Ultrasound and magnetic resonance imaging in sports-related muscle injuries

Rectus abdominus tear in a collegiate cheerleader

Acute muscle injuries can occur at all skill levels across multiple different sports. Imaging is often used for diagnosis and is necessary for recognizing the extent of injury, complications, and overall prognosis. Ultrasound can be used in diagnosing muscle tears. However, there are less than a dozen documented cases that use ultrasound in the evaluation and diagnosis of a rectus abdominus tear, though the actual number of cases are most likely underreported in the literature. This case discusses an 18-year-old college athlete that suffered a distal rectus abdominus tear after performing a stunt as a cheerleader and her subsequent treatment.

Indirect Structural Muscle Injuries of Lower Limb: Rehabilitation and Therapeutic Exercise

Muscle injuries are the most common trauma in team and individual sports. The muscles most frequently affected are those of the lower limb, and in particular hamstrings, adductors, rectus femoris and calf muscles. Although several scientific studies have tried to propose different rehabilitation protocols, still too often the real rehabilitation process is not based on scientific knowledge, especially in non-elite athletes. Moreover, the growing use of physical and instrumental therapies has made it increasingly difficult to understand what can be truly effective. Therefore, the aim of the present paper is to review proposed therapeutic algorithms for muscle injuries, proposing a concise and practical summary. Following a three-phase rehabilitation protocol, this review aims to describe the conservative treatment of indirect structural muscle injuries, which are the more routinely found and more challenging type. For each phase, until return to training and return to sport are completed, the functional goal, the most appropriate practitioner, and the best possible treatment according to current evidence are expressed. Finally, the last section is focused on the specific exercise rehabilitation for the four main muscle groups with a structured explanatory timetable.

Role of ultrasound and magnetic resonance imaging in the prognosis and classification of muscle injuries in professional football players: correlation between imaging and return to sport time

Purpose

To study distractive muscle injuries applying US and MRI specific classifications and to find if any correlation exists between the results and the return to sport (RTS) time. The second purpose is to evaluate which classification has the best prognostic value and if the lesions extension correlates with the RTS time.

Methods

A total of 26 male, professional soccer players (age 21.3 ± 5.6), diagnosed with traumatic muscle injury of the lower limbs, received ultrasound and MRI evaluation within 2 days from the trauma. Concordance between US and MRI findings was investigated. The relationships between MRI and US based injury grading scales and RTS time were evaluated. Correlation between injuries’ longitudinal extension and RTS time was also investigated.

Results

The correlation between US and MRI measurements returned a Spearman value of r_s = 0.61 (p = .001). Peetrons and Mueller-Wohlfahrt grading scales correlations with RTS time were r = 0.43 (p = .02) and r = 0.83 (p =  < .001). The lesion’s extension correlation with RTS time was r = 0.63 (p < .001). The correlation between the site of the lesion and its location with the RTS time were r_s = 0.2 and r_s = 0.25.

Conclusions

Both US and MRI can be used as prognostic indicators along with the Peetrons (US) and the Mueller-Wohlfahrt (MRI) classifications. MRI is more precise and generates more reproducible results. The lesion craniocaudal extension must be considered as a prognostic indicator, while the injury location inside the muscle or along its major axis has doubtful significance.

Use of Magnetic Resonance Imaging for Orthopedic Trauma and Infection in the Emergency Department

Conditions affecting the musculoskeletal system constitute a significant portion of medical emergencies in the United States, with traumatic injury and infection being two of the most common etiologies. Although physical examination and plain radiographs are often sufficient to guide diagnosis and treatment, there are myriad traumatic and infectious pathologies that are commonly missed or simply not detectable on plain radiographs. Advanced imaging is subsequently warranted for additional workup.Magnetic resonance imaging (MRI) has become an increasingly used imaging modality for musculoskeletal complaints in the emergency department due to its superior visualization of soft tissues, focal edematous changes, and occult osseous insults often not visible on plain radiographs. Although multiple studies have evaluated its utility in the workup of emergency musculoskeletal complaints, there remains a dearth of literature examining the use of MRI for certain occult diagnoses.Radiologists, emergency clinicians, and orthopedic surgeons must be knowledgeable of the indications for MRI in the emergency setting, as delayed diagnosis may contribute to increased morbidity and possibly mortality. This review summarizes the use of MRI in diagnoses relating to trauma or infection among patients presenting to the emergency department with a musculoskeletal complaint.

Injury incidence and burden in a youth elite football academy: a four-season prospective study of 551 players aged from under 9 to under 19 years

OBJECTIVE

Investigate the incidence and burden of injuries by age group in youth football (soccer) academy players during four consecutive seasons.

METHODS

All injuries that caused time-loss or required medical attention (as per consensus definitions) were prospectively recorded in 551 youth football players from under 9 years to under 19 years. Injury incidence (II) and burden (IB) were calculated as number of injuries per squad season (s-s), as well as for type, location and age groups.

RESULTS

A total of 2204 injuries were recorded. 40% (n=882) required medical attention and 60% (n=1322) caused time-loss. The total time-loss was 25 034 days. A squad of 25 players sustained an average of 30 time-loss injuries (TLI) per s-s with an IB of 574 days lost per s-s. Compared with the other age groups, U-16 players had the highest TLI incidence per s-s (95% CI lower-upper): II= 59 (52 to 67); IB=992 days; (963 to 1022) and U-18 players had the greatest burden per s-s: II= 42.1 (36.1 to 49.1); IB= 1408 days (1373 to 1444). Across the cohort of players, contusions (II=7.7/s-s), sprains (II=4.9/s-s) and growth-related injuries (II=4.3/s-s) were the most common TLI. Meniscus/cartilage injuries had the greatest injury severity (95% CI lower-upper): II= 0.4 (0.3 to 0.7), IB= 73 days (22 to 181). The burden (95% CI lower-upper) of physeal fractures (II= 0.8; 0.6 to 1.2; IB= 58 days; 33 to 78) was double than non-physeal fractures.

SUMMARY

At this youth football academy, each squad of 25 players averaged 30 injuries per season which resulted in 574 days lost. The highest incidence of TLI occurred in under-16 players, while the highest IB occurred in under-18 players.

Rectus abdominis muscle tear diagnosed with sonography and its conservative management

PURPOSE

This is a rare case of a post-traumatic rectus abdominis muscle tear in an adolescent female diagnosed by ultrasonography (US). Conservative management is also described.

METHODS

A 14-year-old female presented to a chiropractic clinic with extreme pain and tenderness in the right lower quadrant (RLQ) after post-plyometric power kneel box jumps. Movement aggravated her pain and she demonstrated active abdominal guarding with RLQ palpation. Ultrasonography revealed a subacute Grade 2 right rectus abdominis muscle tear, without evidence of hyperemia or a hematoma. Following the diagnosis of a right rectus abdominis muscle tear, she was treated with spinal manipulation and a course of musculoskeletal rehabilitation directed at truncal stabilization.

RESULTS

After treatment, the patient was able to return to play 5 week post-injury without any pain or discomfort. A follow-up US at 3 months provided evidence of muscle healing without complications.

CONCLUSION

This case demonstrates the diagnosis of a rare rectus abdominis muscle tear managed conservatively. To our knowledge, less than a dozen cases are reported using US in the evaluation and diagnosis of a rectus abdominis tear.

[Groin pain in athletes : What does the sports physician expect from the radiologist?]

BACKGROUND

Especially in sports like professional football (soccer) making a diagnosis and generating a final prognosis concerning the time loss is demanding for the team physician and the radiologist. Therefore, the radiologist has to fulfill the requests concerning availability and quality of imaging. This is a particularly difficult task for groin pain because it can be caused by a variety of pathologies.

OBJECTIVES

In addition to the question what the sports physician expects from the radiologist, we have to look at which information the radiologist needs to answer the raised questions. Which external circumstances make a change of the normal procedures necessary when supporting athletes?

RESULTS AND DISCUSSION

Close collaboration between the radiologist and sports physician guarantees that the raised questions from the athlete and the club concerning time loss and necessary therapy can be answered. Thus, the sports physician has to give the radiologist detailed information regarding symptoms, location of the pain and other clinical findings. The radiologist has to include this information into the interpretation of the images to distinguish safely between findings caused by the actual injury and those which are pre-existing.

Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete

Provide the state of the art concerning (1) biology and aetiology, (2) classification, (3) clinical assessment and (4) conservative treatment of lower limb muscle injuries (MI) in athletes. Seventy international experts with different medical backgrounds participated in the consensus conference. They discussed and approved a consensus composed of four sections which are presented in these documents. This paper represents a synthesis of the consensus conference, the following four sections are discussed: (i) The biology and aetiology of MIs. A definition of MI was formulated and some key points concerning physiology and pathogenesis of MIs were discussed. (ii) The MI classification. A classification of MIs was proposed. (iii) The MI clinical assessment, in which were discussed anamnesis, inspection and clinical examination and are provided the relative guidelines. (iv) The MI conservative treatment, in which are provided the guidelines for conservative treatment based on the severity of the lesion. Furthermore, instrumental therapy and pharmacological treatment were discussed. Knowledge of the aetiology and biology of MIs is an essential prerequisite in order to plan and conduct a rehabilitation plan. Another important aspect is the use of a rational MI classification on prognostic values. We propose a classification based on radiological investigations performed by ultrasonography and MRI strongly linked to prognostic factors. Furthermore, the consensus conference results will able to provide fundamental guidelines for diagnostic and rehabilitation practice, also considering instrumental therapy and pharmacological treatment of MI. Expert opinion, level IV.

Muscular Calf Injuries in Runners

Calf pain is a common complaint among runners of all ages but is most frequent in masters athletes. This article focuses on injuries to the triceps surae or true 'calf muscles.' The most common calf injury is a tear of the medial gastrocnemius muscle (Tennis Leg) but other structures including the lateral gastrocnemius, plantaris and soleus also may be the cause of muscular pain. This article looks at the presentation, evaluation, and treatment of these injuries. We also highlight some examples of musculoskeletal ultrasound which is a valuable tool for rapid diagnosis of the cause and extent of injury.

Ultrasound Findings of Delayed-Onset Muscle Soreness

The purpose of this series was to retrospectively characterize the ultrasound findings of delayed-onset muscle soreness (DOMS). The Institutional Review Board approved our study, and informed consent was waived. A retrospective search of radiology reports using the key phrase "delayed-onset muscle soreness" and key word "DOMS" from 2001 to 2015 and teaching files was completed to identify cases. The sonograms were reviewed by 3 fellowship-trained musculoskeletal radiologists by consensus. Sonograms were retrospectively characterized with respect to echogenicity (hypoechoic, isoechoic, or hyperechoic), distribution of muscle involvement, and intramuscular pattern (focal versus diffuse and well defined versus poorly defined). Images were also reviewed for muscle enlargement, fluid collection, muscle fiber disruption, and increased flow on color or power Doppler imaging. There were a total of 6 patients identified (5 male and 1 female). The average age was 22 years (range, 7-44 years). Of the 6 patients, there were a total of 11 affected muscles in 7 extremities (1 bilateral case). The involved muscles were in the upper extremity: triceps brachii in 27% (3 of 11), biceps brachii in 18% (2 of 11), brachialis in 18% (2 of 11), brachioradialis in 18% (2 of 11), infraspinatus in 9% (1 of 11), and deltoid in 9% (1 of 11). On ultrasound imaging, the abnormal muscle was hyperechoic in 100% (11 of 11), well defined in 73% (8 of 11), poorly defined in 27% (3 of 11), diffuse in 73% (8 of 11), and focal in 27% (3 of 11). Increased muscle size was found in 82% (9 of 11) and minimal hyperemia in 87.5% (7 of 8). The ultrasound findings of DOMS include hyperechoic involvement of an upper extremity muscle, most commonly appearing well defined and diffuse with increased muscle size and minimal hyperemia.

Ultrasound of lower limb sports injuries

Musculoskeletal ultrasound utilises high-frequency linear transducers to produce high-resolution images of soft tissue structures. It is an increasingly useful tool in the assessment of both acute and chronic musculoskeletal injuries; it is relatively cheap, portable and can be used to facilitate targeted injections. In this review paper, we aim to provide a summary on the normal and abnormal appearances of skeletal tissue in the setting of acute and chronic lower limb sporting injuries.

Muscle injuries of the lower extremity: a comparison between young and old male elite soccer players

PURPOSE

The aim of this study was to make a comparison between players in two age groups in an elite male soccer team regarding injury localisation within the muscle-tendon unit, injury size and muscle group in terms of muscle injuries of the lower extremity.

METHODS

Cohort study based on data collected from a Swedish elite male soccer team during the seasons 2007-2012. In total, 145 muscle injuries were included. Injury localisation to the tendon or muscle, the size of haematoma and the affected muscle group were assessed using ultrasound. Age comparison was made between younger players (≤23 years) and older players (>23 years).

RESULTS

No difference regarding injury localisation to either the tendon or the muscle, or the size of haematoma between the two age groups was found. However, the older group of players suffered a significantly higher number of injuries to the triceps surae than the younger players (p = 0.012).

CONCLUSIONS

In a Swedish team of male soccer players at elite level, there was no difference between players 23 years or younger and players older than 23 years, in terms of injury distribution to muscles or tendons. Players older than 23 years sustained more injuries to triceps surae when compared with players 23 years or younger. The clinical relevance is to pay attention to muscle function of triceps surae in older players and to screen those players who may need an injury prevention programme.

LEVEL OF EVIDENCE

II.

Groin Injuries (Athletic Pubalgia) and Return to Play

Context:

Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high-level competition.

Evidence Acquisition:

PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results and Conclusion:

Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases.

Reliability of measurements of rat lateral gastrocnemius architectural parameters obtained from ultrasound biomicroscopic images

This study used ultrasound biomicroscopy (UBM) to quantify the pennation angle (PA) and muscle thickness (MT) of rat skeletal muscle and evaluated the reliability and reproducibility of the method by statistical analysis, determining the coefficient of variation (CV), intraclass correlation coefficient (ICC) and typical error of measurement. A UBM system with a center frequency of 40 MHz was used to acquire images of the right lateral gastrocnemius of ten male Wistar rats on two different days and with two ankle positions (90° or 150°). Two independent measurements of the PA and MT were randomly performed in each of three picture frames. The analysis resulted in CVs of 10.47% and 4.81% for the PA and the MT, respectively, for the ankle at 90° and 9.24% and 5.98% for the ankle at 150°. Additionally, the ICC values ranged from 0.75 to 0.92 for the PA and 0.57 to 0.99 for the MT. Statistically significant differences between the ankle positions were observed for the PA (p = 0.00013). The reliability of the PA and MT measurements for the rat right lateral gastrocnemius, determined from the ultrasound biomicroscopy images, was high (>0.90) for the methodology proposed. This finding indicates the potential of ultrasound biomicroscopy for quantitative muscle characterization and the longitudinal examination of tissue adaptation to different conditions of use, disease and rehabilitation.

Ultrasound biomicroscopy for biomechanical characterization of healthy and injured triceps surae of rats

This work describes the use of ultrasound biomicroscopy (UBM) to follow up the degeneration–regeneration process after a laceration injury induced in the lateral gastrocnemius (LG) and soleus (SOL) muscles of rats. UBM (40 MHz) images were acquired and used for biomechanical characterization of muscular tissue, specifically using pennation angle (PA) and muscle thickness (MT). The animals were distributed in three groups: the variability group (VG; N=5), the gastrocnemius injured group (GG; N=6) and the soleus injured group (SG; N=5). VG rats were used to assess data variability and reliability (coefficients of variation of 9.37 and 3.97% for PA and MT, respectively). GG and SG rats were submitted to the injury protocol in the LG and SOL muscles of the right legs, respectively. UBM images of muscles of both legs were acquired at the following time points: before and after injury (immediately, 7, 14, 21 and 28 days). We observed an increase in PA for the non-injured leg 28 days after injury for both GG and SG rats (GG=10.68 to 16.53 deg and SG=9.65 to 14.06 deg; P&lt;0.05). Additionally, MT presented a tendency to increase (GG=2.92 to 3.13 mm and SG=2.12 to 2.35 mm). Injured legs maintained pre-injury PA and MT values. It is suggested that a compensatory hypertrophic response due to the overload condition imposed to healthy leg. The results indicate that UBM allows qualitative and quantitative muscle differentiation among healthy and injured muscle at different stages after lesion.

Ultrasound versus anatomic guidance for intra-articular and periarticular injection: a systematic review

OBJECTIVE

To investigate the clinical efficacy of ultrasound when compared with anatomic standard injection using palpation/anatomic landmarks.

METHODS

PubMed, Ovid Medline/Cochrane Reviews, BIOSIS Previews, and SPORTDiscus™ databases were searched to January 2011. To narrow the search, the following key search terms were used: ultrasound, guided, injection, joint, shoulder, elbow, wrist, hip, knee, and ankle. Fifteen articles were determined to be relevant, and an additional 2 articles were added after bibliography sections of the 15 articles were reviewed, resulting in a total of 17 articles meeting inclusion and exclusion criteria.

RESULTS

Accuracy was greater in the ultrasound-guided group, independent of anatomic site. An improvement in time to symptom onset in the short term (< 6 weeks) was greatest with the use of ultrasound-guided intra-articular injection. Long-term outcomes are not proven to be different between intra-articular injection with ultrasound or anatomic guidance. The greatest trends were observed in the knee and shoulder joints, demonstrating improvements in function, pain, intensity, and range of motion, independent of injection technique. In foot/ankle and wrist/hand, small joint space injections showed a greater accuracy with ultrasound-guided injections contrasted to larger joint spaces, in which these joint injections demonstrated equal accuracy independent of injection technique.

CONCLUSION

This systematic review can confirm that accuracy is improved with the use of ultrasound-guided intra-articular injection. We can also confirm that short-term outcome improvements are present using ultrasound-guided injection techniques but can confirm no difference in long-term outcome measures using either technique.

Ultrasound of skeletal muscle injury: an update

Muscle injury is one of the most common sports-related injuries. Ultrasound and magnetic resonance imaging (MRI) are the most useful imaging techniques for assessing muscle injuries. Ultrasound generates images of a greater spatial resolution than MRI; it allows real-time functional and dynamic assessment of muscles and tendons. It combines this information with physiological assessment of blood flow, is well tolerated, noninvasive, and cost-effective. Conversely, its soft-tissue contrast is not as good as MRI. Muscle injuries are conventionally separated into acute and chronic. This article reviews the spectrum of muscle injury and highlights the role ultrasound plays in providing specific diagnostic and therapeutic answers.

Office-based ultrasound in sports medicine practice

Increasing knowledge, interest, and visibility in the field of sports medicine has equipped clinicians in the field with a novel array of diagnostic and therapeutic options but has also provided a higher level of complexity in patient care. True understanding of the vast spectrum of radiographic technology available to the sports clinician has become more critical than ever. Advances particularly in the areas of magnetic resonance imaging, diagnostic office ultrasound, and 3-dimensional reconstruction computed tomography, as well as nuclear medicine, offer the clinician a myriad of diagnostic options in patient evaluation. As these advances accumulate, the challenge to optimize care, contain cost, and interpret the extensive data generated becomes even more difficult to manage. Improving technology, education, and application of office ultrasound offers an interesting new tool for the bedside evaluation in real time of dynamic motion and pathology of sports-related injuries. As studies continue to validate ultrasound's effectiveness in diagnosing injuries to the upper and lower extremities compared with more costly magnetic resonance imaging and more invasive exploratory surgery, its promise as a cost-effective diagnostic tool is growing. A particularly promising development in the care of sports injuries is the expansion of injection therapies, and in-office ultrasound provides assurance that prolotherapy, platelet-rich plasma, dry needling, corticosteroid, and viscosupplementation are delivered accurately and safely. Communication with patients continues to increase in complexity because a greater understanding of the presence of radiographic abnormalities irrelevant to the current complaint is gained. All the accumulated data must then be interpreted and communicated to the patient with a firm understanding of not only the patient history and physical examination but also the availability, indications, contraindications, sensitivity, specificity, and even the cost implications of the spectrum of diagnostic options.