Prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers.

BACKGROUND: Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes. PURPOSE: To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers. METHODS: A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17-30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated. RESULTS: The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests. CONCLUSION: Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings.

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers.

BACKGROUND: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. PURPOSE/HYPOTHESIS: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. RESULTS: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P = .499). CONCLUSION: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Use of High-Resolution Ultrasound to Guide Alcohol Neurolysis for Chronic Pain.

BACKGROUND: The diagnosis and treatment of neuropathic pain is often clinically challenging, with many patients requiring treatments beyond oral medications. To improve our percutaneous treatments, we established a clinical pathway that utilized ultrasound (US) guidance for steroid injection and alcohol ablation for patients with painful neuropathy. OBJECTIVES: To describe a collaborative neuropathy treatment pathway developed by a neurosurgeon, pain physicians, and a sonologist, describing early clinical experiences and patient-reported outcomes. STUDY DESIGN: A retrospective case series was performed. METHODS: Patients that received percutaneous alcohol ablation with US guidance for neuropathy were identified through a retrospective review of a single provider's case log. Demographics and treatment information were collected from the electronic medical record. Patients were surveyed about their symptoms and treatment efficacy. Descriptive statistics were expressed as medians and the interquartile range ([IQR]; 25th and 75th data percentiles). Differences in the median follow-up pain scores were assessed using a Wilcoxon signed-rank test. RESULTS: Thirty-five patients underwent US-guided alcohol ablation, with the average patient receiving one treatment (range: 1 to 2), having a median duration of 4.8 months until reinjection (IQR: 2.9 to 13.1). The median number of steroid injections that individuals received before US-guided alcohol ablation was 2 (IQR: 1 to 3), and the median interval between steroid injections was 3.7 months (IQR: 2.0 to 9.6). Most (20/35 [57%]) patients responded to the survey, and the median pain scores decreased by 3 units (median: -3, IQR: -6 to 0; P < 0.001) one week following the alcohol ablation. This pain reduction remained significant at one month (P < 0.001) and one year (P = 0.002) following ablation. Most (12/20 [60%]) patients reported that alcohol ablation was more effective in improving their pain than oral pain medications. LIMITATIONS: Given the small sample size, treatment efficacy for alcohol neurolysis cannot be generalized to the broader population. CONCLUSIONS: US-guided percutaneous treatments for neuropathic pain present a growing opportunity for interprofessional collaboration between neurosurgery, clinicians who treat chronic pain, and sonologists. US can provide valuable diagnostic information and guide accurate percutaneous treatments in skilled hands. Further studies are warranted to determine whether a US-guided treatment pathway can prevent unnecessary open surgical management.

Ultrasonography of Superficial Soft-Tissue Masses: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, orthopedic surgery, and pathology to arrive at a consensus regarding the management of superficial soft-tissue masses imaged with US. The recommendations in this statement are based on analysis of current literature and common practice strategies. This statement reviews and illustrates the US features of common superficial soft-tissue lesions that may manifest as a soft-tissue mass and suggests guidelines for subsequent management.

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome.

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased (p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines (p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

Ultrasound-Guided Hydroneurolysis of the Median Nerve for Recurrent Carpal Tunnel Syndrome.

BACKGROUND: Recurrent carpal tunnel syndrome is often associated with perineural scarring around the median nerve. Surgical options include relatively invasive procedures, such as fat pad grafting, ligament reconstruction, muscle transfer, and nerve wraps. All have limited success because of the possibility of repeated recurrent scarring postoperatively. METHODS: We discuss a technique involving injection with external hydroneurolysis of the median nerve under ultrasound guidance for recurrent carpal tunnel. Injection enables a gentler dissection of the surrounding tissues compared with open external neurolysis, with less chance of recurrent scarring. This technique is a unique alternative to repeat operative intervention in recurrent carpal tunnel, as well as a prelude to repeat open decompression and salvage procedures. RESULTS: Ultrasound-guided injection with external hydroneurolysis of the median nerve is a safer, more limited procedure compared with repeat open surgery, usually performed in an office setting. This procedure limits risk, anesthesia, and operating/recovery room expenses, offering relief in 70% to 80% of cases. Furthermore, in the 20% to 30% of patients with inadequate relief, surgery remains a viable option. US provides important information on the anatomy of the median nerve and carpal canal and can rule out covert pathology. CONCLUSIONS: We offer an alternative treatment for recurrent carpal tunnel syndrome, a difficult problem for which many surgeons recommend nonoperative treatment. US provides objective data concerning residual nerve compression and allows for dynamic assessment. Theoretically, this also offers a viable solution for surgeons and their patients with recurrent carpal tunnel syndrome before being pressed to consider repeat open surgery.

Reticular Telangiectatic Erythema: A Chronic Hematoma Subsequent to Hip Replacement as an Underlying Cause.

A 78-year-old woman with a history of bilateral hip replacements presented with an ill-defined erythematous plaque with foci of reticulated and indurated areas on the left thigh. Initially, a few weeks after her surgery, a small area of erythema appeared overlying the incision site. Over a 6-month period, the erythema slowly expanded before stabilizing in size (Figure 1). There was no pruritus, pain, or warmth. Orthopedic evaluation found no evidence of infection or malfunction of the hip prosthesis. A skin biopsy revealed telangiectasia of the superficial vessels. Based on the clinical and histopathologic findings, a diagnosis of reticular telangiectatic erythema (RTE) was established. An ultrasound scan revealed a greater trochanteric bursa distended by a chronic, organized hematoma measuring 12 cm at greatest dimension, secondary to a full-thickness tear of the left gluteus minimus (Figure 2), establishing the underlying cause of the RTE in this patient.

Ultrasound-Guided Percutaneous Needle Fenestration and Corticosteroid Injection for Anterior and Anterolateral Ankle Impingement.

BACKGROUND: Ankle impingement is a common cause of chronic ankle pain. We retrospectively studied the effectiveness of ultrasound-guided percutaneous needle fenestration of the pathological soft tissues combined with corticosteroid injection to treat this condition. METHODS: We administered a telephone survey to patients who underwent the procedure. Patients were asked questions on the Foot Function Index and queried about their overall satisfaction with the procedure on a scale of 0 (completely unsatisfied) to 10 (very satisfied). RESULTS: Forty-nine patients participated in the survey: 26 women and 23 men, mean age 42.7 years (range, 19-65 years). Impingement was anterior in 26/49 (53.1%), anterolateral in 14/49 (28.6%), and both in 9/49 (18.4%). Mean pain level before the procedure was 6.76 ± 1.84 and after the procedure was 2.73 ± 2.21. Reported pain scale levels declined by 4.02 ± 2 units after the procedure (P < .0001). Patient's overall satisfaction was 7.9 ± 2.44. CONCLUSIONS: Ultrasound-guided percutaneous needle fenestration and corticosteroid injection appears to be an effective nonoperative alternative for treatment of anterior and/or anterolateral ankle impingement. LEVELS OF EVIDENCE: Level IV.

Imaging Surveillance in Patients After a Benign Fine-Needle Aspiration Biopsy of the Thyroid: Associated Cost and Incidence of Subsequent Cancer.

OBJECTIVE: The objective of our study was to determine patterns and cost of imaging tumor surveillance in patients after a benign fine-needle aspiration (FNA) biopsy of the thyroid in a large teaching hospital as well as the rate of subsequent cancer detection. MATERIALS AND METHODS: This cohort study was approved by the appropriate institutional review board and complied with HIPAA. All patients who had a benign thyroid FNA biopsy between January 1, 1999, and December 31, 2003, were identified from an institutional pathology database. We gathered information from electronic medical records on imaging tumor surveillance and subsequent cancer detection. Cost was determined using the facility total relative value unit and the 2014 Hospital Outpatient Prospective Payment System conversion factor. RESULTS: Between January 1, 1999, and December 31, 2003, 1685 patients had a benign thyroid FNA biopsy, 800 (47.5%) of whom underwent follow-up imaging. These patients underwent 2223 thyroid ultrasound examinations, 606 ultrasound-guided thyroid FNA biopsies, 78 thyroid scintigraphy examinations, 168 neck CTs, and 53 neck MRIs at a cost of $529,874, $176,157, $39,622, $80,580, and $53,114, respectively, for a total cost of $879,347 or $1099 per patient. The mean length of follow-up was 7.3 years, during which time 19 (2.4%) patients were diagnosed with thyroid cancer at a cost of $46,281 per cancer. Seventeen (89.5%) were diagnosed with papillary carcinoma and two (10.5%) with Hurthle cell carcinoma. CONCLUSION: Over a 5-year period, about half of the patients who had a benign thyroid FNA biopsy underwent follow-up imaging at considerable cost with a small rate of subsequent malignancy.

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Purpose To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. Materials and Methods Institutional review board approval was obtained and the requirement for informed consent was waived. The study is compliant with HIPAA. Baseball players with medial elbow pain underwent US in addition to MR arthrography. Findings were assessed with each modality alone and both combined in this retrospective investigation. For the evaluation of ulnar collateral ligament (UCL) tears with stress US, the interval gapping of the medial elbow joint was measured between rest and valgus stress both at the injured and at the uninjured (contralateral) elbow. Surgical or arthroscopic correlation was available as the so-called gold standard. McNemar tests compared the accuracies of the imaging modalities. Results In this study, 144 baseball players had 191 findings of medial elbow pain, including 53 UCL tears. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. Conclusion The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. (©) RSNA, 2016.

Does the ulnar nerve enlarge after surgical transposition?

OBJECTIVES: The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross-sectional area (CSA) than symptomatic in situ ulnar nerves. METHODS: We conducted a retrospective review of the charts and sonograms of 68 patients who had failed ulnar nerve transposition compared to 48 patients with cubital tunnel syndrome who had not undergone surgical management. In addition, postoperative sonograms were compared with preoperative studies when available. Failure was defined as persistence or recurrence of symptoms of ulnar neuropathy postoperatively. The cross-sectional area of the nerve, subjective echogenicity, and residual sites of compression were recorded. Groups were subsequently compared by t tests. RESULTS: The failed ulnar nerve transposition group showed a mean cross-sectional area ± SD of 17.26 ± 9.93 mm(2), whereas the control group showed a mean cross-sectional area of 13.45 ± 7.33 mm(2). This difference was statistically significant (P= .018). Nontransposed nerves were more likely to have identifiable sites of compression (P< .05). There was a trend toward postoperative enlargement in the 6 patients with available preoperative imaging (P = .17). No difference in subjective echogenicity was found in this analysis. CONCLUSIONS: Patients with failed ulnar nerve transposition show a significantly enlarged cross-sectional area when compared to symptomatic nerves in situ. Although a specific etiology for this difference cannot be determined, the data suggest that the reference ranges for the cross-sectional area of the ulnar nerve may need to be revised for those who have undergone surgery.

Two novel nonsurgical treatments of carpal tunnel syndrome.

This article describes 2 nonsurgical approaches to the treatment of carpal tunnel syndrome that are not routinely offered, probably due to a lack of awareness. Osteopathic manipulative treatment (OMT) is commonly used for many medical problems, including musculoskeletal issues. OMT of the carpal tunnel is well described and researched, and can be clinically used by a skilled practitioner. The second treatment strategy is a more recent development. The use of ultrasound for guidance of injection is established, but a newer technique using sonographically guided percutaneous needle release of the transverse carpal ligament has shown promising results.

The antiangiogenic effects of a vascular endothelial growth factor decoy receptor can be monitored in vivo using contrast-enhanced ultrasound imaging.

The development of antiangiogenic therapies has stimulated interest in noninvasive imaging methods to monitor response. We investigated whether the effects of a vascular endothelial growth factor decoy receptor (VEGF Trap, Regeneron Pharmaceuticals, Tarrytown, NY) could be monitored in vivo using contrast-enhanced ultrasonography (CEUS). Twenty nude mice (in two groups) were implanted with a human melanoma cell line (DB-1). The active group received VEGF Trap (4 × 25 mg/kg over 2 weeks), whereas the control group received an inactive protein. An ultrasound contrast agent was injected followed by power Doppler imaging (PDI) and pulse inversion harmonic imaging (PIHI; regular and intermittent). Specimens were sectioned in the same planes as the images and stained for endothelial cells (CD31), cyclooxygenase-2 (COX-2), VEGF, and hypoxia (Glut1). Measures of tumor vascularity obtained with the different imaging modes were compared to immunohistochemical markers of angiogenesis. Mean tumor volume was smaller in the active group than in the control group (656 ± 225 vs 1,160 ± 605 mm3). Overall, PDI and VEGF correlated (r  =  .34; p =  .037). Vascularity decreased from control to treated mice with intermittent PIHI, as did the expression of CD31 and COX-2 (p ≤ .02), whereas VEGF increased (p  =  .05). CEUS appears to allow in vivo monitoring of the antiangiogenic effects of VEGF Trap in the DB-1 human melanoma xenograft model.

Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study.

BACKGROUND: An injury to the ulnar collateral ligament (UCL) of the elbow is potentially career threatening for elite baseball pitchers. Stress ultrasound (US) of the elbow allows for evaluation of both the UCL and the ulnohumeral joint space at rest and with stress. HYPOTHESIS: Stress US can identify morphological and functional UCL changes and may predict the risk of a UCL injury in elite pitchers. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 368 asymptomatic professional baseball pitchers underwent preseason stress US of their dominant and nondominant elbows over a 10-year period (2002-2012). Stress US examinations were performed in 30° of flexion at rest and with 150 N of valgus stress by a single musculoskeletal radiologist. Ligament thickness, ulnohumeral joint space width, and ligament abnormalities (hypoechoic foci and calcifications) were documented. RESULTS: There were 736 stress US studies. The mean UCL thickness in the dominant elbow (6.15 mm) was significantly greater than that in the nondominant elbow (4.82 mm) (P < .0001). The mean stressed ulnohumeral joint space width in the dominant elbow (4.56 mm) was significantly greater than that in the nondominant elbow (3.72 mm) (P < .02). In the dominant arm, hypoechoic foci and calcifications were both significantly more prevalent (28.0% vs 3.5% and 24.9% vs 1.6%, respectively; P < .001). In the 12 players who incurred a UCL injury, there were nonsignificant (P > .05) increases in baseline ligament thickness, ulnohumeral joint space gapping with stress, and incidence of hypoechoic foci and calcifications. More than 1 stress US examination was performed in 131 players, with a mean increase of 0.78 mm in joint space gapping with subsequent evaluations. CONCLUSION: Stress US indicates that the UCL in the dominant elbow of elite pitchers is thicker, is more likely to have hypoechoic foci and/or calcifications, and has increased laxity with valgus stress over time.

Cost and radiation savings of partial substitution of ultrasound for CT in appendicitis evaluation: a national projection.

OBJECTIVE: The costs of an ultrasound-CT protocol and a CT-only protocol for an appendicitis evaluation are compared. For the ultrasound-CT protocol, patients with right lower quadrant abdominal pain undergo an ultrasound examination. If it is positive for appendicitis, they are sent directly to surgery, avoiding CT. MATERIALS AND METHODS: A comparative effectiveness research study was conducted. The costs of imaging tests, excess surgeries, and excess surgical deaths for the ultrasound-CT protocol and the costs of imaging tests and excess cancer deaths in the CT-only protocol were estimated. Data sources were Centers for Medicare & Medicaid Services (CMS) datasets, national hospital discharge surveys, radiology information system cases, and U.S. Census Bureau life tables. A meta-analysis and sensitivity analyses were also conducted. RESULTS: The meta-analysis showed a positive predictive value of 92.5% for CT and 91.0% for ultrasound. Analysis of CMS files showed that utilization of CT was almost exactly 2.0 examinations (one abdominal and one pelvic) per patient and for ultrasound was almost nil. The cost of this imaging protocol was $547 per patient, whereas the cost of a limited ultrasound study would be $88 per patient. For the total U.S. population, the cost savings in imaging minus the cost of extra surgeries and extra surgical deaths is $24.9 million per year. Following model VII proposed by the Committee on the Biological Effects of Ionizing Radiation (BEIR), which is known as "BEIR VII," the avoidance of a 12.4-mSv exposure for 262,500 persons would prevent 180 excess cancer deaths. The value of the years of life lost would be $339.5 million. The sensitivity analyses indicate that the cost savings are robust. CONCLUSION: An ultrasound-CT protocol for appendicitis evaluation offers potentially large savings over the standard CT-only protocol. There are moderate savings from using a less expensive imaging technique despite extra surgeries and large savings from radiation exposure avoided.

The increasing role of nonradiologists in performing ultrasound-guided invasive procedures.

PURPOSE: Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population. METHODS: Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated. RESULTS: The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types. CONCLUSION: The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance.

Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease. The panel met in Chicago, Ill, on October 18 and 19, 2011, and created this consensus statement regarding the roles of radiography, ultrasonography (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography. The consensus panel consisted of two co-moderators, a facilitator, a statistician and health care economist, and 10 physicians who have specialty expertise in shoulder pain evaluation and/or treatment. Of the 13 physicians on the panel, nine were radiologists who were chosen to represent a broad range of skill sets in diagnostic imaging, different practice types (private and academic), and different geographical regions of the United States. Five of the radiologists routinely performed musculoskeletal US as part of their practice and four did not. There was also one representative from each of the following clinical specialties: rheumatology, physical medicine and rehabilitation, orthopedic surgery, and nonoperative sports medicine. The goal of this conference was to construct several algorithms with which to guide the imaging evaluation of suspected rotator cuff disease in patients with a native rotator cuff, patients with a repaired rotator cuff, and patients who have undergone shoulder replacement. The panel hopes that these recommendations will lead to greater uniformity in rotator cuff imaging and more cost-effective care for patients suspected of having rotator cuff abnormality.

Subscapularis tendon tears: a common sonographic finding in symptomatic postarthroplasty shoulders.

PURPOSE: Subscapularis tendon tears can complicate shoulder arthroplasty because the subscapularis tendon is typically divided surgically to gain access to the joint. The purpose of this study is to document the prevalence of subscapularis tears on sonography of symptomatic postarthroplasty shoulders. METHODS: We retrospectively reviewed official reports of shoulder sonograms performed over an 11-year period by one experienced radiologist. Sonographic findings in 112 (mean age, 61.7 years; age range, 38-87 years; 40% female) symptomatic patients who had undergone either total shoulder arthroplasty or hemiarthroplasty were compared with findings in both a symptomatic control group consisting of 209 patients (mean age, 55.2 years; age range, 32-79 years; 37% female) who had undergone surgery for rotator cuff repair but no arthroplasty, and an asymptomatic control group consisting of 11 (mean age, 66 years; age range, 61-77 years; 45% female) volunteers who had shoulder arthroplasty but were without complaints. RESULTS: The prevalence of subscapularis tears in arthroplasty patients (51%, 57/112) was higher (p < 0.0001) than that of rotator cuff repair patients (16%, 33/209). In the asymptomatic volunteers, subscapularis tears (9%, 1/11) were less common (p < 0.01) than in the symptomatic patients. CONCLUSIONS: Subscapularis tendon tears are a common sonographic finding in symptomatic postarthroplasty shoulders.