Ultrasound-guided procedures to treat sport-related muscle injuries

[Ultrasound in sports traumatology]

Ultrasound (US) has numerous applications in sports traumatology. The technical progress of mobile US devices has led to increasing use of ultrasound as a primary diagnostic tool. New applications such as elastography and 3 D vascularization are used for special indications.The purpose of this review is to present the current status of ultrasound in the diagnosis of sports injuries and sport traumatology including established applications and new technical advances. US is presented both in its comparison to other imaging modalities and as a sole diagnostic tool.US can be used for initial diagnosis to improve the clinical examination and for intensive shortterm follow-up imaging. The main areas of application are currently the diagnosis of acute muscle and tendon injuries as well as overuse injuries. In particular, the exclusion of structural muscle injuries can be adequately ensured with US in the majority of anatomical regions. The recently published guideline on fracture ultrasound has strengthened the clinical evidence in this area, especially in comparison to conventional radiography and in the development of algorithms and standards. The increasing use of mobile ultrasound equipment with adequate image quality makes US a location-independent modality that can also be used at training sites or during road games.

[Muscle injuries: the importance of high-resolution dynamic sonography in diagnostics, treatment and monitoring]

BACKGROUND

Muscle injuries are common in football. Imaging diagnostics have a major role in establishing a diagnosis. The main diagnostic procedures are MRI and ultrasound. Both diagnostics have advantages and disadvantages, which should be balanced against each other.

NEW ULTRASONIC TECHNIQUES

The role of MRI as the gold standard is increasingly being replaced by high-resolution ultrasound techniques, and MRI imaging is not always useful. To detect complications in the early stages it is advised to perform regular ultrasound-imaging check-ups. The healing process can be monitored, and it offers additional options for ultrasound-guided interventions such as hematoma punctures and targeted infiltrations.

ADVANTAGES AND DISADVANTAGES

However, ultrasound imaging is highly user dependent. Experienced operators can eliminate this disadvantage, which makes ultrasound a superior imaging system in many areas, especially for dynamic examinations. Nevertheless, MRI imaging remains a necessary imaging method in certain areas.

Ultrasound in sports traumatology

BACKGROUND

 Ultrasound (US) has numerous applications in sports traumatology. The technical progress of mobile US devices has led to increasing use of ultrasound as a primary diagnostic tool. New applications such as elastography and 3 D vascularization are used for special indications.

METHOD

 The purpose of this review is to present the current status of ultrasound in the diagnosis of sports injuries and sport traumatology including established applications and new technical advances. US is presented both in its comparison to other imaging modalities and as a sole diagnostic tool.

RESULTS AND CONCLUSION

 US can be used for initial diagnosis to improve the clinical examination and for intensive short-term follow-up imaging. The main areas of application are currently the diagnosis of acute muscle and tendon injuries as well as overuse injuries. In particular, the exclusion of structural muscle injuries can be adequately ensured with US in the majority of anatomical regions. The recently published guideline on fracture ultrasound has strengthened the clinical evidence in this area, especially in comparison to conventional radiography and in the development of algorithms and standards. The increasing use of mobile ultrasound equipment with adequate image quality makes US a location-independent modality that can also be used at training sites or during road games.

KEY POINTS

  · Typically used for quick, focused initial diagnostic assessment and short-term follow-up after injury. · Mobile US devices allow increased use in training centers and training camps. · New US applications (SWE, 3 D) increase standardization in follow-up of tendon injuries. · Targeted use of US for musculoskeletal diagnostic assessment saves money and frees up capacity.

CITATION FORMAT

· Lerchbaumer MH, Perschk M, Gwinner C. Ultrasound in sports traumatology. Fortschr Röntgenstr 2024; 196: 440 - 449.

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play

For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.

Traumatic muscle injury

Traumatic muscle injury represents a collection of skeletal muscle pathologies caused by trauma to the muscle tissue and is defined as damage to the muscle tissue that can result in a functional deficit. Traumatic muscle injury can affect people across the lifespan and can result from high stresses and strains to skeletal muscle tissue, often due to muscle activation while the muscle is lengthening, resulting in indirect and non-contact muscle injuries (strains or ruptures), or from external impact, resulting in direct muscle injuries (contusion or laceration). At a microscopic level, muscle fibres can repair focal damage but must be completely regenerated after full myofibre necrosis. The diagnosis of muscle injury is based on patient history and physical examination. Imaging may be indicated to eliminate differential diagnoses. The management of muscle injury has changed within the past 5 years from initial rest, immobilization and (over)protection to early activation and progressive loading using an active approach. One challenge of muscle injury management is that numerous medical treatment options, such as medications and injections, are often used or proposed to try to accelerate muscle recovery despite very limited efficacy evidence. Another challenge is the prevention of muscle injury owing to the multifactorial and complex nature of this injury.

Long Duration Ultrasound Combined with Platelet-Rich Plasma Injection for Return to Sport after Soft Tissue Injury: A Single Center Study

Objective

The use of Long-Duration Ultrasound (LDU) and Platelet-Rich Plasma (PRP) treatments to facilitate injury healing and pain relief are typically utilized independently in sports medicine. Our study aimed to investigate the combined regenerative effect of daily LDU with high-concentration single-injection PRP for treating sport-related musculoskeletal injuries.

Methods

In total, thirty-five competitive athletes (n=35) with grade II sprains and strains and tendinopathies injured during sport and unable to continue to play were sequentially administered PRP (n=20, 20.4 yoa, 18 male, 2 female) or PRP+LDU (n=15, 20.27 yoa, 14 male, 1 female). In the PRP treatment group, each subject was treated with a single injection of PRP consisting of 1.28 billion platelets/mL under ultrasound-image guidance to the injury site. The PRP+LDU treatment group received the same PRP injection procedure with a 14-day, 4 hr per day, 18,720 J ultrasound treatment applied over the injection site. The Numeric Ration pain Scale (NRS, 0-10), Range of Motion (ROM, 0-100%), Clinical Strength numeric score (CS, 0-5), and time of injury to return to sport (days) were measured at baseline and Return to Play (RTP). The global health improvement score (GROC -7 to +7) was measured upon RTP.

Results

All patients completed rehabilitation and returned to the sport after debilitating injuries. PRP+LDU returned athletes to play 21.33 days quicker (p<0.0001), decreased injury pain by 0.88 NRS points (p=0.0086), and improved patient global health by 1.28 points GROC (p<0.0001) over PRP treatment alone (95% Confidence interval, 11.26 to 31.40 days faster). There were no significant differences in strength (p=0.498) or range of motion (p=0.8581) improvement between PRP and PRP+LDU at the RTP or baseline patient demographic variables.

Conclusion

Adding LDU at-home treatment to PRP injection therapy significantly reduces the time to return to sport, increases pain reduction, and improves overall health for patients recovering from sport-related injury. The daily LDU treatment facilitates and enhances regenerative medicine therapies such as PRP.

Point-of-care Ultrasound Helps Differentiate the Causes of Unilateral Lower Limb Swelling with Rapid Progression: A Case Report with Literature Review

Unilateral lower limb swelling is a common complaint among emergency department (ED) patients. However, an isolated intramuscular hematoma is an uncommon cause of lower limb swelling. We present a case of left thigh swelling after a traffic accident in which an intramuscular hematoma was diagnosed using point-of-care ultrasound. A literature review was also conducted.

[CME-Sonography 105: Ultrasound in Sports Injuries]

CME-Sonography 105: Ultrasound in Sports Injuries Abstract. Muscle injuries are frequent in athletes and in the general population. For therapy and prognosis, it is important to understand the total extent of the injury and to be aware of possible complications. In most cases ultrasound is a useful tool for diagnostics of muscle injuries. However, muscle ultrasound is not as common as joint ultrasound; this article discusses the possibilities of high-resolution dynamic ultrasound in diagnostics and its limitations.

Ultrasound Imaging in Sport-Related Muscle Injuries: Pitfalls and Opportunities

Muscle injuries occur frequently in athletes, accounting for more than one-third of sport-related trauma. Athletes most affected by these injuries are those practicing football and track and field, with hamstrings and gastrocnemius-soleus as the mainly involved sites. Muscle injuries lead to loss of competitions, long recovery times and risk of re-injury with a consequent increase of the management costs. It is therefore advisable to make an accurate and timely diagnosis to establish appropriate interventions for proper healing in the shortest time. In this context, ultrasound imaging is widely used for diagnosis of musculoskeletal disorders because of several advantages including absence of radiation, portability, good spatial resolution, and the ability to perform dynamic tests. The aim of this review is to address the role of US in the evaluation of athletes with muscle injuries. US may play a pivotal role for the management of sport-related muscle injuries because it is fast and relatively cheap, allowing dynamic muscle assessment and time series evaluation of the healing process.

Biological Basis of Treatments of Acute Muscle Injuries: A Short Review

Muscle strains occur frequently in recreational and professional sports. This article considers various treatment options in a biological context and reviews evidence of their efficacy. Treatments reviewed include the PRICE principle (P: rotection, R: est, I: ce, C: ompression, E: levation), early mobilization, physical therapy, hematoma aspiration, platelet-rich plasma injections, use of nonsteroidal anti-inflammatory drugs, corticosteroids, and local anesthetics, cellular therapies, and surgery.

Ultrasound of Musculoskeletal Hematomas: Relationship of Sonographic Appearance to Age and Ease of Aspiration

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of ultrasound-guided aspiration of musculoskeletal hematomas, evaluate the associations between the sonographic appearance of hematomas and their age with ease of aspiration, and determine if there is an optimal time frame for aspiration.

MATERIALS AND METHODS

A retrospective search of our radiology database was conducted using the keywords "hematoma" and "aspiration" for procedures performed from January 1, 2008, through September 28, 2017, by three fellowship-trained musculoskeletal radiologists. Associations between the ease of aspiration and echotexture of the hematoma and between the ease of aspiration and age of the hematoma were assessed with a marginal ordinal logistic regression model to account for patient-level clusters. Pairwise comparisons of the ease of aspiration between the different echotextures were adjusted for multiple comparisons with the Tukey-Kramer method. This same method was also used to calculate the odds ratio (OR) for the age of the hematoma and ease of aspiration and decompression. Clinical follow-up was assessed for infection and symptomatic relief.

RESULTS

The cohort was composed of 148 patients (77 male and 71 female patients) with a mean age of 48 years (age range, 16-80 years). One hundred patients underwent clinical follow-up: There were no instances of infection and all patients reported symptomatic relief. Marginal proportional odds model showed an OR of 3.77 when comparing the ease of aspiration between hypoechoic hematomas and hematomas showing the other echotextures combined (i.e., complex, heterogeneous, echo-genic), which was statistically significant (p = 0.010). The OR of the ease of aspiration in relation to the age of a hematoma for each additional week was 1.03 with a p value of 0.547, which shows that there is no correlation between the age of the hematoma and ease of aspiration.

CONCLUSION

Ultrasound-guided aspiration of hematomas is a safe and effective procedure. The sonographic appearance of a hematoma is unrelated to its age. Although a hematoma with a hypoechoic appearance is easier to aspirate than hematomas with other echotextures, the appearance and age of a hematoma should not dissuade one from trying to aspirate it.

Ultrasound of iliotibial band syndrome

Iliotibial band syndrome or friction syndrome is an overuse disorder of the lateral knee. It is commonly reported in athletes, such as runners and cyclists, and refers to pain related to physical activity. The diagnosis is based on clinical history and physical assessment. Imaging, including ultrasound, is mainly performed in recurrent or refractory cases. The purpose of this paper is to review the etiology, diagnosis, and therapy of iliotibial band syndrome with a focus on ultrasound imaging and ultrasound-guided treatment. Ultrasound findings include soft-tissue edematous swelling or discrete fluid collection, suggestive of bursitis, between the iliotibial band and the lateral femoral epicondyle. The thickening of the iliotibial band has been inconsistently reported. Treatment varies according to the disease phase and, in the acute phase, consists of rest, physical therapy, and anti-inflammatory medications. Ultrasound-guided local steroid injections are effective in relieving symptoms.

Ultrasound Imaging and Rehabilitation of Muscle Disorders: Part 1. Traumatic Injuries

Ultrasound imaging has several advantages that include the absence of radiation, portability, excellent resolution of neuromuscular structures, and the ability to perform dynamic examinations. Traumatic muscle injury can be comprehensively evaluated using static, dynamic, and Doppler ultrasound imaging. In the present review, we briefly discuss mechanisms of traumatic muscle injury, present ultrasound images of normal muscles, focus on ultrasound assessment of injured muscles, and concisely discuss treatment and rehabilitation options for muscle injuries.

Treatment of Acute Thigh Muscle Injury with or without Hematoma Puncture in Athletes

Objectives

To correlate the mean time of return of athletes to sport after acute injury of the thigh muscle with hematoma that was punctured or not.

Methods

Study based on clinical intervention, controlled and non-randomized with 20 amateur and professional athletes, divided into moderate and total or subtotal thighs lesions, according with the Munich Consensus Statement. Nine athletes were included in the intervention group and 11 athletes in the control group. In the intervention group, the athletes were submitted to a puncture of the hematoma, associated to physical therapy; the control group did only physical therapy. The variable mean time of return to sport was analyzed using the Mann-Whitney test and a significance level of 5% ( p  < 0.05; 95% confidence interval [CI]) was established.

Results

The mean group was composed mostly of men, eight of them were amateur athletes. There were three women, two of whom were amateur athletes. The average age of participants was 34.70 ± 12.79 years. There were 13 patients with posterior thigh lesions, 5 with anterior lesions and two with adductor lesions. Considering all injuries, the mean time of return to sport was of 48.50 ± 27.50 days in the intervention group. In the control group, this period was of 102.09 ± 52.02 days, showing a statistically significant difference between them ( p  = 0.022).

Conclusion

In the present study, hematoma drainage in athletes with moderate and total or subtotal muscle injuries associated with hematomas decreased their return time to sport.

Ultrasonography-Guided Muscle Hematoma Evacuation

Muscle injuries commonly occur in athletes, and in severe cases, they can result in hematoma formation, leading to pain and loss of function. A technique for minimally invasive ultrasound-guided evacuation of muscle hematoma is presented. A simple and quick outpatient procedure done under local anesthesia for faster muscle recovery provided immediate decompression of the muscle compartment, leading to early return to play.

Technical and clinical feasibility of contrast-enhanced ultrasound evaluation of long bone non-infected nonunion healing

PURPOSE

To assess the technical feasibility of contrast-enhanced ultrasound (CEUS) in the monitoring of non-infected long bone nonunion healing.

METHODS

Twenty-five patients (16 males; mean age: 40.4 ± 11.7) with long bone nonunion were treated using surgery and mesenchymal stem cells and platelet-rich plasma. They performed CEUS up to 15 days before, 7 days, 4 and 8 weeks after treatment. To categorize the angiogenesis around the fracture site, the microvascular blood flow from CEUS was classified into four categories, depending on the portion of the investigated area that was involved in the neovascularization process: grade 0 = 0%; grade 1 = 0-30%; grade 2 = 30-70%; grade 3 = 70-100%. Nonparametric Friedman and Wilcoxon statistics were used.

RESULTS

Before treatment, neovascularization was graded as 0 in 15/25 patients, as 1 in 10/25. Vascularity significantly increased over time (P < 0.001), namely: 1 (25th-75th percentile = 1-2) at 7 days; 2 (1-2) at 4 weeks; 3 (0-2) at 8 weeks. All patients but one showed early progressive increase in neovascularization well identified with CEUS at the fracture site.

CONCLUSION

CEUS is a feasible method to monitor healing in patients with long bone nonunion.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Quadriceps tendon rupture

Acute knee pain is a frequently encountered problem in the clinical settings. In 2003, American Orthopedic Association recorded that 19.4 million people visited a physician because of a knee problem. Knee pain due to injuries is increasing even among the older population, as a greater number of persons are participating in recreational activities. The quadriceps tendon rupture is not a common condition among acute causes of knee pain. However, it can be quite debilitating. The usual clinical presentation includes a middle-aged person presenting with a history of fall accompanied by swelling and inability to extend the knee. Providers who are faced with this clinical situation should be able to recognize this condition sooner than later. It is very important that precise clinical decisions be made, so as to achieve best outcomes. This article reviews the etiology, epidemiology, clinical presentation, differential diagnosis, and management of quadriceps tendon rupture.

Interventional therapeutic procedures in the musculoskeletal system: an Italian Survey by the Italian College of Musculoskeletal Radiology

PURPOSE

To perform an online survey among all members of the Italian College of Musculoskeletal Radiology to understand how therapeutic musculoskeletal procedures are performed in daily practice in Italy.

METHODS

We administered an online survey to all 2405 members about the use of therapeutic musculoskeletal procedures in their institutions asking 16 different questions. Subgroup analysis was performed between general and orthopaedic hospitals with Mann-Whitney U and χ ² statistics.

RESULTS

A total of 129/2405 answers (5.4% of members) were included in our analysis. A median of 142.5 (25th-75th percentiles: 50-535.5; range 10-5000) therapeutic musculoskeletal procedures per single institution was performed in 2016. Arthropathic pain was the main indication. The most common procedures were joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy. Ultrasound-guided procedures were mainly performed in ultrasonography rooms (77.4%) rather than in dedicated interventional rooms (22.6%). Conversely, fluoroscopic procedures were performed almost with the same frequency in interventional radiology suites (52.4%) and in general radiology rooms (47.6%). In most institutions (72%), autologous blood or components were not used. The median number of therapeutic musculoskeletal procedures performed in orthopaedic hospitals was significantly higher than in general hospitals (P = 0.002), as well as for the use of autologous preparations (P = 0.004).

CONCLUSION

Joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy were the most common therapeutic musculoskeletal procedures, being arthropathic pain the main indication. The percentage of procedures and the use of autologous preparations were significantly higher in orthopaedic hospitals than in general hospitals.

Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings

Background

Muscle injuries affecting the Adductor Longus are not all localised at the level of the proximal myotendinous junction and enthesis. Thus, the main purpose of this article was to raise awareness of the imaging features of the Perivascular Adductor Longus muscle injury, which currently remains widely under-recognised.

Methods

The ultrasound (US) and Magnetic Resonance imaging (MRI) images of five professional football players were retrospectively reassessed to identify distinctive imaging details of the Perivascular Adductor Longus muscle injury. Complementary information regarding the traumatic mechanics is presented as well.

Results

All the players presented similar US images in the first seventy-two hours: loss of ecostructural integrity of the lateral epimysium, in proximity to the femoral vessels, and perilesional oedema were the main pathological findings. The injury lead to the formation of a hypoechoic, intramuscular haematoma in three of the subjects. Anyway, this was detectable only after five days, or later. Moreover, MRI sequences showed long-standing haematoma-related signal alterations which were also observable at three months after trauma. Typically, kicking was the traumatic motor task.

Conclusions

The main practical value of this technical note is to compensate for the lack of studies concerning the Perivascular Adductor Longus muscle injury. Promptly identifying its typical imaging features is crucial in order to establish the correct diagnosis and to implement a highly specific rehabilitative program.

Level of evidence

V.