Publications by authors named "Levon N Nazarian"

84 Publications

Correction to: Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes.

Skeletal Radiol 2021 May 20. Epub 2021 May 20.

Department of Radiology and Imaging Sciences, Emory School of Medicine, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.

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http://dx.doi.org/10.1007/s00256-021-03818-4DOI Listing
May 2021

Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes.

Skeletal Radiol 2021 May 8. Epub 2021 May 8.

Department of Radiology and Imaging Sciences, Emory School of Medicine, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.

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 and the mean elastic modulus of 176.8 kPa were recorded. In active maximum dorsiflexion, the mean velocity was 8.3 m sec 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.
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http://dx.doi.org/10.1007/s00256-021-03798-5DOI Listing
May 2021

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Shoulder Sports Injuries: A Narrative Review.

JBJS Rev 2021 04 22;9(4). Epub 2021 Apr 22.

The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

»: 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.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00099DOI Listing
April 2021

Ultrasound Examination Techniques for Elbow Injuries in Overhead Athletes.

J Am Acad Orthop Surg 2021 Mar;29(6):227-234

From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Hultman and Ciccotti), the Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, FL (Goldman), and the Department of Radiology, Thomas Jefferson University, Philadelphia, PA (Nazarian).

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.
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http://dx.doi.org/10.5435/JAAOS-D-20-00935DOI Listing
March 2021

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries.

JBJS Rev 2020 11;8(11):e19.00219

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

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.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00219DOI Listing
November 2020

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome.

AJR Am J Roentgenol 2020 Sep 2. Epub 2020 Sep 2.

Department of Radiology, Thomas Jefferson University Hospital. 132 S 10 Street Philadelphia, PA 19107. (215) 955-6752.

Ultrasound guidance allows carpal tunnel release to be performed with smaller incisions and quicker recovery than traditional open or endoscopic surgery. To evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed in 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. These were performed under local anesthetic at an outpatient radiology offce using the SX-One MicroKnife (Sonex Health). Patients answered three questionnaires (Quick-Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire: symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) assessing the affected wrist's function and discomfort immediately pre-procedure, 2 weeks post-procedure, and at least one year post-procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Pre- and post-procedure scores were compared using paired Wilcoxon signed-rank tests. The 46 patients included 25 women and 21 men. Mean age was 60.6 years (range 21-80). Median pre-procedure scores were 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. Median 2 week post-procedure scores were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS, all decreased (p<0.001) from preprocedure scores and surpassing reference standards for clinically important difference in scores. Follow-up questionnaires were obtained for 90% (55/61) of wrists, a median of 1.7 (1.0-2.8) years post-procedure, with further declines (p<0.001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up, 96% (52/54) of wrists demonstrated lower QDASH, and 98% (53/54) lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS), vs. pre-procedure scores. 93% (37/40) of surveyed patients were satisfied/very satisfied with long-term outcomes. No immediate postoperative complications occurred. Two patients required surgical intervention 8-10 days postoperatively, one for infection following injury and one for post-traumatic compartment syndrome. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persisted beyond one year. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.
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http://dx.doi.org/10.2214/AJR.20.24383DOI Listing
September 2020

Medial Elbow Instability Resulting From Partial Tears of the Ulnar Collateral Ligament: Stress Ultrasound in a Cadaveric Model.

Am J Sports Med 2020 09 19;48(11):2613-2620. Epub 2020 Aug 19.

The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

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.
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http://dx.doi.org/10.1177/0363546520947065DOI Listing
September 2020

Ultrasound-guided treatment of peripheral entrapment mononeuropathies.

Muscle Nerve 2019 09 23;60(3):222-231. Epub 2019 May 23.

Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

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.
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http://dx.doi.org/10.1002/mus.26517DOI Listing
September 2019

Letter to the Editor regarding Gyftopoulos et al: "Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears".

J Shoulder Elbow Surg 2018 10 6;27(10):e318-e319. Epub 2018 Aug 6.

Department of Radiology; Sidney Kimmel Medical College at Thomas Jefferson University; 763E Main Bldg, 132 S 10th St; Philadelphia, PA, 19107-5244 USA.

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http://dx.doi.org/10.1016/j.jse.2018.03.035DOI Listing
October 2018

Reticular Telangiectatic Erythema: A Chronic Hematoma Subsequent to Hip Replacement as an Underlying Cause.

Skinmed 2018;16(3):199-200. Epub 2018 Jun 1.

Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA;

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.
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October 2019

Evaluation of the Anterior Talofibular Ligament via Stress Sonography in Asymptomatic and Symptomatic Populations.

J Ultrasound Med 2018 Aug 24;37(8):1957-1963. Epub 2018 Jan 24.

Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

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.
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http://dx.doi.org/10.1002/jum.14542DOI Listing
August 2018

Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015.

J Am Coll Radiol 2018 03 13;15(3 Pt A):402-407. Epub 2017 Dec 13.

Center for Research on Utilization of Imaging Services (CRUISE), Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; HealthHelp, Inc, Houston, Texas.

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.
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http://dx.doi.org/10.1016/j.jacr.2017.10.015DOI Listing
March 2018

Ultrasound-Guided Hydroneurolysis of the Median Nerve for Recurrent Carpal Tunnel Syndrome.

Hand (N Y) 2019 05 27;14(3):413-421. Epub 2017 Sep 27.

2 Thomas Jefferson University, Philadelphia, PA, USA.

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.
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http://dx.doi.org/10.1177/1558944717731855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535939PMC
May 2019

Ultrasound-Guided Percutaneous Needle Fenestration and Corticosteroid Injection for Anterior and Anterolateral Ankle Impingement.

Foot Ankle Spec 2018 Feb 15;11(1):61-66. Epub 2017 May 15.

Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (LNN, NVG).

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.
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http://dx.doi.org/10.1177/1938640017709904DOI Listing
February 2018

Resident Perspectives of an Interactive Case Review Following Independent Didactic Study as a Method of Teaching a Pediatric Imaging Curriculum.

Curr Probl Diagn Radiol 2017 Nov - Dec;46(6):395-398. Epub 2017 Jan 14.

Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA.

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.
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http://dx.doi.org/10.1067/j.cpradiol.2017.01.003DOI Listing
February 2018

Imaging Surveillance in Patients After a Benign Fine-Needle Aspiration Biopsy of the Thyroid: Associated Cost and Incidence of Subsequent Cancer.

AJR Am J Roentgenol 2017 Feb 8;208(2):358-361. Epub 2016 Dec 8.

1 Department of Radiology, Thomas Jefferson University, Philadelphia, PA.

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.
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http://dx.doi.org/10.2214/AJR.16.16691DOI Listing
February 2017

Factors Related to Increased Ulnar Collateral Ligament Thickness on Stress Sonography of the Elbow in Asymptomatic Youth and Adolescent Baseball Pitchers.

Am J Sports Med 2016 Dec 1;44(12):3179-3187. Epub 2016 Sep 1.

Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

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 = 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.
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http://dx.doi.org/10.1177/0363546516661010DOI Listing
December 2016

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Radiology 2016 Jun 27;279(3):827-37. Epub 2016 Jan 27.

From the Department of Radiology, Thomas Jefferson University Hospital, Jefferson Medical College, 132 S 10th St, Philadelphia, PA 19107 (J.B.R., F.M.G., A.C.Z., W.B.M., M.T.N., L.N.N.); and Division of Sports Medicine, Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, Jefferson Medical College, Philadelphia, Pa (M.G.C.).

Purpose To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. Materials and Methods Institutional review board approval was obtained and the requirement for informed consent was waived. The study is compliant with HIPAA. Baseball players with medial elbow pain underwent US in addition to MR arthrography. Findings were assessed with each modality alone and both combined in this retrospective investigation. For the evaluation of ulnar collateral ligament (UCL) tears with stress US, the interval gapping of the medial elbow joint was measured between rest and valgus stress both at the injured and at the uninjured (contralateral) elbow. Surgical or arthroscopic correlation was available as the so-called gold standard. McNemar tests compared the accuracies of the imaging modalities. Results In this study, 144 baseball players had 191 findings of medial elbow pain, including 53 UCL tears. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. Conclusion The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. (©) RSNA, 2016.
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http://dx.doi.org/10.1148/radiol.2015151256DOI Listing
June 2016

ABR Core Examination Changes That Affect Residency Candidate Decisions.

J Am Coll Radiol 2015 Dec 21;12(12 Pt A):1307-12. Epub 2015 Oct 21.

Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania.

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.
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http://dx.doi.org/10.1016/j.jacr.2015.08.019DOI Listing
December 2015

Early Anatomic Changes of the Ulnar Collateral Ligament Identified by Stress Ultrasound of the Elbow in Young Professional Baseball Pitchers.

Am J Sports Med 2015 Dec 24;43(12):2943-9. Epub 2015 Sep 24.

Rothman Institute, Philadelphia, Pennsylvania, USA Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

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.
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http://dx.doi.org/10.1177/0363546515605042DOI Listing
December 2015

Enthesopathy of the lateral cord of the plantar fascia.

J Ultrasound Med 2014 Sep;33(9):1711-6

Department of Orthopedics and Radiology, Essentia Health, Duluth, Minnesota USA (D.F.H.); Department of Radiology, Thomas Jefferson University Hospital; Philadelphia, Pennsylvania USA (L.N.N.); and Departments of Physical Medicine and Rehabilitation and Radiology, Mayo Clinic College of Medicine and Mayo Clinic Sports Medicine Center, Rochester, Minnesota USA (J.S.).

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.
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http://dx.doi.org/10.7863/ultra.33.9.1711DOI Listing
September 2014

Does the ulnar nerve enlarge after surgical transposition?

J Ultrasound Med 2014 Sep;33(9):1647-52

Departments of Orthopedic Surgery (M.M.V., T.D.T., A.M.I.) and Diagnostic Radiology (L.N.N.), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania USA.

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.
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http://dx.doi.org/10.7863/ultra.33.9.1647DOI Listing
September 2014

State of the journal.

Authors:
Levon N Nazarian

J Ultrasound Med 2014 Sep;33(9):1521-32

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http://dx.doi.org/10.7863/ultra.33.9.1531DOI Listing
September 2014

Stress ultrasound evaluation of medial elbow instability in a cadaveric model.

Am J Sports Med 2014 Oct 14;42(10):2463-9. Epub 2014 Aug 14.

Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA

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.
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http://dx.doi.org/10.1177/0363546514542805DOI Listing
October 2014

National ultrasound curriculum for medical students.

Ultrasound Q 2014 Mar;30(1):13-9

*Department of Radiology, Jefferson Ultrasound Radiology & Education Institute and Thomas Jefferson University, Philadelphia, PA; †Harvard Medical School and Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; ‡Department Diagnostic Radiology, Yale University School of Medicine, New Haven, CT; §Mayo Clinic College of Medicine and Mayo Clinic, Rochester, MN; ∥University of Colorado School of Medicine, Rocky Vista University College of Osteopathic Medicine, and National Jewish Health, Denver, CO; ¶CS Mott Children's Hospital and #University of Michigan, Ann Arbor, MI; **Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine; and ††Department of Radiology, University of Maryland School of Medicine, Baltimore, MD; ‡‡Department of Radiology, Thomas Jefferson University; and §§Penn State Hershey Medical Center, Hershey, PA; ∥∥Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, CA; ¶¶Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; and ##Department of Radiology, University of Washington, Seattle, WA.

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.
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http://dx.doi.org/10.1097/RUQ.0000000000000066DOI Listing
March 2014

Greater trochanteric pain syndrome diagnosis and treatment.

Phys Med Rehabil Clin N Am 2014 May 18;25(2):279-89. Epub 2014 Mar 18.

Department of Radiology, Jefferson Medical College of Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107, USA.

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.
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http://dx.doi.org/10.1016/j.pmr.2014.01.009DOI Listing
May 2014

Two novel nonsurgical treatments of carpal tunnel syndrome.

Phys Med Rehabil Clin N Am 2014 May;25(2):249-64

Department of Radiology, Thomas Jefferson University Hospital, Room 763E Main Building, 132 South 10th Street, Philadelphia, PA 19107-5244, USA.

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.
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http://dx.doi.org/10.1016/j.pmr.2014.01.008DOI Listing
May 2014

The antiangiogenic effects of a vascular endothelial growth factor decoy receptor can be monitored in vivo using contrast-enhanced ultrasound imaging.

Mol Imaging 2014 ;13:1-9

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4459598PMC
December 2014

Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study.

Am J Sports Med 2014 Mar 28;42(3):544-51. Epub 2014 Jan 28.

Alfred Atanda Nemours/Alfred I. duPont Hospital for Children, Department of Orthopedics, 1600 Rockland Road, Wilmington, DE 19803, USA.

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.
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http://dx.doi.org/10.1177/0363546513516592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131844PMC
March 2014