Fibularis Intersection Syndrome: A Rare Cause of Lateral Foot Pain in Runners.

ABSTRACT: Running is a common cause of foot and ankle injuries. Accurate diagnosis is important for appropriate management to resolve the issue. For clarity of diagnoses, the physician should be able to perform a thorough physical examination in conjunction with point-of-care ultrasound. The authors report a case study of a young male runner with lateral ankle pain. Based on clinical assessment and point-of-care ultrasound, a diagnosis of fibularis intersection syndrome was proposed. This type of injury can be treated with graded eccentric loading of fibularis tendons and proprioceptive exercises. This case report highlights the importance of point-of-care ultrasound to determine the appropriate diagnosis and management.

Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy: A Systematic Review.

OBJECTIVE: To systematically review and evaluate the efficacy and complication profile of prolotherapy using hyperosmolar dextrose solution injection for rotator cuff tendinopathy. LITERATURE SURVEY: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (from inception to 1 July, 2019). METHODOLOGY: A comprehensive search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar dextrose solution for rotator cuff tendinopathy. Two reviewers independently screened the titles, abstracts, and full texts, and then extracted data from eligible studies. All reported outcome measures and complications were analyzed descriptively. SYNTHESIS: Five studies satisfied inclusion criteria. Included studies analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months. Prolotherapy differed greatly among studies. Two studies used a multisite enthesis injection protocol while the other three used ultrasound-guided protocols. Two of the studies used an intrasubstance supraspinatus injection and three used a supraspinatus enthesis injection. Control groups consisted of nonoperative rehabilitation including physical therapy and medical management in three studies, supraspinatus saline enthesis injection in one study, and corticosteroid injection in one study. There was statistically significant improvement in pain intensity with multisite injection protocols compared to physical therapy and medical management in both studies. Ultrasound-guided supraspinatus injection trials did not find any statistically significant difference in pain intensity, range of motion, strength, function, or ultrasound characteristics compared to controls of enthesis saline injection or corticosteroid. The complication rate was low, with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1 to 2 days postintervention. CONCLUSIONS: Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.

A Retrospective Study of the Association between Pain Intensity and Opioid Use with Length of Stay during Musculoskeletal Inpatient Rehabilitation after Primary Knee and Hip Arthroplasty.

BACKGROUND: The relationship between pain intensity, opioid consumption, and length of stay (LOS) has received little attention in primary, lower extremity joint arthroplasty patients admitted to inpatient musculoskeletal rehabilitation. OBJECTIVE: To assess how initial pain and other clinical factors are associated with rehabilitation LOS. DESIGN: Retrospective chart review. SETTING: Rehabilitation hospital. PARTICIPANTS: One hundred ninety nine patients admitted for inpatient rehabilitation. INTERVENTIONS: Not Applicable. MAIN OUTCOME MEASURES: Pain intensities on the Numeric Rating Scale (NRS) were completed 3 times daily and total daily opioid consumption recorded in terms of morphine equivalents (MEQ). Confounding variables included patient demographics, medical comorbidity burden using the Charlson Comorbidity Index (CCI), and early functional status as measured by the motor subscale from the Functional Independence Measure (FIM). RESULTS: Mean day 3 NRS values of ≥5.2 and total day 3 opioid consumption of >50 MEQ were associated with a prolonged LOS by nearly 3 and 2 days, respectively. Within a multivariate linear regression, age, mean day 3 pain, comorbidity burden, and early motor functional status accounted for 36% of the variability seen in joint replacement rehabilitation LOS. With all other variables remaining constant, for every unit increase in mean day 3 pain and CCI, this amounted to an additional 5% and 4% increase to LOS, whereas each unit increase in admission motor FIM decreased estimated LOS by 3%. CONCLUSION: Mean pain intensity and total opioid consumption on day 3 of inpatient rehabilitation is associated with LOS. For the rehabilitation physician, this is useful information as the earlier identification of patients with poorly controlled pain can lead to directed intervention, better patient care, and significant cost savings.

Mitochondrial absorption of short wavelength light drives primate blue retinal cones into glycolysis which may increase their pace of aging.

Photoreceptors have high energy demands and densely packed mitochondria through which light passes before phototransduction. Old world primates including humans have three cone photoreceptor types mediating color vision with short (S blue), medium (M green), and long (L red) wavelength sensitivities. However, S-cones are enigmatic. They comprise <10% of the total cone population, their responses saturate early, and they are susceptible in aging and disease. Here, we show that primate S-cones actually have few mitochondria and are fueled by glycolysis, not by mitochondrial respiration. Glycolysis has a limited ability to sustain activity, potentially explaining early S-cone saturation. Mitochondria act as optical filters showing reduced light transmission at 400-450 nm where S-cones are most sensitive (420 nm). This absorbance is likely to arise in a mitochondrial porphyrin that absorbs strongly in the Soret band. Hence, reducing mitochondria will improve S-cone sensitivity but result in increased glycolysis as an alternative energy source, potentially increasing diabetic vulnerability due to restricted glucose access. Further, glycolysis carries a price resulting in premature functional decline as seen in aged S-cones. Soret band absorption may also impact on mitochondrial rich M and L cones by reducing sensitivity at the lower end of their spectral sensitivity range resulting in increased differentiation from S-cone responses. These data add to the list of unique characteristic of S-cones and may also explain aspects of their vulnerability.

Ultrasound-Guided Incisionless Carpal Tunnel Release Using a Hook Knife: A Cadaveric Study.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common entrapment mononeuropathy of the median nerve. In comparison to open surgical and endoscopic carpal tunnel release, a new ultrasound-guided hook knife carpal tunnel release (CTR) procedure was reported to have superior results in terms of reduced morbidity and early return to work. OBJECTIVE: To evaluate the reproducibility of the hook knife CTR procedure when performed by musculoskeletal ultrasound trained physicians without prior experience in this technique. DESIGN: Cadaveric study. SETTING: Tertiary-level academic institute. PARTICIPANTS: Sixteen lightly embalmed forearm and hand specimens. METHODS: The ultrasound-guided CTR was done using a 1-mm proximal wrist puncture, creation of a tunnel, followed by the retrograde percutaneous release of the transverse carpal ligament (TCL) using a 3-mm hook knife. MAIN OUTCOME MEASUREMENTS: Assessment of the completeness of TCL release, the integrity of the surrounding neurovascular structures, and the technical and subjective procedural difficulty encountered during the procedure. RESULTS: In 14 of 16 specimens, complete release of the TCL was achieved. In two specimens with an incomplete release, the TCL resection was 52% and 55%, respectively. The integrity of the surrounding neurovascular structures and superficial anatomy volar to the dissection path was maintained in all specimens. The mean level of procedural difficulty was 2.6 (range 2-4) on a Likert 5-point rating scale. CONCLUSIONS: In cadavers, the ultrasound-guided hook knife CTR procedure was found to be reproducible when performed by ultrasound-trained physicians with no experience in this technique. Further in vivo investigations are required.

Hydrodilatation With Corticosteroid for the Treatment of Adhesive Capsulitis: A Systematic Review.

BACKGROUND: Current evidence suggests that corticosteroid injection alone expedites the recovery of pain-free range of motion (ROM) in patients with adhesive capsulitis compared to physiotherapy or placebo. However, it remains unclear whether the addition of hydrodilatation with corticosteroid provides improvement in pain-free ROM as well as pain relief. OBJECTIVE: A review of the literature was conducted to determine whether the combined intervention of hydrodilatation and corticosteroid injection expedites restoration of pain-free ROM compared to a control treatment of corticosteroid injection in patients with adhesive capsulitis. METHODS: EMBASE, MEDLINE, and CINAHL were searched from database inception to January 2017. Relevant studies were determined as randomized controlled trials written in English, comparing the outcomes of hydrodilatation and corticosteroid injection to a control group treated with corticosteroid injection alone in patients with adhesive capsulitis. Two independent reviewers assessed manuscripts for study inclusion and extracted data. RESULTS: A total of 2276 studies were identified through the search, of which 6 randomized controlled studies (involving 410 shoulders) met criteria for inclusion in this review. Mean age ranged from 51-61 years, with mean symptom duration of 4-9 months. Studies varied significantly regarding the volume of injectate, anatomical injection approach, symptom duration, and the method of glenohumeral capsule distension (capsular rupture versus preservation). Two studies demonstrated clinically and statistically significant improvement in the combination group at 3-month follow-up, and one study demonstrated clinically significant improvement only in ROM and/or pain/functional scales, compared to 3 studies demonstrating no benefit when compared to corticosteroid injection alone. CONCLUSION: Combining hydrodilatation with corticosteroid injection potentially expedites recovery of pain-free ROM. The greatest benefit is experienced within the first 3 months of intervention. Differences in hydrodilatation techniques, inclusion of capsular preservation, anatomical approach, and length of symptoms may explain the variability in efficacy demonstrated. Further trials using larger sample sizes, better anatomical approaches, image guidance, and hydrodilatation techniques are required to determine the true nature of benefits of hydrodilatation with corticosteroid injection. LEVEL OF EVIDENCE: II.

Spontaneous resolution of quadrilateral space syndrome: a case report.

A case of quadrilateral space syndrome is presented, where a large near-circumferential glenoid labrum tear led to a paralabral cyst that dissected into the quadrilateral space and caused a compressive neuropathy of the axillary nerve. This led to a 6-mo history of left shoulder pain, parasthesias, marked weakness to abduction, and marked denervation in both the deltoid and teres minor on electro-diagnostics. This is a presentation of interest as it is the only case report in the literature, to the authors' knowledge, where spontaneous resolution of entrapment occurred. This normally requires intervention for definitive management. It resolved through nonsurgical management with pregabalin, oxycodon, and naproxen medications, leading to good functional return, as well as pain and presumed muscle edema dissipation, while awaiting interventional consultation. It also illustrates that quadrilateral space syndrome is a difficult clinical diagnosis owing to the nonspecific symptom presentation, as well as weakness.

Recovery from stroke: differences between subtypes.

The objective of this study was to compare the differences in patterns of recovery and incidence of medical complications in hemorrhagic and ischemic stroke patients admitted for rehabilitation, using a retrospective case series design. It was set in three tertiary care facilities in London, Ontario, Canada. Eight-hundred-and-nineteen consecutive patients, admitted from 1997 to 2001 for rehabilitation following cerebrovascular event, were reviewed. The main outcome measures were: age, length of hospital stay, time to admission, medical complications, ambulation status and functional independence measure scores on both admission and discharge. The results showed that 110 patients had strokes that were hemorrhagic, while 709 were ischemic. The hemorrhagic stroke patients were younger (66 vs. 70 years, P=0.001) and were admitted later post stroke onset (30 vs. 18 days, P<0.0001). They had a higher incidence of pneumonia (6.4 vs. 2.7%, P=0.04), pulmonary emboli (3.6 vs. 0.07%, P=0.006) and wheelchair ambulation on admission (53 vs. 41%, P=0.026). There was no significant difference in incidence of seizures or wheelchair ambulation on discharge, length of rehabilitation stay or Functional Independence Measure scores on both admission and discharge. In conclusion, hemorrhagic stroke patients took longer than ischemic stroke patients to enter into rehabilitation, and were more inclined to experience ambulatory impairments and develop medical complications.

A comparison of the Barthel Index and the Functional Independence Measure as outcome measures in stroke rehabilitation: patterns of disability scale usage in clinical trials.

In order to compare the frequency and patterns of use of the Barthel Index (BI) and Functional Independence Measure (FIM) in stroke rehabilitation trials, all randomized controlled trials (RCTs) of stroke rehabilitation published between 1968 and 2002 were identified and reviewed to determine the frequency with which the BI and FIM measures were used relative to other measures of disability. The date and location of each study citing either the FIM or the BI were also recorded. Studies were assigned ratings of methodological quality based on the physiotherapy evidence database (PEDro) scoring system. Comparisons of the age, frequency and continents of origin and methodological quality of the studies were explored. Results indicate that the BI and FIM were the most common measures of disability used in RCTs examining stroke rehabilitation. However, the BI was used more often than the FIM (n=86, P<0.001) and was cited in trials of superior quality (P=0.005). Studies from North America were more likely to use the FIM compared with European studies (n=24, P<0.001). Publications citing the BI were significantly more recent when originating in Europe as opposed to North America (P=0.023). These results provide insight into current patterns of scale use in stroke rehabilitation research.

Effect of patient socioeconomic status on perceptions of first- and second-year medical students.

BACKGROUND: Physician decision-making and perceptions of patients are affected by a patient's socioeconomic status (SES). We sought to determine if the perceptions of first- and second-year medical students are similarly affected. We also wanted to determine whether a student's own SES affects his or her perceptions of patients from a low or high SES background. METHODS: Two similar videos of a physician-patient interview were created. One video featured a patient of apparently high SES and the other featured a patient of apparently low SES. Differences in SES were portrayed by means of clothing, accessories and dialogue. First- and second-year medical students at the University of Western Ontario were recruited to view 1 of the videos and to answer a questionnaire using a 5-point Likert scale. RESULTS: Responses were obtained from 205 (89%) of the 231 medical students invited to participate. Respondents' perceptions of the low SES and high SES patients were significantly different in the following respects. The low SES patient was perceived to be less compliant in taking medications and less likely to return for follow-up visits; was perceived to have a lower level of social support, poorer overall health and a worse prognosis; and was perceived to be more adversely affected in his occupational duties by illness (p < 0.05). Furthermore, second-year students who watched the video with the low SES patient were less inclined to want that patient in their practice than second-year students who watched the video with the high SES patient (p = 0.032). One hundred and six students (52%) were categorized as having high SES and 37 (18%) as having low SES (the remaining students were categorized as having mid-level SES). Among students who watched the video with the low SES patient, the level of agreement with the statement "This person is the kind of patient I would like to have in my practice" was greater among low SES students than among high SES students (p = 0.012). INTERPRETATION: First- and second-year medical students have negative perceptions of low SES patients on several dimensions.