The aim of the present study was to determine the validity of ultrasound (US) imaging versus magnetic resonance imaging (MRI) for measuring anterior thigh muscle, subcutaneous adipose tissue (SAT), and fascia thickness. Twenty healthy, moderately active participants (aged 49.1 ± 9.74 (36–64) years), underwent imaging of the anterior thigh, using ultrasound and MRI modalities on the same day. Images were analyzed offline to assess the level of agreement between US and MRI measurements. Pearson’s correlation coefficient showed an excellent relationship between US imaging and MRI for measuring muscle (r = 0.99, p < 0.01), SAT (r = 0.99, p < 0.01), and non-contractile tissue (SAT combined with perimuscular fascia) thickness (r = 0.99, p < 0.01). Perimuscular fascia thickness measurement showed a poor correlation between modalities (r = 0.39, p < 0.01). Intra-class correlation coefficients (ICC3,1) also showed excellent correlation of the measurements with ICC = 0.99 for muscle thickness, SAT, and non-contractile tissue, but not for perimuscular fascia, which showed poor agreement ICC = 0.36. Bland and Altman plots demonstrated excellent agreement between US imaging and MRI measurements. Criterion validity was demonstrated for US imaging against MRI, for measuring thickness of muscle and SAT, but not perimuscular fascia alone on the anterior thigh. The US imaging technique is therefore applicable for research and clinical purposes for muscle and SAT.

Tension-type headache (TTH) is a common condition but the underlying etiology is not understood. Episodic TTH may develop into chronic TTH, and some possible triggers may be involved in generation and maintenance. Nociceptive generators and hyperexcitable spots in neck and shoulder regions may to some degree contribute to TTH. The current paper highlights some of the possible triggers and associated pain mechanisms involved in TTH and discusses whether inhibition of these possible triggers may provide new treatment options. This paper presents possible pathophysiological factors in TTH, the role of muscle pain, and how referred pain from triggers can contribute to development, maintenance of sensitization, or both. Referred pain patterns from trigger points and associated muscle hyperalgesia seem to be clinically important factors. Damping the nociceptive peripheral drive may not only reduce the number of TTH attacks but may also prevent, delay the transition from episodic into more chronic TTH, or both. The role of muscle triggers in driving TTH is debated as the pathogenesis of such triggers is not fully understood. Furthermore, inhibiting the drive from the triggers does not consistently modulate TTH. Understanding the possible triggers in TTH, muscle hyperalgesia, and widespread pain sensitization, may help to develop better management regimes and possibly prevent TTH from developing into more chronic conditions. Currently, there is a striking difference between the clinical observational studies favoring the role of muscle triggers in TTH and the intervention studies generally not supporting the role of muscle triggers in TTH.

Resident's case problem. A 38-year-old man with a history of chronic episodic low back pain (LBP) was referred to physical therapy by his physician. Concerns ascertained from the patient's history included an insidious onset of unrelenting, deep, boring pain that was constant, irrespective of movements or posture changes, or time of day. In addition, the patient reported night pain and the inability to find relief in recumbent positions. The primary warning signs associated with the physical examination were unremarkable examination of the lumbar spine, pelvis, and hip regions (symptoms not altered and minimal impairments detected), and a strong nontender, palpable pulse noted over the left lateral lumbar region, with the patient prone, and over the midline and left upper/lower abdominal quadrants, with the patient supine. Suspicion of the presence of an abdominal aortic aneurysm led the therapist to immediately refer the patient to an allopathic physician. The subsequent abdominal ultrasound and computed tomography scanning revealed a 10-cm-diameter abdominal aortic aneurysm. The patient was immediately hospitalized and underwent surgical repair within two days. LBP is the most frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom LBP may be related to underlying pathological conditions. A prompt referral of patients presenting with suspicious findings to the appropriate physician may lead to a more timely diagnosis, with the goal of minimizing or preventing morbidity and mortality.

Objective : To determine intra-rater and inter-rater reliability of ultrasound imaging for measuring muscle and non-contractile (subcutaneous fat and perimuscular fascia) tissue thickness of the anterior thigh. Approach : Ultrasound imaging has been used for clinical research to assess the morphology and cross-sectional area of muscles and other musculoskeletal structures. Repeatability of measurements with the ultrasound imaging technique between operators and test re-test reliability are important and need to be established for specific muscles. Twenty-four healthy moderately active adults (aged 36–64 years), underwent B-mode ultrasound imaging by two investigators. The anterior thighs were scanned at a site two-thirds of the distance between the antero-superior iliac spine and the superior pole of the patella. Intraclass Correlation Coefficients (ICCs, model 3, 1 for inter-rater and 3, 2 for intra-rater reliability between-days) with 95% confidence intervals (CI) was used to assess reliability. Main results : Inter-rater reliability of ultrasound imaging measurements were ICC3, 1 of 0.98 (95% CI: 0.95–0.99) for muscle thickness, 0.81 (95% CI: 0.60–0.91) for subcutaneous fat, 0.78 (95% CI: 0.56–0.90) for non-contractile tissue (subcutaneous fat combined with perimuscular fascia), and 0.70 (95% CI: 0.42–0.86) for perimuscular fascia. Intra-rater reliability values were ICC3, 2 0.96 (95% CI: 0.90–0.98) for muscle thickness, 0.99 (95% CI: 0.97–0.99) for subcutaneous fat, 0.98 (95% CI: 0.96–0.99) for non-contractile tissue, and −0.02 (95% CI: −0.41–0.38) for perimuscular fascia. Significance : The present findings indicate very high inter-rater and intra-rater reliability of ultrasound imaging thickness measurements of the quadriceps muscles and non-contractile tissue of the anterior thigh, while perimuscular fascia measurements alone were not reliable between days.

A 13-year-old male basketball player presented to a direct-access physical therapy clinic with a chief complaint of left anterolateral knee pain that began 4 weeks earlier and was exacerbated after...