MUSCULOSKELETAL ULTRASOUND

rehabilitation of dysfunctional or injured muscle groups. The most well documented example of biofeedback on lumbar multifidus in the spectrum of chronic back pain (24- 28). Research has shown that therapists have found that the visual biofeedback from real-time ultrasound (VUB) has helped patients to optimise contraction of certain important postural lumbar and abdominal muscles, though MSKUS may also have a future role in the monitoring the response to cervical spine rehabilitation (29).

Though some doubt has been cast as to whether there is any measurable difference in the measured calibre of say the

tranversalis abdomis muscle (30, 31) this is to ignore the likely subjective benefits of VUB to the overall holistic care plan for the patients, and the positive influence on the therapist-patient relationship. Also, because this intervention is not strictly diagnostic, the ultrasound equipment specifications are much more relaxed. This means that cheaper ultrasound equipment is both suitable and more accessible to interest individual professionals, though adequate training is still required to enable correct sonographic identification of anatomical structures and interpretation of their dynamic movements.

References 1. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomised controlled trial. American Journal of Sports Medicine 2006:Nov;34(11):1738-1746 2. McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. Journal of Ultrasound Medicine 2006:Oct;25(10):1281-1289 3. Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surgery and Sports Traumatology Arthroscopy 2006;Nov;14(11):1218- 1224 4. Melegati G, Tornese D, Bandi M, Rubini M. Comparison of two ultrasonographic localization techniques for the treatment of lateral epicondylitis with extracorporeal shock wave therapy: a randomised study. Clinical Rehabilitation 2004:Jun;18(4):366-370 5. Smith J, Hurdle MF, Locketz AJ, Wisniewski SJ. Ultrasound-guided piriformis injection: technique description and verification. Archives of Physical Medicine and Rehabilitation 2006:Dec;87(12):1664-1667 6. Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney R, FitzGerald O. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology 2001:Sep;40(9):1002-1008 7. Mehdizade A, Adler RS. Sonographically guided flexor hallucis longus tendon sheath injection. Journal of Ultrasound in Medicine 2007:Feb;26(2):233-237 8. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: blind or ultrasound-guided? Acta Orthopaedica 2007:Apr;78(2):254-257 9. Tsai WC, Hsu CC, Chen CP, Chen MJ, Yu TY, Chen YJ. Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. Journal of Clinical Ultrasound 2006:Jan;34(1):12- 16 10. Esenyel CZ, Esenyel M, Yesiltepe R, Ayanoglu S, Bulbul M, Sirvanci M, Kara AN. The correlation between the accuracy of steroid injections and subsequent shoulder pain and function in subacromial impingement syndrome] Acta Orthopaedica Traumatologica Turca 2003;37(1):41-45 11. Hans-Erik Henkus, M.D, et al. The Journal of Arthroscopic and Related Surgery 2006:Vol 22, No 3 (March):277-282 12. Farin PU, Jaroma H, Soimakallio S. Rotator cuff calcifications: treatment with US-guided technique. Radiology 1995:Jun;195(3):841- 843 13. Comfort TH, Arafiles RP. Barbotage of the shoulder with image- intensified fluoroscopic control of needle placement for calcific tendinitis. Clinical Orthopaedics and Related Research 1978:Sep;(135):171-178

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14. Hoffman P. Skin disinfection and acupuncture. Acupuncture Medicine 2001:Dec;19(2):112-116 15. Farooq MA, Devitt AT. Perceived efficacy and risks of infection following intra-articular injections: a survey of orthopaedic surgeons. Irish Journal of Medical Science 2005:Jan-Mar;174(1):26-32 16. Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clinical Rheumatology 2003:Dec;22(6):386-390 17. James SL, Ali K, Pocock C, Robertson C, Walter J, Bell J, Connell D. 18. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. British Journal of Sports Medicine 2007:Aug;41(8):518-21; discussion 522 19. Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiology 2006:Jun;35(6):371-377 20. Suresh SP, Ali KE, Jones H, Connell DA. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? British Journal of Sports Medicine 2006:Nov;40(11):935-9; discus- sion 939 21. Boesen MI, Torp-Pedersen S, Koenig MJ, Christensen R, Langberg H, Holmich P, Nielsen MB, Bliddal H. Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study. British Journal of Sports Medicine 2006:Sep;40(9):761-766 22. Kamel M, Kotob H. High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol. 2000 Sep;27(9):2139-41 23. Tsai WC, Wang CL, Tang FT, Hsu TC, Hsu KH, Wong MK. Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection. Archives of Physical Medicine and Rehabilitation 2000:Oct;81(10):1416-1421 24. Dr Lee DH, Gainesville, Texas; unpublished data on sonoscopic treatment for tarsal tunnel syndrome in diabetics, presented at the 17 Annual Meeting of the Musculoskeletal Ultrasound Society, Paris, August 2007 (www.musoc.com) 25. Kiesel KB, Uhl TL, Underwood FB, Rodd DW, Nitz AJ. Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging. Manual Therapy 2007:May;12(2):161-166 26. Van K, Hides JA, Richardson CA. The use of real-time ultrasound imaging for biofeedback of lumbar multifidus muscle contraction in healthy subjects. Journal of Orthopaedic and Sports Physical Therapy 2006:Dec;36(12):920-925 27. Vasseljen O, Dahl HH, Mork PJ, Torp HG. Muscle activity onset in the lumbar multifidus muscle recorded simultaneously by ultrasound imaging and intramuscular electromyography. Clinical Biomechanics 2006:Nov;21(9):905-913 28. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of lumbar multifidus muscle: normal reference ranges for measurements and practical guidance on the technique. Manual Therapy 2005:May;10(2):116-126 29. Coldron Y, Stokes M, Cook K. Lumbar multifidus muscle size does not differ whether ultrasound imaging is performed in prone or side lying. Manual Therapy 2003:Aug;8(3):161-165 30. Lee JP, Tseng WY, Shau YW, Wang CL, Wang HK, Wang SF. Measurement of segmental cervical multifidus contraction by ultrasonography in asymptomatic adults. Manual Therapy 2007:Aug;12(3):286-294 31. Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM, Pulliam JN, Childs JD, Boyles RE, Flynn TW. The use of ultrasound imaging of the abdominal drawing-in manoeuver in subjects with low back pain. Journal of Orthopaedic and Sports Physical Therapy 2005:Jun; 35(6):346-355 32. Henry SM, Westervelt KC. The use of real-time ultrasound feedback in teaching abdominal hollowing exercises to healthy subjects. Journal of Orthopaedic and Sports Physical Therapy 2005:Jun;35(6):338-345

THE AUTHORS

Lt Colonel Duncan Robertson RAMC, MBChB MRCGP DCH MSc(SEM) PGCMskUltsnd FFSEM(UK). Dr Robertson is an army doctor (GPwSI) and musculoskeletal sonographer with a complimentary interest in sports and exercise medicine. On operations in Afghanistan in 2005, Duncan successfully utilised portable (Sonosite) MskUS equipment. He has been involved in MSKUS since 2003, and teaching since

sportEX medicine 2008;35(Jan):21-26