repair and to determine whether patient or injury factors were predictive of tear location. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients who underwent primary patellar tendon repair for rupture between May 15, 2017, and April 10, 2020, were reviewed retrospectively. Exclusion criteria included age <18 years, surgical treatment of multiligamentous knee injury, laceration injury, and knee arthroplasty. Radiographs, MRI scans, MRI reports, clinic notes, and operative notes were evaluated. Statistical analysis was performed to determine factors associated with tear location, complications, and reoperation. Results: In total, 147 patients and 156 tendon tears were included; 82.1% of the tears were patellar avulsions, 14.7% were midsubstance or complex tears, and 3.2% were tibial avulsions. Patient and injury characteristics (body mass index, race, medical comorbidities, presence of patellar tendinitis, mechanism of injury, Insall-Salvati ratio, and the presence of infrapatellar bone fragments) were not predictive of tear location (P > .05). Patellar tendon ruptures were able to be clinically diagnosed correctly in >99% of cases. MRI was used to evaluate 77 (49.4%) knees. Patients who underwent MRI before surgery were more likely to have a history of preexisting tendinitis (P = .015) and a lower preoperative Insall-Salvati ratio (1.68 vs 1.52; P = .017). Conclusion: Patient and injury factors were not predictive of tear location. The majority of patellar tendon tears were avulsion-type injuries from the inferior patella. MRI was not necessary to aid in the diagnosis of patellar tendon rupture, as 99.4% of tears were able to be diagnosed clinically without advanced imaging.

Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective.

The intent of this article is to discuss the evolving role of the myofascial trigger point (MTrP) in myofascial pain syndrome (MPS) from both a historical and scientific perspective. MTrPs are hard, discrete, palpable nodules in a taut band of skeletal muscle that may be spontaneously painful (i.e., active) or painful only on compression (i.e., latent). MPS is a term used to describe a pain condition that can be acute or, more commonly, chronic and involves the muscle and its surrounding connective tissue (e.g. fascia). According to Travell and Simons, MTrPs are central to the syndrome-but are they necessary? Although the clinical study of muscle pain and MTrPs has proliferated over the past two centuries, the scientific literature often seems disjointed and confusing. Unfortunately, much of the terminology, theories, concepts, and diagnostic criteria are inconsistent, incomplete, or controversial. To address these deficiencies, investigators have recently applied clinical, imaging (of skeletal muscle and brain), and biochemical analyses to systematically and objectively study the MTrP and its role in MPS. Data suggest that the soft tissue milieu around the MTrP, neurogenic inflammation, sensitization, and limbic system dysfunction may all play a role in the initiation, amplification, and perpetuation of MPS. The authors chronicle the advances that have led to the current understanding of MTrP pathophysiology and its relationship to MPS, and review the contributions of clinicians and researchers who have influenced and expanded our contemporary level of clinical knowledge and practice.

Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects With Chronic Myofascial Pain.

OBJECTIVE: To determine whether dry needling of an active myofascial trigger point (MTrP) reduces pain and alters the status of the trigger point to either a non-spontaneously tender nodule or its resolution. DESIGN: A prospective, nonrandomized, controlled, interventional clinical study. SETTING: University campus. PARTICIPANTS: A total of 56 subjects with neck or shoulder girdle pain of more than 3 months duration and active MTrPs were recruited from a campus-wide volunteer sample. Of these, 52 completed the study (23 male and 33 female). Their mean age was 35.8 years. INTERVENTIONS: Three weekly dry needling treatments of a single active MTrP. PRIMARY OUTCOMES: Baseline and posttreatment evaluations of pain using a verbal analogue scale, the Brief Pain Inventory, and the status of the MTrP as determined by digital palpation. Trigger points were rated as active (spontaneously painful), latent (requiring palpation to reproduce the characteristic pain), or resolved (no palpable nodule). SECONDARY OUTCOMES: Profile of Mood States, Oswestry Disability Index, and Short Form 36 scores, and cervical range of motion. PRIMARY OUTCOMES: A total of 41 subjects had a change in trigger point status from active to latent or resolved, and 11 subjects had no change (P < .001). Reduction in all pain scores was significant (P < .001). SECONDARY OUTCOMES: Significant improvement in posttreatment cervical rotational asymmetry in subjects as follows: unilateral/bilateral MTrPs (P = .001 and P = 21, respectively); in pain pressure threshold in subjects with unilateral/bilateral MTrPs, (P = .006 and P = .012, respectively); improvement in the SF-36 mental health and physical functioning subscale scores (P = .019 and P = .03), respectively; and a decrease in the Oswestry Disability Index score (P = .003). CONCLUSIONS: Dry needling reduces pain and changes MTrP status. Change in trigger point status is associated with a statistically and clinically significant reduction in pain. Reduction of pain is associated with improved mood, function, and level of disability.

Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain.

Myofascial trigger points (MTrPs) are palpable, tender nodules in taut bands of skeletal muscle that are painful on compression. MTrPs are characteristic findings in myofascial pain syndrome (MPS). The role of MTrPs in the pathophysiology of MPS is unknown. Localization, diagnosis, and clinical outcome measures of painful MTrPs can be improved by objectively characterizing and quantitatively measuring their properties. The goal of this study was to evaluate whether ultrasound imaging and elastography can differentiate symptomatic (active) MTrPs from normal muscle. Patients with chronic (>3 months) neck pain with spontaneously painful, palpable (i.e., active) MTrPs and healthy volunteers without spontaneous pain (having palpably normal muscle tissue) were recruited for this study. The upper trapezius muscles in all subjects were imaged, and the echotexture was analyzed using entropy filtering of B-mode images. Vibration elastography was performed by vibrating the muscle externally at 100 Hz. Color Doppler variance imaging was used to quantify the regions of color deficit exhibiting low vibration amplitude. The imaging measures were compared against the clinical findings of a standardized physical exam. We found that sites with active MTrPs (n = 14) have significantly lower entropy (p < 0.05) and significantly larger nonvibrating regions (p < 0.05) during vibration elastography compared with normal, uninvolved muscle (n = 15). A combination of both entropy analysis and vibration elastography yielded 69% sensitivity and 81% specificity in discriminating active MTrPs from normal muscle. These results suggest that active MTrPs have more homogeneous texture and heterogeneous stiffness when compared with normal, unaffected muscle. Our methods enabled us to improve the imaging contrast between suspected MTrPs and surrounding muscle. Our results indicate that in subjects with chronic neck pain and active MTrPs, the abnormalities are not confined to discrete isolated nodules but instead affect the milieu of the muscle surrounding palpable MTrPs. With further refinement, ultrasound imaging can be a promising objective method for characterizing soft tissue abnormalities associated with active MTrPs and elucidating the role of MTrPs in the pathophysiology of MPS.

A systematic comparison between subjects with no pain and pain associated with active myofascial trigger points.

OBJECTIVE: To determine whether standard evaluations of pain distinguish subjects with no pain from those with myofascial pain syndromes (MPS) and active myofascial trigger points (MTrPs) and to assess whether self-reports of mood, function, and health-related quality of life differ between these groups. DESIGN: A prospective, descriptive study. SETTING: University. PATIENTS: Adults with and without neck pain. METHODS: We evaluated adults with MPS and active (painful) MTrPs and those without pain. Subjects in the "active" (A) group had at least one active MTrP with spontaneous pain that was persistent, lasted longer than 3 months, and had characteristic pain on palpation. Subjects in the "no pain" (NP) group had no spontaneous pain. However, some of these subjects had discomfort upon MTrP palpation (latent MTrP), whereas others in the NP group had no discomfort upon palpation of nodules or had no nodules. OUTCOME MEASURES: Each participant underwent range of motion measurement, a 10-point manual muscle test, and manual and algometric palpation. The latter determined the pain/pressure threshold using an algometer of 4 predetermined anatomic sites along the upper trapezius. Participants rated pain using a verbal analog scale (0-10) and completed the Brief Pain Inventory and Oswestry Disability Scale (which included a sleep subscale), the Short -Form 36 Health Survey, and the Profile of Mood States. RESULTS: The A group included 24 subjects (mean age 36 years; 16 women), and the NP group included 26 subjects (mean age 26 years; 12 women). Group A subjects differed from NP subjects in the number of latent MTrPs (P = .0062), asymmetrical cervical range of motion (P = .01 for side bending and P = .002 for rotation), and in all pain reports (P < .0001), algometry (P < .03), Profile of Mood States (P < .038), Short Form 36 Health Survey (P < .01), and Oswestry Disability Scale (P < .0001). CONCLUSION: A systematic musculoskeletal evaluation of people with MPS reliably distinguishes them from subjects with no pain. The 2 groups are significantly different in their physical findings and self-reports of pain, sleep disturbance, disability, health status, and mood. These findings support the view that a "local" pain syndrome has significant associations with mood, health-related quality of life, and function.

Ultrasonic tissue characterization of the upper trapezius muscle in patients with myofascial pain syndrome.

Myofascial trigger points (MTrPs) are palpable, tender nodules in skeletal muscle that produce symptomatic referred pain when palpated. MTrPs are characteristic findings in myofascial pain syndrome (MPS). The role of MTrPs in the pathophysiology of MPS is unknown. Objective characterization and quantitative measurement of the properties of MTrPs can improve their localization and diagnosis, as well as lead to clinical outcome measures. MTrPs associated with soft tissue neck pain are often found in the upper trapezius muscle. We have previously demonstrated that MTrPs can be visualized using ultrasound imaging. The goal of this study was to evaluate whether texture-based image analysis can differentiate structural heterogeneity of symptomatic MTrPs and normal muscle.