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

Quadriceps muscle injuries in athletes: a narrative review

The quadriceps muscles are a large group of 4 muscles in the anterior compartment of the thigh, comprising the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis, which in combination act as the primary extensors of the knee joint. The rectus femoris is also responsible for hip joint flexion. Quadriceps muscle injuries are frequently encountered in sports and athletic activities and present a significant challenge in the realm of sports medicine, impacting athletes across various disciplines and levels of competition. A spectrum of sporting injuries and imaging findings can affect this muscle group, including strains and tears, avulsions, contusions, degloving injuries, and exercise-related signal abnormalities. A thorough understanding of these various pathologies and imaging features is crucial to guide appropriate diagnosis, management, and rehabilitation, as well as ensure safe and prompt return to play, minimize risk of re-injury or long-term adverse sequelae, optimize performance, and improve career longevity of these athletes. This comprehensive review article aims to review the unique anatomy of the quadriceps muscle group and integrate current knowledge of the various forms of sporting injuries affecting it, with a specific emphasis on the imaging features.

Point of care ultrasonography in physical therapists' clinical practice: a clinical perspective

This paper offers a contemporary, evidence-based perspective on how point of care ultrasonography imaging (POCUS) has the potential to impact orthopedic and sports physical therapists' examination and treatment. Clinical use of POCUS has increased in medicine and is emerging in physical therapist practice. Greater affordability, portability, ease of use, and evidence supporting its' diagnostic value have contributed to increased use. Modern ultrasound devices have improved resolution allowing for the differentiation of anatomical structures. Physical therapists use POCUS in clinical practice as an extension of the physical examination to confirm, refute, expand, or narrow a differential diagnosis. Doctor of Physical Therapy professional education provides entry-level student physical therapists with the foundational knowledge necessary for the clinical application of POCUS. A physical therapist's use of POCUS complements the clinical evaluation and contrasts with the approach of referring out for diagnostic imaging and waiting for results. We present current evidence for expanded use of POCUS by physical therapists in clinical practice. We advocate for using ultrasound imaging in orthopedic and sports physical therapists' practice. Integrating POCUS into physical therapist patient management, could decrease patient healthcare costs through increased diagnostic efficiency.

Approach to Evaluating Superficial Soft Tissue Masses by Ultrasound

The purpose of this article is to give a systematic approach to the ultrasound evaluation of superficial soft-tissue masses. The knowledge of proper technique in image acquisition, the characteristic sonographic appearances of the most common masses, their potential pitfalls, and the location of the lesions can help establish a confident diagnosis. Where the sonographic features of the masses are inconclusive, a percutaneous biopsy is effective in establishing the definitive diagnosis.

[Sonography of muscles : Rheumatology-Neurology-Geriatrics-Sports medicine-Orthopedics]

Muscle sonography is used in rheumatology, neurology, geriatrics, sports medicine and orthopedics. Muscular atrophy with fatty and connective tissue degeneration can be visualized and must be interpreted in conjunction with the sonographic findings of the supplying nerves. Sonography is becoming increasingly more important for the early diagnosis of sarcopenia in rheumatology, geriatrics and osteology. Even if its significance has not yet been conclusively clarified, many publications confirm the high reliability of the method. Sonography can ideally be used in addition to magnetic resonance imaging (MRI) in the diagnostics of myositis as it can speed up the diagnosis, muscle groups that were not imaged by MRI can also be assessed sonographically and all muscle groups can be examined during the course of the procedure. Sonography also helps to make a quick and uncomplicated diagnosis of many sports injuries in addition to MRI and is therefore the basis for a targeted therapeutic approach.

Intramuskuläre Sehnenverletzungen am Oberschenkel: Diagnostik – operative Therapie – Rehabilitation

Intramuskuläre Sehnenverletzungen der Oberschenkelmuskulatur stellen ein relativ häufiges und insgesamt erhebliches Problem in der Sportmedizin, vor allem bei schnellkräftigen Sportarten, dar. Die MRT ist ein wertvolles Instrument zur Diagnose und Beurteilung der Schwere dieser Verletzungen. Therapeutisch stehen, je nach Schwere und Chronizität der Verletzung, die konservative, aber auch die operative Behandlung zur Auswahl. Wir zeigen die typischen MRT-Kriterien bei einer akuten wie auch chronischen Verletzung der intramuskulären Oberschenkelsehnen und beschreiben v.a. die chirurgische Behandlung bzw. die operative Technik im Detail. Sowohl die akuten als auch die chronischen Läsionen können erfolgreich operiert werden. In der Rehabilitation stellt die MRT-Kontrolle erneut ein wertvolles Tool dar; die funktionellen Testungen wie EMG und Kraftmessung auf der Kraftmessplatte und in der Isokinetik dürfen jedoch nicht fehlen. Die Rückkehr zum Wettkampfsport ist innerhalb von ca. 4 Monaten möglich.

Technologies for Studying and Teaching Human Anatomy: Implications in Academic Education

The teaching of human anatomy (HA) constitutes one of the fundamental pillars of the curriculum in biological and healthcare-related programs. Therefore, it is imperative that the methodology and didactics employed in this discipline equip students in the best possible way. The traditional method of teaching HA involves lectures and practical classes with previously dissected cadaveric specimens and dissection activities. Concurrently, the present era is witnessing the emergence and popularization of new digital technologies connected to the internet, among which we can highlight smartphones, quick response codes, and virtual reality devices, along with the dissemination of complementary imaging methods, such as radiography, ultrasonography, magnetic resonance imaging, and computerized tomography. From this perspective, the objective of this review is to analyze how each of these new tools integrates into the academic context, in order to diversify the teaching of HA and contribute to better understanding of the HA content during academic training, as well as the clinical applications.

Clinical applications, safety profiles, and future developments of contrast agents in modern radiology: A comprehensive review

Contrast agents have transformed the field of medical imaging, significantly enhancing the visualisation of internal structures and improving diagnostic accuracy across X‐rays, computed tomography, magnetic resonance imaging (MRI), and ultrasound. This review explores the historical development, physicochemical properties, and mechanisms of action of iodinated, gadolinium‐based, barium sulfate, microbubble, and nanoparticle contrast agents. It highlights key advancements, including the transition from high‐osmolar to low‐ and iso‐osmolar iodinated agents, the integration of gadolinium in MRI, and the innovative use of microbubbles and nanoparticles. The review critically examines the safety profiles and adverse reactions of these contrast agents, categorising them into hypersensitivity and physiological reactions. It outlines risk factors, common misconceptions, and management strategies for adverse reactions, emphasising the importance of personalised approaches in clinical practice. Additionally, it delves into broader implications, including ethical considerations, environmental impact, and global accessibility of contrast media. The review also discusses technological advancements such as targeted contrast agents and the integration of artificial intelligence to optimise contrast dosage. By synthesising current knowledge and emerging trends, this review underscores the pivotal role of contrast agents in advancing medical imaging. It aims to equip clinicians, researchers, and policymakers with a thorough understanding to enhance diagnostic efficacy, ensure patient safety, and address ethical and environmental challenges, thereby informing future innovations and regulatory frameworks to promote equitable access to advanced imaging technologies globally.

Ultrasound Imaging in Diagnosis and Management of Lower Limb Injuries: A Comprehensive Review

Medical imaging tests are widely used to diagnose a broad spectrum of lower-limb injuries. Among these modalities, ultrasound (US) imaging has gained significant traction as a valuable diagnostic instrument for assessing conditions primarily affecting muscles, tendons, ligaments, and other soft tissues. However, there are important dilemmas related to the indications and possibilities of US in lower-limb injuries. Conflicting findings and approaches raise questions regarding the validity, accuracy, and usefulness of the US in that area. This narrative review attempts to summarize the current state of knowledge regarding US imaging of lower-limb injuries. The study provides a detailed discussion of the existing literature and contemporary insights on the diagnosis of lower-limb injuries using US examination, and draws attention to the role of the US in interventional procedures and monitoring of the healing process. The characteristics of normal muscles, tendons, and ligaments in US imaging are presented, along with the most commonly documented conditions affecting these tissues. Furthermore, the benefits and justifications for employing US in interventional procedures are discussed, ranging from platelet-rich plasma injections to physiotherapeutic treatments like percutaneous electrolysis. The study was further augmented with US pictures depicting various lower-limb injuries, mainly affecting young athletes. This article aims to review the role of US imaging in the diagnosis and management of common lower-limb injuries.

Distributed Wearable Ultrasound Sensors Predict Isometric Ground Reaction Force

Rehabilitation from musculoskeletal injuries focuses on reestablishing and monitoring muscle activation patterns to accurately produce force. The aim of this study is to explore the use of a novel low-powered wearable distributed Simultaneous Musculoskeletal Assessment with Real-Time Ultrasound (SMART-US) device to predict force during an isometric squat task. Participants (N = 5) performed maximum isometric squats under two medical imaging techniques; clinical musculoskeletal motion mode (m-mode) ultrasound on the dominant vastus lateralis and SMART-US sensors placed on the rectus femoris, vastus lateralis, medial hamstring, and vastus medialis. Ultrasound features were extracted, and a linear ridge regression model was used to predict ground reaction force. The performance of ultrasound features to predict measured force was tested using either the Clinical M-mode, SMART-US sensors on the vastus lateralis (SMART-US: VL), rectus femoris (SMART-US: RF), medial hamstring (SMART-US: MH), and vastus medialis (SMART-US: VMO) or utilized all four SMART-US sensors (Distributed SMART-US). Model training showed that the Clinical M-mode and the Distributed SMART-US model were both significantly different from the SMART-US: VL, SMART-US: MH, SMART-US: RF, and SMART-US: VMO models (p < 0.05). Model validation showed that the Distributed SMART-US model had an R2 of 0.80 ± 0.04 and was significantly different from SMART-US: VL but not from the Clinical M-mode model. In conclusion, a novel wearable distributed SMART-US system can predict ground reaction force using machine learning, demonstrating the feasibility of wearable ultrasound imaging for ground reaction force estimation.

[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.

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.

Reinjury Following Return to Play

Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.

Anisotropic properties of acoustically induced electric polarization in soft fibrous biological tissues

Acoustically induced electric polarization and its anisotropy in soft fibrous biological tissues were investigated under wet conditions. Assuming that fibrous tissues have polar uniaxial symmetry, stress-induced polarization should occur in the direction of fiber orientation in the non-shear terms of the piezoelectric tensor. Using the acoustically stimulated electromagnetic method, we measured the anisotropic properties of acoustically induced polarization in wet samples of Achilles tendon, skeletal muscle, and aortic wall. In all these tissues, the major non-shear term was confirmed to be d 33 , with polarization occurring along the fibrous direction. In Achilles tendon, which contains highly oriented collagen fibers, the uniaxially symmetric fiber structure explains the anisotropic polarization well. However, substantial polarization perpendicular to the fiber orientation (the d 11 term) was observed in skeletal muscle and aortic wall, suggesting that the presence of fiber crimps and complex extracellular matrix produces polarization that does not occur in the uniaxially symmetric structures.

Exploring the integration of diagnostic musculoskeletal ultrasound imaging into clinical practice by physical therapists

BACKGROUND

Musculoskeletal ultrasound (MSK-US) use for diagnostic purposes is expanding in physical therapy practice. Identifying and describing physical therapy-specific approaches to incorporating MSK-US into the evaluation process is needed. Musculoskeletal ultrasound extends the physical exam to allow clinicians to visualize anatomy and pathophysiology both statically and dynamically. Purpose: To document 1) weekly use of diagnostic MSK-US; and 2) clinical reasoning approach used in challenging patient cases by physical therapists (PTs) registered by Inteleos in musculoskeletal sonography (RMSK-certified).

METHODS

Longitudinal, observational, cohort study using mixed methods for data collection and analysis. All 23 currently RMSK-certified PTs using MSK-US in clinical practice across the United States were contacted, and 16 participated. Data were collected using an online survey created with the Research Electronic Data Capture System. Participants documented MSK-US clinical use and significant cases using weekly, reflective, online journals for three months. Demographic data were summarized using descriptive statistics. Case data were analyzed thematically.

RESULTS

Participating RMSK-certified PTs performed 1110 MSK-US examinations over 110 weeks. Clinicians averaged 7 (range 1-25) MSK-US examinations weekly, representing 28% of an average caseload. Examinations contributed significant anatomical/ pathological information 100% of the time. The most common joints scanned were the knee (n = 281), shoulder (n = 254), and wrist (n = 228). Case data revealed three themes: 1) augmenting the clinical evaluation to extend or narrow a diagnosis; 2) outcomes guiding action; and 3) lessons learned from clinical findings.

CONCLUSION

RMSK-certified PTs regularly used MSK-US to validate and refine their clinical diagnoses and treatment. Ultrasound imaging directly influenced patient care by informing the diagnostic process, guiding treatment, and appropriately identifying referrals.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Managing Lower Limb Muscle Reinjuries in Athletes: From Risk Factors to Return-to-Play Strategies

Muscle injuries and subsequent reinjuries significantly impact athletes, especially in football. These injuries lead to time loss, performance impairment, and long-term health concerns. This review aims to provide a comprehensive overview of the current understanding of muscle reinjuries, delving into their epidemiology, risk factors, clinical management, and prevention strategies. Despite advancements in rehabilitation programs and return-to-play criteria, reinjury rates remain alarmingly high. Age and previous muscle injuries are nonmodifiable risk factors contributing to a high reinjury rate. Clinical management, which involves accurate diagnosis, individualized rehabilitation plans, and the establishment of return-to-training and return-to-play criteria, plays a pivotal role during the sports season. Eccentric exercises, optimal loading, and training load monitoring are key elements in preventing reinjuries. The potential of artificial intelligence (AI) in predicting and preventing reinjuries offers a promising avenue, emphasizing the need for a multidisciplinary approach to managing these injuries. While current strategies offer some mitigation, there is a pressing need for innovative solutions, possibly leveraging AI, to reduce the incidence of muscle reinjuries in football players. Future research should focus on this direction, aiming to enhance athletes' well-being and performance.

Update on muscle imaging in myositis

PURPOSE OF REVIEW

Imaging techniques such as MRI, ultrasound and PET/computed tomography (CT) have roles in the detection, diagnosis and management of myositis or idiopathic inflammatory myopathy (IIM). Imaging research has also provided valuable knowledge in the understanding of the pathology of IIM. This review explores the latest advancements of these imaging modalities in IIM.

RECENT FINDINGS

Recent advancements in imaging of IIM have seen a shift away from manual and qualitative analysis of the images. Quantitative MRI provides more objective, and potentially more sensitive characterization of fat infiltration and inflammation in muscles. In addition to B-mode ultrasound changes, shearwave elastography offers a new dimension to investigating IIM. PET/CT has the added advantage of including IIM-associated findings such as malignancies.

SUMMARY

It is evident that MRI, ultrasound and PET/CT have important roles in myositis. Continued technological advancement and a quest for more sophisticated applications help drive innovation; this has especially been so of machine learning/deep learning using artificial intelligence and the developing promise of texture analysis.

THE ULTRASONOGRAPHY EXAMINATION OF SKELETAL MUSCLES IN TRAUMATIC ISCHEMIA (EXPERIMENTAL STUDY)

OBJECTIVE

The aim: To establish indicators and significance of sonography in the evaluation of muscle necrosis in ischemia of the limb acording to quantitative ultrasonographic indicators and density of collagen by histological method.

PATIENTS AND METHODS

Materials and methods: In experiments, rabbits modeled with 6-hour limb ischemia by applying an elastic tourniquet. On days 5, 15, and 30, ultrasound and histological studies of the muscles and correlation analysis were performed between the muscles' entropy and the degree of their damage (atrophy, fibrosis and necrosis).

RESULTS

Results: The relative amount of structurally altered tissue was estimated morphometrically and compared with entropy. A high correlation of muscle damage with vertical δ-entropy indicates that sonography is highly likely to detect areas of necrosis and, to a lesser extent, fibrosis in the development of ischemic limb contracture in the early stages.

CONCLUSION

Conclusions: Vertical δ-entropy in sonography is a significant indicator of muscle damage after traumatic ischemia and has strong relationship with muscle fibrosis.

Point-of-care ultrasound in musculoskeletal field

The musculoskeletal field is relatively new in point-of-care ultrasound (POCUS), a modality that has been gaining significance with the evolution of ultrasound (US) equipment and high-frequency probes. Images have become progressively clearer over the past decade, making it possible to diagnose many pathological conditions without exposure to radiation. Ultrasonography reveals many soft tissue pathologies that cannot be visualized using plain radiographs, which have historically been the first choice for the evaluation of musculoskeletal disorders. US saves money and time compared to magnetic resonance imaging (MRI). Although it is difficult to diagnose a disorder inside bone, its surface can be visualized very clearly, and it is also possible to visualize cartilage. Furthermore, with POCUS, it is possible to confirm a disorder and the continuity of the fibrous structures of muscles, tendons, and ligaments. In addition, the understanding of pathological conditions of motor disturbances, such as nerve or muscle/tendon injury, nerve paralysis, adhesions of the tendons, and joint instability, is deepened by observing the movement of these structures. Peripheral nerves, even small branches, can be visualized, and pathological conditions can be pinpointed by observing the nerve morphology, continuity, and relationship with the surrounding tissues. Children can be examined in a safe, relaxed environment, without leaving their parents. In addition, US is significantly different from other modalities in that it can be used for both diagnosis and treatment. Being able to visualize target sites improves safety and route accuracy of needle insertion for injection or puncture. Musculoskeletal POCUS is indispensable in routine medical care and is a technique that medical residents should acquire.

Isotonic and Isometric Exercise Interventions Improve the Hamstring Muscles’ Strength and Flexibility: A Narrative Review

Background: Hamstring weakness has been associated with an increased risk of hamstring strain, a common sports injury that occurs when athletes perform actions such as quick sprints. The hamstring complex comprises three distinct muscles: the long and short heads of the bicep femoris, the semimembranosus, and the semitendinosus. Methods: The researchers collected the data from different electronic databases: PubMed, Google Scholar, and the Web of Science. Results: Many studies have been conducted on the numerous benefits of hamstring strength, in terms of athletic performance and injury prevention. Isotonic and isometric exercises are commonly used to improve hamstring strength, with each exercise type having a unique effect on the hamstring muscles. Isotonic exercise improves the muscles’ strength, increasing their ability to resist any force, while isometric training increases strength and the muscles’ ability to produce power by changing the muscle length. Conclusions: These exercises, when performed at low intensity, but with high repetition, can be used by the healthy general population to prepare for training and daily exercise. This can improve hamstring muscle strength and flexibility, leading to enhanced performance and reduced injury risk.

Challenges and Solutions for Musculoskeletal Disorders in Athletes

The etymology of the word "athlete" derives from the ancient Greek ἀθλητής (athletés, from âthlos that is, fight, competition) [...].

[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.