Using Electric Stimulation of the Spinal Muscles and Electromyography during Motor Tasks for Evaluation of the Role in Development and Progression of Adolescent Idiopathic Scoliosis.

Introduction: The role of the spinal muscles in scoliogenesis is not fully substantiated. Do they act scoliogenic (inducing scoliosis) or counteract scoliosis in adolescent idiopathic scoliosis (AIS)? In this study, we will examine this by using selectively placed Transcutaneous Electric Stimulation (TES) combined with a cinematic radiographic technique and by performing electromyographic (EMG) evaluations during various motor tasks. Method: This is a cross-sectional study of subjects with small-curve AIS. Using cinematic radiography, they were evaluated dynamically either under electrical stimulation or when performing motor tasks of left and right lateral bending and rotation whilst measuring the muscle activity by EMG. Results: Forty-five patients with AIS were included as subjects. Five subjects volunteered for TES and six subjects performed the motor tasks with EMG. At the initial visual evaluation, and when stimulated with TES, the frontal plane spatial positions of the vertebral bodies showed discrete changes without an apparent pattern. However, analyzing the spatial positions when calibrated, we found that the spinal muscles exert a compressive 'response' with a minor change in the Cobb angle (CA) in small-curve AIS (CA = 10-20°). In larger curves (CA > 20°), TES induced a 'larger deformity' with a relative four-fold change in the CA compared to small-curve AIS with a ratio of 0.6. When evaluating local amplitude (peak) or cumulative (mean) EMG signals, we were unable to find consistent asymmetries. However, one subject had rapid progression and one regressed to a straight spine. When adding the absolute EMG ratios for all four motor tasks, the subject with progression had almost 10-fold less summed EMG ratios, and the subject with regression had more than 3-fold higher summed EMG ratios. Discussion: Based on these findings, we suggest that the spinal muscles in small-curve AIS have a stabilizing function maintaining a straight spine and keeping it in the midline. When deformities are larger (CA > 20°), the spine muscle curve exerts a scoliogenic 'response'. This suggests that the role of the muscles converts from counteracting AIS and stabilizing the spine to being scoliogenic for a CA of more than 20°. Moreover, we interpret higher EMG ratios as heightened asymmetric spinal muscle activity when the spinal muscles try to balance the spine to maintain or correct the deformity. When progression occurs, this is preceded or accompanied by decreased EMG ratios. These findings must be substantiated by larger studies.

Evaluation of an Unloading Concept for Knee Osteoarthritis: A Pilot Study in a Small Patient Group.

Joint compressive forces have been identified as a risk factor for osteoarthritis disease progression. Therefore, unloader braces are a common treatment with the aim of relieving pain, but their effects are not clearly documented in the literature. A knee brace concept was tested with the aim of reducing joint loads and pain in knee osteoarthritis patients by applying an extension moment exclusively during the stance phase. The ideal effects were evaluated during gait based on musculoskeletal modeling of six patients, and experimental tests with a prototype brace were conducted on one patient. The effects were evaluated using electromyography measurements and musculoskeletal models to evaluate the muscle activation and knee compressive forces, respectively. The ideal brace simulations revealed a varying reduction of the first peak knee force between 3.5% and 33.8% across six patients whereas the second peak was unaffected. The prototype reduced the peak vasti muscle activation with 7.9% and musculoskeletal models showed a reduction of the first peak knee compressive force of up to 26.3%. However, the prototype brace increased the knee joint force impulse of up to 17.1% and no immediate pain reduction was observed. The reduction of the first peak knee compressive force, using a prototype on a single patient, indicates a promising effect from an applied knee extension moment for reducing knee joint loads during normal gait. However, further clinical experiments with this brace method are required to evaluate the long-term effects on both pain and disease progression in knee osteoarthritis patients.

Simulation-based design optimization of a wrist exoskeleton.

Exoskeletons are widely used in the field of rehabilitation robotics. Upper limb exoskeletons (ULEs) can be very useful for patients with diminished ability to control their limbs in aiding activities of daily living (ADLs). The design of ULEs must account for a human's limitations and ability to work with an exoskeleton. It can typically be achieved by the involvement of vulnerable end-users in each design cycle. On the other hand, simulation-based design methods on a model with human-in-the-loop can limit the design cycles, thereby reducing research time and dependency on end users. This study makes it evident by using a case where the design of an exoskeleton wrist can be optimized with the usage of a torsional spring at the joint, that compensates for the required motor torque. Considering the human-in-the-loop system, the multibody modeling results show that the usage of a torsional spring in the joint can be useful in designing a lightweight and compact exoskeleton joint by downsizing the motor.Clinical Relevance- The proposed methodology of designing an upper-limb exoskeleton has a utility in limiting design cycles and making it both convenient and useful to assist users with severe impairment in ADLs.

Predicting Tissue Loads in Running from Inertial Measurement Units.

BACKGROUND: Runners have high incidence of repetitive load injuries, and habitual runners often use smartwatches with embedded IMU sensors to track their performance and training. If accelerometer information from such IMUs can provide information about individual tissue loads, then running watches may be used to prevent injuries. METHODS: We investigate a combined physics-based simulation and data-based method. A total of 285 running trials from 76 real runners are subjected to physics-based simulation to recover forces in the Achilles tendon and patella ligament, and the collected data are used to train and test a data-based model using elastic net and gradient boosting methods. RESULTS: Correlations of up to 0.95 and 0.71 for the patella ligament and Achilles tendon forces, respectively, are obtained, but no single best predictive algorithm can be identified. CONCLUSIONS: Prediction of tissues loads based on body-mounted IMUs appears promising but requires further investigation before deployment as a general option for users of running watches to reduce running-related injuries.

Near-Infrared Fluorescence Tomography and Imaging of Ventricular Cerebrospinal Fluid Flow and Extracranial Outflow in Non-Human Primates.

The role of the lymphatics in the clearance of cerebrospinal fluid (CSF) from the brain has been implicated in multiple neurodegenerative conditions. In premature infants, intraventricular hemorrhage causes increased CSF production and, if clearance is impeded, hydrocephalus and severe developmental disabilities can result. In this work, we developed and deployed near-infrared fluorescence (NIRF) tomography and imaging to assess CSF ventricular dynamics and extracranial outflow in similarly sized, intact non-human primates (NHP) following microdose of indocyanine green (ICG) administered to the right lateral ventricle. Fluorescence optical tomography measurements were made by delivering ~10 mW of 785 nm light to the scalp by sequential illumination of 8 fiber optics and imaging the 830 nm emission light collected from 22 fibers using a gallium arsenide intensified, charge coupled device. Acquisition times were 16 seconds. Image reconstruction used the diffusion approximation and hard-priors obtained from MRI to enable dynamic mapping of ICG-laden CSF ventricular dynamics and drainage into the subarachnoid space (SAS) of NHPs. Subsequent, planar NIRF imaging of the scalp confirmed extracranial efflux into SAS and abdominal imaging showed ICG clearance through the hepatobiliary system. Necropsy confirmed imaging results and showed that deep cervical lymph nodes were the routes of extracranial CSF egress. The results confirm the ability to use trace doses of ICG to monitor ventricular CSF dynamics and extracranial outflow in NHP. The techniques may also be feasible for similarly-sized infants and children who may suffer impairment of CSF outflow due to intraventricular hemorrhage.

Imaging peripheral lymphatic dysfunction in chronic conditions.

The lymphatics play important roles in chronic diseases/conditions that comprise the bulk of healthcare worldwide. Yet the ability to routinely image and diagnose lymphatic dysfunction, using commonly available clinical imaging modalities, has been lacking and as a result, the development of effective treatment strategies suffers. Nearly two decades ago, investigational near-infrared fluorescence lymphatic imaging and ICG lymphography were developed as routine diagnostic for clinically evaluating, quantifying, and treating lymphatic dysfunction in cancer-related and primary lymphedema, chronic venous disease, and more recently, autoimmune and neurodegenerative disorders. In this review, we provide an overview of what these non-invasive technologies have taught us about lymphatic (dys) function and anatomy in human studies and in corollary animal studies of human disease. We summarize by commenting on new impactful clinical frontiers in lymphatic science that remain to be facilitated by imaging.

Accelerations Recorded by Simple Inertial Measurement Units with Low Sampling Frequency Can Differentiate between Individuals with and without Knee Osteoarthritis: Implications for Remote Health Care.

Determining the presence and severity of knee osteoarthritis (OA) is a valuable application of inertial measurement units (IMUs) in the remote monitoring of patients. This study aimed to employ the Fourier representation of IMU signals to differentiate between individuals with and without knee OA. We included 27 patients with unilateral knee osteoarthritis (15 females) and 18 healthy controls (11 females). Gait acceleration signals were recorded during overground walking. We obtained the frequency features of the signals using the Fourier transform. The logistic LASSO regression was employed on the frequency domain features as well as the participant's age, sex, and BMI to distinguish between the acceleration data from individuals with and without knee OA. The model's accuracy was estimated by 10-fold cross-validation. The frequency contents of the signals were different between the two groups. The average accuracy of the classification model using the frequency features was 0.91 ± 0.01. The distribution of the selected features in the final model differed between patients with different severity of knee OA. In this study, we demonstrated that using logistic LASSO regression on the Fourier representation of acceleration signals can accurately determine the presence of knee OA.

Plasma Cytokines/Chemokines as Predictive Biomarkers for Lymphedema in Breast Cancer Patients.

Breast cancer-related lymphedema (BCRL) occurs in ~ 40% of patients after axillary lymph node dissection (ALND), radiation therapy (RT), or chemotherapy. First-line palliative treatment utilizes compression garments and specialized massage. Reparative microsurgeries have emerged as a second-line treatment, yet both compression and surgical therapy are most effective at early stages of LE development. Identifying patients at the highest risk for BCRL would allow earlier, more effective treatment. Perometric arm volume measurements, near-infrared fluorescent lymphatic imaging (NIRF-LI) data, and blood were collected between 2016 and 2021 for 40 study subjects undergoing treatment for breast cancer. Plasma samples were evaluated using MILLIPLEX human cytokine/chemokine panels at pre-ALND and at 12 months post-RT. A Mann-Whitney t-test showed that G-CSF, GM-CSF, IFN-2α, IL-10, IL-12p40, IL-15, IL-17A, IL-1ß, IL-2, IL-3, IL-6, and MIP-1ß were significantly higher at pre-ALND in those presenting with BCRL at 12 months post-RT. MIP-1ß and IL-6 were significantly higher at pre-ALND in those who developed dermal backflow, but no BCRL, at 12 months post-RT. Plasma IL-15, IL-3, and MIP-1ß were elevated at 12 months after RT in those with clinical BCRL. These findings establish BCRL as a perpetual inflammatory disorder, and suggest the use of plasma cytokine/chemokine levels to predict those at highest risk.

Predicting Vertical Ground Reaction Forces in Running from the Sound of Footsteps.

From the point of view of measurement, footstep sounds represent a simple, wearable and inexpensive sensing opportunity to assess running biomechanical parameters. Therefore, the aim of this study was to investigate whether the sounds of footsteps can be used to predict the vertical ground reaction force profiles during running. Thirty-seven recreational runners performed overground running, and their sounds of footsteps were recorded from four microphones, while the vertical ground reaction force was recorded using a force plate. We generated nine different combinations of microphone data, ranging from individual recordings up to all four microphones combined. We trained machine learning models using these microphone combinations and predicted the ground reaction force profiles by a leave-one-out approach on the subject level. There were no significant differences in the prediction accuracy between the different microphone combinations (p < 0.05). Moreover, the machine learning model was able to predict the ground reaction force profiles with a mean Pearson correlation coefficient of 0.99 (range 0.79−0.999), mean relative root-mean-square error of 9.96% (range 2−23%) and mean accuracy to define rearfoot or forefoot strike of 77%. Our results demonstrate the feasibility of using the sounds of footsteps in combination with machine learning algorithms based on Fourier transforms to predict the ground reaction force curves. The results are encouraging in terms of the opportunity to create wearable technology to assess the ground reaction force profiles for runners in the interests of injury prevention and performance optimization.

Biomechanical Morphing for Personalized Fitting of Scoliotic Torso Skeleton Models.

The use of patient-specific biomechanical models offers many opportunities in the treatment of adolescent idiopathic scoliosis, such as the design of personalized braces. The first step in the development of these patient-specific models is to fit the geometry of the torso skeleton to the patient's anatomy. However, existing methods rely on high-quality imaging data. The exposure to radiation of these methods limits their applicability for regular monitoring of patients. We present a method to fit personalized models of the torso skeleton that takes as input biplanar low-dose radiographs. The method morphs a template to fit annotated points on visible portions of the spine, and it relies on a default biomechanical model of the torso for regularization and robust fitting of hardly visible parts of the torso skeleton, such as the rib cage. The proposed method provides an accurate and robust solution to obtain personalized models of the torso skeleton, which can be adopted as part of regular management of scoliosis patients. We have evaluated the method on ten young patients who participated in our study. We have analyzed and compared clinical metrics on the spine and the full torso skeleton, and we have found that the accuracy of the method is at least comparable to other methods that require more demanding imaging methods, while it offers superior robustness to artifacts such as interpenetration of ribs. Normal-dose X-rays were available for one of the patients, and for the other nine we acquired low-dose X-rays, allowing us to validate that the accuracy of the method persisted under less invasive imaging modalities.

Prediction of breast cancer-related lymphedema by dermal backflow detected with near-infrared fluorescence lymphatic imaging.

PURPOSE: Mild breast cancer-related lymphedema (BCRL) is clinically diagnosed as a 5%-10% increase in arm volume, typically measured no earlier than 3-6 months after locoregional treatment. Early BCRL treatment is associated with better outcomes, yet amid increasing evidence that lymphedema exists in a latent form, treatment is typically delayed until arm swelling is obvious. In this study, we investigated whether near-infrared fluorescence lymphatic imaging (NIRF-LI) surveillance could characterize early onset of peripheral lymphatic dysfunction as a predictor of BCRL. METHODS: In a prospective, longitudinal cohort/observational study (NCT02949726), subjects with locally advanced breast cancer who received axillary lymph node dissection and regional nodal radiotherapy (RT) were followed serially, between 2016 and 2021, before surgery, 4-8 weeks after surgery, and 6, 12, and 18 months after RT. Arm volume was measured by perometry, and lymphatic (dys) function was assessed by NIRF-LI. RESULTS: By 18 months after RT, 30 of 42 study subjects (71%) developed mild-moderate BCRL (i.e., ≥ 5% arm swelling relative to baseline), all manifested by "dermal backflow" of lymph into lymphatic capillaries or interstitial spaces. Dermal backflow had an 83% positive predictive value and 86% negative predictive value for BCRL, with a sensitivity of 97%, specificity of 50%, accuracy of 83%, positive likelihood ratio of 1.93, negative likelihood ratio of 0.07, and odds ratio of 29.00. Dermal backflow appeared on average 8.3 months, but up to 23 months, before the onset of mild BCRL. CONCLUSION: BCRL can be predicted by dermal backflow, which often appears months before arm swelling, enabling early treatment before the onset of edema and irreversible tissue changes.

Criterion Validity of Linear Accelerations Measured with Low-Sampling-Frequency Accelerometers during Overground Walking in Elderly Patients with Knee Osteoarthritis.

Sensors with a higher sampling rate produce higher-quality data. However, for more extended periods of data acquisition, as in the continuous monitoring of patients, the handling of the generated big data becomes increasingly complicated. This study aimed to determine the validity and reliability of low-sampling-frequency accelerometer (SENS) measurements in patients with knee osteoarthritis. Data were collected simultaneously using SENS and a previously validated sensor (Xsens) during two repetitions of overground walking. The processed acceleration signals were compared with respect to different coordinate axes to determine the test-retest reliability and the agreement between the two systems in the time and frequency domains. In total, 44 participants were included. With respect to different axes, the interclass correlation coefficient for the repeatability of SENS measurements was [0.93-0.96]. The concordance correlation coefficients for the two systems' agreement were [0.81-0.91] in the time domain and [0.43-0.99] in the frequency domain. The absolute biases estimated by the Bland-Altman method were [0.0005-0.008] in the time domain and [0-0.008] in the frequency domain. Low-sampling-frequency accelerometers can provide relatively valid data for measuring the gait accelerations in patients with knee osteoarthritis and can be used in the future for remote patient monitoring.

Biomechanical Analysis of Stoop and Free-Style Squat Lifting and Lowering with a Generic Back-Support Exoskeleton Model.

Musculoskeletal disorders (MSDs) induced by industrial manual handling tasks are a major issue for workers and companies. As flexible ergonomic solutions, occupational exoskeletons can decrease critically high body stress in situations of awkward postures and motions. Biomechanical models with detailed anthropometrics and motions help us to acquire a comprehension of person- and application-specifics by considering the intended and unintended effects, which is crucial for effective implementation. In the present model-based analysis, a generic back-support exoskeleton model was introduced and applied to the motion data of one male subject performing symmetric and asymmetric dynamic manual handling tasks. Different support modes were implemented with this model, including support profiles typical of passive and active systems and an unconstrained optimal support mode used for reference to compare and quantify their biomechanical effects. The conducted simulations indicate that there is a high potential to decrease the peak compression forces in L4/L5 during the investigated heavy loaded tasks for all motion sequences and exoskeleton support modes (mean reduction of 16.0% without the optimal support mode). In particular, asymmetric motions (mean reduction of 11.9%) can be relieved more than symmetric ones (mean reduction of 8.9%) by the exoskeleton support modes without the optimal assistance. The analysis of metabolic energy consumption indicates a high dependency on lifting techniques for the effectiveness of the exoskeleton support. While the exoskeleton support substantially reduces the metabolic cost for the free-squat motions, a slightly higher energy consumption was found for the symmetric stoop motion technique with the active and optimal support mode.

Lymphatic function and anatomy in early stages of lipedema.

OBJECTIVE: Lipedema is an inflammatory subcutaneous adipose tissue disease that develops in women and may progress to lipolymphedema, a condition similar to lymphedema, in which lymphatic dysfunction results in irresolvable edema. Because it has been shown that dilated lymphatic vessels, impaired pumping, and dermal backflow are associated with presymptomatic, cancer-acquired lymphedema, this study sought to understand whether these abnormal lymphatic characteristics also characterize early stages of lipedema prior to lipolymphedema development. METHODS: In a pilot study of 20 individuals with Stage I or II lipedema who had not progressed to lipolymphedema, lymphatic vessel anatomy and function in upper and lower extremities were assessed by near-infrared fluorescence lymphatic imaging and compared with that of a control population of similar age and BMI. RESULTS: These studies showed that, although lower extremity lymphatic vessels were dilated and showed intravascular pooling, the propulsion rates significantly exceeded those of control individuals. Upper extremity lymphatics of individuals with lipedema were unremarkable. In contrast to individuals with lymphedema, individuals with Stage I and II lipedema did not exhibit dermal backflow. CONCLUSIONS: These results suggest that, despite the confusion in the diagnoses between lymphedema and lipedema, their etiologies differ, with lipedema associated with lymphatic vessel dilation but not lymphatic dysfunction.

Triceps surae strength balancing as a management option for early-stage knee osteoarthritis: A patient case.

BACKGROUND: Knee osteoarthritis is a progressive disease that may require management for years before knee arthroplasty can be considered. Previously reported musculoskeletal models suggest that rebalancing the strength of the triceps surae muscles can reduce the joint loads. METHODS: A single patient diagnosed with mild/moderate medial left knee osteoarthritis was treated with botulinum toxin injections in the gastrocnemius muscle of the calf, based on the hypothesis that this would rebalance the triceps surae load distribution and reduce tibiofemoral joint loads. Tests were performed before and 4 weeks after injection to record functional clinical scores and to obtain lower limb joint kinematic and kinetic data of walking, which were subsequently analyzed with a musculoskeletal simulation model. FINDINGS: The patient experienced a clinically relevant improvement in self-reported pain levels in activities-of-daily-living, stair climbing, 6 minutes' treadmill test, range-of-motion, and in the functional knee questionnaire, KOOS. No improvement was seen when performing lunges. The musculoskeletal simulations showed the expected shift in loads between the muscles, reduced knee loads, and improvement of the load symmetry between the legs. INTERPRETATION: The case corroborates the hypothesis, and this suggests further tests by randomized controlled trials. If confirmed, this simple and reversible medical intervention can improve the management of early-stage knee osteoarthritis.

Development and Functional Testing of an Unloading Concept for Knee Osteoarthritis Patients: A Pilot Study.

This paper presents a knee brace design that applies an extension moment to unload the muscles in stance phase during gait, and thereby the knee, as alternative to conventional valgus braces for knee osteoarthritis patients. The concept was tested on one healthy subject during normal gait with a prototype, which was designed to activate and deactivate in order to apply the extension moment in the stance phase only and hereby avoid any interference during the swing phase. Electromyography measurements and musculoskeletal models were used to evaluate the brace effects on muscle activation and knee compressive forces, respectively. Simulations predicted an ideal reduction of up to 36%, whereas experimental tests revealed a reduction of up to 24% with the current prototype. The prototype brace also reduced the knee joint force impulse up to 9% and electromyography (EMG) peak signal of the vasti muscles with up to 19%. Due to these reductions on a healthy subject, this bracing approach seems promising for reducing knee loads during normal gait. However, further clinical experiments on knee osteoarthritis patients are required to evaluate the effect on both pain and disease progression.

Biomechanical Evaluation of the Effect of Minimally Invasive Spine Surgery Compared with Traditional Approaches in Lifting Tasks.

Fusion of spinal vertebrae can be accomplished by different surgical approaches. We investigated Traditional Open Spine Surgery (TOSS) versus Minimally Invasive Spine Surgery (MISS). While TOSS sacrifices spine muscles originating or inserting on the affected vertebrae, MISS seeks to minimize the approach-related morbidity and preserve the tendon attachments of the muscles in the area. We captured 3-D motions of the full body of one healthy subject performing a variety of 10 kg box lifting operations representing activities-of-daily-living that are likely to challenge the spine biomechanically. The motion data were transferred to a full-body biomechanical model with a detailed representation of the biomechanics of the spine, and simulations of the internal spine loads and muscle forces were performed under a baseline configuration and muscle configurations typical for TOSS respectively MISS for the cases of L3/L4, L4/L5, L5/S1, L4/S1 and L3/L5 fusions. The computational model was then used to investigate the biomechanical differences between surgeries. The simulations revealed that joint reaction forces are more affected by both surgical approaches for lateral lifting motions than for sagittal plane motions, and there are indications that individuals with fused joints, regardless of the approach, should be particularly careful with asymmetrical lifts. The MISS and TOSS approaches shift the average loads of different muscle groups in different ways. TOSS generally leads to higher post-operative muscle loads than MISS in the investigated cases, but the differences are smaller than could be expected, given the differences of surgical technique.

How Precisely Can Easily Accessible Variables Predict Achilles and Patellar Tendon Forces during Running?

Patellar and Achilles tendinopathy commonly affect runners. Developing algorithms to predict cumulative force in these structures may help prevent these injuries. Importantly, such algorithms should be fueled with data that are easily accessible while completing a running session outside a biomechanical laboratory. Therefore, the main objective of this study was to investigate whether algorithms can be developed for predicting patellar and Achilles tendon force and impulse during running using measures that can be easily collected by runners using commercially available devices. A secondary objective was to evaluate the predictive performance of the algorithms against the commonly used running distance. Trials of 24 recreational runners were collected with an Xsens suit and a Garmin Forerunner 735XT at three different intended running speeds. Data were analyzed using a mixed-effects multiple regression model, which was used to model the association between the estimated forces in anatomical structures and the training load variables during the fixed running speeds. This provides twelve algorithms for predicting patellar or Achilles tendon peak force and impulse per stride. The algorithms developed in the current study were always superior to the running distance algorithm.

Factors correlated with running economy among elite middle- and long-distance runners.

Running economy (RE) at a given submaximal running velocity is defined as oxygen consumption per minute per kg body mass. We investigated RE in a group of 12 male elite runners of national class. In addition to RE at 14 and 18 km h-1 we measured the maximal oxygen consumption (VO2max ) and anthropometric measures including the moment arm of the Achilles tendon (LAch ), shank and foot volumes, and muscular fascicle lengths. A 3-D biomechanical movement analysis of treadmill running was also conducted. RE was on average 47.8 and 62.3 ml O2  min-1  kg-1 at 14 and 18 km h-1 . Maximal difference between the individual athletes was 21% at 18 km h-1 . Mechanical work rate was significantly correlated with VO2 measured in L min-1 at both running velocities. However, RE and relative work rate were not significantly correlated. LAch was significantly correlated with RE at 18 km h-1 implying that a short moment arm is advantageous regarding RE. Neither foot volume nor shank volume were significantly correlated to RE. Relative muscle fascicle length of m. soleus was significantly correlated with RE at 18 km h-1 . Whole body stiffness and leg stiffness were significantly correlated with LAch indicating that a short moment arm coincided with high stiffness. It is concluded that a short LAch is correlated with RE. Probably, a short LAch allows for storage of a larger amount of elastic energy in the tendon and influences the force-velocity relation toward a lower contraction velocity.

Lymphatic Dissemination and Axillary Web Syndrome in Primary Cutaneous Tuberculosis Secondary to Needlestick Injury.

Cutaneous tuberculosis secondary to skin inoculation of Mycobacterium tuberculosis is uncommon but it can occur in the health care settings. Herein, we report an unusual case of primary cutaneous tuberculosis of the thumb following a needlestick injury. The infection progressed with a necrotic granuloma, lymphatic dysfunction as visualized by near-infrared fluorescence lymphatic imaging, and the development of an axillary web syndrome.