Coincidence between the distribution of myofascial trigger points and the presence of blood vessels in the gastrocnemius muscle: Implications for invasive procedures.

PURPOSE: The gastrocnemius venous system presents different anatomical variants. There have been described four locations of myofascial trigger points (MTrPs) in this muscle. However, no studies have analyzed the coincidence between vessels and MTrPs present in the gastrocnemius. Therefore, the main objective was to study the anatomical variability of the venous system by ultrasound and its coincidence with the location of the MTrPs. METHODS: A total of 100 lower limbs were studied. The gastrocnemius vessels were analyzed one by one by sector (medial, central, and lateral), quantifying the number of vessels, their distribution, and the coincidence with MTrPs. RESULTS: All muscle heads showed at least one vessel per section. A large variability was observed, from one to eight vessels per muscle head, with the most frequent number being three in the gastrocnemius medialis and two in the gastrocnemius lateralis. In all cases, the location of the vessels coincided with the MTrPs. CONCLUSIONS: The proximal gastrocnemius venous pattern is very variable between subjects in number of vessels and distribution, which has made it impossible to define a "safe" approach window for invasive procedures without ultrasound guidance. The coincidence between the clinical location of MTrPs of the gastrocnemius and the presence of vessels is total.

Galvanic current activates the NLRP3 inflammasome to promote Type I collagen production in tendon.

The NLRP3 inflammasome coordinates inflammation in response to different pathogen- and damage-associated molecular patterns, being implicated in different infectious, chronic inflammatory, metabolic and degenerative diseases. In chronic tendinopathic lesions, different non-resolving mechanisms produce a degenerative condition that impairs tissue healing and which therefore complicates their clinical management. Percutaneous needle electrolysis consists of the application of a galvanic current and is an emerging treatment for tendinopathies. In the present study, we found that galvanic current activates the NLRP3 inflammasome and induces an inflammatory response that promotes a collagen-mediated regeneration of the tendon in mice. This study establishes the molecular mechanism of percutaneous electrolysis that can be used to treat chronic lesions and describes the beneficial effects of an induced inflammasome-related response.

Galvanic current dosage and bacterial concentration are determinants of the bactericidal effect of percutaneous needle electrolysis: an in vitro study.

Percutaneous needle electrolysis (PNE) is a physiotherapy technique that has been shown to be effective in different pathologies such as tendinopathies or mammary fistula. For many years, theoretical bactericidal and germicidal effects have been attributed to this type of galvanic currents, partly explained by the changes in pH that it generates. However, these effects have not yet been demonstrated. The aim of this study was to evaluate the bactericidal effect and the changes in pH caused by PNE. S. aureus were prepared in two different solutions (TSB and saline solution) and in different concentrations (from 9 to 6 Log10 CFU/mL). Bacteria were treated with three experimental PNE doses to assess bacterial death levels and the changes caused to the pH of the medium. The viable cell count showed that all experimental PNE doses had a bactericidal effect against a high concentration (9 Log10 CFU/mL) of S. aureus in saline solution (p < 0.001). Furthermore, we found that when the concentration of bacteria decreased, a lower dose of galvanic current generated the same effect as a higher dose. Changes in pH were registered only in experiments performed with saline solution. PNE had a bactericidal effect against S. aureus and the level of this effect was mainly modulated by the solution, the bacterial concentration and the dose. Changes affecting pH were modulated by the type of solution and there was no relationship between this and bacterial death.

Safety analysis of percutaneous needle electrolysis: a study of needle composition, morphology, and electrical resistance.

BACKGROUND: Percutaneous needle electrolysis (PNE) consists of a galvanic current combined with the insertion of a solid needle into the tissues of the musculoskeletal system. The application of a galvanic current through a needle can alter the morphology and composition during treatment application. This procedure may also provoke a localized temperature increase. AIM: The aim was to evaluate the safety of the PNE procedure by analyzing possible alterations of the needles employed. METHODS: Physio Invasiva® and AguPunt EPI® brand needles, commonly used for the application of this technique, were analyzed in response to three different treatment protocols. Temperature changes were evaluated with the needles immersed in a test tube containing Ringer's solution, and electrical resistance was evaluated with a multimeter. The morphology of the needles, pre- and post-treatment, was examined with a scanning electron microscope (FEI Quanta 600), and the composition of the needles was evaluated using RX diffusion with Oxford Instruments software. RESULTS: Ringer's solution contained in the test tubes examined did not present temperature changes. No changes were observed in the needles under investigation with respect to electrical resistance, morphology, or composition with a protocol applying 3-mA intensity for 3 s and three applications. However, important morphological alterations were observed that affected needle composition after 50 applications (at 3 mA for 3 s). CONCLUSION: PNE, applied according to conventional protocols, appeared to be safe and athermal, and did not provoke a loss of metal particles or modify the morphology of the needles used when studied in vitro.

Comparison of Pain Measures Between Tendons of Elite Basketball Players With Different Sonographic Patterns.

CONTEXT: The prevalence and negative consequences of the symptoms surrounding patellar tendinopathy constitute an important problem for sports medicine professionals. The identification of potential pain mediators is, therefore, of major interest to improve both the prevention and management of this injury. OBJECTIVE: To compare the pain experienced by elite male adult basketball players and patterns of patellar tendon abnormalities. Also, to identify whether structural and vascular sonographic abnormalities (focal area of hypoechogenicity, thickening, and neovascularization [NV]) are equal in determining pain perceptions. DESIGN: An observational study with professional basketball teams (ACB-Spanish league). PARTICIPANTS: A total of 73 male basketball players (mean age 26.8 y). MAIN OUTCOME MEASURES: Patellar tendon ultrasonography images. Pain scores were compared between the identified patterns. Multiple regression analysis was used to examine the relative importance of abnormalities. RESULTS: Of the 146 tendons, 91 had some degree of sonographic abnormality. Three main patterns were identified: I (1 structural abnormality without NV), II (2 structural abnormalities without NV), and III (2 structural abnormalities and NV). A total of 31 tendons (21.2%) exhibited pattern I, 46 (31.5%) presented pattern II, and 13 tendons (8.9%) exhibited pattern III. The mean visual analog scale and the Victorian Institute of Sport assessment questionnaire-patellar tendon (VISA-P) scores for pattern III were significantly different (P < .05) compared with patterns I and II; however, the pain pressure threshold (PPT) scores were not. NV was significantly associated with worsened scores for all pain measures; however, the focal area of hypoechogenicity was only associated with PPT scores. CONCLUSION: Patterns of sonographic abnormalities, including NV, demonstrated greater pain. Although NV determined scores for the visual analog scale, VISA-P, and PPT, the presence of focal area of hypoechogenicity on its own is a determining factor for the PPT. This study suggests that the combination of 2 or more sonographic abnormalities may help explain pain variations among basketball players.

Lower Limb Dominance, Morphology, and Sonographic Abnormalities of the Patellar Tendon in Elite Basketball Players: A Cross-Sectional Study.

CONTEXT: Patellar tendinopathy is common in basketball players, and structural ultrasound abnormalities can be found in symptomatic and asymptomatic tendons. Lower limb dominance may also be a critical load factor, potentially leading to overloading of the patellar tendon. OBJECTIVE: To describe and compare the prevalence by lower limb dominance of patellar tendons with structural and vascular abnormalities and to describe the morphologic measures of tendons without abnormalities among adult male elite basketball players. DESIGN: Cross-sectional study. SETTING: Medical center of a professional basketball team in the Spanish league. PATIENTS OR OTHER PARTICIPANTS: A total of 73 adult male elite basketball players (146 patellar tendons; age = 26.8 ± 4.9 years, height = 198.0 ± 0.1 cm, mass = 95.4 ± 11.4 kg). MAIN OUTCOME MEASURE(S): We used ultrasound to screen the patellar tendons for the presence of structural and vascular abnormalities. Tendons were categorized as abnormal if they demonstrated a focal area of hypoechogenicity, thickening, or neovascularization. We also examined the cross-sectional area and thickness of tendons without abnormalities. Prevalence and morphologic measures were compared by limb dominance. RESULTS: A total of 35 players (48%) had bilateral abnormalities, whereas 21 (28.7%) had unilateral abnormalities. Among the 91 abnormal tendons, 90 (61.6% of 146 tendons) exhibited a focal area of hypoechogenicity, 59 (40.4% of 146 tendons) exhibited thickening, and 14 (9.6% of 146 tendons) exhibited neovascularization. No group differences were detected between the dominant and nondominant limbs. Among the 55 normal patellar tendons, 34 were bilateral (from 17 players) and 21 were unilateral. Approximately 25% (n = 14) of all 55 normal tendons had a cross-sectional area that was greater than 182.8 mm2 and a thickness greater than 7.2 mm. Among the 34 bilateral normal tendons, no group differences were observed between the dominant and nondominant limbs for either cross-sectional area or thickness. CONCLUSIONS: The prevalence of abnormal tendons was high among adult male elite basketball players, and bilateral presentations were more frequent. Structural abnormalities were most common.

Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results.

BACKGROUND: Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle. OBJECTIVE: To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time. METHODS: A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4-6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients' perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates. RESULTS: All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as 'successful' at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a 'successful' outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks. CONCLUSIONS: Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT02085928.

Quality measures for the care of patients with lateral epicondylalgia.

BACKGROUND: Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments. The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE. METHODS: Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel. RESULTS: Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (Kappa > 0.8). CONCLUSIONS: A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators.