Iron deficiency in athletes: A narrative review.

Iron deficiency is a concern for athletes due to potential for performance impairments attributed to lower iron status with, or without, accompanying anemia. Despite the high interest in the topic for endurance athletes and medical providers who care for this population, the evaluation and management of athletes with iron deficiency is still evolving, particularly in relation to iron deficiency non-anemia (IDNA). This narrative review presents causes of iron deficiency in the athlete, clinical presentation, differential diagnoses, diagnostic evaluation, and proposed strategies for treatment.

Ultrasound-Guided Cutting Wire Release of the Posterior Iliotibial Band: A Feasibility Study.

BACKGROUND: Distal iliotibial band friction syndrome (ITBFS) is a common cause of knee pain in endurance athletes. Nonsurgical treatment is usually successful, but surgery is occasionally required for recalcitrant cases. No published studies to date have evaluated the feasibility of an ultrasound-guided (USG) partial iliotibial band (ITB) release. OBJECTIVE: To determine the feasibility of an USG partial ITB release using a cutting wire. A secondary aim was to assess whether adjacent structures were damaged. We hypothesized that the posterior distal ITB could be partially transected with a cutting wire under USG with no injury to adjacent structures. DESIGN: Cadaveric study. SETTING: Quaternary-care academic institute. PARTICIPANTS: Ten cadaveric knees ranging from 76-89 years old with a mean body mass index of 21.9 kg/m2 . INTERVENTIONS: One physician sonographer performed USG releases of the posterior ITBs at the level of the lateral femoral epicondyle with a cutting wire. Dissection was carried out by an independent second physician to assess for primary and secondary outcomes. MAIN OUTCOME MEASURES: (1) Release of the posterior border of the ITB; (2) width of the release; (3) evaluation for any injury to adjacent structures; (4) technical difficulty of the procedure (0 = no difficulty, 10 = most difficult procedure possible); (5) duration of time it took to complete the procedure. RESULTS: All 10 knees had the posterior border of the ITB transected. Mean release length was 16 mm (range 15-17), which was within 1 mm of the target release length of 15 mm. No adjacent structures were damaged. CONCLUSION: A USG release of the posterior ITB utilizing a cutting wire is feasible and safe in a cadaveric model. Translational research is warranted to determine how these results apply to the clinical setting.

Isolated meniscus extrusion associated with meniscotibial ligament abnormality.

PURPOSE: The purpose of this study was to describe meniscus extrusion, present imaging characteristics, and provide clinical correlations for patients with isolated meniscus extrusion. METHODS: Of the 3244 MRI reports identified as having meniscus extrusion, 20 patients were identified to have isolated meniscus extrusion (0.62%). Patients with moderate to severe chondromalacia, meniscus tears, intra-articular fractures, tumours, and ligament tears were excluded. Radiographs were reviewed and graded using Kellgren-Lawrence (K-L) scores. MRI's were reviewed for the extent of extrusion and whether or not the meniscotibial ligament was intact. Clinical presentation and management were recorded. RESULTS: The study population consisted of 12 females and 8 males with a mean age of 40.5, diagnosed with meniscus extrusion and minimal concomitant knee pathology. 68% of patients were considered symptomatic as their knee pain correlated with the side of their meniscus extrusion and no other reason for pain was identified. The mean amount of meniscus extrusion was 2.5 mm (SD ± 1.1 mm) with 45% (9 of 20) having 3 + mm of extrusion. Meniscotibial ligament abnormality was identified in 65% of cases (13 of 20). Patients with 3 + mm of meniscus extrusion were much more likely to have associated meniscotibial ligament abnormality (100%, 9 of 9) compared to those with < 3 mm of extrusion (36%, 4 of 11) (RR 2.75, p = 0.048). The mean K-L grade obtained at the initial visit was 0.9 (95% CI 0.7-1.4) and the mean K-L grade obtained on final follow-up was 1.3 (95% CI 0.8-2.8) (n.s.) at a mean of 44.7 months. No correlation was found between K-L grade, gender, age, acute injury, and BMI in relation to meniscotibial ligament abnormality or amount of meniscal extrusion. CONCLUSIONS: Meniscus extrusion often occurs in the presence of significant knee pathology, predominantly with meniscus tears or osteoarthritis. Isolated meniscus extrusion is a rare occurrence that may present clinically with knee pain, commonly to the side in which the extrusion occurs. In patients with three or more millimetres of meniscus extrusion, an intact meniscus and minimal knee pathology, meniscotibial ligament abnormality is likely. This may provide an opportunity to treat the meniscotibial ligament abnormality with meniscus centralisation technique and decrease the amount of meniscus extrusion.

Ultrasound-Guided Cubital Tunnel Decompression in a Collegiate Swimmer: A Case Report.

A 19-year-old female collegiate swimmer presented to our sports medicine clinic with a history and physical examination consistent with right ulnar neuropathy at the cubital tunnel. Diagnostic ultrasound (US) revealed compression of the ulnar nerve under the cubital tunnel retinaculum (CTR) with nerve swelling proximal to the site of compression. Electrodiagnostic studies confirmed the diagnosis of a moderate to severe ulnar neuropathy at the elbow. Treatment consisted of an US-guided decompression of the ulnar nerve in the cubital tunnel by cutting the CTR using a rotated stylet "v" cutting technique. The patient's symptoms resolved, and she was able to begin a swimming progression 2 weeks after the procedure. After completion of this progression, she was able to successfully resume full, unrestricted competitive collegiate swimming without return of her symptoms. To the best of our knowledge, this is the first description of an US-guided cubital tunnel decompression surgery.

Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Case Report.

Chronic exertional compartment syndrome (CECS) is characterized by an excessive increase in intracompartmental muscle pressures after exercise. Athletes with CECS report pain, pressure, and occasionally neurologic symptoms in the affected compartment during exercise that abates with rest. Although many treatment options have been proposed, athletes often require a fasciotomy to return to unrestricted sports participation. Surgical success rates vary; complications are not uncommon; and after surgery, it usually takes athletes 6 or more weeks to return to unrestricted impact activities. This case report describes a new ultrasound-guided fasciotomy technique for the treatment of anterior leg compartment CECS. The procedure required a 3 mm incision, was performed in the office under local anesthesia, and allowed the athlete to resume running within 1 week of the procedure. Although the preliminary results of this study are promising, further translational research is required before the widespread adoption of this procedure is recommended.

Ultrasound-Guided Cutting Wire Release of the Proximal Adductor Longus Tendon: A Feasibility Study.

BACKGROUND: Adductor longus tendinopathy is a well-known etiology of chronic groin pain in elite athletes. Surgery is indicated for those who fail conservative treatment. No studies to date have evaluated the feasibility of an ultrasound-guided release of the proximal adductor longus tendon. PURPOSE/HYPOTHESIS: The primary aim of this study was to determine the feasibility of an ultrasound-guided selective adductor longus release with a cutting wire. A secondary aim was to determine safety by avoiding injury to adjacent structures. We hypothesized that the proximal adductor longus tendon can be released under ultrasound guidance with a cutting wire without injury to adjacent neurovascular or genitourinary structures. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten adductor longus tendons (5 cadaveric specimens) from 4 males and 1 female between 76 and 89 years of age with a mean body mass index of 21.9 kg/m2 (range, 16.8-29.6 kg/m2) were used during this study. A single experienced physician sonographer performed ultrasound-guided proximal adductor longus tendon releases on all cadaveric specimens using a cutting wire. Dissection was performed by a second physician to determine the completeness of the tendon transections and to detect injury to adjacent neurovascular or genitourinary structures. RESULTS: All 10 adductor longus tendons were transected. Eight of 10 transections were complete, whereas in 2 transections, >99% of the tendon was transected. There were no injuries to adjacent genitourinary or neurovascular structures. CONCLUSION: Ultrasound-guided adductor tendon release is feasible and safe in a cadaveric model. Further translational research should be performed to determine whether these results can be replicated in the clinical setting. CLINICAL RELEVANCE: Adductor longus tendinopathy frequently requires surgical intervention and prolonged time away from sport. The present study suggests that a selective adductor longus tendon release can be performed with ultrasound guidance. This procedure warrants further translational research to explore its use in clinical practice.

Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is a common cause of exertional leg pain. It is commonly treated with a surgical fasciotomy, which has a surgical complication rate of up to 16% and takes approximately 6-12 weeks to return to preprocedure activity levels. Therefore, the development of a less invasive, effective outpatient intervention to treat CECS is desirable. OBJECTIVE: To describe and validate an ultrasound-guided (USG) fasciotomy technique for the anterior and lateral compartments of the lower limb in an unembalmed cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Academic institution procedural skills laboratory. SUBJECTS: Ten unembalmed cadaveric knee-ankle-foot specimens from 1 female (2 specimens) and 7 male donors aged 62-91 years (mean 78.6 years) with body mass indices of 18.9-35.3 kg/m2 (mean 27.1 kg/m2). METHODS: Two experienced operators each performed USG anterior and lateral compartment fasciotomies on 5 unembalmed cadaveric legs. A third physician subsequently dissected the legs to assess the continuity of the fasciotomies and to identify any neurovascular damage related to the procedures. MAIN OUTCOME MEASURES: Fasciotomy length (in centimeters) and classification by completeness (achieved target length or did not achieve target length) and continuity (continuous or discontinuous) based on predetermined criteria. Muscles, retinaculae, and neurovascular structures were assessed for damage. RESULTS: No neurovascular injuries occurred in any of the 20 USG fasciotomies. The average fasciotomy length was 22.5 cm. All 20 of the fasciotomies achieved the target length. A continuous cephalocaudal fasciotomy was accomplished in 13 of 20 fasciotomies. When a fasciotomy was not continuous, the average length and number of intact fascial bands was 1.52 cm and 2.3, respectively. CONCLUSIONS: USG fasciotomy of the anterior and lateral leg compartments can be safely performed in a cadaveric model and can achieve a fasciotomy length comparable to surgical fasciotomy. Most procedures successfully achieved a continuous cephalocaudal fasciotomy, although small areas of intact fascial bands were identified in approximately one-third of procedures. The clinical significance of this finding is indeterminate. Given the safety demonstrated with this minimally invasive USG fasciotomy in a cadaveric model, further research is warranted to develop and refine the technique for clinical application. LEVEL OF EVIDENCE: Not applicable.

Ultrasound-Guided, Percutaneous Needle Fascial Fenestration for the Treatment of Chronic Exertional Compartment Syndrome: A Case Report.

Chronic exertional compartment syndrome (CECS) involves a painful increase in compartment pressure caused by exercise and relieved by rest. The most common site for CECS in the lower extremity is the anterior leg compartment. We report a case of a collegiate athlete with bilateral anterior and lateral leg compartment CECS who was successfully treated with an ultrasound-guided, percutaneous needle fascial fenestration of the affected compartments in both legs and was able to return to full, unrestricted activity within 1 week of the procedure. This case highlights the potential application of this procedure for the treatment of anterior and lateral leg CECS.

Variability of the Ischiofemoral Space Relative to Femur Position: An Ultrasound Study.

BACKGROUND: Ischiofemoral impingement is caused by compression of the quadratus femoris muscle between the ischial tuberosity and lesser trochanter. The evaluation of ischiofemoral impingement includes radiologic studies to evaluate the ischiofemoral space dimensions. No prior study has evaluated the effect of femoral position on ischiofemoral space dimensions. OBJECTIVE: To determine whether the dimensions of the ischiofemoral space vary with changes in femoral position. DESIGN: Cross-sectional study. SETTING: Academic institution. PARTICIPANTS: Six male and four female subjects with no hip pain and no history of hip disorders or surgery were selected to participate in the study. The subjects' mean age was 31.5 years; mean height, 176.8 cm; mean weight, 70.2 kg; and mean body mass index, 23.6 kg/m(2). METHODS: Ultrasound was used to measure the ischiofemoral space in bilateral gluteal regions of each volunteer. The volunteers underwent imaging in a prone position. The ischiofemoral space was measured with the femur in 9 different positions created through various combinations of frontal (15° abduction, neutral, and 15° adduction) and transverse (30° internal rotation, neutral, and 30° external rotation) plane hip motions. MAIN OUTCOME MEASUREMENTS: The narrowest ischiofemoral interval, defined as the narrowest distance between the medial cortex of the lesser trochanter and the lateral cortex of the ischial tuberosity. RESULTS: The anatomic landmarks used to measure the ischiofemoral space were easily identified in all subjects. The frontal plane main effect (F2,18 = 38.611) was statistically significant (P < .001), as was the transverse plane main effect (F2,18 = 82.452, P < .001). These findings indicated that there was a statistically significant difference in ischiofemoral space according to hip position in the frontal and transverse planes. The largest ischiofemoral space measurement occurred with the hip in abduction and internal rotation (51.8 mm; 95% confidence interval [CI], 49.2-54.5 mm), whereas hip adduction and external rotation resulted in the narrowest ischiofemoral space measurement (30.8 mm; 95% CI, 25.5-36.0 mm). The largest difference was between the adduction-external rotation and the abduction-internal rotation positions (mean difference = 21.1 mm; 95% CI, 13.7-28.5 mm; P < .001), and the smallest difference was between the adducted-neutral rotation and the abducted-external rotation positions (mean difference = 0.23 mm; 95% CI, -8.07-8.55 mm; P = .99). CONCLUSIONS: Femoral position affects ischiofemoral space dimensions. The ischiofemoral space widens with abduction and internal rotation and narrows with adduction and external rotation, and thus femoral position should be considered when imaging and measuring the ischiofemoral space.

The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections.

OBJECTIVE: The aim of this study was to describe and to validate an ultrasound-guided peroneal tendon sheath (PTS) injection technique and to compare the accuracy of ultrasound-guided vs. palpation-guided PTS injections in a cadaveric model. DESIGN: Twenty cadaveric lower limbs were injected with and without ultrasound guidance, using a different color of liquid latex for each injection technique. The injections were performed by a single investigator in a randomized order. Cadaveric specimens were dissected 1 wk later by a blinded investigator who graded injection accuracy on a 3-point scale (1, accurate; 2, partially accurate; 3, inaccurate). RESULTS: Ultrasound-guided injections were 100% (20 of 20) accurate whereas palpation-guided injections were 60% (12 of 20) accurate (P = 0.008). Six palpation-guided injections were partially accurate, and two were inaccurate. Two of the partially accurate and both of the inaccurate injections were intratendinous. CONCLUSIONS: In a cadaveric model, ultrasound-guided PTS injections are significantly more accurate than palpation-guided injections. When performing PTS injections, clinicians should consider ultrasound guidance to improve injection accuracy and minimize potential complications such as intratendinous injection.

Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: a cadaveric study.

OBJECTIVES: To evaluate the accuracy of ultrasound (US)-guided and palpation-guided knee injections by an experienced and a less-experienced clinician with use of a superolateral approach. DESIGN: Single-blinded, prospective study. SETTING: Academic institution procedural skills laboratory. PARTICIPANTS: Twenty cadaveric knee specimens without trauma, surgery, or major deformity. INTERVENTION: US-guided and palpation-guided knee injections of colored liquid latex were performed in each specimen by an experienced and a less-experienced clinician with use of a superolateral approach. The order of injections was randomized. The specimens were subsequently dissected by a blinded investigator and assessed for accuracy. MAIN OUTCOMES: Accuracy was divided into 3 categories: (1) accurate (all of the injectate was within the joint), (2) partially accurate (some of the injectate was within the joint and some was within the periarticular tissues), and (3) inaccurate (none of the injectate was within the joint). The accuracy rates were calculated for each clinician and guidance method. RESULTS: US-guided knee injections that used a superolateral approach were 100% accurate for both clinicians. Palpation-guided knee injections that used a superolateral approach were significantly influenced by experience, with the less-experienced investigator demonstrating an accuracy rate of 55% (95% confidence interval = 34%-74%) and the more experienced investigator demonstrating an accuracy rate of 100% (95% confidence interval = 81%-100%). CONCLUSIONS: US-guided knee injections that use a superolateral approach are very accurate in a cadaveric model, whereas the accuracy of palpation-guided knee injections that use the same approach is variable and appears to be significantly influenced by clinician experience. These findings suggest that US guidance should be considered when one performs knee injections with a superolateral approach that require a high degree of accuracy.