Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique.

PURPOSE: To evaluate clinical response to treatment of calcified tendinitis of the shoulder by using a modified percutaneous ultrasonography (US)-guided fine-needle technique. MATERIALS AND METHODS: Thirty shoulders of 30 consecutive patients (23 women, seven men; mean age, 47.4 years) with chronic shoulder pain (average duration, 43.1 months) refractory to medical treatment were treated percutaneously by using a fine needle and US guidance. Patients were prospectively evaluated by using a shoulder pain and disability index consisting of 13 items and divided into two subcategories: pain and disability. The patient completed the questionnaire before the procedure and during the follow-up visit approximately 1 month later. A diagnostic US examination was also performed at that time. RESULTS: There was a statistically significant improvement in the shoulder pain and disability index total score (27.0%) and the pain (30.5%) and disability (23.9%) scores. According to the index, these results indicate a significant clinical response. CONCLUSION: This modified US-guided fine-needle technique for calcified tendinitis of the shoulder appears to be an effective therapy and was less aggressive than previously described percutaneous techniques.

Gout: radiographic findings mimicking infection.

OBJECTIVE: To describe radiographic features of gout that may mimic infection. DESIGN AND PATIENTS: We report five patients with acute bacterial gout who presented with clinical as well as radiological findings mimicking acute bacterial septic arthritis or osteomyelitis. Three patients had delay in the appropriate treatment with the final diagnosis being established after needle aspiration and identification of urate crystals under polarized light microscopy. Two patients underwent digit amputation for not responding to antibiotic treatment and had histological findings confirming the diagnosis of gout. CONCLUSION: It is important for the radiologist to be aware of the radiological manifestations of acute gout that can resemble infection in order to avoid inappropriate diagnosis and delay in adequate treatment. The definitive diagnosis should rely on needle aspiration and a specific search for urate crystals.

Role of ultrasound in musculoskeletal infections.

Ultrasound is able to play a key role in the management of musculoskeletal soft tissue infections. It is an easily accessible imaging modality that can be used immediately after plain radiographs have been obtained. Quick diagnosis is essential in the clinical setting of musculoskeletal infection because delay can lead to significant morbidity. In addition to its diagnostic capabilities, US offers a safe, real-time, and convenient technique to perform immediately a guided-needle aspiration of any suspicious fluid collection. US provides the most efficient way to document quickly an infection of the musculoskeletal soft tissues and to identify the offending micro-organism.

Imaging of musculoskeletal and spinal infections in AIDS.

The diagnosis of common and opportunistic infections in patients with HIV begins with clinical suspicion and involves relatively standard methodology. Musculoskeletal infection is sometimes the first manifestation of an HIV infection. In patients with HIV, the infections tend to be more advanced at presentation, occur in unusual sites, are caused by a wider spectrum of pathogens, and tend to show an inadequate or delayed response to therapy. The index of suspicion for musculoskeletal infections should be high when reviewing imaging studies of patients with HIV.

Imaging of fungal, viral, and parasitic musculoskeletal and spinal diseases.

There are many nonbacterial infections that have musculoskeletal manifestations and radiologic findings. These infections produce a limited range of tissue responses, depending on the organism, the tissue compartment affected, and the immune competence of the host. Diagnosis is dependent on obtaining an appropriate travel or geographic history, the clinical and laboratory features, and on occasion the specific radiologic findings.

Normal and acutely torn posterior cruciate ligament of the knee at US evaluation: preliminary experience.

PURPOSE: To determine the ultrasonographic (US) findings of normal and acutely torn posterior cruciate ligament (PCL) of the knee and evaluate the usefulness of US in the injured PCL. MATERIALS AND METHODS: US images were obtained in 30 knees in 15 asymptomatic volunteers as a control group and in 35 patients clinically suspected of having an acute PCL injury. Only the distal half of the PCL was evaluated. Of the 35 patients, 28 had their PCL status confirmed: 13 had a normal PCL at magnetic resonance (MR) imaging plus clinical examination, and 15 had a torn PCL at either MR imaging and surgery or MR imaging and clinical follow-up. RESULTS: Normal PCLs were homogeneously hypoechoic, with a well-defined posterior border. Torn PCLs were heterogeneously hypoechoic (12 [80%] of 15 patients), with an indistinct posterior margin (11 [73%] of 15 patients). Torn PCLs were significantly thicker (range, 12.0-20.0 mm; mean, 15.6 mm +/- 2.5 [SD]; P <.01), as compared with normal PCLs in 13 patients (range, 3.8-5.8 mm; mean, 4.6 mm +/- 1.0; P <.01) and in the volunteers (range, 3.7-6.2 mm; mean, 4.5 mm +/- 1.2; P <.01). CONCLUSION: An acutely torn PCL thickens (>10 mm), loses its sharply defined posterior border, and has a heterogeneously hypoechoic appearance. US may be useful as a screening examination for patients suspected of having PCL injury and for deciding whether to perform more expensive MR imaging or surgical intervention.

Extraarticular snapping hip: sonographic findings.

OBJECTIVE: The aim of the study was to determine the sonographic findings of snapping hip and to correlate the findings with the presence or absence of pain. MATERIALS AND METHODS: Twenty patients with snapping hip were examined with sonography. Conventional and dynamic sonographic examinations of both hips were performed using a 5.0- or 7.0-MHz transducer. RESULTS: Conventional sonographic studies allowed identification of various structural abnormalities (tendinitis, bursitis, synovitis) and helped to document tenderness along the course of specific tendons. Dynamic sonographic studies revealed 26 cases of snapping hip. In 24 of these 26 cases, the underlying cause was clearly identified. Twenty-two snapping hips were caused by an abnormal movement of the iliopsoas tendon, and two were caused by iliotibial band friction over the greater trochanter. One patient reported a bilateral snapping sensation that could not be documented on sonography. Snapping hip was elicited by a wide variety of hip movements. Sonography established an immediate temporal correlation between the jerky tendon motion and the painful snap reported by the patient. Only 14 cases of snapping hip were painful. CONCLUSION: Conventional sonographic studies can identify signs of tendinitis, bursitis, or synovitis. Dynamic sonographic studies revealed the cause of snapping hip in most patients. Snapping hip is characterized on sonography by a sudden abnormal displacement of the snapping structure. In our study, a significant proportion of the cases of snapping hip were not painful.

Posterior ankle impingement syndrome: MR imaging findings in seven patients.

PURPOSE: To report the magnetic resonance (MR) imaging findings in seven patients with posterior ankle impingement (PAI) syndrome. MATERIALS AND METHODS: Seven patients-three ballet dancers, one badminton player, one soccer player, one hockey player, and one construction worker-who presented with posterior ankle pain were assessed with MR imaging. Their clinical records and imaging studies were reviewed. The MR imaging studies were assessed for the presence of abnormal bone marrow signal intensity, osseous lesions, and soft-tissue abnormalities. RESULTS: One patient was treated surgically. In all patients, MR imaging demonstrated abnormal bone marrow signal intensity in the os trigonum and/or lateral talar tubercle, consistent with bone contusions. Two patients had a fragmented os trigonum or lateral tubercle, and two had a pseudoarthrosis of the posterolateral talus. Increased signal intensity was seen with distention of the posterior recess of the tibiotalar joint in two patients and with distention of the posterior recess of the subtalar joint in four patients. Three patients had fluid accumulation in the flexor hallucis longus tendon sheath. CONCLUSION: Bone contusions of the lateral talar tubercle and os trigonum are prevalent MR imaging findings of PAI syndrome. MR imaging clearly depicts the osseous and soft-tissue abnormalities associated with PAI syndrome and is useful in the assessment of this condition.

Musculoskeletal infections: US manifestations.

One of the most important prognostic factors in patients with musculoskeletal infections is the delay in establishing therapy. Early diagnosis of septic arthritis requires analysis of joint fluid. Ultrasonography (US) is a rapid, portable, sensitive technique for confirming the presence of joint effusions. The study can be easily repeated for follow-up of lesions. US allows real-time guidance of fluid aspiration and can reduce the risk of contaminating other anatomic compartments, especially in the hands, wrists, and feet. Radiography provides complementary information and should be performed in conjunction with US. US is the imaging modality of choice for diagnosis of superficial abscesses. Dynamic compression with the US probe and color Doppler imaging can facilitate detection of superficial abscesses. US may help in the early diagnosis of osteomyelitis by demonstrating subperiosteal or juxtacortical fluid collections and by providing guidance for aspiration of these collections. Evaluation of osseous involvement requires additional imaging; a US examination with normal results does not allow exclusion of bone infection. US is not degraded by metallic artifact and may be useful in cases of osteomyelitis complicating metallic fixation in an extremity. After initial radiography, US can play an important role in the management of musculoskeletal infections.

Joint sonography.

Sonographic evaluation of joint and periarticular pathology clearly has applications in numerous clinical scenarios, not only for diagnosis but in some situations for US-guided biopsy, aspiration, and injections. It is a rapid, inexpensive technique that with adequate equipment, training, and expertise makes it compelling for use as a first-line imaging modality for the assessment of periarticular masses, localized pain, possible infection, joint swelling, as well as posttraumatic articular and periarticular lesions.

Vertebral involvement in SAPHO syndrome: MRI findings.

We report on the MRI findings in the vertebrae and surrounding soft tissues in two patients with the SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis). The MRI findings include abnormal bone marrow signal, either focal or diffuse, of the vertebral bodies and posterior elements; hyperintense paravertebral soft tissue swelling and abnormal signal of the intervertebral discs. These changes are consistent with discitis and osteitis.

Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations.

STUDY DESIGN: Independent evaluation by two observers of 132 lumbar discs in 45 patients with chronic low back pain investigated by both magnetic resonance imaging and discography. OBJECTIVES: To assess some of the fundamental differences between lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity on T2-weighted magnetic resonance images. SUMMARY OF BACKGROUND DATA: Moderate interobserver agreement has been reported when the morphologic terms normal, bulge, protrusion, and extrusion are used. The validity of this nomenclature remains unknown. METHODS: Discs were evaluated on magnetic resonance images for central and peripheral signal characteristics, height, contour, and nerve root compression. Discograms were classified according to degrees of disc degeneration, disruption, and pain reproduction. RESULTS: Loss of intervertebral height or abnormal signal intensity on magnetic resonance imagery was significantly associated with disc disruptions extending into or beyond the outer anulus on discograms. All 23 protrusions (100%) and 12 of 15 disc bulges (80%) were associated with Stage 2 or 3 anular disruptions and, in most instances, similar or exact reproduction of pain during disc injection. There was no significant difference between disc protrusions, disc bulges, and discs with normal contour but abnormal signal, with respect to degree of disc degeneration, extent of disruptions, or presence of discogenic pain. CONCLUSIONS: In patients with chronic low back pain, loss of disc height or abnormal signal intensity is highly predictive of symptomatic tears extending into or beyond the outer anulus. Disc bulges and disc protrusions do not represent discs with significantly different internal architecture, based on the findings of discography, and are no more suggestive of symptomatic tears than discs showing normal contour but decreased height or abnormal signal intensity.

Ultrasound-guided interventional procedures in the musculoskeletal system.

Ultrasound is a low-cost, nonionizing, readily available diagnostic technique for the evaluation of tendons, muscles, soft tissue masses, cysts, and other fluid collections. Ultrasound is also a valuable tool for guiding a variety of musculoskeletal interventions. Procedures that can be performed under ultrasound guidance include aspiration of fluid for analysis, injection for medication, decompression of cysts, drainage of abscess and hematoma, biopsy, treatment of calcified tendinitis, and foreign body retrieval.

Spinal metastases as a first presentation of malignant astrocytoma.

A 46-year-old man presented with low dorsal pain and paresthesia. Computed tomography showed an osteolytic lesion involving most of the vertebral body and the left pedicle of the 12th thoracic vertebra (T12). Contrast-enhanced magnetic resonance imaging (MRI) of the spine showed an enhancing soft-tissue mass that involved the T11 and T12 vertebral bodies, as well as that of the first lumbar vertebra; the mass caused cord compression. Another lesion was identified at T9. The findings of percutaneous needle aspiration biopsy of the lesion were consistent with metastatic astrocytoma, a diagnosis confirmed at surgery. MRI of the brain showed an asymptomatic lesion of the left temporal lobe; histologic confirmation of malignant astrocytoma was obtained by stereotactic biopsy. This report shows that metastatic bone disease secondary to malignant astrocytoma may manifest itself before the primary lesion becomes symptomatic. This presentation of astrocytoma was unusual because there were no symptoms of the intracranial tumour and because metastatic disease to the bones is less common than to the chest and the lymph nodes.

Plantar fasciitis: sonographic evaluation.

PURPOSE: To evaluate the sonographic findings of plantar fasciitis. MATERIALS AND METHODS: Both feet of 15 patients who had a clinical diagnosis of plantar fasciitis were evaluated with ultrasound (US) by using a 7.0-MHz linear-array transducer. Heel pain was unilateral in 11 patients and bilateral in four. Sagittal sonograms were obtained, and the thickness of the plantar fascia was measured at its proximal end near its insertion into the calcaneus. Other observations included hypoechoic fascia, fiber rupture, perifascial fluid collections, and calcifications. Both feet of 15 healthy volunteers were also evaluated as a control group. RESULTS: Plantar fascia thickness was significantly increased in the heels in patients with plantar fasciitis (3.2-6.8 mm; mean, 5.2 mm +/- 1.13) compared with their asymptomatic heels (2.0-4.0 mm; mean, 2.9 mm +/- 0.70) (P < .0001) and compared with the heels of the patients in the control group (1.6-3.8 mm; mean, 2.6 mm +/- 0.48) (P < .0001). The proximal plantar fascia of 16 (84%) symptomatic heels were diffusely hypoechoic compared with none of the patients' asymptomatic heels and only one heel of a patient in the volunteer group. No fascia rupture, perifascial fluid collection, or calcifications were identified. CONCLUSION: Increased thickness of the fascia and hypoechoic fascia are sonographic findings of plantar fasciitis. US may be a valuable noninvasive technique for the diagnosis of plantar fasciitis.

Understanding medication-related needs of low-literacy patients.

An important thrust in preparing pharmacy students to provide pharmaceutical care is acquiring sensitivity to the unique medication-related needs of at-risk patient populations. Low literacy, which affects 21% to 23% of the American population, defines one such population. In collaboration with the Lafayette Adult Reading Academy (LARA), the authors developed an evolving project to increase pharmacy studies' understanding of the medication-related needs and perspectives of low-literacy patients. This was accomplished through a relation-building, three-step oral interview process. The interviewers asked open-ended questions to assess each patient's medication use habits and perspectives. The interview sensitized the pharmacy students to the needs of low-literacy patients for pharmaceutical care. The principal finding was that a caring relationship between pharmacists and patients is prerequisite to patients' openness to share and receive advice about problems and misconceptions associated with their medication use experiences.

US of the snapping iliopsoas tendon.

PURPOSE: To determine the value of ultrasound (US) in the diagnosis of snapping iliopsoas tendon. MATERIALS AND METHODS: In three patients, dynamic US of the hip was performed as the flexed, abducted, and externally rotated hip was extended. The contralateral hip was also evaluated. Hip arthrography was performed in all three patients, magnetic resonance imaging in two, and iliopsoas bursography in two, which was successful in only one case. One patient underwent surgical release of the iliopsoas tendon. RESULTS: At US, an abnormal jerk of the iliopsoas tendon during hip motion was correlated with the painful audible snap. The motion of the contralateral iliopsoas tendon was smooth. No intraarticular abnormality was found in two patients, and an associated labral tear was suspected at arthrography in the third patient. The patient who underwent surgical release of the iliopsoas tendon had great improvement. CONCLUSION: US is a useful dynamic noninvasive technique for the diagnosis of snapping iliopsoas tendon.

Kinematic magnetic resonance imaging of the normal shoulder: assessment of the labrum and capsule.

OBJECTIVE: To examine the normal shoulder, specifically the labrum and the capsule, with kinematic magnetic resonance imaging (MRI) in asymptomatic volunteers. SUBJECTS AND METHODS: Fourteen asymptomatic volunteers 22 to 53 years of age were studied with a 1.5-T Signa Advantage imager (GE Medical Systems, Milwaukee). Successive static gradient-echo images were obtained in the transverse plane at the mid-glenoid level as the shoulder was successively positioned from full internal to full external rotation. These images were correlated with standard transverse T1-weighted spin-echo images and gradient-echo volume images obtained in the neutral position. RESULTS: The anterior labrum was slightly mobile during rotation in 11 subjects and changed shape from blunted or round to triangular in 8 subjects. A wide variation in morphologic features of the anterior labrum was observed. During rotation, a slight increase in signal intensity was noted in the anterior labrum of five of the subjects. The posterior labrum maintained a relatively stable triangular shape in most cases. Dynamic study allowed assessment of the anterior capsule insertion in all cases. Three subjects had type 1 and 11 had type 2 capsular insertion. No cases of type 3 insertion were identified. CONCLUSIONS: Variation in the shape and signal intensity of the anterior labrum observed in normal asymptomatic volunteers during transverse kinematic examination of the shoulder should be taken into account during evaluation of shoulder instability, since this variation may be clinically insignificant. Kinematic MRI allows easy evaluation of the anterior capsule.