Nonhealing, progressive stress fractures of the foot in a 13-year-old basketball player: is vitamin K deficiency a risk factor?

[Purpose] To report an adolescent male basketball player with nonhealing stress fractures of the foot and discuss the probable factors. [Subject and Methods] A 13-year-old basketball player presented with right foot pain. He had been playing basketball for three years and practicing 5 days/week. He denied any increase in daily training intensity. Magnetic resonance imaging confirmed stress fractures of the cuboid and cuneiform, with mild edema of the soft tissues between the tarsal bones and tenosynovitis of the flexor hallucis and flexor digitorum longi. The foot was immobilized for 4 weeks, with progressive weight bearing introduced at the fifth week. At the 6th week, while still restricted to partial weight bearing, he reported diffuse severe pain. The entire foot was painful with palpation, and new imaging showed stress fractures of the talus, cuboid, cuneiform, and proximal first metatarsal bones, and tenosynovitis of the flexor hallucis longus and flexor digitorum longus tendons with progression of the soft tissue edema around the tarsal bones. Acute phase reactants were elevated; vitamin K level was low. [Results] He started participating in games again at the 6th month post-injury. [Conclusion] Management of patients with stress fractures includes immobilization, physical therapy, and biomechanical arrangements. If the expected healing does not occur, a deficiency of vitamin K might be considered as a factor. Questioning on dietary habits of the patient and encouraging adequate intake of the deficient nutrient might assist in the healing process.

Comparison of the efficacy of physical therapy and corticosteroid injection in the treatment of pes anserine tendino-bursitis.

[Purpose] The aims of this study were twofold. The first was to compare the functional capacity and pain of patients with knee osteoarthritis (KOA), with or without pes anserine tendino-bursitis (PATB). The second is to compare the efficacy of two treatment methods (physical therapy and corticosteroid injection) for patients with PATB. [Subjects and Methods] Sixty patient with KOA and PATB (Group 1) and 57 patients with KOA but without PATB (Group 2) were enrolled in the study. The patients' visual analog scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scores and three-meter timed-up and go scores were measured. The PATB group was randomly divided into two groups (Group A and B). Physical therapy (PT) modalities were applied to the first group (Group A), and the second group (Group B) received corticosteroid injections to the pes anserine area. Eight weeks later, patients' parameters were measured again. [Results] Initial WOMAC scores and timed up-and-go times were significantly higher in Group 1 than in Group 2. Both treatments resulted in significant improvements in all measured parameters, but no significant difference was detected between Group A and B. [Conclusion] Patients with PATB tend to have more severe pain, more altered functionality, and greater disability than those with KOA but without PATB. Both corticosteroid injection and PT are effective methods of treatment for PATB. Injection therapy can be considered an effective, inexpensive and fast therapeutic method.

Effects of osteoarthritis and fatigue on proprioception of the knee joint.

OBJECTIVE: To evaluate the impact of knee osteoarthritis (OA) and periarticular muscular fatigue on knee joint kinesthesia. DESIGN: Cross-sectional study. SETTING: A physical medicine and rehabilitation outpatient clinic. PARTICIPANTS: Fifty patients with bilateral OA of the knee, and a control group of 30 age-matched healthy volunteers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Kellgren-Lawrence grading system was used to determine the radiographic severity of knee OA. The Lequesne index of severity for knee osteoarthritis was used for assessment of pain, kinesthesia was measured by determining angle reposition error at the knee joint using isokinetic dynamometry, and muscle strength was measured by isokinetic dynamometry. RESULTS: Reposition errors did not differ between the patient and the control groups, nor did they differ between pre- and postexercise. CONCLUSIONS: Mild-to-moderate OA of the knees does not affect reposition error. Fatigue produced by mild-to-moderate exercise also has no effect on reposition error.

The effect of abdominal massage on bowel function in patients with spinal cord injury.

OBJECTIVES: To investigate the effect of abdominal massage on clinical aspects of bowel dysfunction and colonic transit time in patients with spinal cord injury. Twenty-four patients were placed on a standard bowel program (phase I), after which abdominal massage was added to the regimen (phase II). Parameters of gastrointestinal system function and colonic transit times were evaluated. DESIGN: Uncontrolled clinical study. RESULTS: Eleven (45.8%) of the 24 patients had abdominal distention, and 10 (41.7%) had fecal incontinence in phase I; corresponding results for phase II were three (12.5%) and four (16.7%) (P = 0.008 and 0.031, respectively). There were no significant differences between the proportions of patients with difficult intestinal evacuation or abdominal pain or in mean time required for bowel evacuation in phase I vs. phase II. The mean frequencies of defecation in phases I and II were 3.79 +/- 2.15 (2.75-4.55) and 4.61 +/- 2.17 (3.67-5.54) bowel movements per week, respectively (P = 0.006). Mean total colonic transit time decreased from 90.60 +/- 32.67 (75.87-110.47) hrs in phase I to 72 +/- 34.10 (58.49-94.40) hrs in phase II (P = 0.035). CONCLUSIONS: Abdominal massage has positive effects on some clinical aspects of neurogenic bowel dysfunction in patients with spinal cord injury.

Serum albumin and comorbidity relative to rehabilitation outcome in geriatric stroke, and possible links with stroke etiology.

Factors that describe the disability status of the stroke patient on discharge are important when starting a rehabilitation program, both from a psychosocial and a financial point of view. The objective of this study was to assess how comorbidity and serum albumin levels relate to rehabilitation outcome in geriatric stroke patients. Another aim was to assess whether stroke etiology (ischemic or hemorrhagic) influences these links. Medical records of 80 patients (68 ischemic and 12 hemorrhagic strokes) older than 65 years, who had suffered their first stroke, were investigated. Functional performance levels at admission and discharge were evaluated using the Functional Independence Measure (FIM). Length of stay in hospital was recorded. Serum albumin levels and comorbidity scores on admission were noted. Correlations between these variables and differences between the groups categorized according to stroke etiology were analyzed. In the group of geriatric stroke patients as a whole, serum albumin level was correlated with FIM score at admission and discharge. Comorbidity score was negatively correlated with length of stay. In the ischemic stroke subgroup, serum albumin level was positively correlated with length of stay and with functional gain, and comorbidity score was negatively correlated with functional gain. Analysis of the data for the hemorrhagic stroke subgroup revealed none of these correlations. It was concluded that serum albumin level and comorbidity are useful indices in geriatric ischemic stroke patients for predicting functional outcome and time spent in rehabilitation.

Relationships between muscle strength and bone mineral density of three body regions in sedentary postmenopausal women.

This cross-sectional study was designed to investigate correlations between muscle strength and regional bone mineral density (BMD) in sedentary postmenopausal women. Sixty-two women who ranged in age from 41 to 76 years were investigated. Hip and trunk muscle strength was measured by isokinetic dynamometry. Grip strength of the nondominant hand was measured using a hand-held dynamometer. Bone mineral density of the lumbar spine, femur, and distal radius was measured by dual-energy X-ray absorptiometry. Only the correlation between hip abductor strength and femoral BMD was significant (P = 0.009, r = 0.327). There was no correlation between trunk muscle strength and lumbar vertebral BMD or between grip strength and distal radius BMD. Subjects with osteoporosis (T score < -2.5) or osteopenia T (-2.5 to -1) and normal subjects (T > -1) exhibited similar isokinetic hip and trunk muscle strength. Women with osteoporotic distal radii had significantly lower grip strength than subjects who were osteopenic or normal at this site, but the osteoporotic group was also significantly older. In conclusion, our results indicate that the isokinetic strength of hip abductors weakly correlates with femoral BMD in postmenopausal women with and without osteoporosis. Trunk muscle strength did not correlate with lumbar vertebral BMD in either of these groups. The weaker handgrip we observed in the women with osteoporotic radii may be attributed to older age.

Value of the D-dimer test in diagnosing deep vein thrombosis in rehabilitation inpatients.

OBJECTIVE: To assess the utility of the D-dimer test-a widely available, less costly, and less time-consuming test than others used to diagnose or exclude deep vein thrombosis (DVT) and pulmonary embolism. DESIGN: Blind comparison. SETTING: An inpatient rehabilitation facility in Turkey. PARTICIPANTS: Sixty-eight consecutive inpatients being rehabilitated after stroke, spinal cord injury, hip arthroplasty, or traumatic brain injury. INTERVENTIONS: A latex D-dimer assay was performed on each patient at admission and then weekly throughout the hospital stay. Color Doppler ultrasonography of the lower limbs was also done for each patient at admission and was repeated when indicated by clinical signs and symptoms of DVT or by elevated D-dimer levels. Main outcome measures Patients' clinical findings, D-dimer test results, and ultrasonography results were recorded. Sensitivity, specificity, and positive and negative predictive values were calculated for the D-dimer test, each clinical finding, and combinations of D-dimer results and clinical findings in relation to DVT diagnosis. RESULTS: The sensitivity and negative predictive value of the D-dimer test were high, at 95.2% and 96.2%, respectively. The specificity and positive predictive value were low, at 55.3% and 48.7%, respectively. No single clinical finding was reliably diagnostic for DVT. CONCLUSIONS: The D-dimer assay is a reliable method for ruling out DVT. In the rehabilitation setting, it can be used as a routine screening test or to assess cases of suspected DVT. D-dimer testing may reduce the need for sophisticated, time-consuming, and expensive diagnostic workup of rehabilitation inpatients, a group that is at increased risk for DVT.

Trunk muscle strength in relation to balance and functional disability in unihemispheric stroke patients.

OBJECTIVE: To evaluate trunk muscle strength in unihemispheric stroke patients and to assess how it relates to body balance and functional disability in this patient group. DESIGN: This prospective case-comparison study investigated isometric and isokinetic reciprocal trunk flexion and extension strength at angular velocities in 38 unihemispheric stroke patients and 40 healthy volunteers. The Berg balance scale was used to assess balance and stability, and the FIM instrument was used to evaluate functional disability in the patient group. Patients were evaluated as soon as they were able to stand long enough for testing. RESULTS: Peak torque values for trunk flexion and extension were lower in the stroke patients than in the controls. The differences were significant for trunk flexion and for trunk extension. In both groups, peak torque values for trunk flexors were greater than peak torque values for trunk extensors. There was a significant positive correlation between trunk muscle strength and Berg balance scale score at discharge. Trunk muscle strength was not correlated with FIM total score or FIM motor score, but the locomotion-transfers FIM subscore at discharge was positively correlated with trunk muscle torque values, except for isometric extension. CONCLUSION: The findings indicate trunk flexion and extension muscle weakness in unihemispheric stroke patients, which can interfere with balance, stability, and functional disability.

Hemorrhagic transformation in stroke patients.

OBJECTIVE: To identify the predictors of hemorrhagic transformation in stroke patients and to evaluate the impact of hemorrhagic transformation on rehabilitation outcome. DESIGN: The records of 203 hemiplegic patients hospitalized for rehabilitation after the acute phase of stroke were retrospectively analyzed. In 121 cases, the first computed tomographic scan and a repeat scan were compared to determine whether hemorrhagic transformation occurred. Correlations between the occurrence of hemorrhagic transformation and use of anticoagulants, antiaggregants, and antiedema drugs were evaluated. Admission and discharge FIM trade mark and Adapted Patient Evaluation Conference System scores were noted, and functional gain was calculated from these. These data were also analyzed for associations with hemorrhagic transformation. RESULTS: Hemorrhagic transformation was detected in 39 of the 121 cases. There was no significant difference in functional outcome between patients who did and did not show hemorrhagic transformation. Although not statistically significant, the use of antiedema drugs was found to increase the risk of hemorrhagic transformation, whereas the use of anticoagulants and antiaggregants had no influence. CONCLUSIONS: Hemorrhagic transformation of an ischemic lesion does not affect rehabilitation outcome in stroke survivors. The study results favor the use of anticoagulants and antiaggregants in the acute phase unless these drugs are contraindicated by the patient's condition. Still, prospective trials are needed to make definite conclusions.

Diffuse idiopathic skeletal hyperostosis in a patient with idiopathic retroperitoneal fibrosis: a case report.

Idiopathic retroperitoneal fibrosis (IRF) is a rare rheumatologic disease with obscure pathogenesis. Its manifestations depend upon the structures involved. Diffuse idiopathic skeletal hyperostosis (DISH) is usually seen in male patients over 45 years of age and characterized by new bone formation at the entheses. The dorsal spine is most commonly involved, but radiographic findings in both the spine and extraspinal structures suggest a generalized disorder of ossification rather than a localized spinal disease. The association of IRF and DISH has not been reported before. There is proliferation of connective tissue in both of these diseases, and they may share a common etiopathogenetic basis. We describe a patient having features of both IRF and DISH.