A Rare Case Report of Exertional Leg Pain.

ABSTRACT: The accurate diagnosis of exertional leg pain in athletes is often delayed because of vague presenting symptoms and nonspecific physical examination findings. This case report outlines exertional leg pain in a runner caused by combined popliteal artery entrapment and soleal sling syndromes, 2 uncommon causes of exertional leg pain. This case report highlights the overlapping clinical presentation of these 2 diagnoses and the intricate differences in diagnostic workup and surgical approach to management.

The Physiatrist's Guide to Cyclist Palsy: A Narrative Review.

TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: At the conclusion of this educational module, participants will be able to: (1) Describe the possible clinical presentations of Cyclist Palsy based on Ulnar nerve anatomy in the wrist and hand; (2) State the cycling-related risk factors for Cyclist Palsy; and (3) Outline the principles in management for Cyclist Palsy. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Treatment Options for Patellofemoral Arthritis.

PURPOSE OF REVIEW: To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis RECENT FINDINGS: Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.

Iron deficiency in athletes: A narrative review.

Iron deficiency is a concern for athletes due to potential for performance impairments attributed to lower iron status with, or without, accompanying anemia. Despite the high interest in the topic for endurance athletes and medical providers who care for this population, the evaluation and management of athletes with iron deficiency is still evolving, particularly in relation to iron deficiency non-anemia (IDNA). This narrative review presents causes of iron deficiency in the athlete, clinical presentation, differential diagnoses, diagnostic evaluation, and proposed strategies for treatment.

Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than Patellofemoral Pain).

PURPOSE OF REVIEW: This review presents a framework for constructing a differential diagnosis for chronic anterior knee pain associated with overuse other than patellofemoral pain. Traumatic, systemic, and pediatric injuries will not be covered. RECENT FINDINGS: From superficial to deep, the anterior knee can be conceptually organized into four layers: (1) soft tissue, (2) extensor mechanism, (3) intracapsular/extrasynovial, and (4) intra-articular. From superficial to deep, diagnoses to consider include bursitis, patellar and quadriceps tendinosis, fat pad impingement, and plica syndromes.

Narrative Review - Knee Pain in the Pediatric Athlete.

PURPOSE OF REVIEW: This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations. RECENT FINDINGS: Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.

Gait features for discriminating between mobility-limiting musculoskeletal disorders: Lumbar spinal stenosis and knee osteoarthritis.

BACKGROUND: Functional ambulation limitations are features of lumbar spinal stenosis (LSS) and knee osteoarthritis (OA). With numerous validated walking assessment protocols and a vast number of spatiotemporal gait parameters available from sensor-based assessment, there is a critical need for selection of appropriate test protocols and variables for research and clinical applications. RESEARCH QUESTION: In patients with knee OA and LSS, what are the best sensor-derived gait parameters and the most suitable clinical walking test to discriminate between these patient populations and controls? METHODS: We collected foot-mounted inertial measurement unit (IMU) data during three walking tests (fast-paced walk test-FPWT, 6-min walk test- 6MWT, self-paced walk test - SPWT) for subjects with LSS, knee OA and matched controls (N = 10 for each group). Spatiotemporal gait characteristics were extracted and pairwise compared (Omega partial squared - ωp2) between patients and controls. RESULTS: We found that normal paced walking tests (6MWT, SPWT) are better suited for distinguishing gait characteristics between patients and controls. Among the sensor-based gait parameters, stance and double support phase timing were identified as the best gait characteristics for the OA population discrimination, whereas foot flat ratio, gait speed, stride length and cadence were identified as the best gait characteristics for the LSS population discrimination. SIGNIFICANCE: These findings provide guidance on the selection of sensor-derived gait parameters and clinical walking tests to detect alterations in mobility for people with LSS and knee OA.

Utilizing Digital Health Technologies for Patient Education in Lifestyle Medicine.

Technology has redefined the way patients and providers communicate and obtain health information. The realm of digital health encompasses a diverse set of technologies, including mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies have begun to improve care delivery without the traditional constraints of distance, location, and time. A growing body of evidence supports the use of digital health technology for improving patient education and implementation of skills and behaviors integral to lifestyle medicine. Patient education can now be delivered in standard formats (eg, articles, written messages) as well a wide array of multimedia (video, audio, interactive games, etc), which may be more appropriate for certain topics and learning styles. In addition, patient engagement in their care plays an important role in improving health outcomes. Despite digital health technology development often outpacing its research, there is sufficient evidence to support the use of many current technologies in clinical practice. Digital health tools will continue to grow in their ability to cost-effectively monitor and encourage healthy behaviors at scale, and better methods of evaluation will likely increase clinician confidence in their use.

Venous Thromboembolism in Upper Extremity Fractures.

BACKGROUND: Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes. METHODS: Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality. RESULTS: Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021). CONCLUSIONS: VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Sacral-Alar-Iliac Fixation in Children with Neuromuscular Scoliosis: Minimum 5-Year Follow-Up.

OBJECTIVE: To investigate the 5-year outcomes of children with neuromuscular scoliosis treated with sacral-alar-iliac screws. METHODS: We reviewed clinical and radiographic records of patients aged ≤18 years treated by 1 pediatric orthopedic surgeon for neuromuscular scoliosis with spinal fusion using sacral-alar-iliac pelvic anchors. Thirty-eight patients with a minimum 5-year radiographic follow-up (mean, 6.0 ± 1.2 years) were studied. The mean patient age was 13 ± 2.0 years, and 47% were female. The mean number of levels fused was 18 ± 0.7. Two-thirds (66%) of the patients were diagnosed with cerebral palsy. RESULTS: Between the preoperative period and final follow-up, the patients exhibited a mean correction of the major coronal curve of 79% (preoperative, 85° to final, 18°) and a mean 57% correction of the pelvic obliquity (preoperative, 16° to final, 7°). Patients maintained the correction of mean pelvic obliquity from the early postoperative period (6°) to final follow-up (7°). Preoperatively, 76% of the patients had a pelvic obliquity of >10°, compared with 26% of patients postoperatively. There were no cases of neurologic or vascular complications or pseudarthrosis. Radiographs revealed bilateral sacral-alar-iliac screw lucency in 8 patients; 4 of these patients had deep wound infections, and the other 4 were asymptomatic. Unilateral screw fracture was found in 1 patient with an 8-mm-diameter screw (1.3%; 1 of 76 screws); the patient was observed and remained asymptomatic. There were no cases of set screw displacement, screw back-out, or rod dislodgement. CONCLUSIONS: Sacral-alar-iliac screws are safe and effective pelvic anchors for use in children with neuromuscular scoliosis.

Children with Warts: A Retrospective Study in an Outpatient Setting.

BACKGROUND: The purpose is to investigate the demographics and course of common warts in children in an outpatient setting. METHODS: A retrospective medical chart review and telephone survey study were completed on an outpatient cohort of children (0-17 yrs) with a clinical diagnosis of warts at a single-center, university-based pediatric dermatology practice. The main outcome measures included management, time to resolution, and associated factors of warts in children. RESULTS: Of the 254 patients we contacted, 214 agreed to participate in the survey. The most commonly involved sites were the hands and the head and neck area. Most children received some form of therapy, but it is unclear that any form of treatment altered the course. However, children with a medical history of childhood infections or more than one anatomic site had significantly greater risk of having a longer time to resolution. CONCLUSION: Warts resolved in 65% of children by 2 years and in 80% within 4 years, regardless of treatment. With the exception of a history of childhood infections and having more than one anatomic site, time to resolution was not altered by wart or patient characteristics. Thus counseling without aggressive destructive treatment is a reasonable approach to managing warts in most children. Our findings will provide guidance in the process of shared decision making with parents and children.

Convection-enhanced delivery of targeted quantum dot-immunoliposome hybrid nanoparticles to intracranial brain tumor models.

AIM: The aim of this work is to evaluate combining targeting strategy and convection-enhanced delivery in brain tumor models by imaging quantum dot-immunoliposome hybrid nanoparticles. MATERIALS & METHODS: An EGF receptor-targeted, quantum dot-immunoliposome hybrid nanoparticle (QD-IL) was synthesized. In vitro uptake was measured by flow cytometry and intracellular localization was imaged by confocal microscopy. In the in vivo study, QD-ILs were delivered to intracranial xenografts via convection-enhanced delivery and fluorescence was monitored noninvasively in real-time. RESULTS: QD-ILs exhibited specific and efficient uptake in vitro and exhibited approximately 1.3- to 5.0-fold higher total fluorescence compared with nontargeted counterpart in intracranial brain tumor xenografts in vivo. CONCLUSION: QD-ILs serve as an effective imaging agent in vitro and in vivo, and the data suggest that ligand-directed liposomal nanoparticles in conjunction with convection-enhanced delivery may offer therapeutic benefits for glioblastoma treatment as a result of specific and efficient uptake by malignant cells.