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BACKGROUND: The purpose of this study was to introduce a novel operative technique and to evaluate the clinical outcomes in a cohort of patients with missed or neglected Achilles tendon ruptures. METHODS: Fifteen consecutive patients with missed complete Achilles tendon ruptures and 5-cm or larger gaps had reconstruction with V-Y lengthening and flexor hallucis longus tendon transfer through a single incision. The patients were evaluated at an average of 106 weeks after surgery. At the time of followup, all patients were assessed with regard to their self-reported level of satisfaction and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Ankle strength and active range of motion were evaluated using Biodex (Biodex Medical Systems, Shirley, NY) isokinetic dynamometry. In addition, seven patients were evaluated using diagnostic ultrasound. RESULTS: We found a 7.7 N-m (-22.3%) loss of plantarflexion torque at 60 degrees/sec and a 3.5 N-m (-13.5%) loss of plantarflexion torque at 120 degrees/sec, as well as a 5 degrees loss of active range of motion. AOFAS scores were all good to excellent, with an average score of 94.1 of 100. All patients were satisfied with their outcomes (rated good or very good). Excellent exposure of the Achilles tendon repair was obtained with ultrasound. CONCLUSIONS: For patients with missed or neglected Achilles tendon rupture with a rupture gap of at least 5 cm, operative repair using V-Y lengthening and flexor hallucis longus tendon transfer through a single incision technique achieved a high percentage of satisfactory results. [ABSTRACT FROM AUTHOR]

Background: Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes., Purpose: To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers., Methods: A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17-30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated., Results: The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests., Conclusion: Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Despite the importance of accurately detecting ulnar nerve subluxation in vulnerable athletes, few studies have compared the performance of physical examination and ultrasound in this population., Purpose/hypothesis: The purpose of this study was to compare the diagnostic validity of physical examination versus ultrasound in detecting ulnar nerve subluxation at the cubital tunnel of the elbow in professional baseball pitchers. It was hypothesized that ultrasound would more sensitively detect ulnar nerve subluxation., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Physical and sonographic examinations for ulnar nerve subluxation were performed on 186 elbows of 95 consecutive male professional baseball pitchers (age, 17-30 years) as a routine part of their spring training assessments. Provocative maneuvers consisting of the Tinel and elbow flexion-compression tests were evaluated over the cubital tunnel. The validity of physical examination for detecting ulnar nerve subluxation at the elbow was determined using ultrasonographic examination for comparison., Results: Ulnar nerve subluxation was detected by physical examination in 58 (31.2%) elbows and by ultrasonography in 61 (32.8%) elbows. Of the 58 elbows with positive physical examination, 47 were positive on ultrasound. Using a positive ultrasound as a reference, the accuracy of the physical examination was 86.6%, with 77% sensitivity and 91.2% specificity. The positive and negative predictive values of physical examination were 81% and 89.1%, respectively. There was no relationship between nerve instability and positive provocative tests overall, in dominant versus nondominant arms, or in right versus left arms ( P > .05 for all)., Conclusion: Physical examination had moderate sensitivity and high specificity for detecting ulnar nerve subluxation at the cubital tunnel of the elbow when compared with ultrasound. These findings suggest that when detecting the presence of a subluxating ulnar nerve is most important, it may be advisable to obtain an ultrasound evaluation instead of relying on a physical examination; however, physical examination alone may be appropriate for ruling out subluxation., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.M.L. has received education payments from Liberty Surgical. M.P.R. has received education payments from Liberty Surgical and Medical Device Business Services. L.N.N. has received honoraria from Canon Medical System. S.B.C. has received education payments from Liberty Surgical; consulting fees from ConMed Linvatec and Zimmer Biomet; research support from Arthrex and Major League Baseball; speaking fees from Zimmer; and royalties from Slack and Zimmer. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Philadelphia University–Thomas Jefferson University (no. 21D.056)., (© The Author(s) 2023.)

Background: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results., Purpose/hypothesis: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location., Study Design: Cohort study; Level of evidence, 3., Methods: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist., Results: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping ( P = .499)., Conclusion: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Ultrasound of the elbow can be incorporated into routine pediatric practice in the radiology department, emergency department, orthopedic clinic, and interventional suite. Ultrasound is complementary to radiography and magnetic resonance imaging for the evaluation of elbow pain in athletes with overhead activities or valgus stress, focusing on the ulnar collateral ligament medially and capitellum laterally. As a primary imaging modality, ultrasound can be used for a variety of indications including inflammatory arthritis, fracture diagnosis, and ulnar neuritis/subluxation. Ultrasound is also well-suited to guide diagnostic and therapeutic elbow joint interventions with precise localization of anatomic landmarks and needle placement. Here, we describe technical aspects of elbow ultrasound and illustrate its application in pediatric patients from infants to teen athletes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The diagnosis and treatment of neuropathic pain is often clinically challenging, with many patients requiring treatments beyond oral medications. To improve our percutaneous treatments, we established a clinical pathway that utilized ultrasound (US) guidance for steroid injection and alcohol ablation for patients with painful neuropathy., Objectives: To describe a collaborative neuropathy treatment pathway developed by a neurosurgeon, pain physicians, and a sonologist, describing early clinical experiences and patient-reported outcomes., Study Design: A retrospective case series was performed., Methods: Patients that received percutaneous alcohol ablation with US guidance for neuropathy were identified through a retrospective review of a single provider's case log. Demographics and treatment information were collected from the electronic medical record. Patients were surveyed about their symptoms and treatment efficacy. Descriptive statistics were expressed as medians and the interquartile range ([IQR]; 25th and 75th data percentiles). Differences in the median follow-up pain scores were assessed using a Wilcoxon signed-rank test., Results: Thirty-five patients underwent US-guided alcohol ablation, with the average patient receiving one treatment (range: 1 to 2), having a median duration of 4.8 months until reinjection (IQR: 2.9 to 13.1). The median number of steroid injections that individuals received before US-guided alcohol ablation was 2 (IQR: 1 to 3), and the median interval between steroid injections was 3.7 months (IQR: 2.0 to 9.6). Most (20/35 [57%]) patients responded to the survey, and the median pain scores decreased by 3 units (median: -3, IQR: -6 to 0; P < 0.001) one week following the alcohol ablation. This pain reduction remained significant at one month (P < 0.001) and one year (P = 0.002) following ablation. Most (12/20 [60%]) patients reported that alcohol ablation was more effective in improving their pain than oral pain medications., Limitations: Given the small sample size, treatment efficacy for alcohol neurolysis cannot be generalized to the broader population., Conclusions: US-guided percutaneous treatments for neuropathic pain present a growing opportunity for interprofessional collaboration between neurosurgery, clinicians who treat chronic pain, and sonologists. US can provide valuable diagnostic information and guide accurate percutaneous treatments in skilled hands. Further studies are warranted to determine whether a US-guided treatment pathway can prevent unnecessary open surgical management.

Objectives: The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication., Methods: A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%., Results: Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein., Conclusions: The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine., (© 2022 American Institute of Ultrasound in Medicine.)

Objectives: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students., Methods: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting., Results: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care., Conclusions: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice., (© 2022. The Author(s).)

The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, orthopedic surgery, and pathology to arrive at a consensus regarding the management of superficial soft-tissue masses imaged with US. The recommendations in this statement are based on analysis of current literature and common practice strategies. This statement reviews and illustrates the US features of common superficial soft-tissue lesions that may manifest as a soft-tissue mass and suggests guidelines for subsequent management., (© RSNA, 2022.)

Objective: To assess the functional parameters of the Achilles tendons among asymptomatic college level athletes using shear wave elastography (SWE) and to describe the relationship to athlete demographics and anthropometric lower extremity measurements., Material and Methods: Sixty-five athletes were included in this IRB-approved study. SWE measurements were made on two tendon positions (neutral state and active maximum dorsiflexion) with two different probe orientations (longitudinal and transverse). Associations were assessed with BMI, tibial/foot length, type of sports, and resting/maximal dorsiflexion-plantar flexion angles., Results: Thirty-five (53.8%) males and 30 (46.2%) females with an overall mean age of 20.9 years (± 2.8), mean height of 176 cm (± 0.11), and mean weight of 74.1 kg (± 12) were studied. In the neutral state, the mean wave velocity of 7.5 m sec -1 and the mean elastic modulus of 176.8 kPa were recorded. In active maximum dorsiflexion, the mean velocity was 8.3 m sec -1 and mean elastic modulus was 199 kPa. On the transverse view, the mean velocity and elastic measurements were significantly lower (p = 0.0001). No significant differences in SWE parameters were seen between male and female athletes regardless of probe orientation (p < 0.05) with SWE values being higher in the running group vs non-running group (p < 0.05). In neutral state, longitudinal SWE measurements correlated with the tibia-foot length whereas transverse measurements correlated with the tendon diameter and ankle resting angle (ARA) (p < 0.005)., Conclusion: SWE can distinguish functional differences in Achilles tendon stiffness between athletes engaged in running-intensive sports compared with other athletes., (© 2021. ISS.)

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased ( p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines ( p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

»: Ultrasonography (US) is valued for its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing upper-extremity shoulder injury has expanded, but several features require definition before more widespread adoption can be realized., »: In particular, the evaluation of rotator cuff tears (RCTs) with US has been extensively studied, and authors generally agree that US is comparable with magnetic resonance imaging for the detection of full-thickness RCTs, whereas partial-thickness RCTs are more difficult to accurately identify with US. Dynamic evaluation is particularly useful for pathologies such as subacromial impingement and glenohumeral instability., »: US has shown particular usefulness for the assessment of athletes, where there is additional motivation to delay more invasive techniques. US has demonstrated promising results as a diagnostic modality for common shoulder injuries in athletes, and it is an important imaging tool that complements a thorough history and physical examination., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A687)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Elbow pain is a frequent complaint among overhead athletes. Standard evaluation of the elbow uses history and physical examination, with radiographic imaging and MRI aiding in the confirmation of diagnosis. Musculoskeletal ultrasonography (US) provides dynamic, functional assessment of tendons and ligaments in the elbow, allowing the visualization of structures under stress and motion. Stress US offers the ability to detect injuries to the ulnar collateral ligament by measuring changes in joint space under stress. The freedom of dynamic imaging means results are dependent on the skill of the US operator to obtain the most accurate and complete evaluation. US is cost efficient and portable, allowing for quick examination at the point of care. This article provides a technique guide for sports medicine specialists performing US examination of the elbow., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.

Background: There is consensus that most complete ulnar collateral ligament (UCL) injuries in throwers would benefit from surgical intervention. Optimal treatment for partial UCL tears remains controversial. Stress ultrasonography has become a well-accepted diagnostic modality for assessing UCL injury., Hypothesis: Partial UCL tears will result in an intermediate increase in ulnohumeral joint space gapping as compared with that of an intact UCL and a complete UCL tear, but the degree of joint space gapping will vary by anatomic location of the partial tear., Study Design: Controlled laboratory study., Methods: Twenty-one cadaveric elbows were divided into 7 groups representing different anatomic locations of UCL partial tears. Partial tears were simulated by cutting 50% of the measured width of the UCL at 6 locations: distal anterior/posterior, midsubstance anterior/posterior, and proximal anterior/posterior. A seventh partial tear was created by partially elevating the undersurface of the distal UCL to simulate the radiographic "T-sign." Valgus stress (15 daN) was applied to each cadaveric elbow at 30° of flexion using a standardized device. Each specimen was tested intact, partially torn, and completely torn. At each state, joint space was measured using stress ultrasonography, and the difference in joint space from unstressed to stressed (delta) was recorded., Results: There were 10 right and 11 left upper extremity specimens. The mean delta was 0.58 mm for the intact state and <0.75 mm in all groups. Both distal partial tear groups had mean deltas <0.75 mm, similar to intact elbows. Proximal tears and the T-sign demonstrated intermediate deltas (0.99-1.23 mm). Midsubstance partial tears demonstrated the largest deltas (1.57-2.03 mm), similar to those of the complete tears. All complete tear groups had a mean delta >1.5 mm (1.54-3.03 mm)., Conclusion: These findings suggest that partial tears introduce a spectrum of instability from functionally intact to completely torn. As a result, some may be biomechanically amenable to nonoperative treatment, while others would be indicated for early reconstruction. Further research into the biological and biomechanical determinants of nonoperative treatment failure will assist with more precise treatment recommendations., Clinical Relevance: Describing the biomechanical consequences of different, clinically significant partial UCL tears potentially allows more precise recommendations for operative and nonoperative treatment.

The advent of high-resolution neuromuscular ultrasound (US) has provided a useful tool for conservative treatment of peripheral entrapment mononeuropathies. US-guided interventions require careful coordination of transducer and needle movement along with a detailed understanding of sonoanatomy. Preprocedural planning and positioning can be helpful in performing these interventions. Corticosteroid injections, aspiration of ganglia, hydrodissection, and minimally invasive procedures can be useful nonsurgical treatments for mononeuropathies refractory to conservative care. Technical aspects as well as the current understanding of the indications and efficacy of these procedures for common entrapment mononeuropathies are reviewed in this study. Muscle Nerve, 2019., (© 2019 Wiley Periodicals, Inc.)

Background: Recurrent carpal tunnel syndrome is often associated with perineural scarring around the median nerve. Surgical options include relatively invasive procedures, such as fat pad grafting, ligament reconstruction, muscle transfer, and nerve wraps. All have limited success because of the possibility of repeated recurrent scarring postoperatively., Methods: We discuss a technique involving injection with external hydroneurolysis of the median nerve under ultrasound guidance for recurrent carpal tunnel. Injection enables a gentler dissection of the surrounding tissues compared with open external neurolysis, with less chance of recurrent scarring. This technique is a unique alternative to repeat operative intervention in recurrent carpal tunnel, as well as a prelude to repeat open decompression and salvage procedures., Results: Ultrasound-guided injection with external hydroneurolysis of the median nerve is a safer, more limited procedure compared with repeat open surgery, usually performed in an office setting. This procedure limits risk, anesthesia, and operating/recovery room expenses, offering relief in 70% to 80% of cases. Furthermore, in the 20% to 30% of patients with inadequate relief, surgery remains a viable option. US provides important information on the anatomy of the median nerve and carpal canal and can rule out covert pathology., Conclusions: We offer an alternative treatment for recurrent carpal tunnel syndrome, a difficult problem for which many surgeons recommend nonoperative treatment. US provides objective data concerning residual nerve compression and allows for dynamic assessment. Theoretically, this also offers a viable solution for surgeons and their patients with recurrent carpal tunnel syndrome before being pressed to consider repeat open surgery.

Objectives: Sonography during externally applied stress has the potential to identify ligamentous instability, but diagnostic parameters for the most commonly sprained ankle ligament, the anterior talofibular ligament (ATFL), have not yet been established. The purpose of this study was to determine normative values of the change in the length of the ATFL in an asymptomatic population during manual stress sonography and to compare these values to those in patients with clinical findings of anterolateral ankle instability., Methods: Sonography of the ATFL at rest and with maximally applied manual stress was performed bilaterally in 20 asymptomatic volunteers from each of three 10-year age groups from 20 to 50 years. Data were compared to those for 34 patients retrospectively identified who underwent stress sonography of the ATFL for clinical signs and symptoms of chronic anterolateral ankle instability., Results: In the asymptomatic population (10 men and 10 women), for men, the mean change in ATFL length between stress and neutral positions was 0.44 mm (95% confidence interval [CI], 0.32-0.57 mm). For women, it was 0.43 mm (95% CI, 0.31-0.55 mm). The difference in laxity between sexes was not significant (P = .85). In the symptomatic population, the mean ATFL length difference between stress and neutral positions was 1.26 mm (95% CI, 0.97-1.55 mm). A t test comparing the mean change in ATFL length showed a statistically significant increase in laxity in the symptomatic group (P < .0001)., Conclusions: The normal ATFL shows minimal laxity in both men and women on stress sonography, with significantly greater laxity among patients with ankle instability. Given these findings, stress sonography may have an important role in the imaging diagnosis of anterolateral ankle instability., (© 2018 by the American Institute of Ultrasound in Medicine.)

A 78-year-old woman with a history of bilateral hip replacements presented with an ill-defined erythematous plaque with foci of reticulated and indurated areas on the left thigh. Initially, a few weeks after her surgery, a small area of erythema appeared overlying the incision site. Over a 6-month period, the erythema slowly expanded before stabilizing in size (Figure 1). There was no pruritus, pain, or warmth. Orthopedic evaluation found no evidence of infection or malfunction of the hip prosthesis. A skin biopsy revealed telangiectasia of the superficial vessels. Based on the clinical and histopathologic findings, a diagnosis of reticular telangiectatic erythema (RTE) was established. An ultrasound scan revealed a greater trochanteric bursa distended by a chronic, organized hematoma measuring 12 cm at greatest dimension, secondary to a full-thickness tear of the left gluteus minimus (Figure 2), establishing the underlying cause of the RTE in this patient.

Purpose: MRI and ultrasound (US) are effective diagnostic tools to evaluate extremities. In this study, we analyze utilization trends in musculoskeletal (MSK) US and MRI from 2003 to 2015 within the Medicare population., Methods: Our data sources were the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2003 to 2015. They cover all Medicare fee-for-service enrollees (37.5 million in 2015). Current Procedural Terminology codes for nonvascular, nonspine joint MRI and extremity US were selected and volumes within these codes were determined. Medicare's physician specialty codes were used to identify provider specialty. We accounted for the 2011 code change that created both complete and limited US examinations., Results: Total Medicare joint MRI volume increased from 738,509 in 2003 to 1,131,503 in 2015 (+53%), although there was little change after 2007. Radiologist MRI share in 2015 was 93%, followed by orthopedic surgeons at 5%. Total MSK US volume grew from 96,235 in 2003 to 429,695 in 2015 (+347%). Radiologists' market share of US decreased from 65% in 2003 to 37% in 2015, with nonradiologists now representing a majority of ultrasound examinations. Multiple nonradiology subspecialties also exceed radiology in volume of complete ultrasounds., Conclusion: The potential negative impact of MSK US on MSK MRI volume is likely overestimated because MRI volume has remained stable. MSK ultrasound is increasingly utilized outside radiology. If radiologists want to maintain their market share as MSK imaging leaders, more emphasis should be placed on increasing their involvement and expertise in MSK US., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Ankle impingement is a common cause of chronic ankle pain. We retrospectively studied the effectiveness of ultrasound-guided percutaneous needle fenestration of the pathological soft tissues combined with corticosteroid injection to treat this condition., Methods: We administered a telephone survey to patients who underwent the procedure. Patients were asked questions on the Foot Function Index and queried about their overall satisfaction with the procedure on a scale of 0 (completely unsatisfied) to 10 (very satisfied)., Results: Forty-nine patients participated in the survey: 26 women and 23 men, mean age 42.7 years (range, 19-65 years). Impingement was anterior in 26/49 (53.1%), anterolateral in 14/49 (28.6%), and both in 9/49 (18.4%). Mean pain level before the procedure was 6.76 ± 1.84 and after the procedure was 2.73 ± 2.21. Reported pain scale levels declined by 4.02 ± 2 units after the procedure (P < .0001). Patient's overall satisfaction was 7.9 ± 2.44., Conclusions: Ultrasound-guided percutaneous needle fenestration and corticosteroid injection appears to be an effective nonoperative alternative for treatment of anterior and/or anterolateral ankle impingement., Levels of Evidence: Level IV.

Purpose: The ABR has recently changed the format of the board examination, in which the oral examination was replaced by a computer based multiple-choice test. The purpose of this study was to determine resident's perceptions of a new conference resembling the new ABR format., Methods: Residents were requested to review a series of didactic pediatric imaging presentations prior to attending case conference. During conference, unknown cases reflecting the subject matter from the didactic presentations were presented along with multiple-choice questions. We then surveyed resident perspectives after each case conference., Results: Between 14 and 18 residents were surveyed at the end of each subspecialty case review presentation. About 94% of resident respondents felt that the independent didactic study followed by an interactive case review session would better prepare them for the ABR certification exams, compared to didactic lectures alone. Furthermore, 95% of the respondents indicated that they preferred the independent didactic review followed by interactive case review versus didactic lecture alone. Most the respondents (85%) felt that combining independent didactic review with interactive unknown case sessions made the material more interesting and provided greater understanding of the material. There was no statistically significant difference in the distribution of answers across the subspecialty sessions (p > .05)., Conclusion: Radiology residents favorably reviewed the combination of independent review of didactic material prior to interactive case review. Material presented in this fashion is felt to be more interesting and is thought to result in enhanced understanding of pediatric radiology material., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The objective of our study was to determine patterns and cost of imaging tumor surveillance in patients after a benign fine-needle aspiration (FNA) biopsy of the thyroid in a large teaching hospital as well as the rate of subsequent cancer detection., Materials and Methods: This cohort study was approved by the appropriate institutional review board and complied with HIPAA. All patients who had a benign thyroid FNA biopsy between January 1, 1999, and December 31, 2003, were identified from an institutional pathology database. We gathered information from electronic medical records on imaging tumor surveillance and subsequent cancer detection. Cost was determined using the facility total relative value unit and the 2014 Hospital Outpatient Prospective Payment System conversion factor., Results: Between January 1, 1999, and December 31, 2003, 1685 patients had a benign thyroid FNA biopsy, 800 (47.5%) of whom underwent follow-up imaging. These patients underwent 2223 thyroid ultrasound examinations, 606 ultrasound-guided thyroid FNA biopsies, 78 thyroid scintigraphy examinations, 168 neck CTs, and 53 neck MRIs at a cost of $529,874, $176,157, $39,622, $80,580, and $53,114, respectively, for a total cost of $879,347 or $1099 per patient. The mean length of follow-up was 7.3 years, during which time 19 (2.4%) patients were diagnosed with thyroid cancer at a cost of $46,281 per cancer. Seventeen (89.5%) were diagnosed with papillary carcinoma and two (10.5%) with Hurthle cell carcinoma., Conclusion: Over a 5-year period, about half of the patients who had a benign thyroid FNA biopsy underwent follow-up imaging at considerable cost with a small rate of subsequent malignancy.

Background: Stress ultrasound (SUS) of the elbow has demonstrated changes in the anterior band of the ulnar collateral ligament (UCL) in professional and high school-aged pitchers. However, there have been no large reports correlating pitching history data with SUS changes in youth and adolescent baseball pitchers., Hypothesis: Changes of the UCL on SUS will correlate with pitching volume in youth and adolescent baseball pitchers., Study Design: Cross-sectional study; Level of evidence, 3., Methods: SUS of the elbow was performed in both elbows of 102 youth and adolescent baseball pitchers. UCL thickness and the width of the ulnohumeral joint, at rest and with 150 N of valgus stress, were measured using a standardized, instrumented device. Demographic data, arm measurements, and a pitching history questionnaire were recorded as well. The pitchers were separated into 2 groups based on age: group 1 (12-14 years) and group 2 (15-18 years). SUS findings of the dominant elbows were compared between the 2 groups. Correlation analysis and linear regression were used to identify relationships between SUS findings and pitching history data., Results: In all pitchers, the mean UCL thickness was 4.40 mm in the dominant elbow and 4.11 mm in the nondominant elbow (P =.03). There was no significant difference between elbows in any joint space characteristics. A comparison of group 1 versus group 2 demonstrated significant differences in UCL thickness (4.13 vs 4.96 mm; P < .001), resting joint space width (6.56 vs 4.04 mm; P < .001), and stressed joint space width (7.68 vs 4.07 mm; P < .001). There was no difference in the change in joint space width between the 2 groups (1.11 vs 0.76 mm; P = .05). The UCL was significantly thicker in pitchers who threw more than 67 pitches per appearance (4.69 vs 4.14 mm), who pitched more than 5 innings per appearance (4.76 vs 4.11 mm), and who had more than 5.5 years of pitching experience (4.71 vs 4.07 mm; P < .001). Linear regression demonstrated that age, weight, and pitches per appearance (R 2 = 0.114, 0.370, and 0.326, respectively) significantly correlated with UCL thickness., Conclusion: These findings suggest that UCL thickness increases as pitchers get older and heavier and as they increase their pitch volumes., (© 2016 The Author(s).)

Background: Stress ultrasound (SUS) of the elbow has demonstrated changes in the anterior band of the ulnar collateral ligament (UCL) in professional baseball pitchers. However, there have been no reports documenting the chronological appearance of these changes., Purpose: To characterize the chronology of anatomic changes of the UCL in a cohort of young professional baseball pitchers., Study Design: Cross-sectional study; Level of evidence, 3., Methods: SUS of the elbow was performed on the dominant arm in 127 asymptomatic professional pitchers aged 17 to 21 years. UCL thickness was measured at rest. The width of the ulnohumeral joint was measured at 30° of elbow flexion, both at rest and with 150 N of valgus stress, using a standardized instrumented device. Any ligament heterogeneity and calcifications were documented. Players were divided into 3 groups based on the number of years of professional experience before the ultrasound examination: 0 years (n = 51), 1-2 years (n = 54), and 3-4 years (n = 22). Additionally, players were divided into 5 groups based on chronological age at the time of the first SUS examination: 17 years (n = 5), 18 years (n = 18), 19 years (n = 33), 20 years (n = 20), and 21 years (n = 51). Statistically significant differences between the groups were determined., Results: The mean UCL thickness was 5.85 ± 1.22 mm, 6.23 ± 1.32 mm, and 6.94 ± 2.12 mm in the players with 0, 1-2, and 3-4 years of professional experience, respectively. This difference was statistically significant overall (P = .024) as well as statistically significant between each consecutive group. There was no statistically significant difference in joint space width at rest or with applied stress between groups (P = .944). Additionally, there was no statistically significant difference in the presence of calcifications (27.5%, 27.8%, and 40.9%, respectively; P = .144) or heterogeneity (29.4%, 16.7%, and 40.9%, respectively; P = .502) as years of professional experience increased from 0 to 3-4 years. There were no significant differences in UCL thickness (P = .363), joint space width with stress (P = .648), or echotextural abnormalities based on chronological age (P = .871 [hypoechoic foci] and P = .520 [calcifications])., Conclusion: These findings suggest that an increase in UCL thickness may be one of the first changes to develop in young professional baseball pitchers., (© 2015 The Author(s).)

Purpose: The recent restructuring of the ABR core examination has prompted changes to radiology residency training. The purpose of this study is to determine how factors related to the core examination restructuring influenced radiology applicants' match decisions., Methods: We surveyed 626 applicants to our institution's radiology residency, after the 2014 match. Applicants rated 21 factors on a 5-point scale. Eight of the factors pertained to the core examination. The respondents additionally listed the top three factors in order of importance., Results: The response rate was 153 of 626 (24.4%). The three most influential factors were current resident satisfaction (average score: 4.74 of 5.00 [95% confidence interval (CI) = 4.64-4.83]), quality of faculty (4.63 [95% CI = 4.52-4.73]) and quality of educational curriculum and clinical training (4.60 [95% CI = 4.50-4.70]). Of factors related to the core examination, the highest rated were core examination pass rate (4.21 [95% CI = 4.07-4.35]) and program resources/time off for external review courses (3.92 [95% CI = 3.79-4.04]). Core examination pass rate (16 of 459 [3.5%]) and time off from clinical duties to study for the examination (6 of 459 [1.3%]) appeared infrequently in respondents' lists of the top three most influential factors., Conclusions: Factors influencing candidates' choice of radiology program are similar to those reported previously, despite the addition of topics related to core examination restructuring. Although programs vary in how they have addressed the changes, these issues are less important to candidates than are more traditional factors., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: An injury of the ulnar collateral ligament (UCL) is potentially career threatening for elite overhead-throwing athletes. Stress ultrasonography (SUS) allows for a rapid, cost-effective, and noninvasive evaluation of the UCL and elbow joint both at rest and with applied stress., Purpose/hypothesis: To determine the amount of cadaveric elbow valgus gapping with sequential sectioning of medial elbow structures as measured by SUS. It was hypothesized that the greatest increase in ulnohumeral joint gapping would be noted with release of the anterior bundle of the UCL., Study Design: Descriptive laboratory study., Methods: Twelve cadaveric elbows were divided into 2 groups and dissected in reverse sequences under the direct supervision of an experienced orthopaedic surgeon. Baseline ultrasound and SUS with applied valgus loads were performed by an experienced radiologist. A valgus load was applied at each sectioning interval using a standardized device. Ulnohumeral joint gapping in millimeters was measured by SUS for each step as the width of the medial joint from the trochlea to the sublime tubercle. The mean increases in joint gapping (Δ) between each step were calculated to quantify the additional gapping achieved with release of each sequential stabilizer., Results: Release of the anterior band of the anterior bundle resulted in a mean Δ of 2.0 mm (95% CI, 1.1-2.8 mm). Release of the posterior band of the anterior bundle resulted in a mean Δ of 1.4 mm (95% CI, 0.6-2.2 mm). Release of the entire anterior bundle caused a mean increase in ulnohumeral valgus joint gapping of 3.4 mm (95% CI, 2.4-4.3 mm). Release of the remaining individual structures each resulted in a mean increase in valgus joint gapping of ≤0.8 mm., Conclusion: The results of the current cadaveric study suggest that different amounts of gapping are seen on SUS with sectioning of the medial elbow stabilizers. The hypothesis was confirmed with release of the anterior bundle of the UCL resulting in the greatest increase in joint gapping as measured by SUS., Clinical Relevance: This study illustrates that SUS can identify the contributions of each anatomic portion of the UCL and the flexor-pronator mass to ulnohumeral joint stability in a cadaveric model., (© 2014 The Author(s).)

Objectives: The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross-sectional area (CSA) than symptomatic in situ ulnar nerves., Methods: We conducted a retrospective review of the charts and sonograms of 68 patients who had failed ulnar nerve transposition compared to 48 patients with cubital tunnel syndrome who had not undergone surgical management. In addition, postoperative sonograms were compared with preoperative studies when available. Failure was defined as persistence or recurrence of symptoms of ulnar neuropathy postoperatively. The cross-sectional area of the nerve, subjective echogenicity, and residual sites of compression were recorded. Groups were subsequently compared by t tests., Results: The failed ulnar nerve transposition group showed a mean cross-sectional area ± SD of 17.26 ± 9.93 mm(2), whereas the control group showed a mean cross-sectional area of 13.45 ± 7.33 mm(2). This difference was statistically significant (P= .018). Nontransposed nerves were more likely to have identifiable sites of compression (P< .05). There was a trend toward postoperative enlargement in the 6 patients with available preoperative imaging (P = .17). No difference in subjective echogenicity was found in this analysis., Conclusions: Patients with failed ulnar nerve transposition show a significantly enlarged cross-sectional area when compared to symptomatic nerves in situ. Although a specific etiology for this difference cannot be determined, the data suggest that the reference ranges for the cross-sectional area of the ulnar nerve may need to be revised for those who have undergone surgery., (© 2014 by the American Institute of Ultrasound in Medicine.)

The objective of this study was to raise awareness of the diagnosis of enthesopathy of the lateral cord of the plantar fascia (LCPF) and describe its sonographic findings. We conducted a retrospective case series of 13 sonographic examinations with the diagnosis of LCPF enthesopathy. Two cadaver dissections of the plantar foot were performed for anatomic correlation. Sonographic findings of LCPF enthesopathy included generalized or focal hypoechoic thickening, loss of the normal fibrillar echo texture, cortical irregularity of the fifth metatarsal tuberosity, and vascularity on color Doppler imaging. Anatomic dissections of the plantar foot detailed the course of the LCPF and served as a guide for optimal sonographic imaging. Enthesopathy of the LCPF is an important etiology of nontraumatic pain at the base of the fifth metatarsal. Sonographic evaluation can readily show the characteristic findings of LCPF enthesopathy., (© 2014 by the American Institute of Ultrasound in Medicine.)

Lateral hip pain, or greater trochanteric pain syndrome, is a commonly seen condition; in this article, the relevant anatomy, epidemiology, and evaluation strategies of greater trochanteric pain syndrome are reviewed. Specific attention is focused on imaging of this syndrome and treatment techniques, including ultrasound-guided interventions., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This article describes 2 nonsurgical approaches to the treatment of carpal tunnel syndrome that are not routinely offered, probably due to a lack of awareness. Osteopathic manipulative treatment (OMT) is commonly used for many medical problems, including musculoskeletal issues. OMT of the carpal tunnel is well described and researched, and can be clinically used by a skilled practitioner. The second treatment strategy is a more recent development. The use of ultrasound for guidance of injection is established, but a newer technique using sonographically guided percutaneous needle release of the transverse carpal ligament has shown promising results., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: An injury to the ulnar collateral ligament (UCL) of the elbow is potentially career threatening for elite baseball pitchers. Stress ultrasound (US) of the elbow allows for evaluation of both the UCL and the ulnohumeral joint space at rest and with stress., Hypothesis: Stress US can identify morphological and functional UCL changes and may predict the risk of a UCL injury in elite pitchers., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 368 asymptomatic professional baseball pitchers underwent preseason stress US of their dominant and nondominant elbows over a 10-year period (2002-2012). Stress US examinations were performed in 30° of flexion at rest and with 150 N of valgus stress by a single musculoskeletal radiologist. Ligament thickness, ulnohumeral joint space width, and ligament abnormalities (hypoechoic foci and calcifications) were documented., Results: There were 736 stress US studies. The mean UCL thickness in the dominant elbow (6.15 mm) was significantly greater than that in the nondominant elbow (4.82 mm) (P < .0001). The mean stressed ulnohumeral joint space width in the dominant elbow (4.56 mm) was significantly greater than that in the nondominant elbow (3.72 mm) (P < .02). In the dominant arm, hypoechoic foci and calcifications were both significantly more prevalent (28.0% vs 3.5% and 24.9% vs 1.6%, respectively; P < .001). In the 12 players who incurred a UCL injury, there were nonsignificant (P > .05) increases in baseline ligament thickness, ulnohumeral joint space gapping with stress, and incidence of hypoechoic foci and calcifications. More than 1 stress US examination was performed in 131 players, with a mean increase of 0.78 mm in joint space gapping with subsequent evaluations., Conclusion: Stress US indicates that the UCL in the dominant elbow of elite pitchers is thicker, is more likely to have hypoechoic foci and/or calcifications, and has increased laxity with valgus stress over time.

Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: "What should a student graduating from medical school know about US?" To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.

Objective: The costs of an ultrasound-CT protocol and a CT-only protocol for an appendicitis evaluation are compared. For the ultrasound-CT protocol, patients with right lower quadrant abdominal pain undergo an ultrasound examination. If it is positive for appendicitis, they are sent directly to surgery, avoiding CT., Materials and Methods: A comparative effectiveness research study was conducted. The costs of imaging tests, excess surgeries, and excess surgical deaths for the ultrasound-CT protocol and the costs of imaging tests and excess cancer deaths in the CT-only protocol were estimated. Data sources were Centers for Medicare & Medicaid Services (CMS) datasets, national hospital discharge surveys, radiology information system cases, and U.S. Census Bureau life tables. A meta-analysis and sensitivity analyses were also conducted., Results: The meta-analysis showed a positive predictive value of 92.5% for CT and 91.0% for ultrasound. Analysis of CMS files showed that utilization of CT was almost exactly 2.0 examinations (one abdominal and one pelvic) per patient and for ultrasound was almost nil. The cost of this imaging protocol was $547 per patient, whereas the cost of a limited ultrasound study would be $88 per patient. For the total U.S. population, the cost savings in imaging minus the cost of extra surgeries and extra surgical deaths is $24.9 million per year. Following model VII proposed by the Committee on the Biological Effects of Ionizing Radiation (BEIR), which is known as "BEIR VII," the avoidance of a 12.4-mSv exposure for 262,500 persons would prevent 180 excess cancer deaths. The value of the years of life lost would be $339.5 million. The sensitivity analyses indicate that the cost savings are robust., Conclusion: An ultrasound-CT protocol for appendicitis evaluation offers potentially large savings over the standard CT-only protocol. There are moderate savings from using a less expensive imaging technique despite extra surgeries and large savings from radiation exposure avoided.

The development of antiangiogenic therapies has stimulated interest in noninvasive imaging methods to monitor response. We investigated whether the effects of a vascular endothelial growth factor decoy receptor (VEGF Trap, Regeneron Pharmaceuticals, Tarrytown, NY) could be monitored in vivo using contrast-enhanced ultrasonography (CEUS). Twenty nude mice (in two groups) were implanted with a human melanoma cell line (DB-1). The active group received VEGF Trap (4 × 25 mg/kg over 2 weeks), whereas the control group received an inactive protein. An ultrasound contrast agent was injected followed by power Doppler imaging (PDI) and pulse inversion harmonic imaging (PIHI; regular and intermittent). Specimens were sectioned in the same planes as the images and stained for endothelial cells (CD31), cyclooxygenase-2 (COX-2), VEGF, and hypoxia (Glut1). Measures of tumor vascularity obtained with the different imaging modes were compared to immunohistochemical markers of angiogenesis. Mean tumor volume was smaller in the active group than in the control group (656 ± 225 vs 1,160 ± 605 mm3). Overall, PDI and VEGF correlated (r  =  .34; p =  .037). Vascularity decreased from control to treated mice with intermittent PIHI, as did the expression of CD31 and COX-2 (p ≤ .02), whereas VEGF increased (p  =  .05). CEUS appears to allow in vivo monitoring of the antiangiogenic effects of VEGF Trap in the DB-1 human melanoma xenograft model.

Purpose: Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population., Methods: Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated., Results: The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types., Conclusion: The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Greater trochanteric pain syndrome is a common condition with clinical features of pain and tenderness at the lateral aspect of the hip. Diagnosing the origin of greater trochanteric pain is important because the treatment varies depending on the cause. We hypothesized that sonographic evaluation of sources for greater trochanteric pain syndrome would show that bursitis was not the most commonly encountered abnormality., Materials and Methods: We performed a retrospective review of musculoskeletal sonographic examinations performed at our institution over a 6-year period for greater trochanteric pain syndrome; completed a tabulation of the sonographic findings; and assessed the prevalence of trochanteric bursitis, gluteal tendon abnormalities, iliotibial band abnormalities, or a combination of findings. Prevalence of abnormal findings, associations of bursitis, gluteal tendinosis, gluteal tendon tears, and iliotibial band abnormalities were calculated., Results: The final study population consisted of 877 unique patients: 602 women, 275 men; average age, 54 years; and age range, 15-87 years). Of the 877 patients with greater trochanteric pain, 700 (79.8%) did not have bursitis on ultrasound. A minority of patients (177, 20.2%) had trochanteric bursitis. Of the 877 patients with greater trochanteric pain, 438 (49.9%) had gluteal tendinosis, four (0.5%) had gluteal tendon tears, and 250 (28.5%) had a thickened iliotibial band., Conclusion: The cause of greater trochanteric pain syndrome is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.

Background: The diagnosis and validation of thoracic outlet syndrome/brachial plexopathy (TOS) remains a difficult challenge for surgeons, neurologists, and radiologists. This is due to the fact that the responses of standard elevated arm stress tests can be considered somewhat subjective and can vary. Therefore, non-vascular TOS cases are presently diagnosed clinically, and any objective diagnosis has been controversial., Methods: This is a technique paper describing the use of dynamic neuromusculoskeletal ultrasound to assist in the diagnosis of thoracic outlet/brachial plexus pathology. We propose a new way to observe the brachial plexus dynamically, so that physical verification of nerve compression between the anterior and middle scalene muscles can be clearly made at the onset of clinical symptoms. This gives a way to objectively identify clinically significant brachial plexus compression., Results: Dynamic testing can add objective analysis to tests such as the elevated arm stress tests and can correlate the onset of symptoms with plexus compression between the anterior and middle scalene muscles. With this, the area of pathologic compression can be identified and viewed while performing the dynamic testing. If compression is seen and the onset of symptoms ensues, this is a positive confirmatory test for the presence of TOS and a clinically significant disease., Conclusions: This paper offers a simple, objective, and visual diagnostic test that can validate the presence or absence of brachial plexus compression during arm elevation in patients with brachial plexus injury and thoracic outlet syndrome.

Context: Subacromial impingement is a common injury in baseball players and has been linked to a reduction in the subacromial space. In addition, it has been suggested that decreases in scapular upward rotation will lead to decreases in the subacromial space and ultimately impingement syndrome., Objective: The objective of this study was to evaluate the relationship between acromiohumeral distance and scapular upward rotation in healthy college baseball players., Design: Posttest-only study design., Setting: Controlled laboratory setting., Participants: 24 healthy college baseball players., Intervention: Participants were measured for all dependent variables at preseason., Main Outcome Measures: Acromiohumeral distance at rest and 90° of abduction was measured with a diagnostic ultrasound unit. Scapular upward rotation at rest and 90° of abduction was measured with a digital inclinometer., Results: Dominant-arm acromiohumeral distance at rest and 90° of abduction (P = .694, P = .840) was not significantly different than in the nondominant arm. In addition, there was not a significant correlation between acromiohumeral distance and scapular upward rotation at rest and 90° of abduction for either the dominant or the nondominant arm., Conclusions: These results indicate that the acromiohumeral distance is not adapting in the dominant arm in healthy throwing athletes. In addition, a relationship was not identified between acromiohumeral distance and scapular upward rotation, which was previously suggested. These results may suggest that changes that are typically seen in an injured population may be occurring due to the injury and are not preexisting. In addition, scapular upward rotation may not be the only contributing factor to acromiohumeral distance.

Diagnostic radiology training programs must produce highly skilled diagnostic radiologists capable of interpreting radiological examinations and communicating results to clinicians. Established training performance tools evaluate interpretive skills, but trainees' competency in reporting skills is also essential. Our semi-automated passive electronic tool entitled the Quantitative Reporting Skills Evaluation (QRSE) allows radiology training programs to evaluate the quantity of edits made to trainee preliminary reports by attending physicians as a metric to evaluate trainee reporting performance. Consecutive report pairs and metadata extracted from the radiology information system were anonymized and exported to a MySQL database. To perform the QRSE, for each report pair, open source software was first utilized to calculate the Levenshtein Percent (LP), the percent of character changes required to convert each preliminary report to its corresponding final report. The average LP (ALP), ALP for each trainee, and standard deviations were calculated. Eighty-four trainees and 56 attending radiologists interpreted 228,543 radiological examinations during the study period. The overall ALP was 6.38 %. Trainee-specific ALPs ranged from 1.1 to 15.3 %. Among trainee-specific ALPs, the standard deviation was 3.7 %. Our analysis identified five trainees with trainee-specific ALPs above 2 standard deviations from the mean and 14 trainees with trainee-specific ALPs less than 1 standard deviation below the mean. The QRSE methodology allows for the passive, quantitative, and longitudinal evaluation of the reporting skills of trainees during diagnostic radiology residency training. The QRSE identifies trainees with high and low levels of edits to their preliminary reports, as a marker for trainee overall reporting skills, and thus represents a novel performance metric for radiology training programs.