- Email: [email protected]
Current Trends in Musculoskeletal Ultrasound
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MODEL
Journal of Medical Ultrasound (2016) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
EDITORIAL
Current Trends in Musculoskeletal Ultrasound Musculoskeletal ultrasound (MSUS) is being utilized in routine daily clinical practice by an increasing number of physiatrists, orthopedists, anesthesiologists, radiologists, and rheumatologists, etc. Many doctors are familiar with applications of MSUS in disorders of the shoulder, knee, and ankle joints. In addition to aiding in diagnosis based on morphological changes on B-mode MSUS, recent efforts have also focused on its applications in dynamic study, intervention guidance, and sonoelastography. MSUS provides high-resolution and real-time imaging of the musculoskeletal system. In certain conditions, static Bmode MSUS may not detect anatomical abnormalities on the patient. Dynamic examination helps doctors to identify those diseases that are difficult to visualize on static imaging studies, such as peroneal tendon subluxation [1,2], snapping hip syndrome [3], and ulnar nerve subluxation [4]. In clinical practice, dynamic examination can be used for detection of minimal effusion, such as shoulder external rotation and internal rotation for posterior glenohumeral joint effusion, and isometric quadriceps contraction and relaxation for suprapatellar pouch effusion. In shoulder impingement syndrome, dynamic examination of coracoacromial ligament displacement during shoulder abduction and internal rotation may help identify abnormal shoulder kinetics [5,6]. When no anatomical abnormality is detected on B-mode MSUS, dynamic examination may help identify functional impairment. Based on its real-time nature, MSUS can also be used for evaluation of swallowing dysfunction (dysphagia). In patients with stroke, the distance between the thyroid cartilage and hyoid bone may be measured by MSUS. By subtracting the shortest distance between the hyoid bone and thyroid cartilage during swallowing from that at rest, hyoidelarynx approximation could be evaluated, which was found to be significantly reduced in stroke patients with dysphagia [7]. In such patients, MSUS may also measure changes in tongue thickness and hyoid bone displacement during swallowing. In those needing tube feeding, tongue thickness change and hyoid bone displacement were Conflicts of interest: All contributing authors declare no conflicts of interest.
significantly less than those on oral intake [8]. Future studies may be conducted to investigate the effects of pharyngeal strengthening and electrical stimulation on these parameters. Ultrasound-guided interventions allow for clear depiction of target lesions while avoiding injury to adjacent tissues such as nerves or blood vessels. It has been widely used in pain management [9,10]. A successful ultrasound-guided procedure depends on coordination between one hand holding the probe and the other holding the needle. Recognition of peripheral nerves not only facilitates nerve block procedures, but also helps in avoiding nerve injury during injection for joints, tendons, and ligaments [11,12]. During intramuscular injection (e.g., botulinum toxin), identifying nerves also helps in differentiation of different muscle layers, such as the median nerve between flexor digitorum superficialis and flexor digitorum profundus muscles. Sonoelastography provides a noninvasive estimation of tissue stiffness. Its applications in the musculoskeletal field have drawn an increasing attention in recent years. There are two major principles of sonoelastography: compression (strain) elastography and shear wave elastography. For compression elastography, tissue displacement is calculated in real time by repeated manual compression with a handheld transducer. The strain (displacement) is higher in softer tissues. The displacement is then converted into a color-coded strain distribution map (elastogram), and the gray- or color-scale encoding is adjustable by the user. This technique has shown stiffness changes in diseased tissues, such as plantar fascia softening in plantar fasciitis [13,14]. Providing only information on “relative” stiffness and concerns about reliability are the main drawbacks of compression elastography. A visual indicator for confirming quality of image acquisition and strain ratio between an objective region of interest (ROI) and a reference ROI are two methods to improve quality of stiffness measurements. For shear wave elastography, the measurement of the propagation velocity distribution of the directional shear wave produced by an ultrasound pulse allows for quantitative measurements of tissue elasticity because the shear waves travel faster in stiffer tissues. It has been used in
http://dx.doi.org/10.1016/j.jmu.2016.03.007 0929-6441/ª 2016, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Wu C-H, Wang T-G, Current Trends in Musculoskeletal Ultrasound, Journal of Medical Ultrasound (2016), http://dx.doi.org/10.1016/j.jmu.2016.03.007
+
MODEL
2 evaluation of muscle stiffness in neck pain [15] and cerebral palsy [16]. In adhesive capsulitis of the shoulder, shear wave elastography also showed a stiffer coracohumeral ligament, which may be related to limitation in shoulder external rotation [17]. Sonoelastography provides another aspect of tissue properties in addition to morphology and vascularity. Future studies may focus on its histopathological correlation and the cutoff value for diagnosis.
References [1] Wu CH, Shyu SG, Ozcakar L, et al. Dynamic ultrasound imaging for peroneal tendon subluxation. Am J Phys Med Rehabil 2015; 94:e57e8. [2] Hsiao MY, Shyu SG, Wu CH, et al. Dynamic ultrasound imaging for type A intrasheath subluxation of the peroneal tendons. Am J Phys Med Rehabil 2015;94:e53e4. [3] Chang KS, Cheng YH, Wu CH, et al. Dynamic ultrasound imaging for the iliotibial band/snapping hip syndrome. Am J Phys Med Rehabil 2015;94:e55e6. [4] Chuang HJ, Hsiao MY, Wu CH, et al. Dynamic ultrasound imaging for ulnar nerve subluxation and snapping triceps syndrome. Am J Phys Med Rehabil 2016. in press. [5] Wu CH, Wang YC, Wang HK, et al. Evaluating displacement of the coracoacromial ligament in painful shoulders of overhead athletes through dynamic ultrasonographic examination. Arch Phys Med Rehabil 2010;91:278e82. [6] Wu CH, Chang KV, Su PH, et al. Dynamic ultrasonography to evaluate coracoacromial ligament displacement during motion in shoulders with supraspinatus tendon tears. J Orthop Res 2012;30:1430e4. [7] Huang YL, Hsieh SF, Chang YC, et al. Ultrasonographic evaluation of hyoidelarynx approximation in dysphagic stroke patients. Ultrasound Med Biol 2009;35:1103e8. [8] Hsiao MY, Chang YC, Chen WS, et al. Application of ultrasonography in assessing oropharyngeal dysphagia in stroke patients. Ultrasound Med Biol 2012;38:1522e8. [9] Chang KV, Hung CY, Wang TG, et al. Ultrasound-guided proximal suprascapular nerve block with radiofrequency lesioning for patients with malignancy-associated recalcitrant shoulder pain. J Ultrasound Med 2015;34:2099e105.
Editorial [10] Hung YH, Wu CH, Ozcakar L, et al. Ultrasound-guided steroid injections for two painful neuromas in the stump of a belowelbow amputee. Am J Phys Med Rehabil 2016 May;95(5): e73e4. [11] Wu CH, Chang KV, Ozcakar L, et al. Sonographic tracking of the upper limb peripheral nerves: a pictorial essay and video demonstration. Am J Phys Med Rehabil 2015;94:740e7. [12] Hung CY, Hsiao MY, Ozcakar L, et al. Sonographic tracking of the lower limb peripheral nerves: a pictorial essay and video demonstration. Am J Phys Med Rehabil 2016. in press. [13] Wu CH, Chang KV, Mio S, et al. Sonoelastography of the plantar fascia. Radiology 2011;259:502e7. [14] Wu CH, Chen WS, Wang TG. Plantar fascia softening in plantar fasciitis with normal B-mode sonography. Skeletal Radiol 2015;44:1603e7. [15] Kuo WH, Jian DW, Wang TG, et al. Neck muscle stiffness quantified by sonoelastography is correlated with body mass index and chronic neck pain symptoms. Ultrasound Med Biol 2013;39:1356e61. [16] Wu CH, Wang TG. Measurement of muscle stiffness in children with spastic cerebral palsy. Radiology 2012;265:647. [17] Wu CH, Chen WS, Wang TG. Elasticity of the coracohumeral ligament in patients with adhesive capsulitis of the shoulder. Radiology 2016;278:458e64.
Chueh-Hung Wu Tyng-Guey Wang* Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan *Correspondence to: Dr Tyng-Guey Wang, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Number 7, Chung-Shan South Road, 100, Taipei, Taiwan. E-mail address: [email protected] (T.-G. Wang) 15 March 2016
Please cite this article in press as: Wu C-H, Wang T-G, Current Trends in Musculoskeletal Ultrasound, Journal of Medical Ultrasound (2016), http://dx.doi.org/10.1016/j.jmu.2016.03.007
MODEL
Journal of Medical Ultrasound (2016) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
EDITORIAL
Current Trends in Musculoskeletal Ultrasound Musculoskeletal ultrasound (MSUS) is being utilized in routine daily clinical practice by an increasing number of physiatrists, orthopedists, anesthesiologists, radiologists, and rheumatologists, etc. Many doctors are familiar with applications of MSUS in disorders of the shoulder, knee, and ankle joints. In addition to aiding in diagnosis based on morphological changes on B-mode MSUS, recent efforts have also focused on its applications in dynamic study, intervention guidance, and sonoelastography. MSUS provides high-resolution and real-time imaging of the musculoskeletal system. In certain conditions, static Bmode MSUS may not detect anatomical abnormalities on the patient. Dynamic examination helps doctors to identify those diseases that are difficult to visualize on static imaging studies, such as peroneal tendon subluxation [1,2], snapping hip syndrome [3], and ulnar nerve subluxation [4]. In clinical practice, dynamic examination can be used for detection of minimal effusion, such as shoulder external rotation and internal rotation for posterior glenohumeral joint effusion, and isometric quadriceps contraction and relaxation for suprapatellar pouch effusion. In shoulder impingement syndrome, dynamic examination of coracoacromial ligament displacement during shoulder abduction and internal rotation may help identify abnormal shoulder kinetics [5,6]. When no anatomical abnormality is detected on B-mode MSUS, dynamic examination may help identify functional impairment. Based on its real-time nature, MSUS can also be used for evaluation of swallowing dysfunction (dysphagia). In patients with stroke, the distance between the thyroid cartilage and hyoid bone may be measured by MSUS. By subtracting the shortest distance between the hyoid bone and thyroid cartilage during swallowing from that at rest, hyoidelarynx approximation could be evaluated, which was found to be significantly reduced in stroke patients with dysphagia [7]. In such patients, MSUS may also measure changes in tongue thickness and hyoid bone displacement during swallowing. In those needing tube feeding, tongue thickness change and hyoid bone displacement were Conflicts of interest: All contributing authors declare no conflicts of interest.
significantly less than those on oral intake [8]. Future studies may be conducted to investigate the effects of pharyngeal strengthening and electrical stimulation on these parameters. Ultrasound-guided interventions allow for clear depiction of target lesions while avoiding injury to adjacent tissues such as nerves or blood vessels. It has been widely used in pain management [9,10]. A successful ultrasound-guided procedure depends on coordination between one hand holding the probe and the other holding the needle. Recognition of peripheral nerves not only facilitates nerve block procedures, but also helps in avoiding nerve injury during injection for joints, tendons, and ligaments [11,12]. During intramuscular injection (e.g., botulinum toxin), identifying nerves also helps in differentiation of different muscle layers, such as the median nerve between flexor digitorum superficialis and flexor digitorum profundus muscles. Sonoelastography provides a noninvasive estimation of tissue stiffness. Its applications in the musculoskeletal field have drawn an increasing attention in recent years. There are two major principles of sonoelastography: compression (strain) elastography and shear wave elastography. For compression elastography, tissue displacement is calculated in real time by repeated manual compression with a handheld transducer. The strain (displacement) is higher in softer tissues. The displacement is then converted into a color-coded strain distribution map (elastogram), and the gray- or color-scale encoding is adjustable by the user. This technique has shown stiffness changes in diseased tissues, such as plantar fascia softening in plantar fasciitis [13,14]. Providing only information on “relative” stiffness and concerns about reliability are the main drawbacks of compression elastography. A visual indicator for confirming quality of image acquisition and strain ratio between an objective region of interest (ROI) and a reference ROI are two methods to improve quality of stiffness measurements. For shear wave elastography, the measurement of the propagation velocity distribution of the directional shear wave produced by an ultrasound pulse allows for quantitative measurements of tissue elasticity because the shear waves travel faster in stiffer tissues. It has been used in
http://dx.doi.org/10.1016/j.jmu.2016.03.007 0929-6441/ª 2016, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Wu C-H, Wang T-G, Current Trends in Musculoskeletal Ultrasound, Journal of Medical Ultrasound (2016), http://dx.doi.org/10.1016/j.jmu.2016.03.007
+
MODEL
2 evaluation of muscle stiffness in neck pain [15] and cerebral palsy [16]. In adhesive capsulitis of the shoulder, shear wave elastography also showed a stiffer coracohumeral ligament, which may be related to limitation in shoulder external rotation [17]. Sonoelastography provides another aspect of tissue properties in addition to morphology and vascularity. Future studies may focus on its histopathological correlation and the cutoff value for diagnosis.
References [1] Wu CH, Shyu SG, Ozcakar L, et al. Dynamic ultrasound imaging for peroneal tendon subluxation. Am J Phys Med Rehabil 2015; 94:e57e8. [2] Hsiao MY, Shyu SG, Wu CH, et al. Dynamic ultrasound imaging for type A intrasheath subluxation of the peroneal tendons. Am J Phys Med Rehabil 2015;94:e53e4. [3] Chang KS, Cheng YH, Wu CH, et al. Dynamic ultrasound imaging for the iliotibial band/snapping hip syndrome. Am J Phys Med Rehabil 2015;94:e55e6. [4] Chuang HJ, Hsiao MY, Wu CH, et al. Dynamic ultrasound imaging for ulnar nerve subluxation and snapping triceps syndrome. Am J Phys Med Rehabil 2016. in press. [5] Wu CH, Wang YC, Wang HK, et al. Evaluating displacement of the coracoacromial ligament in painful shoulders of overhead athletes through dynamic ultrasonographic examination. Arch Phys Med Rehabil 2010;91:278e82. [6] Wu CH, Chang KV, Su PH, et al. Dynamic ultrasonography to evaluate coracoacromial ligament displacement during motion in shoulders with supraspinatus tendon tears. J Orthop Res 2012;30:1430e4. [7] Huang YL, Hsieh SF, Chang YC, et al. Ultrasonographic evaluation of hyoidelarynx approximation in dysphagic stroke patients. Ultrasound Med Biol 2009;35:1103e8. [8] Hsiao MY, Chang YC, Chen WS, et al. Application of ultrasonography in assessing oropharyngeal dysphagia in stroke patients. Ultrasound Med Biol 2012;38:1522e8. [9] Chang KV, Hung CY, Wang TG, et al. Ultrasound-guided proximal suprascapular nerve block with radiofrequency lesioning for patients with malignancy-associated recalcitrant shoulder pain. J Ultrasound Med 2015;34:2099e105.
Editorial [10] Hung YH, Wu CH, Ozcakar L, et al. Ultrasound-guided steroid injections for two painful neuromas in the stump of a belowelbow amputee. Am J Phys Med Rehabil 2016 May;95(5): e73e4. [11] Wu CH, Chang KV, Ozcakar L, et al. Sonographic tracking of the upper limb peripheral nerves: a pictorial essay and video demonstration. Am J Phys Med Rehabil 2015;94:740e7. [12] Hung CY, Hsiao MY, Ozcakar L, et al. Sonographic tracking of the lower limb peripheral nerves: a pictorial essay and video demonstration. Am J Phys Med Rehabil 2016. in press. [13] Wu CH, Chang KV, Mio S, et al. Sonoelastography of the plantar fascia. Radiology 2011;259:502e7. [14] Wu CH, Chen WS, Wang TG. Plantar fascia softening in plantar fasciitis with normal B-mode sonography. Skeletal Radiol 2015;44:1603e7. [15] Kuo WH, Jian DW, Wang TG, et al. Neck muscle stiffness quantified by sonoelastography is correlated with body mass index and chronic neck pain symptoms. Ultrasound Med Biol 2013;39:1356e61. [16] Wu CH, Wang TG. Measurement of muscle stiffness in children with spastic cerebral palsy. Radiology 2012;265:647. [17] Wu CH, Chen WS, Wang TG. Elasticity of the coracohumeral ligament in patients with adhesive capsulitis of the shoulder. Radiology 2016;278:458e64.
Chueh-Hung Wu Tyng-Guey Wang* Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan *Correspondence to: Dr Tyng-Guey Wang, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Number 7, Chung-Shan South Road, 100, Taipei, Taiwan. E-mail address: [email protected] (T.-G. Wang) 15 March 2016
Please cite this article in press as: Wu C-H, Wang T-G, Current Trends in Musculoskeletal Ultrasound, Journal of Medical Ultrasound (2016), http://dx.doi.org/10.1016/j.jmu.2016.03.007