Subscapularis pyomyositis: a rare presentation of shoulder pain.

We present a rare case of a subscapularis pyomyositis in a 38-year-old woman and examine the diagnostic and surgical challenges posed. History and examination features were similar to that of septic shoulder arthritis without overlying features of warmth or erythema. Serological markers revealed a C-reactive protein of 221 mg/L and white cell count of 11.1×109/L. A dry shoulder aspirate was obtained. Contrast-enhanced MRI demonstrated a peripheral rim-enhancing lesion within the subscapularis muscle belly with lack of central enhancement. These features are consistently seen with an infective aetiology. A deltopectoral approach to surgical drainage was utilised and subsequent fluid cultures grew Panton-Valentine Leukocidin positive Staphylococcus aureus species. This rare bacterium is associated with an increased risk of osteomyelitis and despite making a full recovery, the patient was advised to reattend if any future shoulder pain was encountered.

Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability.

BACKGROUND: Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis. HYPOTHESIS: Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated. RESULTS: The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity. CONCLUSION: The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.

Soft tissue masses with "cyst-like" appearance on MR imaging: Distinction of benign and malignant lesions.

The purpose of this study was to assess the reliability of MR imaging features in distinguishing between benign and malignant soft tissue masses that have a "cyst-like" appearance (hypointense to muscle on T1-weighted and hyperintense on T2-weighted or fluid-sensitive MR sequences). MR imaging features of 40 patients with histologically proven soft tissue masses (27 benign and 13 malignant lesions) that were hypointense to muscle on T1-weighted and hyperintense on T2-weighted or fluid-sensitive MR sequences were analysed to see if a distinction could be made between benign and malignant lesions. There were 23 females and 17 males (mean age, 56 years; age range, 23-82 years). MR imaging features analysed for statistical significance included lesion size, lesion homogeneity, presence of lobulation, depth in relation to fascia and border definition. Clinical assessment included the age and sex of the patient and location of the lesion. Statistically significant MR imaging features favouring a diagnosis of a malignant lesion included larger average dimension of the mass (P < or = 0.004), larger greatest dimension of the mass (P < or = 0.028) and heterogeneity of the lesion on T1-weighted sequences (P = 0.017). The most statistically significant predictor of malignancy was the larger average dimension of the mass.

Ultrasound-guided autologous blood injection for tennis elbow.

OBJECTIVE: To assess the efficacy of autologous blood injection under sonographic guidance for the treatment of lateral epicondylitis. DESIGN AND PATIENTS: Thirty-five patients (23 men, 12 women, mean age 40.9) with refractory lateral epicondylitis (mean symptom duration 13.8 months) underwent sonographic evaluation prior to dry-needling the tendon and injection with autologous blood. Patients were reviewed, and measures of Nirschl and Visual Analogue Scores (VAS) were taken pre-procedure and post-procedure, at 4 weeks and 6 months. RESULTS: Following autologous blood injections, significant reductions were reported for Nirschl scores, which decreased from a median (inter-quartile range) pre-procedure score of 6 (6-7), to 4 (2-5) at 4 weeks (p < 0.001), and to 0 (0-1) at 6 months (p < 0.001). Similarly, significant reductions were reported for VAS scores from a median (inter-quartile range) pre-procedure score of 9 (8-10), to 6 (3-8) at 4 weeks (p < 0.001), and to 0 (0-1) at 6 months (p < 0.001). Sonography demonstrated a reduction in the total number of interstitial cleft formations and anechoic foci; a significant reduction in tendon thickness from a mean (SD) of 5.15 mm (0.79) at baseline to 4.82 mm (0.62) at 6 months post-procedure (p < 0.001) was observed. Hypoechoic change significantly reduced from a median (inter-quartile range) of 7 (6-7) at baseline to 2 (1-3) at 6 months post-procedure (p < 0.001). Neovascularity also significantly decreased from a median (inter-quartile range) of 6 (4-7) at baseline to 1 (0-3) at 6 months post-procedure (p < 0.001), although sonographic abnormality remained in many asymptomatic patients. CONCLUSIONS: Autologous blood injection is a primary technique for the treatment of lateral epicondylitis. Sonography can be used to guide injections and monitor changes to the common extensor origin.