Dynamic Visualization of the Coracoacromial Ligament by Ultrasound

Subacromial impingement syndrome (SIS) is prevalent in athletes who make throwing motions over their heads, as well as in the normal population, but it is difficult to diagnose precisely using physical examination and traditional imaging modalities. Furthermore, the diagnostic testing protocols have not been strictly standardized. We used ultrasound to dynamically visualize coracoacromial ligament (CAL) morphology during shoulder impingement tests: the CAL is the key impinging structure in SIS. Fifty normal shoulders were examined. With the transducer placed on the CAL, the shoulders were examined with seven different testing protocols described in the literature. The degree of CAL bulge from the resting position was measured, and the degree of bulge in different testing protocols was compared. We found that the Hawkins-Kennedy impingement test caused more CAL bulge than the Neer's impingement test, and the most prominent morphological change in the CAL occurred with an internally rotated and horizontally abducted shoulder. We conclude that high-resolution ultrasound is an excellent tool for dynamically inspecting the impinging structures, is applicable in clinical settings, and allows more accurate diagnosis of SIS. (E-mail: tgw@ntu.edu.tw)     

Scapular Muscle Activity in Overhead Athletes With Symptoms of Secondary Shoulder Impingement During Closed Chain Exercises

Tucker WS, Armstrong CW, Gribble PA, Timmons MK, Yeasting RA. Scapular muscle activity in overhead athletes with symptoms of secondary shoulder impingement during closed chain exercises.

Objective

To determine the amount of muscle activation in 4 scapular muscles in overhead athletes with and without a history of secondary shoulder impingement, during 3 upper extremity closed chain exercises.

Design

One-between (group), one-within (exercise) repeated measures.

Setting

Controlled laboratory study.

Participants

Overhead athletes (n=15; mean age ± SD, 21.0±2.5y; mean height ± SD, 176.0±7.8cm; mean weight ± SD, 76.1±13.4kg) demonstrating with symptoms of shoulder impingement and overhead athletes (n=15; mean age ± SD, 20.4±3.8y; mean height ± SD, 174.1±9.7cm; mean weight ± SD, 73.3±11.7kg) with no shoulder pathologies.

Interventions

Subjects completed 5 individual trials of a standard push-up, a push-up on an unstable surface, and a revolution on a shoulder rehabilitation device while electromyography (EMG) recorded muscle activity of the serratus anterior, upper trapezius, middle trapezius, and lower trapezius.

Main Outcome Measures

The mean EMG data for the 4 muscles from the standard push-up, push-up on an unstable surface, and shoulder rehabilitation device trials were normalized as a percentage of a maximum voluntary isometric contraction for each muscle.

Results

There was a statistically significant interaction for the middle trapezius (F_2,56=3.856; P=.027). The shoulder impingement push-up on an unstable surface (33.76%±26.45%) had significantly greater activation compared with the shoulder impingement standard push-up (25.88%±13.76%), the shoulder impingement shoulder rehabilitation device (9.40%±5.86%), and the nonpathology push-up on an unstable surface (19.49%±7.73%). The shoulder impingement standard push-up had significantly greater activation compared with the shoulder impingement shoulder rehabilitation device and nonpathology standard push-up (17.99%±7.31%). The nonpathology standard push-up and nonpathology push-up on an unstable surface had significantly greater activation compared with the nonpathology shoulder rehabilitation device (7.95%±4.30%).

Conclusions

These results suggest that the muscle activation of the middle trapezius differs in overhead athletes with a history of secondary shoulder impingement compared with those who lack this history during closed chain exercise, as well as within the 3 closed chain exercises. The levels of muscle activation of the serratus anterior and upper trapezius during these closed chain exercises were similar between the 2 groups. These results support the use of closed chain exercises in the rehabilitation process of overhead athletes with secondary shoulder impingement. However, clinicians should consider the muscle(s) of interest when selecting an exercise.     

摔跤运动员耳的超声表现

目的 探讨摔跤运动员耳的超声特征.方法 摔跤和柔道运动员共12例为病例组,健康志愿者15例为对照组,对双侧耳廓行超声检查.结果 病例组的超声表现为耳廓增厚,积液,血流信号增加,软骨破坏.病例组耳廓厚度为(0.95±0.41)cm,对照组耳廓厚度为(0.41±0.07)cm,二者比较差异有统计学意义(t=7.06,P＜0.01).结论 摔跤运动员耳具有特征性的超声表现,超声在其诊断和治疗中有一定的应用价值.     

Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis

Ottenheijm RP, Jansen MJ, Staal JB, van den Bruel A, Weijers RE, de Bie RA, Dinant G-J. Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta-analysis.

Objective

To determine the diagnostic accuracy of ultrasound for detecting subacromial disorders in patients presenting in primary and secondary care settings.

Data Sources

Medline and Embase were searched on June 9, 2010. In addition, the reference list of 1 systematic review and all included articles were searched to identify relevant studies.

Study Selection

Two reviewers independently selected the articles evaluating the accuracy of ultrasound for detecting subacromial disorders from the title and abstracts retrieved by the literature search. Selection criteria were ultrasound frequency greater than or equal to 7.5MHz as index test, surgery, magnetic resonance imaging and/or radiography as reference standards, and subacromial disorders as target conditions.

Data Extraction

Two reviewers independently extracted the data on study characteristics and results to construct 2 by 2 tables and performed a methodologic quality assessment.

Data Synthesis

Twenty-three studies were included: 22 reported on full-thickness rotator cuff tears, 15 on partial-thickness tears, 3 on subacromial bursitis, 2 on tendinopathy, and 2 on calcifying tendonitis, respectively. For full-thickness tears, pooled sensitivity of ultrasound was .95 (95% confidence interval, .90-.97), and specificity .96 (.93-.98). For partial-thickness tears, pooled sensitivity was .72 (.58-.83), and specificity .93 (.89-.96). Statistical pooling was not possible for the other disorders. For subacromial bursitis, sensitivity ranged from .79 to .81, and specificity from .94 to .98. For tendinopathy, sensitivity ranged from .67 to .93, specificity from .88 to 1.00. Sensitivity for calcifying tendonitis was 1.00 in both studies, with specificity ranging from .85 to .98.

Conclusions

We strongly recommend ultrasound in patients for whom conservative treatment fails, to rule in or out full-thickness tears, to rule in partial-thickness tears, and to a lesser extent to diagnose tendinopathy, subacromial bursitis, and calcifying tendonitis. These results can help physicians tailor treatment.     

Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial

Hong JY, Yoon S-H, Moon DJ, Kwack K-S, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial.

Objective

To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain, function, and active range of motion (AROM).

Design

Multicenter, randomized, triple-blind, placebo-controlled trial.

Setting

Primary (n=2) and university-affiliated (n=1) tertiary-care hospitals.

Participants

Volunteers (N=79) with periarticular shoulder disorders with at least 1 month's duration of pain.

Intervention

Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide, 40 or 20mg, or placebo. After a single injection, participants were followed up for 8 weeks.

Main Outcome Measures

Visual analog scale (VAS) of average shoulder pain level during the past 1 week, Shoulder Disability Questionnaire (SDQ), and angles of shoulder AROM (including flexion, abduction, external rotation, internal rotation) pre- and posttreatment at weeks 2, 4, and 8.

Results

There were no significant differences among the 3 groups (triamcinolone acetonide, 40mg, group 1, n=27; triamcinolone acetonide, 20mg, group 2, n=25; placebo, group 3, n=27) in terms of demographic and clinical characteristics at baseline. (1) Within-group comparison: VAS score, SDQ score, and AROM for groups 1 and 2 significantly improved at weeks 2, 4, and 8 (P<.0167). However, there was no difference in VAS score, SDQ score, and AROM scores for group 3. (2) Between-group comparison: significant differences in VAS score, SDQ score, and abduction, external rotation, and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2, 4, and 8 (P<.05).

Conclusions

This was the first study to assess the efficacy of corticosteroid according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. This study showed no significant differences between the high- (triamcinolone acetonide, 40mg) and low-dose (20mg) corticosteroid groups, indicating preferred use of a low dose at the initial stage.     

肩峰下撞击综合征的经皮超声引导下肩峰下滑囊造影表现

目的 探讨肩峰下撞击综合征（SIS）的经皮超声引导下肩峰下滑囊造影（PUSB）表现。方法 对150例经临床诊断为SIS患者行PUSB检查,动态观察造影剂在滑囊内的弥散情况及是否进入肩袖、关节腔。结果 53例造影剂在滑囊内呈线状均匀分布,诊断为单纯性肩峰下滑囊炎。97例造影剂在滑囊内分布不均匀,诊断为粘连性肩峰下滑囊炎。40例可见造影剂由滑囊进入肩袖肌腱,但未达肱骨头表面;32例可见造影剂由滑囊进入肩袖肌腱,到达肱骨头表面;78例造影剂未进入肩袖肌腱。结论 PUSB可实时动态评估肩峰下滑囊炎、滑囊粘连、肩袖损伤等情况,对SIS的诊断具有较高的应用价值。     

Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement

Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement.

Objective

To investigate the reliability and diagnostic accuracy of individual tests and combination of tests for subacromial impingement syndrome (SAIS).

Design

A prospective, blinded study design.

Setting

Orthopedic surgeon shoulder clinic.

Participants

Patients with shoulder pain (n=55, mean age=40.6y).

Interventions

Patients were evaluated with 5 physical examination tests for SAIS: Neer, Hawkins-Kennedy, painful arc, empty can (Jobe), and external rotation resistance tests. Surgical diagnosis was the reference standard.

Main Outcome Measures

Diagnostic accuracy calculated with a receiver operating characteristic (ROC) curve and sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (−LR). A forward stepwise binary logistic regression analysis was used to determine the best test combination for SAIS. An ROC curve analysis was also used to determine the cut point of the number of tests discriminating between the presence and absence of SAIS. Kappa coefficients and percent agreement assessed interrater reliability.

Results

The ROC analyses revealed a significant area under the curve (AUC) (AUC=.67-.72, P<.05) for all tests, except for the Hawkins-Kennedy. The tests with a +LR greater than or equal to 2.0 were the painful arc (+LR=2.25; 95% CI, 1.33-3.81), empty can (+LR=3.90; 95% CI, 1.5-10.12), and the external rotation resistance tests (+LR=4.39; 95% CI, 1.74-11.07). Tests with −LR less than or equal to 0.50 were the painful arc (−LR=.38; 95% CI, .16-.90), external rotation resistance (−LR=.50; 95% CI, .28-.89), and Neer tests (−LR=.35; 95% CI, .12-.97). The regression analysis had no specific test combinations for confirming or ruling out SAIS. The ROC analysis was significant (AUC=.79, P=.001), with a cut point of 3 positive tests out of 5 tests. Reliability was moderate to substantial agreement (κ=.45-.67) for the painful arc, empty can, and external rotation resistance tests and fair strength of agreement (κ=.39-.40) for the Neer and Hawkins-Kennedy tests.

Conclusions

The single tests of painful arc, external rotation resistance, and Neer are useful screening tests to rule out SAIS. The single tests of painful arc, external rotation resistance, and empty can are helpful to confirm SAIS. The reliability of all tests was acceptable for clinical use. Based on reliability and diagnostic accuracy, the single tests of the painful arc, external rotation resistance, and empty can have the best overall clinical utility. The cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS, while less than 3 positive of 5 rules out SAIS.     

Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review

Gebremariam L, Hay EM, Koes BW, Huisstede BM. Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review.

Objective

To provide an evidence-based overview of the effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome.

Data Sources

The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched.

Study Selection

Two reviewers independently selected relevant systematic reviews and randomized controlled trials (RCTs).

Data Extraction

Two reviewers independently extracted data and assessed the methodologic quality.

Data Synthesis

If pooling of data was not possible, a best-evidence synthesis was used to summarize the results.

Results

One review and 5 RCTs reporting on various surgical techniques, and postsurgical interventions were included. Moderate evidence was found in favor of adding platelet-leukocyte gel versus open subacromial decompression. No evidence was found for the superiority of subacromial decompression versus conservative treatment in the short, mid, and long term or in favor of 1 surgical technique when compared with another. Limited evidence was found in favor of early activation after arthroscopic decompression in the short and long term.

Conclusions

This review shows that there is no evidence that surgical treatment is superior to conservative treatment or that1 particular surgical technique is superior to another. Because of possibly lower risks for complications, conservative treatment may be preferred. When choosing for surgery, arthroscopic decompression may be preferred because of the less invasive character of the procedure.     

Ultrasound imaging of acute biceps tendon changes after wheelchair sports

OBJECTIVES: To investigate acute changes in the biceps tendon after a high-intensity wheelchair propulsion activity and to determine whether these changes are related to subject characteristics. DESIGN: The biceps tendon was imaged with ultrasound before and after wheelchair basketball or quad rugby. The average diameter of the tendon was calculated as well as the echogenicity ratio (the pixel intensity ratio of the biceps tendon to a reference just superficial to the tendon sheath). SETTING: National Veterans Wheelchair Games in 2004 and 2005. PARTICIPANTS: Forty-two subjects who participated in wheelchair basketball or quad rugby at the Veterans Games. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Biceps tendon diameter and biceps echogenicity. RESULTS: The echogenicity ratio of the tendon significantly decreased from 1.97 to 1.73 after the event (P=.038). The diameter of the biceps tendon increased from 4.60 to 4.82 mm (P=.178). Also, it was found that the change in tendon diameter positively correlated with the time of play (P=.004). CONCLUSIONS: Acute changes in biceps tendon properties after exercise were found and likely represent edema, a first sign of overuse injury. The significance of continuous activity was shown by the fact that subjects who had more playing time showed a larger increase in tendon diameter.     

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury

Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury.

Objectives

To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight.

Design

Case series.

Setting

National Veterans' Wheelchair Games 2005 and 2006.

Participants

Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games.

Interventions

Not applicable.

Main Outcome Measures

Presence of relationships between US findings, PE findings, pain, and subject characteristics.

Results

The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002).

Conclusions

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated.     

超声诊断肩关节盂唇损伤的价值

目的 探讨超声诊断盂唇损伤的价值。方法 对33例肩关节损伤患者术前进行超声检查，并与手术结果比较。结果 29例超声检查结果与手术符合，4例超声诊断与手术不符，超声诊断敏感性84％，特异性90％，准确性88％。结论 超声是诊断盂唇损伤的一种有价值的检查方法。     

健康志愿者和职业运动员髌韧带及其肌腱端的高频超声表现

目的 比较健康志愿者和职业运动员髌韧带及其肌腱端的超声影像学表现，初步探讨超声用于肌腱疾病检查的可行性。方法应用GE Logiq 700 MR Expert Series超声仪，5～10MHz变频线阵探头，对52名健康志愿者和20名职业运动员的双侧髌韧带进行超声检查。结果正常髌韧带表现为边界清楚，由平行的高回声线构成的束状结构，有厚度为0．02cm的腱鞘，止点骨面光滑连续。健康志愿组中男性髌韧带比女性长（P〈0．01），运动员组止点处平均灰度较健康志愿组高（P〈0．05）。有4名健康志愿者（7．7％）和16名职业运动员（80．0％）出现超声异常（P〈0．001），其中13名运动员（65．0％）出现了止点处滑囊炎（P〈0．001）。结论超声检查髌韧带具有可信、无创、方便等优越性，值得在临床中推广应用。运动员出现较高比例的止点处滑囊炎可能为机体的一种保护性变化。     

Comparision of Ultrasound Therapy of Various Durations in the Treatment of Subacromial Impingement Syndrome

[Purpose] A prospective, randomized, single-blind study was performed in order tocompare the efficacy of ultrasound treatments of various durations for patients withsubacromial impingement syndrome. [Subjects and Methods] One hundred patients who had beendiagnosed with subacromial impingement syndrome by clinical examination and magneticresonance imaging were included in this study. Patients were randomly divided into twogroups of fifty patients per group. The first group received 15 sessions of therapeuticultrasound (4 minutes), superficial heat and transcutaneous electrical stimulation therapycombined with exercise. The second group received the same treatment except that each ofthe 15 ultrasound sessions were eight minutes in length. The patients were evaluatedbefore and after the treatment. A visual analog scale (VAS) was used to assess pain, theUniversity of California at Los Angeles (UCLA) and Constant Scale were used to assessshoulder function and the Beck Depression Inventory (BDI) was used to quantify depressivesymptoms. [Results] There were no statistically significant differences between the groupsin age, time since the onset of pain, sex, education and depression levels prior to thetreatment. The post-treatment evaluation of patients VAS, UCLA, Constant, and BDI scoresshowed statistically significant within group improvements. When the two groups werecompared, we found no statistically significant differences in the Constant activities ofdaily living, Constant external rotation, Constant force and BDI scores. However, thesecond group scored better than the first group in all the remaining parameters.[Conclusion] Ultrasound therapy was found to have beneficial effects on pain andfunctional status in the treatment of subacromial impingement syndrome. Eight minutes ofultrasound treatment was shown to be more effective than 4 minutes of ultrasoundtreatment.     

网球腿的超声诊断

目的：超声检查评估小腿三头肌损伤（网球腿）的程度和范围，以期为临床治疗方式的选择提供帮助。方法：76例具有运动时和（或）运动后小腿肚区域疼痛的患者接受超声检查，观察是否有以下阳性表现：三头肌肿胀伴回声异常、肌纤维撕裂、肌内或肌间隙血肿、肌肉-肌腱连接处腱膜肥厚、肌肉完全断裂等，并观察小腿区静脉血栓。结果：76例中，50例超声检查小腿三头肌异常，并结合临床诊为网球腿。损伤程度为：腓肠肌内侧头部分撕裂30例（60％），腓肠肌和比目鱼肌间积血6例（12％），小腿三头肌之一完全断裂6例（12％），腓肠肌外侧头和比目鱼肌撕裂各2例，肌肉明显肿胀但未见撕裂4例。有11例经手术治疗，余39例接受保守治疗后痊愈。结论：超声检查不仅可提示网球腿的诊断，并可准确判断损伤程度，为临床治疗方式的选择提供帮助。     

Needle Insertion Into the Tibialis Posterior: Ultrasonographic Evaluation of an Anterior Approach

Rha D-W, Im SH, Lee SC, Kim S-K. Needle insertion into the tibialis posterior: ultrasonographic evaluation of an anterior approach.

Objective

To investigate the ultrasonographic anatomy of the lower leg for safe and accurate needle placement into the tibialis posterior using the anterior approach.

Design

Cross-sectional study.

Setting

University rehabilitation hospital.

Participants

Healthy volunteers (N=62; 30 men, 32 women).

Interventions

Not applicable.

Main Outcome Measures

The safety window (the tibia to the neurovascular bundle) and the depth to the midpoint of the safety window (skin to the tibialis posterior) at the upper third and the midpoint of the tibia were measured with a transverse ultrasonographic scan.

Results

The safety window at the upper third of the tibia was significantly larger than that at the midpoint (P<.01). The safety window ranged from .64cm to 2.13cm at the upper third tibialis point and from .32cm to 1.30cm at the midpoint. The depth to the tibialis posterior at the upper third of the tibia was significantly deeper than that in the midpoint (P<.01). The depth ranged from 2.47cm to 4.66cm at the upper third tibias point and from 2.35cm to 4.28cm at the midpoint.

Conclusions

Ultrasonography is a useful tool in measuring the safety window and the depth to the tibialis posterior using the anterior approach. Considering the safety window, we suggest the needle placement at the upper third point of tibia rather than that at the midpoint.     

Pulsed Electromagnetic Field and Exercises in Patients With Shoulder Impingement Syndrome: A Randomized,Double-Blind,Placebo-Controlled Clinical Trial

Objective

To evaluate the effects of pulsed electromagnetic field (PEMF) and exercises in reducing pain and improving function and muscle strength in patients with shoulder impingement syndrome (SIS).

Design

Double-blind, randomized controlled trial with a 3-month posttreatment follow-up.

Setting

Outpatient rehabilitation of a public hospital.

Participants

Patients (N=56) between 40 and 60 years of age, with a diagnosis of SIS, were randomly assigned to receive active PEMF (n=26; mean age, 50.1y) or placebo PEMF (n=30; mean age, 50.8y).

Interventions

After 3 weeks of active or placebo PEMF, both groups performed the same program of exercises that focused on shoulder strengthening.

Main Outcome Measures

A visual analog scale, the University of California/Los Angeles shoulder rating scale, the Constant-Murley shoulder score, and handheld dynamometry for muscle strength were used as outcome measures at baseline (pretreatment), at 3 weeks (after active or placebo PEMF), at 9 weeks (postexercise), and at 3 months posttreatment.

Results

Patients in the active PEMF group had a higher level of function and less pain at all follow-up time frames compared with baseline (P<.05). However, the placebo PEMF group had increased function and reduced pain only at the 9-week and 3-month follow-ups (P<.05)—that is, after performing the associated exercises. For the shoulder dynamometry, the active PEMF group had increased strength for lateral rotation at 9 weeks (P<.05), and increased strength for medial rotation at 9 weeks and 3 months (both P<.05) when compared with baseline. There was no significant difference for shoulder strength in the placebo PEMF group (P>.05), as well as no significant differences (P>.05) for all outcome measures.

Conclusions

The combination of PEMF and shoulder exercises is effective in improving function and muscle strength and decreasing pain in patients with SIS. However, these results should be carefully interpreted because of the lack of differences between groups.     

Endartery stenosis of the popliteal artery mimicking gastrocnemius strain: a case report

This report presents a case of leg pain in a recreational athlete that was caused by a stenotic lesion of an endartery branch of the popliteal artery. Isolated areas of arterial stenosis are rarely reported in the sports medicine literature as the primary cause of leg pain. This may be due in part to the difficulty of obtaining the diagnosis. This study includes a review of the relevant anatomic, pathophysiologic, diagnostic, and therapeutic considerations and concludes with a discussion of the potentially underrecognized significance of arterial stenosis in the sports population.     

Effectiveness of Home Exercise on Pain,Function, and Strength of Manual Wheelchair Users With Spinal Cord Injury: A High-Dose Shoulder Program With Telerehabilitation

Objective

To test the effectiveness of a high-dose home exercise/telerehabilitation program for manual wheelchair users who have a spinal cord injury (SCI) by determining whether the intervention would reduce pain and increase function, as we hypothesized.

Design

A pre-post trial with outcomes measured at 3 time points: baseline, postintervention (12wk), and follow-up (>24 wk).

Setting

Subjects performed an exercise program at their homes using telerehabilitation for therapist monitoring of technique and exercise advancement. Baseline and postintervention data were collected at a motion analysis laboratory in a tertiary medical center.

Participants

A convenience sample of manual wheelchair users (N=16, 3 women; average age, 41y; average time in a wheelchair, 16y) with shoulder pain (average pain duration, 9y) and mechanical impingement signs on physical examination.

Interventions

A 12-week home exercise program of rotator cuff and scapular stabilization exercises was given to each participant. The program included a high dose of 3 sets of 30 repetitions, 3 times weekly, and regular physical therapist supervision via videoconferencing.

Main Outcome Measures

Primary outcomes of pain and function were measured with the Wheelchair User's Shoulder Pain Index (WUSPI), Disabilities of Arm, Shoulder, and Hand (DASH) Index, and Shoulder Rating Questionnaire (SRQ). Secondary outcomes of strength were measured with isometric strength tests of scapulothoracic and glenohumeral muscles, and a static fatigue test of the lower trapezius.

Results

Pain was reduced and function improved after the intervention. There was a significant main effect for pain and function between the 3 time points based on the Friedman signed-ranked test, WUSPI (χ²₂=5.10, P=.014), DASH Index (χ²₂=5.41, P=.012), and SRQ (χ²₂=23.71, P≤.001). Wilcoxon signed-rank tests demonstrated that isometric strength measurements of the serratus anterior and scapular retractors increased after the exercise intervention ([t=2.42, P=.04] and [t=4.67, P=.003], respectively). Muscle impulse produced by the lower trapezius during a fatigue task also improved (t=2.2, P=.02). No differences were measured in isometric strength for the lower trapezius, glenohumeral rotators, and abductors between the baseline and 12-week time points.

Conclusions

A high-dose scapular stabilizer and rotator cuff strengthening program using telerehabilitation for supervision holds promise for shoulder pain treatment in manual wheelchair users with SCI. Additional work is needed to determine the effectiveness compared with other interventions, as well as the potential for earlier intervention to prevent development of shoulder pain.     

Ultrasonographic evaluation of needle electromyography insertion into the tibialis posterior using a posterior approach

Won SJ, Kim JY, Yoon JS, Kim SJ. Ultrasonographic evaluation of needle electromyography insertion into the tibialis posterior using a posterior approach.

Objective

To estimate the safety window for needle insertion in the posterior approach to the tibialis posterior by ultrasonography, particularly in a clinical setting.

Design

Cross-sectional study.

Setting

University hospital.

Participants

Healthy volunteers (108 legs, from 22 men and 32 women).

Interventions

Not applicable.

Main Outcome Measures

Distance between the tibia and neurovascular bundles in the posterior aspect of the tibia on a transverse ultrasonographic scan.

Results

The safety window at the midpoint was significantly larger than the upper third (0.62–2.16cm, average 1.47±0.38cm vs 0.51–1.62cm, average 1.16±0.31cm). The depth at the midpoint was significantly more shallow than the upper third (1.57–3.16cm, average 2.31±0.34cm vs 1.76–3.66cm, average 2.52±0.38cm). Body weight, height, tibial length, and leg circumference showed positive correlation with the safety window at both points.

Conclusions

The midpoint may be more favorable than the upper third for needle insertion to the tibialis posterior with a posterior approach.     

Diagnostic Accuracy of History Taking and Physical Examination for Assessing Anterior Cruciate Ligament Lesions of the Knee in Primary Care

Wagemakers HP, Luijsterburg PA, Boks SS, Heintjes EM, Berger MY, Verhaar JA, Koes BK, Bierma-Zeinstra SM. Diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament lesions of the knee in primary care.

Objective

To assess the diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament (ACL) lesions in primary care.

Design

Cross-sectional diagnostic study.

Setting

Primary care.

Participants

Patients (N=134; age, 18-65y) who consulted their general practitioner (GP) within 5 weeks after injury.

Interventions

Not applicable.

Main Outcome Measures

Index tests were obtained with a questionnaire and physical examination. Magnetic resonance imaging (MRI) was used as the reference test. Logistic regression analysis was used to determine associations with ACL lesions. Diagnostic accuracy was determined by calculating sensitivity (Se), specificity (Sp), predictive values, and likelihood ratio (LR).

Results

MRI showed an ACL lesion in 28 of 134 included patients. “Effusion,” “popping sensation,” “giving way,” and “anterior drawer test (ADT)” showed associations with an ACL lesion (P<.05). Popping sensation showed Se, Sp, positive predictive value (PPV), and positive LR (LR⁺) of .63, .73, .39, and 2.3, respectively. Combining determinants from history taking (2 of 3 positive results regarding effusion, popping sensation, and giving way) improved diagnostic accuracy (Se, .71; Sp, .71; PPV, .42; and LR⁺, 2.5). The ADT added diagnostic accuracy to these combinations (Se, .63; Sp, .85; PPV, .52; and LR⁺, 4.2).

Conclusions

ACL lesions are seen frequently. Based on history taking (effusion, popping sensation, and/or giving way) and physical examination (ADT), GPs can screen for ACL lesions in primary care.