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Hamstring strain injuries (HSI) are a common occurrence in athletics and complicated by high rates of reinjury. Evidence of remaining injury observed on magnetic resonance imaging (MRI) at the time of return to sport (RTS) may be associated with strength deficits and prognostic for reinjury, however, conventional imaging has failed to establish a relationship. Quantitative measure of muscle microstructure using diffusion tensor imaging (DTI) may hold potential for assessing a possible association between injury-related structural changes and clinical outcomes. The purpose of this study was to determine the association of RTS MRI-based quantitative measures, such as edema volume, muscle volume, and DTI metrics, with clinical outcomes (i.e., strength and reinjury) following HSI. Spearman’s correlations and Firth logistic regressions were used to determine relationships in between-limb imaging measures and between-limb eccentric strength and reinjury status, respectively. Twenty injuries were observed, with four reinjuries. At the time of RTS, between-limb differences in eccentric hamstring strength were significantly associated with principal effective diffusivity eigenvalue λ1 (r = -0.64, p = 0.003) and marginally associated with mean diffusivity (r = -0.46, p = 0.056). Significant relationships between other MRI-based measures of morphology and eccentric strength were not detected, as well as between any MRI-based measure and reinjury status. In conclusion, this preliminary evidence indicates DTI may track differences in hamstring muscle microstructure, not captured by conventional imaging at the whole muscle level, that relate to eccentric strength.

Background Rehabilitation progression and return-to-play (RTP) decision making following hamstring strain injury (HSI) can be challenging for clinicians, owing to the competing demands of reducing both convalescence and the risk of re-injury. Despite an increased focus on the RTP process following HSI, little attention has been paid to rehabilitation progression and RTP criteria, and subsequent time taken to RTP and re-injury rates. Objective The aim of this systematic review is to identify rehabilitation progression and RTP criteria implemented following HSI and examine the subsequent time taken to RTP and rates of re-injury. Methods A systematic literature review of databases MEDLINE, CINAHL, SPORTDiscus, Cochrane Library, Web of Science and EMBASE was conducted to identify studies of participants with acute HSI reporting time taken to RTP and rates of re-injury after a minimum 6-month follow-up. General guidelines and specific criteria for rehabilitation progression were identified for each study. In addition, RTP criteria were identified and categorised as performance tests, clinical assessments, isokinetic dynamometry or the Askling H-test. Results Nine studies were included with a total of 601 acute HSI confirmed by clinical examination or magnetic resonance imaging within 10 days of initial injury. A feature across all nine studies was that the injured individual’s perception of pain was used to guide rehabilitation progression, whilst clinical assessments and performance tests were the most frequently implemented RTP criteria. Mean RTP times were lowest in studies implementing isokinetic dynamometry as part of RTP decision making (12–25 days), whilst those implementing the Askling H-test had the lowest rates of re-injury (1.3–3.6%). Conclusions This systematic review highlights the strong emphasis placed on the alleviation of pain to allow HSI rehabilitation progression, and the reliance on subjective clinical assessments and performance tests as RTP criteria. These results suggest a need for more objective and clinically practical criteria, allowing a more evidence-based approach to rehabilitation progression, and potentially reducing the ambiguity involved in the RTP decision-making process.

Background The role played by the thoracolumbar fascia in chronic low back pain (LBP) is poorly understood. The thoracolumbar fascia is composed of dense connective tissue layers separated by layers of loose connective tissue that normally allow the dense layers to glide past one another during trunk motion. The goal of this study was to quantify shear plane motion within the thoracolumbar fascia using ultrasound elasticity imaging in human subjects with and without chronic low back pain (LBP). Methods We tested 121 human subjects, 50 without LBP and 71 with LBP of greater than 12 months duration. In each subject, an ultrasound cine-recording was acquired on the right and left sides of the back during passive trunk flexion using a motorized articulated table with the hinge point of the table at L4-5 and the ultrasound probe located longitudinally 2 cm lateral to the midline at the level of the L2-3 interspace. Tissue displacement within the thoracolumbar fascia was calculated using cross correlation techniques and shear strain was derived from this displacement data. Additional measures included standard range of motion and physical performance evaluations as well as ultrasound measurement of perimuscular connective tissue thickness and echogenicity. Results Thoracolumbar fascia shear strain was reduced in the LBP group compared with the No-LBP group (56.4% ± 3.1% vs. 70.2% ± 3.6% respectively, p < .01). There was no evidence that this difference was sex-specific (group by sex interaction p = .09), although overall, males had significantly lower shear strain than females (p = .02). Significant correlations were found in male subjects between thoracolumbar fascia shear strain and the following variables: perimuscular connective tissue thickness (r = -0.45, p <.001), echogenicity (r = -0.28, p < .05), trunk flexion range of motion (r = 0.36, p < .01), trunk extension range of motion (r = 0.41, p < .01), repeated forward bend task duration (r = -0.54, p < .0001) and repeated sit-to-stand task duration (r = -0.45, p < .001). Conclusion Thoracolumbar fascia shear strain was ~20% lower in human subjects with chronic low back pain. This reduction of shear plane motion may be due to abnormal trunk movement patterns and/or intrinsic connective tissue pathology. There appears to be some sex-related differences in thoracolumbar fascia shear strain that may also play a role in altered connective tissue function.

Sophisticated network‐based approaches such as structural connectomics may help to detect a biomarker of mild traumatic brain injury (mTBI) in children. This study compared the structural connectome of children with mTBI or mild orthopedic injury (OI) to that of typically developing (TD) children. Children aged 8–16.99 years with mTBI (n = 83) or OI (n = 37) were recruited from the emergency department and completed 3T diffusion MRI 2–20 days postinjury. TD children (n = 39) were recruited from the community and completed diffusion MRI. Graph theory metrics were calculated for the binarized average fractional anisotropy among 90 regions. Multivariable linear regression and linear mixed effects models were used to compare groups, with covariates age, hemisphere, and sex, correcting for multiple comparisons. The two injury groups did not differ on graph theory metrics, but both differed from TD children in global metrics (local network efficiency: TD > OI, mTBI, d = 0.49; clustering coefficient: TD < OI, mTBI, d = 0.49) and regional metrics for the fusiform gyrus (lower degree centrality and nodal efficiency: TD > OI, mTBI, d = 0.80 to 0.96; characteristic path length: TD < OI, mTBI, d = −0.75 to −0.90) and in the superior and middle orbital frontal gyrus, paracentral lobule, insula, and thalamus (clustering coefficient: TD > OI, mTBI, d = 0.66 to 0.68). Both mTBI and OI demonstrated reduced global and regional network efficiency and segregation as compared to TD children. Findings suggest a general effect of childhood injury that could reflect pre‐ and postinjury factors that can alter brain structure. An OI group provides a more conservative comparison group than TD children for structural neuroimaging research in pediatric mTBI. Children with mTBI and OI demonstrated reduced global and regional network efficiency and segregation as compared to TD children. Findings suggest a general effect of childhood injury that could reflect pre‐ and postinjury factors that can alter brain structure. An OI group provides a more conservative comparison group than TD children for pediatric mTBI research.

Purpose Early clinical examination combined with MRI allows accurate diagnosis of syndesmosis instability after a high ankle sprain. However, patients often present late. The aims of the current study were to describe MRI characteristics associated with syndesmosis instability and to test the hypothesis that MRI patterns would differ according to time from injury. Methods Over a 5-year period, 164 consecutive patients who had arthroscopically proven syndesmosis instability requiring fixation were retrospectively studied. Patients with distal fibula fractures were not included. Injuries were classified as acute in 108 patients (< 6 weeks), intermediate in 32 (6–12 weeks) and chronic in 24 patients (> 12 weeks). Results Posterior malleolus bone oedema was noted in 65 (60.2%), and posterior malleolus fracture in 17 (15.7%) of acute patients, respectively, which did not significantly differ over time. According to MRI, reported rates of posterior syndesmosis disruption significantly differed over time, observed in 101 (93.5%), 28 (87.5%) and 13 (54.2%) of acute, intermediate and chronic patients, respectively ( p  < 0.001). Apparent rates of PITFL injury significantly reduced with time ( p  < 0.001). Conclusions MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. The clinical relevance of this study is that posterior malleolus bone oedema may be the only marker of a complete syndesmosis injury and can help clinically identify those injuries which require arthroscopic assessment for instability. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries as MRI becomes less reliable after 12 weeks. Level of evidence III.

ObjectiveTo test the hypothesis if presence and amount of effusion in the tibiotalar and talocalcaneal joints are associated with an increased risk for severe structural injury in ankle sprains.MethodsA total of 261 athletes sustaining acute ankle sprains were assessed on MRI for the presence and the amount of joint effusion in the tibiotalar and talocalcaneal joints, as well as for ligamentous and osteochondral injury. Specific patterns of injury severity were defined based on lateral collateral ligament, syndesmotic, and talar osteochondral involvement. The presence and the amount effusion (grades 1 and 2) were considered as risk factors for severe injury, while physiological amount of fluid (grade 0) was considered as the referent. Conditional logistic regression was used to assess the risk for associated severe injuries (syndesmotic ligament rupture and talar osteochondral lesions) based on the presence and amount of tibiotalar and talocalcaneal effusions.ResultsFor ankles exhibiting large (grade 2) effusion in the tibiotalar joint (without concomitant grade 2 effusion in the talocalcaneal joint), the risk for partial or complete syndesmotic ligament rupture was increased more than eightfold (adjusted odds ratio 8.7 (95% confidence intervals 3.7–20.7); p < 0.001). The presence of any degree of effusion in any of the joints was associated with an increased risk for severe talar osteochondral involvement (several odds ratio values reported; p < 0.001), including large subchondral contusions and any acute osteochondral lesion.ConclusionThe presence of tibiotalar and talocalcaneal effusions is associated with an increased risk for severe concomitant structural injury in acute ankle sprains.Key Points• For ankles exhibiting severe (grade 2) effusion in the tibiotalar joint after sprain, the risk for partial or complete syndesmotic ligament rupture increases more than eightfold.• The presence of effusion in both tibiotalar and talocalcaneal joints is associated with an increased risk for severe ligament injury such as complete ATFL rupture as well as partial or complete syndesmotic ligament rupture.• The presence of effusion in the tibiotalar or talocalcaneal joints after sprain is associated with an increased risk for severe talar osteochondral involvement.

Lateral ankle sprains (LAS) result in chronic ankle instability (CAI), causing ongoing instability. Although peroneal muscle weakness is documented in CAI, surface electromyography shows similar activation patterns between CAI and healthy individuals, suggesting structural rather than neural deficits. Ultrasound imaging (USI) uniquely enables noninvasive assessment of muscle morphology and quality through cross-sectional area and echogenicity measurements. However, previous USI studies examined peroneals only in nonweight-bearing positions, potentially missing functional deficits. This study examines peroneal muscle characteristics in CAI versus healthy individuals specifically during weight-bearing functional positions using USI. A case-control study was conducted with 58 participants (29 CAI and 29 healthy controls), aged 18-30 years. Cross-sectional area (CSA), echogenicity (grayscale analysis where higher values indicate fatty infiltration/fibrosis), and functional activation ratio (FAR) of the peroneal muscles were assessed using USI in nonweight-bearing (side lying) and weight-bearing (bilateral-leg standing (BLS) and single-leg standing (SLS)) positions. CSA images were averaged from three measurements for each position. The CAI group had significantly smaller CSA in BLS (p < 0.01) and SLS (p < 0.01) but not lying (p = 0.06), higher echogenicity indicating poorer muscle quality (69.7 ± 10.3 vs. 61.3 ± 7.0, p < 0.01), and lower FAR in both BLS (0.99 ± 0.13 vs. 1.13 ± 0.16, p < 0.01) and SLS (1.01 ± 0.17 vs. 1.12 ± 0.22, p = 0.03) compared to healthy controls. Individuals with CAI showed reduced peroneal muscle CSA, lower activation, and poorer muscle quality specifically in weight-bearing positions compared to healthy controls. These findings suggest altered muscle function in CAI especially in functional weight-bearing positions. This demonstrates the need to assess peroneals in functional weight-bearing position compared to resting.

Background Calf muscle strain injuries (CMSI), also known as “tennis leg,” are frequently observed in middle-aged and physically active people, including non-professional athletes. While magnetic resonance imaging (MRI) is frequently used to assess the extent of these injuries, the relationship between MRI findings and long-term functional outcomes in non-athletic populations remains underexplored. This study aimed to investigate the correlation between MRI-detected injury severity and functional outcomes using the Achilles Tendon Rupture Score (ATRS) and the Tegner Activity Scale (TAS). Methods A retrospective review was conducted on 78 non-athletic patients diagnosed with CMSI and were followed for an average of 25.6 ± 16.1 months. Injury severity was classified into three grades: Grade 1 (edema without architectural disruption), Grade 2 (partial muscle disruption with hematoma), and Grade 3 (complete muscle disruption or tendon detachment) based on MRI examination. The functional outcomes were assessed using the ATRS and TAS. A simple linear regression analysis was conducted to assess the impact of demographic variables and MRI findings on ATRS. Results The mean ATRS at the final follow-up was 92.9 ± 10.6, with 75.6% of patients achieving an excellent outcome. Despite the excellent ATRS scores, a notable reduction in TAS was evident from the pre-injury assessment (4.4 ± 1.2) to the final follow-up (3.8 ± 1.3; p  < 0.001). Moreover, 44.9% of patients did not resume their pre-injury activity levels. The regression analysis demonstrated no statistically significant correlation between MRI-detected injury severity, demographic factors (age, gender, BMI), and ATRS outcomes (R² = 0.094, adjusted R² = -0.011). Conclusion MRI-detected injury severity does not significantly predict long-term functional outcomes in patients with CMSI, even though most patients achieved excellent ATRS scores. However, nearly half of the patients did not return to their pre-injury activity levels. These findings suggest that additional factors might influence recovery, and further research is needed to elucidate these factors in non-athletic patients. Level of evidence Level IV, Retrospective case series.

ObjectiveTo identify the region of interest (ROI) to represent injury and observe between-limb diffusion tensor imaging (DTI) microstructural differences in muscle following hamstring strain injury.Materials and methodsParticipants who sustained a hamstring strain injury prospectively underwent 3T-MRI of bilateral thighs using T1, T2, and diffusion-weighted imaging at time of injury (TOI), return to sport (RTS), and 12 weeks after RTS (12wks). ROIs were using the hyperintense region on a T2-weighted sequence: edema, focused edema, and primary muscle injured excluding edema (no edema). Linear mixed-effects models were used to compare diffusion parameters between ROIs and timepoints and limbs and timepoints.ResultsTwenty-four participants (29 injuries) were included. A significant ROI-by-timepoint interaction was detected for all diffusivity measures. The edema and focused edema ROIs demonstrated increased diffusion at TOI compared to RTS for all diffusivity measures (p-values < 0.006), except λ1 (p-values = 0.058–0.12), and compared to 12wks (p-values < 0.02). In the no edema ROI, differences in diffusivity measures were not observed (p-values > 0.82). At TOI, no edema ROI diffusivity measures were lower than the edema ROI (p-values < 0.001) but not at RTS or 12wks (p-values > 0.69). A significant limb-by-timepoint interaction was detected for all diffusivity measures with increased diffusion in the involved limb at TOI (p-values < 0.001) but not at RTS or 12wks (p-values > 0.42). Significant differences in fractional anisotropy over time or between limbs were not detected.ConclusionHyperintensity on T2-weighted imaging used to define the injured region holds promise in describing muscle microstructure following hamstring strain injury by demonstrating between-limb differences at TOI but not at follow-up timepoints.

Background This study aimed to compare the clinical efficacy of Jingshang Gao in the treatment of lateral ankle sprains by observing the healing process with musculoskeletal ultrasound. Methods We enrolled 90 patients with lateral ankle sprains who were admitted to our hospital from July 1, 2022, to July 1, 2023. The average age was 36.21 years, and 35 patients were male (38.9%). Patients were divided into two groups based on different treatment methods: the control group received oral celecoxib capsules(200 mg once daily), and the research group received Jingshang Gao topical application. We compared the basic data between the two groups. Results In terms of pain score, both groups had lower VAS scores at T1-T4 than at T0, and the research group had significantly lower VAS scores than the control group at T3 and T4 ( p  < 0.01, Cohen’s d = 0.82). In terms of functional score, both groups had higher Kaikkonen ankle injury function scores at T1-T4 than at T0, and the research group had significantly higher scores than the control group at T3 and T4 ( p  < 0.01, Cohen’s d = 0.87). In terms of AOFAS score, the research group had significantly higher functional scores than the control group (94.307 ± 18.206 vs. 81.216 ± 17.22, p  < 0.001, Cohen’s d = 0.75). Musculoskeletal ultrasound showed that the healing rate of the ligament in the research group was 82.2% (95% CI: 71.1–93.3%), which was significantly higher than the control group’s 57.8% (95% CI: 43.3–72.3%), p  = 0.011. In terms of SF-36 score, the research group had a higher VT score than the control group (75.6 ± 9.2 vs. 68.4 ± 8.9, p  = 0.024, Cohen’s d = 0.79), and a lower MH score than the control group (60.2 ± 7.8 vs. 65.9 ± 8.2, p  = 0.032, Cohen’s d = 0.71). In terms of the thickness of the anterior talofibular ligament and calcaneofibular ligament, the research group had thinner ATFL (1.78 ± 0.21 vs. 2.05 ± 0.24 mm, p  < 0.001, Cohen’s d = 1.19) and CFL (1.32 ± 0.09 vs. 1.41 ± 0.08 mm, p  < 0.001, Cohen’s d = 1.06) than the control group. Conclusion Musculoskeletal ultrasound observation of Jingshang Gao treatment for lateral ankle sprains has shown promising results in relieving pain, improving function, and promoting ligament healing. These findings suggest potential benefits of this treatment approach, though randomized controlled trials are needed for definitive efficacy assessment. Clinical trial number Not applicable.