convenient tool to augment physical examination in thediagnosis of the painful shoulder. Many diagnostic abnor-malities can be seen and used to guide treatment. Awarenessof the most common findings, as well as the pathology that ismost easily seen in the ultrasonographic examination of thepainful shoulder will encourage physiatrists to use this ben-eficial diagnostic tool to correlate with physical examinationfindings and aid in planning treatment.Keywords: Rehabilitation, Ultrasonography, Musculoskel-etal system, Shoulder joint.

Poster 177

Ultrasound Evaluation of Vastus Intermedius(VI) as Outcome Measure for Knee ROM inPostoperative Knee Contractures: A CaseSeries.Michael K. Yoshida, MD PhD (Kansai MedicalUniversity, Hirakata-shi, Japan).

Disclosures: M. K. Yoshida, None.Patients or Programs: Eight patients with postoperativeknee contractures during physical therapy.Program Description: Diagnoses and treatments in-cluded unicondylar knee arthroplasty for osteonecrosis, in-tramedullary rod, screws, plates, wires and external fixationsfor femur fractures and total knee arthroplasty for osteoar-thritis.Setting: Tertiary university general hospital.Results: A 10-MHz linear transducer was placed over thedistal femur at 10 cm proximal to patella to evaluate thevastus intermedius (VI) muscle sliding, thickness and muscleviability. Eleven limbs of 8 patients are compared with thenormal and unaffected limb of the patients during musclecontraction and rest. Dynamic diagnostic ultrasound re-vealed loss of muscle contractility of VI in the quadricepsmuscles in patients with knee contracture.Discussion: Diagnostic use of musculoskeletal ultrasoundhas increased due to high-quality images, safety and value ofdynamic evaluation during rehabilitation therapy and inoutpatient clinical settings. Knee contracture develops in theligaments, joint capsule and muscles. This study focused onthe VI in the quadriceps group and its role in knee contrac-ture. The VI is crucial for knee extension; however, its palpa-tion may be inaccessible or difficult, particularly after surgicalrepair of femoral fractures.Conclusions: Ultrasound measurement of the VI is usefulto prescribe physical therapy and to quantify its outcome.Dynamic ultrasound evaluation of the VI muscle in the quad-riceps group can measure and predict outcome of kneecontracture and the efficacy of postsurgical physical therapy.Ultrasound images showed that extreme VI muscle atrophy,loss of VI contraction, hyperechoic findings of muscle fibersand loss of muscle sliding are strongly associated with kneecontractures.Keywords: Ultrasound, Knee contracture, Rehabilitationoutcome, Vastus intermedius.

Poster 178

Ultrasound Findings of Anterior CapsularThickening in Association with AdhesiveCapsulitis.Joseph P. Purcell, DO (Lags Spine and Sportscare,Santa Maria, CA); Annie Davidson; Francis P.Lagattuta, MD; David L. Tashima, MD.

Disclosures: J. P. Purcell, None.Objective: To determine if the ultrasonographic finding ofanterior capsular thickening is associated with adhesive cap-sulitis.Design: Retrospective chart review.Setting: Outpatient musculoskeletal and chronic painclinic.Participants: The most recent 100 shoulders of patientswith shoulder pain (55 females, 35 males) ranging in agefrom 26 to 80 years.Interventions: Not applicable.Main Outcome Measures: Shoulder ultrasound exam-inations of all diagnoses were reviewed for the presence orabsence of anterior capsular thickening.Results: Among 100 shoulders, 18 carried a referring diag-nosis of adhesive capsulitis. Of these 18 shoulders, 10showed signs of anterior capsular thickening (55.5%), while2 of the other 82 painful shoulders evaluated showed capsu-lar thickening (2.4%).Conclusions: There appears to be a correlation betweensigns of anterior capsular thickening with the clinical diag-nosis of adhesive capsulitis, however it is not specific toadhesive capsulitis alone. Further research is needed to moreclearly delineate this association.Keywords: Rehabilitation, Ultrasonography, Shoulder,Adhesive capsulitis.

Poster 179

Ultrasound-Guided Sacroiliac Injection afterDifficulty with Fluoroscopically GuidedInjection of a Partially Ankylosed Joint: ACase Report.Jeffrey Smith, MD, MBA (MetroHealth MedicalCenter, Cleveland, OH); Michael P. Schaefer, MD.

Disclosures: J. Smith, None.Patients or Programs: A 49-year-old woman withchronic lumbosacral pain.Program Description: The patient presented withchronic low back pain, left lower extremity pain and positiveclinical examination findings for sacroiliac (SI) joint dysfunc-tion. The patient had received 4 left sacroiliac region injec-tions under fluoroscopy during the preceding 18 months,with only brief decrease in pain (�50% reduction for 2-3weeks). Each time, difficulty was encountered with needleplacement within the joint despite good visualization onfluoroscopy. Subsequently, a repeat left SI intraarticular in-jection was scheduled with ultrasound guidance with hopesof improving localization.

S181PM&R Vol. 1, Iss. 9S, 2009

Setting: Academic outpatient PM&R musculoskeletalclinic.Results: On ultrasound examination, the left SI joint wasunable to be visualized. Two weeks prior to the procedure,the patient had undergone a CT scan of the pelvis for anunrelated medical condition. Upon closer review, the CTdemonstrated partial ankylosis of the left SI joint with a bonybridge across the posterior-inferior joint. This was not appar-ent on fluoroscopy. The joint was subsequently entered at amore superior location, with excellent relief of symptoms.Discussion: The SI joint is estimated to contribute to ap-proximately 30% of chronic low back and buttock pain. Thegold standard for diagnosing SI joint pain is relief withintraarticular SI joint injection. Due to its complex anatomi-cal configuration, fluoroscopy is required for SI joint injec-tion entry. The use of ultrasound is a becoming a commonpractice for a variety of musculoskeletal indications includingvisualization of the SI joint. Numerous factors including itssafety, portability, and relative cost, make ultrasound anattractive alternative or complement for musculoskeletal im-aging.Conclusions: The use of ultrasound may be a useful diag-nostic modality when difficulty is encountered performingfluoroscopically guided SI joint intraarticular injection.Keywords: Rehabilitation, Ultrasonography, Sacroiliacjoint, Intra-articular injection.

Poster 180

Ultrasound Imaging of Myofascial TriggerPoints and Adjacent Soft Tissue.Siddhartha Sikdar, PhD (George Mason University,Fairfax, VA); Jerome Danoff, PhD; Tadesse M.Gebreab, BS; Naomi Lynn H. Gerber, MD;Elizabeth A. Gilliams, BA; Jay P. Shah, MD;Ru-Huey Yen.

Disclosures: S. Sikdar, None.Objective: To develop objective descriptions of the tissueand blood flow characteristics of myofascial trigger points(MTrPs) and the immediately adjacent structures using ultra-sound (US) imaging.Design: Descriptive (exploratory) study.Setting: Biomedical research center.Participants: 9 subjects meeting Travell and Simons’s cri-teria for MTrPs of painful nodules in a taut band in the uppertrapezius.Interventions: None.Main Outcome Measures: MTrPs were evaluated by 1)physical examination, 2) pressure algometry, and 3) threetypes of ultrasound imaging, including grayscale (2D US),vibration sonoelastography (VSE) and Doppler. Four sites ineach patient were labeled as either active MTrP (spontane-ously painful, A-MTrP), latent MTrP (non-painful, L-MTrP),or normal muscle based on physical examination. VSE wasperformed by color Doppler variance imaging, while simul-taneously inducing vibrations (�100Hz) with a handheldmassage vibrator. Each site was assigned a tissue imaging

score (TIS) as follows: 0 � uniform echogenicity and stiff-ness; 1 � focal hypoechoic and/or stiff nodule; 2 � multiplehypoechoic and stiff nodules. Blood flow in the neighbor-hood of MTrPs was assessed using Doppler imaging. Eachsite was assigned a blood flow waveform score (BFS) asfollows: 0 � normal arterial flow in muscle; 1 � elevateddiastolic flow; 2 � high-resistance flow waveform with ret-rograde diastolic flow.Results: MTrPs appeared as focal, hypoechoic regions on2D US, indicating local changes in tissue echogenicity, and asfocal regions of reduced vibration amplitude on VSE, indi-cating a localized stiff nodule. Sites containing MTrPs weremore likely to have higher TIS compared to normal muscle(P � .002). Small arteries near A-MTrPs showed retrogradeflow in diastole indicating a highly resistive vascular bed,consistent with possible blood vessel compression. A-MTrPsites were more likely to have higher BFS compared toL-MTrPs (P � .021).Conclusions: Preliminary findings suggest that US imag-ing techniques enable visualization and some characteriza-tion of MTrPs and adjacent soft tissue.Keywords: Rehabilitation, Ultrasound, Myofascial pain,Trigger point.

Poster 181

Upper Rib Syndrome after Motor VehicleAccident: An Ultrasound Case Series.Brad D. Fullerton, MD (The Patient-Physician Part-nership, Austin, TX).

Disclosures: B. D. Fullerton, None.Objective: To describe ultrasonographic findings at the1st and 2nd costovertebral joints (CVJ) in patients withhistory of motor-vehicle accident (MVA) and chronic, unilat-eral, upper quadrant symptoms relieved by lidocaine injec-tion.Design: This is a retrospective, observational case series.Setting: Physiatrist’s private office.Participants: Thirteen patients (age range from 27 to 80years old) presenting with chronic, unilateral, upper quad-rant symptoms (pain, dysesthesias, muscle spasms, or lim-ited mobility in the head, neck or upper extremity) and ahistory of motor-vehicle accident. Time since onset of symp-toms ranged from 8 months to 30 years.Interventions: Ultrasound imaging was performed incoronal (longitudinal to rib) and sagittal (transverse to rib)planes bilaterally. Motion clips were saved in both planeswith patient performing maximal deep inspiration/expira-tion. The same examiner performed ultrasound guided injec-tion of the CVJ capsules and adjacent tendinous entheseswith 15-25% dextrose and 0.3-0.5% lidocaine (dextroseprolotherapy) from a posterior approach.Main Outcome Measures: Unilateral ultrasonographicfindings in patients with temporary relief of symptoms 5-10minutes after injection.Results: All patients reported greater pain to palpation overthe 1st/2nd CVJs on the side with ultrasound findings. Symp-

S182 POSTER PRESENTATIONS