Case Report: Portable handheld ultrasound facilitates intra-articular injections in articular foot pathologies.

Background: Intra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies. Methods: A retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant. Results: We included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study. Conclusion: This pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Ultrasound-Guided A1 Pulley Release: A Systematic Review.

The purpose of this review was to summarize the current literature pertaining to ultrasound-guided percutaneous A1 pulley release procedures. We searched PubMed, Cochrane Library, Embase, and Web of Science for clinical studies examining ultrasound-guided percutaneous A1 pulley release. A total of 17 studies involving 749 procedures were included in this review. The overall success rate was 97%. There were 23 minor complications (4 cases of hematomas, 15 cases of persistent pain, and 4 cases of transient numbness) and no major complications reported. Ultrasound-guided A1 pulley release is an effective and safe procedure for the treatment of trigger fingers and thumb.

Lateral epicondylitis: comparing ultrasound-guided tenotomy with or without amniotic membrane allograft injection.

Aim: To evaluate the clinical response to augmenting ultrasound-guided tenotomy (USGT) with an amniotic membrane (AM) allograft injection. Design: Retrospective study. Materials & methods: Subjects underwent either a USGT (N = 16) or a combined USGT plus AM injection (N = 14). Results: Both groups demonstrated a significant reduction in pain from baseline starting after 2 weeks in the USGT plus AM group (p = 0.036) and after 8 weeks in the USGT group (p = 0.021). The reduction in pain was sustained for the entire duration of the study (52 weeks). There was no significant difference in pain levels at 26- or 52-week follow-up or patient satisfaction between the two groups. Conclusion: USGT with or without AM allograft injections results in a significant reduction in pain with high patient satisfaction.

The goal of this study was to determine if a single injection of an amniotic membrane (AM) tissue improves clinical outcomes for patients with chronic tennis elbow treated with ultrasound-guided tenotomy. Ultrasound-guided tenotomy involves using a cutting device to remove degenerative tissue with ultrasound-guidance to help tendon's healing process. An AM injection is thought to reduce inflammation in the surrounding tissue, provide growth factors that help with the tendon's healing process, and minimize painful scar formation. 30 patients were included in this study (16 ultrasound-guided tenotomy [USGT] and 14 USGT plus AM injection). Both groups showed improvement in pain levels compared with their baseline at the short-term follow-up, and this reduction in pain was sustained for 52 weeks. There were no long-term differences between the two groups at the 52 week follow-up in pain levels or satisfaction. Our findings suggest that USGT, with or without AM injection, is an effective method of treatment for chronic tennis elbow.

Pseudoseptic reaction to an intra-articular platelet-rich plasma injection into the knee: a case report.

A variety of intra-articular injections are used for the management of osteoarthritis. A rare complication of intra-articular injections is acute pseudoseptic arthritis, which mimics true septic arthritis. To the authors knowledge, pseudosepsis has not been reported as a complication after platelet-rich plasma (PRP) injections. We present a case report of pseudoseptic arthritis resulting in acute postinjection pain and a joint effusion after an intra-articular PRP injection into the knee. Clinically, pseudosepsis can occur after PRP treatment with significantly elevated white blood cell counts in the synovial fluid, and should be a consideration in cases of post-PRP injection flares.

Heterotopic Mineralization of the Medial Collateral Ligament: Our Experience Treating Two Cases of Calcific Versus Ossific Lesions With Ultrasonic Vacuum Debridement.

Chronic injury to the medial collateral ligament (MCL) is common following an acute knee injury. This case report presents two patients that failed to respond to conservative treatment with clinical evidence of an MCL injury and radiographic finding of a benign-appearing soft tissue lesion in the MCL. Calcified or ossified lesions have been described with chronic MCL injuries. Ossification and calcification of the MCL have been observed as potential causes of chronic MCL pain. Here, we detail the distinction between these two distinct intra-ligamentous heterotopic deposits and describe a novel treatment approach using ultrasonic percutaneous debridement, a technique that is typically reserved for tendinopathies. In both cases, pain improved, and they were able to return to their prior level of function.

Traumatic Humeral Shaft Non-union With Ulnar Nerve Transection: An Orthobiologics Success Story.

Long bone non-union is a detrimental, yet common condition that affects many individuals after injury. It can lead to significant pain and weakness that may impact lifetime productivity and quality of life. This report describes a patient who suffered from greater than two years of a distal humerus fracture non-union along with an ulnar nerve transection that failed traditional surgical management and underwent a percutaneous injection with bone marrow aspirate concentrate, platelet-rich plasma, and platelet lysate, demonstrating subsequent fracture resolution and strength improvement.

Basic Science of Allograft Orthobiologics.

Orthobiologic procedures are based on altering the microenvironment of musculoskeletal tissues to induce an anti-inflammatory effect and reduce pain, promote healing of these tissues, or provide mechanical support. Allograft tissues have these inherent qualities and can be used as such. This could provide patients whose own autologous tissues may be compromised or have contraindications to harvesting an alternative to treat their orthopedic conditions. Although these allograft therapies are promising, they lack high-quality clinical studies and regulatory guidelines currently limit their use.

Plantar fasciitis: a comparison of ultrasound-guided fasciotomy with or without amniotic membrane allograft injection.

Aim: The purpose of this study was to evaluate the clinical response to augmenting an ultrasound-guided percutaneous plantar fasciotomy (UGPF) with an amniotic membrane (AM) allograft injection. Design: Retrospective, single-center, matched, case-controlled study. Methods: Patients underwent either an UGPF (n = 15) or a combined UGPF and AM injection (n = 16). Results: The UGPF plus AM group demonstrated a significant reduction in pain (p = 0.02) from baseline at the short-term follow-up, but there was no significant difference in pain or patient satisfaction between groups at the 52-week follow-up. Conclusion: Both groups demonstrated a significant reduction in pain and high level of patient satisfaction, but the combination of UGPF with an AM injection may provide a greater reduction in pain earlier in the post-operative period.

Calcific Tendinopathy of the Shoulder: A Retrospective Comparison of Traditional Barbotage Versus Percutaneous Ultrasonic Barbotage.

OBJECTIVE: The purpose of this study was to compare a traditional barbotage technique with percutaneous ultrasonic barbotage (PUB) for the treatment of rotator cuff (RC) calcific tendinopathy. DESIGN: Three-year retrospective review. SETTING: Participants aged 18 to 75 presenting at 2 highly specialized outpatient orthopedic referral centers with symptomatic RC calcific tendinopathy. PATIENTS: There were 75 patients included (23 patients in the traditional barbotage group; 52 patients in the PUB group) with an average age of 55.3(6.5) and 55.9(9.8), respectively. There was no significant difference in demographics between groups. INTERVENTIONS: Traditional barbotage or PUB. MAIN OUTCOME MEASURES: Primary outcome measure was pain rated on the Numeric Pain Rating Scale (NPRS) with secondary outcomes investigating patient satisfaction. RESULTS: The barbotage and PUB group demonstrated a significant improvement in pain (barbotage 2.4, P = 0.01; PUB = 2.6, P < 0.001) with no statistically significant difference between the 2 treatment modalities (95% CI: -1.8 to 2.2; P = 0.83, P = 0.83). Median follow-up for NPRS recordings was 17-weeks in the barbotage group and 8-weeks in the PUB group ( P = 0.004). Both groups demonstrated similar patient-reported satisfaction, without major complications. CONCLUSION: The traditional barbotage and PUB procedures improved pain with a high patient satisfaction rate. LEVEL OF EVIDENCE: Level III.

Chronic Medial Collateral Ligament Sprain Treated With Percutaneous Ultrasonic Debridement: A Case Report.

ABSTRACT: The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Most grade I and II injuries respond to conservative management, but symptoms persist in some patients. In these cases, treatment options are limited. Percutaneous ultrasonic debridement is increasingly being used for tendinopathy and fasciopathy refractory to conservative management, but this has not been reported as a treatment for ligament injury. Here, we present a case of a chronic grade II MCL sprain successfully treated with percutaneous ultrasonic debridement.

Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report.

ABSTRACT: Osteitis pubis is a common source of groin pain in athletes participating in sports requiring kicking, twisting, and pivoting movements. Athletes will present with progressive pain or discomfort in the pubic area or groin. There is usually point tenderness over the pubic symphysis and pain localizing to the adductor or rectus abdominis tendons. Conservative management often includes activity modification, oral medications, progressive rehabilitation, therapeutic ultrasound, steroid injections, and prolotherapy. Osteitis pubis can be refractory to conservative management and can keep an athlete sidelined for as long as 2 years. Platelet-rich plasma (PRP) injections have been used for pubic symphysis pain, but reports have focused on pathology affecting the rectus abdominis or hip adductor muscle tendons. In this article, we present a case of isolated osteitis pubis, without overlapping rectus abdominis or adductor tendon involvement, successfully treated with an ultrasound-guided PRP injection of the fibrocartilage.

Percutaneous ultrasound-guided resection of a painful osteophyte using novel Tenex-Bone device in a residual limb: A case report.

Residual limb pain is common after amputation. Painful osteophytes are one of many causes of residual limb pain, and cases that fail conservative management may require open surgical resection. Here we present a novel percutaneous ultrasound-guided approach to remove a painful osteophyte in a transfemoral amputee. This procedure successfully treated this patient's residual limb pain while minimizing the risks associated with open surgical resection.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Physical Medicine and Rehabilitation Residency Training.

ABSTRACT: A sports medicine physician manages musculoskeletal (MSK) injuries and sport-related medical and MSK conditions of patients of all ages and abilities. Physical medicine and rehabilitation physicians (physiatrists) must be adequately trained to provide this care for all patients including, but not limited to, athletes participating in organized sports, the weekend warrior as well as athletes with disabilities. Accreditation Council of Graduate Medical Education core requirements and basic guidelines help physiatry residency training programs develop and implement residency curriculums. The goal of this article is to provide suggested curricular guidelines to optimize physiatrist training in MSK and sports medicine.

The Impact of an Ultrasound Curriculum on the Accuracy of Resident Joint Line Palpation.

BACKGROUND: Ultrasound education has been used as a tool to help improve physical examination skills. However, its utility in increasing accuracy of joint line palpation has yet to be investigated. OBJECTIVE: To evaluate the accuracy of resident palpation and identification of the lateral knee joint line before and after introducing a musculoskeletal ultrasound (MSUS) curriculum. DESIGN: Cohort study. SETTING: A physical medicine and rehabilitation (PM&R) residency program at an academic institution. PARTICIPANTS: Seventeen PM&R residents. INTERVENTIONS: Residents underwent a knee-focused MSUS workshop. MAIN OUTCOME MEASURES: Distance from needle placement to joint line confirmed with ultrasound. RESULTS: All residents demonstrated improved accuracy in lateral knee joint line palpation after completing a knee-focused MSUS workshop, with statistically significant (P < .05) improvement in postgraduate year (PGY) 2 (P = .02), PGY-3 (P = .04), and across all residents (P = .001). CONCLUSIONS: MSUS education significantly improved lateral knee joint line palpation accuracy in resident physicians.

Subluxing fractured plantar fat pad: a case series and description of novel sonographic findings.

Plantar fat pad syndrome has received little attention in the literature. A variety of structural changes of the plantar fat pad have been described in the literature, including atrophy, contusion, and fractured fat pad. This case series presents 4 patients (5 heels) with subluxation of a fractured plantar fat pad on dynamic ultrasound. Patients with subluxing fractured fat pad typically present with heel pain and a "snapping" or "popping" sensation when weight-bearing. Other causes of heel pain were excluded, and all patients in this series had an MRI that initially did not report any findings in the fat pad. Retrospective review of the MRI showed evidence of diffuse low T1 and T2 infiltration. To the authors' knowledge, subluxation of the plantar fat pad and the respective correlation to MRI findings have not been described in the literature. Here we describe the sonographic findings of this novel condition.

Treatment of Insertional Peroneus Brevis Tendinopathy by Ultrasound-Guided Percutaneous Ultrasonic Needle Tenotomy: A Case Report.

Insertional peroneus brevis tendinopathy is uncommon and treatment options for recalcitrant insertional lesions are rarely described in the literature. Ultrasound-guided percutaneous ultrasonic needle tenotomy has been described for the treatment of recalcitrant tendinopathy in the elbow, knee, and plantar fascia, but has not been described for the treatment of peroneal tendinopathy. We report a case of recalcitrant insertional peroneus brevis tendinopathy successfully treated with an ultrasound-guided percutaneous ultrasonic needle tenotomy. The treatment resulted in a rapid recovery, and the patient remained asymptomatic at the 6-month follow up. No complications were observed during follow up and the minimally invasive percutaneous procedures offers clear advantage over open techniques.