Imaging of calcific tendinopathy: Natural history, migration patterns, pitfalls and management: a review.

Calcific tendinopathy is characterized by the deposition of calcium hydroxyapatite crystals in various tendons of the body. Terms like calcium tendinitis, tendinosis, and tendinopathy are used interchangeably. Calcific tendinopathy is a common and well-documented ailment in the literature. Although common, the natural history, etiology, and progression of calcific tendinitis are poorly understood. The treatment options include conservative and interventional measures. However, these measures cannot be applied as a blanket and are often tailored depending on the stage/phase of the disease. Out of the recognized stages of the disease, the resorptive stage causes the utmost symptoms when the calcium is rather soft and unstable. During this stage, the calcium may migrate beyond expected resorption and get deposited in the adjacent tissues contiguous with the calcium focus. The common destinations include bursal migration, intraosseous migration, muscular migration, and other less common migration sites. Such atypical presentations can lead to dilemmas in the diagnosis, prolongation of the diagnostic pathway, unwarranted apprehension, and treatment delay. Radiologists' role in this situation is to correctly recognize the imaging findings of atypical presentations of calcific tendinopathy and prevent unnecessary diagnostic and interventional studies. In this review article, we describe the pathogenic pathway and natural history of calcific tendinopathy from a radiologist's perspective and discuss different migratory patterns of calcium in calcific tendinopathy not only around the shoulder but also in other areas of the body on different imaging modalities. We also show a few examples of mimics and pitfalls on imaging. Finally, we discuss the appropriate management option of this condition.

Shear wave elastography of tibial nerve in patients with diabetic peripheral neuropathy-A cross-sectional study.

OBJECTIVE: To explore the role of shear wave elastography of the tibial nerve as a potential ultrasonographic method for the diagnosis of tibial neuropathy in patients with type 2 diabetes. MATERIALS AND METHODS: This cross-sectional study included 50 subjects each in case (patients with diabetic tibial neuropathy diagnosed on the basis of clinical features and nerve conduction study) and control groups (non-diabetic non-neuropathic healthy volunteers). The exclusion criteria included the presence of type 1 diabetes, a known history of neuropathy from other causes except for type 2 diabetes, or a history of leg or ankle fracture. Cross-sectional area and shear wave velocity values of the tibial nerve were measured in both groups. Demographic details and body mass index were obtained in both groups and additionally, the duration of type 2 diabetes and HbA1c values in the case group were also noted. Wilcoxon Mann-Whitney U test was used to compare these variables in study groups. ROC curve analysis provided additional findings. RESULTS: Tibial nerve stiffness was significantly higher in the case group (p-value < 0.001). The study groups did not significantly differ in the Cross-sectional area of the tibial nerve (p-value 0.57). The case group exhibited a higher frequency of loss of the fascicular pattern of the tibial nerve (40% vs 18%, p-value 0.027). Duration of diabetes mellitus and HbA1c values did not significantly affect Shear wave velocity values in the case group. At the cut-off value of Shear wave velocity of 3.13 m/s, sensitivity and specificity to diagnose diabetic peripheral neuropathy were 94% and 88% respectively. CONCLUSION: Increased nerve stiffness is seen in patients with diabetic peripheral neuropathy. Shear wave elastography might prove as a novel noninvasive technology for screening/early diagnosis of diabetic peripheral neuropathy.

Musculoskeletal steroid injections in pregnancy: a review.

Pregnant women experience a wide range of musculoskeletal pain disorders, which include general ailments occurring during pregnancy, exacerbation of pre-existing conditions, or pregnancy-specific pain/inflammatory conditions. There are significant concerns and knowledge gaps surrounding the safety, dosage, and potential long-term effects of several drugs used during pregnancy. Our article reviews the use of focal steroid injections during pregnancy. A mixture of case studies, meta-analyses, and randomised controlled trials have shown at least there is no adverse side effect to the mother or baby from maternal use of non-systemic injection during pregnancy and a significant improvement in symptoms of pain or paraesthesia can be achieved in patients that do not respond to more conservative measures. As with all patients, the use of steroid injection should be judged on a case-by-case basis to ensure that it is the most appropriate treatment choice. However, being pregnant should not be considered a contraindication to a single dose of non-systemic steroid administration, as these women can achieve significant symptomatic relief that reduces reliance on systemic medication and can significantly improve their quality of life.

Role of diffusion kurtosis imaging in evaluating microstructural changes in spinal cord of patients with cervical spondylosis.

STUDY DESIGN: Analytical cross-sectional study. PURPOSE: To study the role of diffusion kurtosis imaging (DKI) in evaluating microstructural changes in patients with cervical spondylosis. OVERVIEW OF LITERATURE: Cervical spondylosis is a common progressive degenerative disorder of the spine. Conventional magnetic resonance imaging (MRI) can only detect the changes in the spinal cord once there are visual signal changes; hence, it underestimates the extent of the injury. Newer imaging techniques like Diffusion Tensor and Kurtosis Imaging can evaluate the microstructural changes in cervical spinal cord before the obvious signal changes appear. METHODS: Conventional MRI, diffusion tensor imaging (DTI), and DKI scans were performed for 90 cervical spondylosis patients on 1.5-T MR Siemens Magnetom aera after obtaining informed consent. Eight patients were excluded due to poor image quality. Fractional anisotropy (FA) colour maps and diffusion kurtosis (DK) maps corresponding to spinal cord cross sections at C2-C3 intervertebral disc level (control) and at the most stenotic levels were obtained. Modified Japanese Orthopaedic Association (mJOA) scoring was used for clinical assessment of the spinal cord function. The changes in DTI and DKI parameters and their correlation with mJOA scores were analysed by SPSS 23 software. RESULTS: In our study, mean FA and mean kurtosis (MK) values at the stenotic level (0.54, 1.02) were significantly lower than values at the non-stenotic segment (0.70, 1.27). The mean diffusivity (MD) value at the stenotic segment (1.25) was significantly higher than in the non-stenotic segment (1.09). We also observed a strong positive correlation between mJOA score and FA and MK values and a negative correlation between mJOA score and MD values, suggesting a correlation of FA, MK, and MD with the clinical severity of the disease. CONCLUSION: Addition of DTI and DKI sequences helps in early identification of the disease without any additional cost incurred by the patient.

Ultrasonographic Evaluation of Thickness and Stiffness of Achilles Tendon and Plantar Fascia in Type 2 Diabetics Patients: A Cross-sectional Observation Study.

Background: Diabetes mellitus (DM) can contribute to the development of foot ulcers, a known complication of DM with a high financial and social burden. Achilles tendon (AT) and plantar fascia (PF) are well known to play an important role in foot biomechanics. The present study focuses on the alteration in thickness and stiffness of the AT and PF in Type 2 DM patients compared with the normal controls. Methods: A cross-sectional observational study was conducted with 55 DM patients and 55 healthy volunteers as controls. The thickness of the AT and PF were measured using B-mode ultrasound and stiffness was measured using shear wave elastography. Both the thickness and stiffness in the patient group and controls were compared. The values were also compared with the clinical and demographic profiles of the patients. Results: DM patients had considerably thicker AT and PF than controls (P < 0.05); mean values of AT thickness for DM patients and controls were 5.66 ± 0.54 mm and 4.61 ± 0.39 mm, respectively, and for PF were 2.53 ± 0.51 mm and 1.97 ± 0.19 mm, respectively. Furthermore, the stiffness of AT and PF was significantly (P < 0.05) lower in DM patients compared to controls, suggestive of softening of AT and PF in Type 2 DM patients. Mean values of shear wave velocity for DM patients and controls in AT were 5.53 ± 0.54 m/s and 7.25 ± 0.61 m/s, respectively, and for PF, 4.53 ± 0.89 m/s and 6.28 ± 0.88 m/s, respectively. Conclusion: We conclude that there is softening and thickening of the AT and PF in Type 2 DM patients, which can impair foot biomechanics.

Multiparametric evaluation of bone tumors utilising diffusion weighted imaging and dynamic contrast enhanced magnetic resonance imaging.

Aim: This study aimed to use multiparametric magnetic resonance imaging (MRI) techniques, namely, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to evaluate bone tumors. Methods: Thirty-three patients with primary untreated bone tumors were assessed utilizing DWI and DCE-MRI. Various parameters like ADC values from DWI and percentage peak signal intensity (%PSI), the maximum slope of increase (MSI), and time to peak signal intensity (TTP) values were assessed in different cases, and the final correlation was drawn with histopathological findings. Result: Parameters of semi-quantitative DCE-MRI, i.e., %PSI, MSI and, TTP, correlated significantly with the histopathological characteristics of the tumor (p values < 0.001). Minimum ADC value in the tumor also showed a strong correlation with the tumor characteristic (p values < 0.001). Also, the correlation between parameters of DWI and DCI-MRI is well correlated with each other. Conclusion: The results of this study provide grounds for the integration of multiparametric pre-treatment evaluation of bone tumors. In our study, we not only tried to utilize different parameters of functional MRI in bone tumors as well as re-explored the semi-quantitative analysis of DCE-MRI.

Intramural Gastric Metastasis: A Rare Presentation of Esophageal Squamous Cell Carcinoma.

Intramural gastric metastasis of the esophageal carcinoma, excluding the direct extension of primary neoplasm, is rare. However, intramural metastasis to the esophagus is commoner than this. These are more common in squamous cell carcinoma variant. This signifies a poor prognosis. It is due to the spread of pathology through the intramural lymphatic channels. Sometimes the metastatic lesion is more extensive in volume than the primary. This is more often diagnosed on histopathology in postoperative specimens. We share our imaging experience with surface esophageal squamous cell carcinoma with giant intramural gastric metastasis infiltrating the liver in a 39-year-old male. Due to its rarity, and secondary lesion being more extensive than the primary leads to misinterpretation and wrong diagnosis. Knowledge of this rare phenomenon can prevent misdiagnosis, fasten the imaging workup, and ultimately improve the patient's survival.