Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries.

PURPOSE: The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes. METHODS: Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4 weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury. RESULTS: Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21-29) and median follow-up period was 33.7 months (range; 16-65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1 months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation. CONCLUSIONS: Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases. LEVEL OF EVIDENCE: IV.

Case report and review of the potential role of the Type A piriformis muscle in dynamic sciatic nerve entrapment variant of piriformis syndrome.

Piriformis syndrome (PS) is an underdiagnosed but common cause of chronic buttock pain and sciatica. Anatomical variants of the piriformis muscle and sciatic nerve have not been thought to be significant in the pathophysiology of PS however, recent description of the piriformis musculotendinous junction has identified a common variant that we believe frequently results in dynamic sciatic nerve entrapment at the infra-piriformis fossa. We performed ultrasound guided low-dose Botulinum Toxin-A (BTX-A) injection to the lower piriformis muscle belly in an elite Australian Rules football player with PS and Type A piriformis muscle to relieve symptomatic sciatic nerve compression. Positive response to targeted BTX-A piriformis muscle injections support the hypothesis that sciatic nerve compression by Type A piriformis muscles may contribute to the pathophysiology of neuropathic PS, along with other functional factors. Sciatic nerve compression due to Type A piriformis at the infra-piriformis fossa has not been described previously and is a potentially common cause of neuropathic PS, especially when combined with other functional factors such as piriformis muscle spasm/hypertrophy and sacroiliac joint counternutation.

Early postoperative repair status after rotator cuff repair cannot be accurately classified using questionnaires of patient function and isokinetic strength evaluation.

BACKGROUND: This study investigated if patients with an intact tendon repair or partial-thickness retear early after rotator cuff repair display differences in clinical evaluations and whether early tendon healing can be predicted using these assessments. METHODS: We prospectively evaluated 60 patients at 16 weeks after arthroscopic supraspinatus repair. Evaluation included the Oxford Shoulder Score, 11-item version of the Disabilities of the Arm, Shoulder and Hand, visual analog scale for pain, 12-item Short Form Health Survey, isokinetic strength, and magnetic resonance imaging (MRI). Independent t tests investigated clinical differences in patients based on the Sugaya MRI rotator cuff classification system (grades 1, 2, or 3). Discriminant analysis determined whether intact repairs (Sugaya grade 1) and partial-thickness retears (Sugaya grades 2 and 3) could be predicted. RESULTS: No differences (P < .05) existed in the clinical or strength measures. Although discriminant analysis revealed the 11-item version of the Disabilities of the Arm, Shoulder and Hand produced a 97% true-positive rate for predicting partial thickness retears, it also produced a 90% false-positive rate whereby it incorrectly predicted a retear in 90% of patients whose repair was intact. The ability to discriminate between groups was enhanced with up to 5 variables entered; however, only 87% of the partial-retear group and 36% of the intact-repair group were correctly classified. CONCLUSIONS: No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16 weeks. An intact repair or partial-thickness retear could not be accurately predicted. Our results suggest that correct classification of healing in the early postoperative stages should involve imaging.

Sonographic 'flash': A case report of a new sign in dynamic ultrasound of extra-articular snapping hip and knee.

Snapping phenomena at the hip and knee are common clinical presentations in the general population and athletes. Dynamic ultrasound is a useful tool in the evaluation of these syndromes, especially when intra-articular pathology has been excluded. We report on a new ultrasound sign, the 'sonographic flash', which identified the source of audible snapping in two cases where snapping phenomena were present.

MRI findings are associated with time to return to play in first class cricket fast bowlers with side strain in Australia and England.

OBJECTIVES: To investigate the reliability of reporting and relationship between MRI parameters at injury and time to return to play (RTP) in first class cricket fast bowlers with side strain in Australia and England. DESIGN: Cohort study. METHODS: Eighty MRI scans of side strain injuries to 57 fast bowlers were sourced. Ten scans were reported by three experienced radiologists to determine intra- and inter-rater reliability. The relationship between six MRI parameters (muscle injured, presence of a muscle tear, rib level of injury, presence of blood fluid products/haematoma, periosteal stripping, rib oedema) and time to RTP was investigated with 39 scans reported by a single radiologist with known intra-rater reliability. The association between parameters and time to RTP was analysed with an ordinal logistic regression model. RESULTS: Recovery time was prolonged with a mean of 39days (standard deviation: 14days) and 44% of bowlers requiring more than 6weeks to RTP. Reliability levels between parameters varied widely. The presence or absence of a muscle tear was the only MRI parameter associated with time to RTP. Players with a muscle tear were 8 times more likely to take more than 6weeks to RTP. The multifactorial model was predictive of recovery time in only 53% of this cohort, leaving 47% of total variance in time to RTP unexplained. CONCLUSIONS: The presence of a muscle tear was associated with time to RTP in cricket fast bowlers with side strain injury in first class cricket in Australia and England.

VIBE MRI: an alternative to CT in the imaging of sports-related osseous pathology?

MRI is an excellent diagnostic tool in the imaging of sports-related musculoskeletal pathology; however, standard slice thickness acquisitions can lack the spatial resolution to accurately define and characterise osseous abnormalities. Standard MRI sequences may be supplemented with CT to reduce diagnostic uncertainty. We provide a clinical perspective, in the form of pictorial review, on the potential applications of 3D MRI sequences, specifically using volumetric interpolated breath-hold examination in the characterisation of various musculoskeletal osseous pathologies. The potential to negate the requirement for CT in a young radiation sensitive cohort is a clinically significant concept and suggests the requirement for further studies comparing the performance of volumetric MRI to CT.

Pediatric Lateral Patellar Retinacular Sleeve Avulsion.

A 10-year-old girl presented to the physical therapist with acute left knee pain, after sprinting that morning. She reported a pop and lateral knee pain, which caused her to stop her run. The physical therapist referred the patient for radiographs that day, which showed a possible lateral patellar avulsion. Magnetic resonance imaging was performed the following day, given the poor accuracy of radiographs in patellar avulsions, which confirmed a lateral patellar retinacular sleeve avulsion. J Orthop Sports Phys Ther 2017;47(10):815. doi:10.2519/jospt.2017.6616.

The effects of Botulinum Toxin injection in an elite sportsman with Functional Popliteal Artery Entrapment Syndrome: A case report.

BACKGROUND: Botulinum Toxin-A (BoNT-A) is an effective intervention for Functional Popliteal Artery Entrapment Syndrome (FPAES) however, concerns with this intervention include reductions in strength and performance. CASE REPORT: This case presents an elite male athlete with FPAES who underwent BoNT-A injection and the results of testing before and after injection. The athlete experienced a decrease in strength and performance at one week post-injection however, he returned to baseline levels within four weeks. When comparing sprint distance during games, before and after injection, the athlete had an increase in his sprint distance per game post-injection. Finally on ultrasound he had visible medial gastrocnemius denervation atrophy with a decrease in arterial flow velocity at four weeks post-injection. CONCLUSION: BoNT-A may be an effective minimally invasive treatment option for FPAES however, athletes may experience a transient decrease in function following BoNT-A injection and consequently caution must be taken with regard to treatment timing.

Do postoperative platelet-rich plasma injections accelerate early tendon healing and functional recovery after arthroscopic supraspinatus repair? A randomized controlled trial.

BACKGROUND: Tendon-bone healing after rotator cuff repair directly correlates with a successful outcome. Biological therapies that elevate local growth-factor concentrations may potentiate healing after surgery. PURPOSE: To ascertain whether postoperative and repeated application of platelet-rich plasma (PRP) to the tendon repair site improves early tendon healing and enhances early functional recovery after double-row arthroscopic supraspinatus repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients underwent arthroscopic double-row supraspinatus tendon repair. After randomization, half the patients received 2 ultrasound-guided injections of PRP to the repair site at postoperative days 7 and 14. Early structural healing was assessed with MRI at 16 weeks, and cuff appearances were graded according to the Sugaya classification. Functional scores were recorded with the Oxford Shoulder Score; Quick Disability of the Arm, Shoulder and Hand; visual analog scale for pain; and Short Form-12 quality-of-life score both preoperatively and at postoperative weeks 6, 12, and 16; isokinetic strength and active range of motion were measured at 16 weeks. RESULTS: PRP treatment did not improve early functional recovery, range of motion, or strength or influence pain scores at any time point after arthroscopic supraspinatus repair. There was no difference in structural integrity of the supraspinatus repair on MRI between the PRP group (0% full-thickness retear; 23% partial tear; 77% intact) and the control group (7% full-thickness retear; 23% partial tear; 70% intact) at 16 weeks postoperatively (P = .35). CONCLUSION: After arthroscopic supraspinatus tendon repair, image-guided PRP treatment on 2 occasions does not improve early tendon-bone healing or functional recovery.

Ultrasound of skeletal muscle injury.

The professional and recreational demands of modern society make the treatment of muscle injury an increasingly important clinical problem, particularly in the athletic population. In the elite athlete, significant financial and professional pressures may also exist that emphasize the need for accurate diagnosis and treatment. With new advances in ultrasound technology, images of exquisite detail allow diagnosis of muscle injury that matches the accuracy of magnetic resonance imaging (MRI). Furthermore, the benefits of real-time and Doppler imaging, ability to perform interventional procedures, and relative cost benefits compared with MRI place ultrasound at the forefront for investigation for these injuries in many circumstances. Muscle injury may be divided into acute and chronic pathology, with muscle strain injury the most common clinical problem presenting to sports physicians. This article reviews the spectrum of acute and chronic muscle injuries, with particular attention to clinical features and some common or important muscle strain injuries.

Anterior infradiaphragmatic free gas following bronchial rupture: case report and literature review.

Bronchial rupture is an uncommon injury that presents clinically and radiologically with tension or non-tension pneumothorax, pneumomediastinum and subcutaneous emphysema caused by air leak and migration of free gas. Infradiaphragmatic gas has previously been demonstrated in mechanically ventilated patients with pneumomediastinum and is secondary to passage of air via anterior and posterior trans-diaphragmatic pathways. We present a case of bronchial rupture complicated by extensive infradiaphragmatic gas following mechanical ventilation that illustrates these pathways and some of the major radiographic signs associated with this injury.

Shocking abdominal trauma: review of an uncommon disorder of small intestine perfusion.

'Shock bowel' is a rare disorder of gastrointestinal physiology with characteristic radiological features. It usually occurs in the setting of blunt abdominal trauma and hypovolaemia, with complete reversibility of these findings following resuscitation. We present a case demonstrating the classic features of this complex of imaging findings thought to be caused by end-organ hypoperfusion.