Hung et al. 5 Sadeghi S, Abdollahifard G, Nasabi N, Mehrabi M, Safarpour A. Effectiveness of single dose intravenous aminophylline administration on prevention of postdural puncture headache in patients who received spinal anesthesia for elective cesarean section. World J Med Sci 2012;7:13–6.
6 Turnbull DK, Shepherd DB. Post-dural puncture headache: Pathogenesis, prevention and treatment. Br J Anaesth 2003;91:718–29. 7 Anderson M. The properties of aminophylline. Emerg Nurse 2007;15:24–7.
Snapping Hip due to Gluteus Medius Tendinopathy: Ultrasound Imaging in the Diagnosis and Guidance for Prolotherapy type, usually involving an abnormal iliotibial band [2]. Herewith, literature as regards gluteus medius and minimus tendon problems in the causation of snapping hip and dextrose prolotherapy in its treatment is scarce.
Dear Editor, Snapping hip syndrome refers to the scenario of audible snapping during hip movements whereby the underlying causes are classified as intra-articular and extra-articular [1]. The latter accounts for a majority of the cases and can further be categorized into external and internal snapping hip. The external form is the most common
A 37-year-old male started to complain of right lateral hip pain after he had initiated weight training half a year ago. The physical examination revealed tenderness near the greater trochanteric region with a reproducible and palpable snapping during hip flexion and extension. The ultrasound (US) examination showed swelling and hypoechogenicity in the gluteus medius tendon at its
Figure 1 (A) The gluteus medius tendon (black arrow) on the asymptomatic side; (B) The swollen, hypoechoic gluteus medius (GME) tendon (white arrow) on the painful side; (C) Demonstration of dextrose hydrodissecting the space between the iliotibial band and gluteus medius tendon; (D) The gluteus medius tendon (black arrow) after treatment. GTC: greater trochanter; GMI: gluteus minumus; triangle: needle shaft. 2040
Downloaded from http://painmedicine.oxfordjournals.org/ at Monash University on April 10, 2016
Disclosure: The authors have no funding, financial benefits, or previous presentation of this manuscript to disclose.
Letters to the Editor
In our patient, US demonstrated its well-suited role in depicting the lateral hip muscle-tendon complex (i.e., gluteus maximus, medius, minimus tendons, and the iliotibial band). Its real-time dynamic capability enabled us to assess the reciprocal movements of all pertinent structures leading to hip snapping as well. Another important advantage of US is indisputably precise guidance during interventions. In our patient, we did not use corticosteroid due to its weak benefit in treating chronic tendinopathy and its detrimental effect on tendon healing. As such, in accordance with the growing evidence of dextrose prolotherapy in chronic tendinopathy [3], we applied direct dextrose injection into the tendon using the peppering method under US guidance. Furthermore, we could have precisely dilated the intertendinous space by dextrose solution, reducing friction between the iliotibial band and the underlying gluteus medius tendon.
In short, the present case scenario highlighted the advantages of US imaging both for the diagnostic evaluation of lateral hip pain and prolotherapy (using the peppering method and hydrodissection) for external snapping hip caused by gluteus medius tendinopathy.
CHEN-YU HUNG, MD,* KE-VIN CHANG, MD,† and € ZC¸AKAR MD‡ LEVENT O *Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Chu-Tung Branch, Hsinchu, Taiwan; †Department of Physical Medicine and Rehabilitation National Taiwan University Hospital, BeiHu Branch, Taipei, Taiwan; ‡Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
References 1 Jacobson JA, Bedi A, Sekiya JK, Blankenbaker DG. Evaluation of the painful athletic hip: Imaging options and imaging-guided injections. AJR Am J Roentgenol 2012;199:516–24. 2 Lee KS, Rosas HG, Phancao JP. Snapping hip: Imaging and treatment. Semin Musculoskelet Radiol 2013;17:286–94. 3 Rabago D, Yelland M, Patterson J, Zgierska A. Prolotherapy for chronic musculoskeletal pain. Am Fam Physician 2011;84:1208–10.
Myofascial Trigger Points as a Cause of Abnormal Cocontraction in Writer’s Cramp Dear Editor, Writer’s cramp (WC) is a task specific focal hand dystonia characterized by abnormal movements and posturing of upper limb. Various treatments including invasive therapies like botulinum toxin (BTX) and thalamotomy have shown limited success [1,2]. We report the sustained complete reversal of painful WC in a 24-year-old doctor, till date at 2 years; with ultrasonography guided dry needling (USGDN). The patient presented with WC of 3 years; unresponsive to supportive therapies by neurologists like using flat pen, left handed writing, tetrabenazine, and alprazolam. Brain MRI, nerve conduction, electromyography, and serum ceruloplasmin were normal. He was accustomed to daily, 2 hour violin practice for the past decade. His complaints were severe stiffness in his index finger and thumb causing cramping pain in the hand and forearm
immediately on writing. The cramps prevented the flexion/extension movements at the metacarpophalangeal joints (MCPJs) and interphalangeal joints (IPJs) essential for writing. The pen would drop from his weakened grip after writing eight lines with pain aggravation to 8/10 on Numerical rating scale (NRS). Attempts at compensation with repetitive wrist flexion-extensions or using the thumb and middle finger for pen-holding did not help. Palpable bands could be felt in the muscles of forearm and neck. Figure 1 shows the grip strength, pinch gauge measurements and neck radiographs. The Burke Fahn Marsden Scale (BFM) [3] for movement disorder was 3/16 and dystonia disability score for handwriting was 2/4. We explained to the patient that the digital stiffening and forearm cramping could be because of an abnormal cocontraction occurring as a result of incoordinate functioning of muscles having myofascial trigger points 2041
Downloaded from http://painmedicine.oxfordjournals.org/ at Monash University on April 10, 2016
insertion on the lateral facet of the greater trochanter (Figure 1A and B). The overlying iliotibial band appeared normal in echotexture and thickness when compared with the asymptomatic side. In the short-axis view, a snapping was clearly visualized when the iliotibial band glided over the swollen gluteus medius tendon during hip flexion and extension (Video). Under US guidance, 25% dextrose solution was administered into the gluteus medius tendon (1.5 mL) using the peppering technique and into the space between the iliotibial band and the gluteus medius tendon (2.5 mL; Figure 1C; Video). After two cycles of dextrose injections in 2 weeks, the patient became free of hip pain and snapping. Additionally, the US images demonstrated increased echogenicity and reduced swelling in the gluteus medius tendon (Figure 1D).
6 Turnbull DK, Shepherd DB. Post-dural puncture headache: Pathogenesis, prevention and treatment. Br J Anaesth 2003;91:718–29. 7 Anderson M. The properties of aminophylline. Emerg Nurse 2007;15:24–7.
Snapping Hip due to Gluteus Medius Tendinopathy: Ultrasound Imaging in the Diagnosis and Guidance for Prolotherapy type, usually involving an abnormal iliotibial band [2]. Herewith, literature as regards gluteus medius and minimus tendon problems in the causation of snapping hip and dextrose prolotherapy in its treatment is scarce.
Dear Editor, Snapping hip syndrome refers to the scenario of audible snapping during hip movements whereby the underlying causes are classified as intra-articular and extra-articular [1]. The latter accounts for a majority of the cases and can further be categorized into external and internal snapping hip. The external form is the most common
A 37-year-old male started to complain of right lateral hip pain after he had initiated weight training half a year ago. The physical examination revealed tenderness near the greater trochanteric region with a reproducible and palpable snapping during hip flexion and extension. The ultrasound (US) examination showed swelling and hypoechogenicity in the gluteus medius tendon at its
Figure 1 (A) The gluteus medius tendon (black arrow) on the asymptomatic side; (B) The swollen, hypoechoic gluteus medius (GME) tendon (white arrow) on the painful side; (C) Demonstration of dextrose hydrodissecting the space between the iliotibial band and gluteus medius tendon; (D) The gluteus medius tendon (black arrow) after treatment. GTC: greater trochanter; GMI: gluteus minumus; triangle: needle shaft. 2040
Downloaded from http://painmedicine.oxfordjournals.org/ at Monash University on April 10, 2016
Disclosure: The authors have no funding, financial benefits, or previous presentation of this manuscript to disclose.
Letters to the Editor
In our patient, US demonstrated its well-suited role in depicting the lateral hip muscle-tendon complex (i.e., gluteus maximus, medius, minimus tendons, and the iliotibial band). Its real-time dynamic capability enabled us to assess the reciprocal movements of all pertinent structures leading to hip snapping as well. Another important advantage of US is indisputably precise guidance during interventions. In our patient, we did not use corticosteroid due to its weak benefit in treating chronic tendinopathy and its detrimental effect on tendon healing. As such, in accordance with the growing evidence of dextrose prolotherapy in chronic tendinopathy [3], we applied direct dextrose injection into the tendon using the peppering method under US guidance. Furthermore, we could have precisely dilated the intertendinous space by dextrose solution, reducing friction between the iliotibial band and the underlying gluteus medius tendon.
In short, the present case scenario highlighted the advantages of US imaging both for the diagnostic evaluation of lateral hip pain and prolotherapy (using the peppering method and hydrodissection) for external snapping hip caused by gluteus medius tendinopathy.
CHEN-YU HUNG, MD,* KE-VIN CHANG, MD,† and € ZC¸AKAR MD‡ LEVENT O *Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Chu-Tung Branch, Hsinchu, Taiwan; †Department of Physical Medicine and Rehabilitation National Taiwan University Hospital, BeiHu Branch, Taipei, Taiwan; ‡Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
References 1 Jacobson JA, Bedi A, Sekiya JK, Blankenbaker DG. Evaluation of the painful athletic hip: Imaging options and imaging-guided injections. AJR Am J Roentgenol 2012;199:516–24. 2 Lee KS, Rosas HG, Phancao JP. Snapping hip: Imaging and treatment. Semin Musculoskelet Radiol 2013;17:286–94. 3 Rabago D, Yelland M, Patterson J, Zgierska A. Prolotherapy for chronic musculoskeletal pain. Am Fam Physician 2011;84:1208–10.
Myofascial Trigger Points as a Cause of Abnormal Cocontraction in Writer’s Cramp Dear Editor, Writer’s cramp (WC) is a task specific focal hand dystonia characterized by abnormal movements and posturing of upper limb. Various treatments including invasive therapies like botulinum toxin (BTX) and thalamotomy have shown limited success [1,2]. We report the sustained complete reversal of painful WC in a 24-year-old doctor, till date at 2 years; with ultrasonography guided dry needling (USGDN). The patient presented with WC of 3 years; unresponsive to supportive therapies by neurologists like using flat pen, left handed writing, tetrabenazine, and alprazolam. Brain MRI, nerve conduction, electromyography, and serum ceruloplasmin were normal. He was accustomed to daily, 2 hour violin practice for the past decade. His complaints were severe stiffness in his index finger and thumb causing cramping pain in the hand and forearm
immediately on writing. The cramps prevented the flexion/extension movements at the metacarpophalangeal joints (MCPJs) and interphalangeal joints (IPJs) essential for writing. The pen would drop from his weakened grip after writing eight lines with pain aggravation to 8/10 on Numerical rating scale (NRS). Attempts at compensation with repetitive wrist flexion-extensions or using the thumb and middle finger for pen-holding did not help. Palpable bands could be felt in the muscles of forearm and neck. Figure 1 shows the grip strength, pinch gauge measurements and neck radiographs. The Burke Fahn Marsden Scale (BFM) [3] for movement disorder was 3/16 and dystonia disability score for handwriting was 2/4. We explained to the patient that the digital stiffening and forearm cramping could be because of an abnormal cocontraction occurring as a result of incoordinate functioning of muscles having myofascial trigger points 2041
Downloaded from http://painmedicine.oxfordjournals.org/ at Monash University on April 10, 2016
insertion on the lateral facet of the greater trochanter (Figure 1A and B). The overlying iliotibial band appeared normal in echotexture and thickness when compared with the asymptomatic side. In the short-axis view, a snapping was clearly visualized when the iliotibial band glided over the swollen gluteus medius tendon during hip flexion and extension (Video). Under US guidance, 25% dextrose solution was administered into the gluteus medius tendon (1.5 mL) using the peppering technique and into the space between the iliotibial band and the gluteus medius tendon (2.5 mL; Figure 1C; Video). After two cycles of dextrose injections in 2 weeks, the patient became free of hip pain and snapping. Additionally, the US images demonstrated increased echogenicity and reduced swelling in the gluteus medius tendon (Figure 1D).
