Off the Courts: Occupational "Tennis Leg".

OBJECTIVE: Injury to the gastrocnemius muscle (tennis leg) is a presenting complaint often associated with athletic pursuits. Despite that label, this form of injury is likely to be common to a variety of salaried and nonsalaried pursuits beyond sports. METHOD: We describe the presentation and management of two cases of "tennis leg" injury occurring in an occupational rather than athletic setting and review the relevant medical literature. RESULTS: Partial tears of the medial insertion of the gastrocnemius tendon were documented in both cases, in the first through magnetic resonance imaging and in the second by ultrasound. CONCLUSION: Rupture of the tendon to the medial head of the gastrocnemius, the so-called "tennis leg" injury, should be considered as potentially work-related trauma, rather than taken to be solely a sports injury.

Incorporating longitudinal pediatric patient-centered outcome measurement into the clinical workflow using a commercial electronic health record: a step toward increasing value for the patient.

Patient-centered outcomes measurement provides healthcare organizations with crucial information for increasing value for patients; however, organizations have struggled to obtain outcomes data from electronic health record (EHR) systems. This study describes how Texas Children's Hospital customized a commercial EHR system and assembled a cross-functional team to capture outcomes data using existing functionality. Prior to its installation and customization, no surgical subspecialties besides the congenital heart and transplant surgery groups conducted prospective, patient outcomes measurement, but by 2015, the outcomes of over 1300 unique patients with supracondylar fractures, cleft lip and/or palate, or voiding dysfunction had been tracked. Key factors for integrating outcomes measurement into the clinical workflow include ongoing communication between cross-functional teams composed of clinicians and technical professionals, an iterative design process, organizational commitment, and prioritizing measurement as early as possible during EHR optimization.

Physiologic alterations and predictors of performance in a 160-km ultramarathon.

OBJECTIVE: To describe physiologic alterations in runners competing in a 160-km endurance event and to evaluate the utility of weight and blood pressure measurements in the assessment of runner performance. DESIGN: Prospective cohort study. SETTING: One hundred sixty-km ultramarathon. PARTICIPANTS: Ninety-one of the 101 participants in the 2010 Tahoe Rim 100 Mile Endurance Run. ASSESSMENT OF RISK FACTORS: Brachial blood pressure, heart rate, and weight were assessed before competition, at 80 km, and at 160 km. MAIN OUTCOME MEASURES: Alterations in brachial blood pressure, heart rate, and weight were assessed in finishers. Weight loss, brachial blood pressure, pulse pressure, and heart rate at 80 km were assessed in all participants for their ability to predict failure to finish the race. RESULTS: Participants who finished 160 km (57%) experienced their fastest heart rates (P < 0.05), lowest systolic pressures (P < 0.05), highest diastolic pressures (P < 0.05), narrowest pulse pressures (P < 0.05), and lowest weights (P < 0.05) at 80 km. High rates of finishing were seen in those who lost >5% of their prerace weight (87%). Categorical weight loss (<3%, 3%-5%, and >5%) was not associated with the ability to finish (P > 0.05) or finishing time (P > 0.05), whereas the presence of a narrow pulse pressure was associated with a high likelihood (likelihood ratio = 9.84; P = 0.002) of failure to finish. CONCLUSIONS: Greater intracompetition weight loss is not associated with impaired performance but rather may be an aspect of superior performance. Narrow pulse pressure was associated with a high likelihood of failure to finish.

A pain in the buttock.

Spondylolysis, a fracture of the pars interarticularis, is a common source back pain in children and adolescents. While the incidence is significantly higher in Asian and Inuit populations, it is never seen in nonambulatory children and is most commonly associated with athletic activities that involve extension or rotational deformity about the spine suggesting a functional component. Given that the associated pain is typically insidious in onset, lacks preceding trauma, and is accompanied by muscular spasm, prompt diagnosis requires a high index of suspicion, familiarity with provocative testing, and knowledge of the appropriate radiographic evaluation. Treatment requires cessation of athletic activity, bracing, and rest for a minimum of four to six weeks, or until symptomatic and radiographic resolution.

Prevalence and predictors of pain in surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Multicenter, prospective, consecutive clinical series. OBJECTIVE: To report on back pain and its association with patients' perceptions of appearance in a prospective cohort study of children before and after posterior spinal fusion for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Back pain in idiopathic scoliosis has been noted to be reduced after surgery. However, uncertainty over its prevalence before and after operation persists. There is a paucity of data on correlations between patients' perceptions of their appearance and preoperative and postoperative pain. METHODS: We reviewed 1433 patients entered consecutively into the Prospective Pediatric Scoliosis Study, a database of children (8-22 years) undergoing operation for idiopathic scoliosis who have been followed for 1 and 2 years (n = 295) with the Scoliosis Research Society-22 and Spinal Appearance Questionnaire instruments. RESULTS: Preoperative pain was reported by 77.9% of patients and 44% of surgeons. More preoperative pain correlated with older age (ρ = -.140, P = 0.000), greater body mass index (ρ = -0.168, P = 0.000), larger proximal thoracic curve ρ = -0.086, P = 0.019), and a higher score on the Spinal Appearance Questionnaire Appearance (greater perception of spinal deformity, ρ = -0.223, P = 0.000) and Appearance Desire scales (stronger desire to change the appearance of their spine, ρ = -0.153, P = 0.000).Pain was reduced at 1 and 2 years after operation (P = 0.0002). Patients who perceived themselves as less deformed (ρ = -0.284, P < 0.01) or had less desire to change their spinal appearance (ρ = -0.183, P < 0.01) experienced a greater reduction in pain 2 years after operation.Preoperative analgesic use for back pain was high (28.8%) and remained high at 2 years after operation (29.5%) (P > 0.05). CONCLUSION: Back pain affects three-quarters of adolescents with idiopathic scoliosis and is reduced after posterior fusion. Patients who are overweight, older, and have larger proximal thoracic curve magnitudes report more preoperative pain. Patients who view themselves as more deformed tend to have more absolute pain, and less reduction in pain after operation.

Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Multicenter, prospective, consecutive clinical series. OBJECTIVE.: To report on the use and outcomes of preoperative magnetic resonance imaging (MRI) in a prospective cohort study of 2206 children undergoing posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: There is no consensus on the use of MRI in the preoperative evaluation of children with idiopathic scoliosis. Also, there is no consensus on the rate of abnormality and the relevance of abnormality on surgical outcome in so-called "idiopathic" scoliosis. METHODS: We reviewed the first 2206 patients entered consecutively into the Prospective Pediatric Scoliosis Study, a database of children (8-18 years) undergoing operation for scoliosis by pediatric spinal surgeons in the Spinal Deformity Study Group. RESULTS: There were 1812 girls (80.8%) and 394 boys (17.5%). Mean age at operation was 14 years and 3 months. A total of 191 (8.6%) had juvenile idiopathic scoliosis (age ≤ 10 years). A total of 923 patients (41.8%) underwent spine MRI. Ninety-one abnormalities of the spine were detected (9.9% of the 923 screened), of which 39 (4.2%) were neural. There were 26 syringes (66.7% of neural abnormalities and 28.6% of all abnormalities), 12 Chiari malformations (30.7% and 13.2%, respectively), and 1 tethered cord (2.6% and 1.1%, respectively). Fifty-three patients (5.7%) demonstrated abnormalities affecting "other" parts of the spine than the neural elements. Patients undergoing MRI more frequently had a thoracic hyperkyphosis (P < 0.001), had a diagnosis of juvenile idiopathic scoliosis (P < 0.001), had a Risser grade between 0 and 2 (P = 0.022), had a greater curve magnitude (P < 0.001), had three major curves (P < 0.001), were male (P = 0.004), and underwent a combined anterior-posterior surgical approach (P < 0.001). Thoracic hyperkyphosis and juvenile onset were associated with greater chance of neural lesion on MRI of the spine. Incidence of abnormal MRI did not differ significantly by direction of apex, Risser grade, curve magnitude or type, male sex, or body mass index. CONCLUSION: Use of preoperative MRI was 41.8%; 9.9% of patients with so-called "idiopathic" scoliosis had an abnormality on MRI, of which 4.2% were neural anomalies. Of these, syrinx was 66.7%, Chiari was 30.7%, and tethered cord was 2.6%. Significant risk factors for neural abnormality were thoracic hyperkyphosis and juvenile onset. Other characteristics, including apex left thoracic curve, Risser less than or equal to 1, large curve magnitude, triple major curve, male sex, and obesity were not associated with neural abnormality. There were no differences in complication rates between normal and abnormal MRI patients. Our data question the routine use of MRI as a screening tool for adolescent idiopathic scoliosis.

Reducing immunization discomfort in 4- to 6-year-old children: a randomized clinical trial.

OBJECTIVE: The goal was to test a multifaceted distraction method designed to reduce injection-associated pain in school-aged children. METHODS: A clinical trial evaluated 41 children, 4 to 6 years of age, who were given 3 standard prekindergarten immunizations; 21 were assigned randomly to an office routine control group, whereas 20 received a multifaceted, discomfort-reducing intervention. The intervention added verbal suggestions of diminished sensation and a visual focusing activity to the use of ethyl chloride, an established pain-reducing measure. The distraction materials used for the intervention consisted of topical ethyl chloride spray, an improvised, plastic, multipronged arm gripper, and a vibrating instrument descending on the contralateral arm, which provided the focusing task and visual distraction. RESULTS: According to patient and parent Faces Pain Scale-Revised scores and nonblinded, video-taped observations scored according to the face-legs-activity-crying-consolability method, the intervention group showed highly significant reductions in pain and discomfort, compared with the control group (patient self-report, P < .0013; parent report, P < .0002; observation score, P < .0001). CONCLUSION: This multifaceted distraction intervention reduced significantly the pain and discomfort of childhood immunizations in children 4 to 6 years of age.