Hurdle, Mark Friedrich B.

ObjectiveTo present a case of ultrasonic diagnosis and nonoperative management of a complete proximal rectus femoris avulsion in a National Collegiate Athletic Association Division 1 soccer goalkeeper.BackgroundWhile delivering a goal kick, a previously uninjured 24-year-old collegiate soccer goalkeeper had the sudden onset of right anterior thigh pain. He underwent rehabilitation with rapid resolution of his presenting pain but frequent intermittent recurrence of anterior thigh pain. After he was provided a definitive diagnosis with musculoskeletal ultrasound, he underwent an extended period of rehabilitation and eventually experienced complete recovery without recurrence.Differential DiagnosisRectus femoris avulsion, rectus femoris strain or partial tear, inguinal hernia, or acetabular labral tear.TreatmentOperative and nonoperative options were discussed. In view of the player's recovery, nonoperative options were pursued with a good result.UniquenessComplete proximal rectus femoris avulsions are rare. Our case contributes to the debate on whether elite-level kicking and running athletes can return to full on-field performance without surgery.ConclusionsComplete proximal rectus femoris avulsions can be treated effectively using nonoperative measures with good preservation of function even in the elite-level athlete. In addition, musculoskeletal ultrasound is an excellent tool for on-site evaluation and may help guide prognosis and management.

ObjectivesTo 1) describe and validate an ultrasound‐guided ischial bursa injection technique in an unembalmed cadaveric model and 2) to compare the distance between the ischial tuberosity and the sciatic nerve in a hip neutral versus 90° flexed hip position in asymptomatic volunteers.DesignThe first part was a single‐blind prospective study. The second part was a prospective cohort study.SettingAn academic institution procedural skills laboratory and outpatient clinic.ParticipantsThe first part of the study involved 1 cadaveric specimen. The second part of the study involved 20 asymptomatic subjects. The mean age of the subjects was 28 years, and the mean (standard deviation) body mass index was 23.2 ± 2.8 kg/m2 (minimum, 18.3 kg/m2; maximum, 29.5 kg/m2).MethodsIn the first part of the study, a single operator completed bilateral ultrasound‐guided ischial bursa injections in an unembalmed cadaveric specimen by using diluted colored latex. In the second part of the study, ultrasound was used in 20 asymptomatic volunteer subjects (10 men and 10 women) to measure the distance from the lateral edge of the ischial tuberosity to the sciatic nerve.Main Outcome MeasurementsThe injections were graded for accuracy as follows: accurate (all injectate contained within the ischial bursa), accurate with overflow (injectate within the ischial bursa but also located in adjacent structures other than the needle track), or inaccurate (injectate not within the ischial bursa). The second part of the study measured the distance from the ischial tuberosity to the sciatic nerve with subjects in 2 different positions (prone and side lying with the tested hip flexed to 90°).ResultsPostinjection cadaveric dissections revealed that both ultrasound‐guided injections accurately placed liquid latex within the ischial bursae. There was no evidence of injury to surrounding neurovascular structures. Among asymptomatic volunteers, the average distance between the ischial tuberosity and the sciatic nerve increased from 28.4 mm (range, 20.5‐38.9 mm) in the neutral position to 41.9 mm (range, 30.9‐66.0 mm) with the hip flexed to 90° (average change, 13.5 mm away from the ischial tuberosity; P = .0001).ConclusionsUltrasound‐guided ischial bursa injections are technically feasible. Flexing the hip to 90° increases the distance between the ischial tuberosity and the sciatic nerve in asymptomatic volunteers, thus potentially resulting in a safer needle trajectory when ischial bursa injections are clinically indicated. Further investigation in clinical settings is warranted to validate these findings.