Intramuscular Degloving Injury of the Rectus Femoris From Kickball: A Case Report and Review.

Intramuscular degloving injuries (IDIs) are a rare and unique type of muscle injury where there is a dissociation between the inner and outer components of a particular muscle. This type of injury is seen exclusively within the rectus femoris (RF) muscle due to its unique muscle-within-a-muscle anatomy and represents 9% of RF injuries. Despite the significance of this injury, limited knowledge exists regarding the mechanism, management, and prognosis of IDIs, and IDIs are not currently included among the various muscle injury classifications. We present a 38-year-old active male with a one-week history of acute onset right anterior mid-thigh pain and palpable lump after playing kickball. Right thigh MRI revealed an IDI of the RF muscle, edema within the inner and outer muscular portions of the muscle, and a retraction of the torn inner indirect myotendinous complex of the RF. He was managed with physical therapy while being advised to avoid aggressive quadriceps contractions, high-intensity, or high-impact exercise. This is the first reported case of an IDI that occurred in an older recreational athlete (versus young competitive athletes), and the first case of an IDI in a kicking sport other than soccer (kickball). This case emphasizes the importance of a broader awareness of this injury, and a heightened index of suspicion is advised in assessing potential IDIs to improve patient prognosis and rehabilitation. Given the limited understanding and rarity of this injury, we also provide a comprehensive review describing the IDI to the RF.

Return to Sport Using Corticosteroid Injections for Knee Pain in Triathletes.

Introduction Despite the prevalence of corticosteroid injections in athletes, little is known about their efficacy in triathletes. We aim to assess attitudes, use, subjective effectiveness, and time to return to sport with corticosteroid injections compared to alternative methods in triathletes with knee pain. Methods This is an observational study during the COVID-19 pandemic. Triathletes answered a 13-question survey posted to three triathlon-specific websites. Results Sixty-one triathletes responded, 97% of whom experienced knee pain at some point in their triathlete career; 63% with knee pain received a corticosteroid injection as treatment (average age 51 years old). The most popular attitude (44.3%) regarding corticosteroid injections was "tried them, with good improvement". Most found the cortisone injection helpful for two to three months (28.6%), or more than one year (28.6%); of individuals who found the injections useful for more than one year, four-eight (50%) had received multiple injections during that same period. After injection, 80.6% returned to sport within one month. The average age of people using alternative treatment methods was 39 years old; most returned to sport within one month (73.7%). Compared to alternative methods, there was an ~80% higher odds of returning to sport within one month using corticosteroid injections; however, this relationship was not significant (OR=1.786, p=0.480, 95% CI:0.448-7.09). Conclusion This is the first study to examine corticosteroid use in triathletes. Corticosteroid use is more common in older triathletes and results in subjective pain improvement. A strong association does not exist for a quicker return to sport using corticosteroid injections compared to alternative methods. Triathletes should be counseled on the timing of injections, duration of side effects, and be aware of potential risks.

Underlying Subclavian Artery Occlusion Initially Misdiagnosed in Weightlifter Using Anabolic Steroids: A Case Report and Review of Literature.

Subclavian artery occlusion (SAO) is a rare form of peripheral artery disease, sometimes associated with arterial thoracic outlet syndrome (ATOS). Subclavian arterial and venous occlusions are often misdiagnosed initially, and their clinical presentation can be confusing in bodybuilding athletes with increased vascularity in combination with anabolic steroid use. We present a 63-year-old male weightlifter with a history of hypertensive cardiomyopathy, renal transplant with left upper extremity arteriovenous fistula and subsequent takedown, cervical spinal stenosis, left rotator cuff surgery, and decades of testosterone injections who presented with years of left shoulder and neck pain. After having seen multiple providers and being diagnosed with various common disorders, CT angiography and conventional angiography were eventually performed and confirmed the presence of chronic SAO. The chronic occlusion was not deemed amenable to surgery or endovascular intervention and was treated medically with anticoagulation. Although anabolic steroid use is associated with arterial thrombosis, to our knowledge, this is the first reported case of SAO in a weightlifter. Initial misdiagnosis resulted in a long and costly workup. Although the patient's symptoms were consistent with occlusion (and his increased vascularity could potentially suggest chronic thrombosis of any kind), these key signs were masked given his weightlifting history, anabolic steroid use, and concurrent degenerative musculoskeletal conditions common to the weightlifting population. A thorough history, comprehensive physical examination, appropriate imaging studies, and a high index of suspicion for vascular occlusion in athletes who use steroids are critical for the timely diagnosis and treatment of SAO.

RARE CASE OF HIP PAIN DUE TO ILIOPSOAS TENDON RUPTURE; A CASE REPORT AND REVIEW OF THE LITERATURE.

Objective: Hip pain is common in patients of advanced age and has a very broad differential. Of the potential aetiologies, iliopsoas tendon ruptures are rare. Consequently, there is a paucity of literature on iliopsoas rupture in the older adult population, and its rarity can lead to a delay in its diagnosis. When iliopsoas ruptures do occur, they are typically secondary to trauma; however, they can occur spontaneously. Iliopsoas injuries can be disabling, but they respond well to conservative management. We report here a case of a 70-year-old woman who presented to an unaffiliated emergency department with left anterior hip pain 2 weeks after a fall from standing height. Results: Initial X-ray and computed tomography were negative for fracture, and the patient was discharged with home health physical therapy. Her symptoms persisted. At a subsequent emergency department visit several weeks later, magnetic resonance imaging revealed a complete left iliopsoas tendon rupture with retraction. She was treated conservatively and made a complete recovery after physical therapy. Discussion: This paper reviews the literature related to iliopsoas injuries, highlights the importance of iliopsoas tendon injuries among the differential for acute hip pain, and provides management recommendations for this rare, but probably underdiagnosed, injury. This treatable condition warrants further attention, as delay in diagnosis can prolong morbidity.

Pickleball: Review and Clinical Recommendations for this Fast-growing Sport.

Pickleball is a single or doubles volley sport played with paddles and ball on a hardcourt. Growing in popularity in recent years, injuries can occur similar to racquet sports; however, there is a scarcity of references in the literature for sports medicine providers encountering these athletes and injuries. This review provides clinicians treating pickleball athletes with an overview of the sport, a case study demonstrating the significant injuries that can occur in pickleball, and a review of the available literature. We provide a discussion on common pickleball injuries, injury prevention strategies, and event coverage recommendations to better equip sports medicine providers with a base of knowledge and a clinical approach to treat these athletes, or "picklers," who enjoy this fast-growing sport.

"Bumpy" ride for the female cyclist: A rare case of perineal nodular induration, the ischial hygroma.

INTRODUCTION: Cycling is known to cause groin pain, typically adductor/hamstring strains and "saddle sores" (skin abrasion, ulceration and/or folliculitis). Rarely does it result in pathological mesenchymal lesions. PRESENTATION OF CASE: We report a case of a 52-year-old female avid cyclist with chronic groin pain. Activity alteration, bike fit, and saddle modification did not ameliorate her symptoms. MRI revealed no hamstring or bony abnormality but demonstrated low T1/high T2 signal in the right perineum inferior to the ischial tuberosity. DISCUSSION: Perineal nodular induration, or "cyclist's nodule," is a reactive fibroblastic and myofibroblastic pseudotumor almost exclusively reported in male cyclists. PNI can become so nodular that it has even been referred to as an accessory testicle or "the cyclist's third testicle." CONCLUSION: We report an unusual case of PNI in a female cyclist and review the differential diagnosis of non-infectious soft tissue perineal pain in cyclists. Clinicians should be aware of this rare condition to avoid confusion with other mesenchymal lesions.

Hooverball: Case Study, Literature Review and Clinical Recommendations.

With the increasing popularity of extreme conditioning programmes, athletes and patients are searching for new, engaging, high-intensity, total-body workouts. The sport of Hooverball is increasingly used as a workout. First devised in the USA in 1929 to keep President Hoover physically fit, Hooverball has experienced increasing popularity in the past 15 years. The game is scored like tennis and played like volleyball, with players throwing and catching a heavy medicine ball over a volleyball net. Players use complex, multi-joint, explosive movements, featuring torsion, flexion and extension to absorb the forces involved. This paper reports a case of a Hooverball player who presented with a knee injury. The paper also reviews the origins of the sport, and its increase in popularity related to the increasing prominence of extreme conditioning programmes. A literature review, and common Hooverball-related injuries, are presented. Clinical recommendations are set out for patient safety, injury prevention and game coverage, including a prehabilitation strategy for players prior to engaging in this revived and growing sport.

Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations.

For elite athletes who exercise at a high level, sleep is critical to overall health. Many studies have documented the effects of sleep deprivation in the general population, but few studies exist regarding specific effects in the athlete. This review summarizes the effects of sleep deprivation and sleep extension on athletic performance, including reaction time, accuracy, strength and endurance, and cognitive function. There are clear negative effects of sleep deprivation on performance, including reaction time, accuracy, vigor, submaximal strength, and endurance. Cognitive functions such as judgment and decision-making also suffer. Sleep extension can positively affect reaction times, mood, sprint times, tennis serve accuracy, swim turns, kick stroke efficiency, and increased free throw and 3-point accuracy. Banking sleep (sleep extension prior to night of intentional sleep deprivation before sporting event) is a new concept that may also improve performance. For sports medicine providers, the negative effects of sleep deprivation cannot be overstated to athletes. To battle sleep deprivation, athletes may seek supplements with potentially serious side effects; improving sleep quality however is simple and effective, benefiting not only athlete health but also athletic performance.

Nutrition and Supplement Update for the Endurance Athlete: Review and Recommendations.

BACKGROUND: Endurance events have experienced a significant increase in growth in the new millennium and are popular activities for participation globally. Sports nutrition recommendations for endurance exercise however remains a complex issue with often opposing views and advice by various health care professionals. METHODS: A PubMed/Medline search on the topics of endurance, athletes, nutrition, and performance was undertaken and a review performed summarizing the current evidence concerning macronutrients, hydration, and supplements as it pertains to endurance athletes. RESULTS: Carbohydrate and hydration recommendations have not drastically changed in years, while protein and fat intake have been traditionally underemphasized in endurance athletes. Several supplements are commercially available to athletes, of which, few may be of benefit for endurance activities, including nitrates, antioxidants, caffeine, and probiotics, and are reviewed here. The topic of "train low," training in a low carbohydrate state is also discussed, and the post-exercise nutritional "recovery window" remains an important point to emphasize to endurance competitors. CONCLUSIONS: This review summarizes the key recommendations for macronutrients, hydration, and supplements for endurance athletes, and helps clinicians treating endurance athletes clear up misconceptions in sports nutrition research when counseling the endurance athlete.

Peripheral Neuropathy Due to Common Variable Immunodeficiency: Case Report and Narrative Review.

A 63-year-old woman with common variable immunodeficiency (CVID) presented with 1 year of insidious onset lower extremity pain and weakness. She underwent a circuitous workup, failed to improve despite treatment for various presumed diagnoses. She presented to a University physical medicine and rehabilitation clinic with continued symptoms. Electrophysiologic testing was recommended revealing a lower extremity motor greater than sensory axonal neuropathy. While CVID has known central nervous system complications, to our knowledge, this represents the second known reported case of peripheral neuropathy. We review the literature on CVID and summarize neurological disease mechanisms and manifestations. Although peripheral neuropathy is a rarely documented complication of CVID, providers need to be aware of potential peripheral nervous system complications of primary immune deficiencies such as CVID due to its significant impact on physical performance, balance, and fall risks.

Medial iliac stress fractures in athletes: report of two rare cases: review of literature and clinical recommendations.

Stress fractures are a common diagnosis in sports medicine and can result in significant loss of function, athlete playing time, and potentially lead to chronic symptoms. However, unusual locations of stress fractures may present with vague symptoms and a relatively benign physical exam, leading to difficulty in arriving at the correct diagnosis. Pelvic stress fractures are less common than lower-extremity stress fractures in athletes, occurring in only 1-5% of all stress fractures and typically occur in pubic rami. Furthermore, iliac bone stress fractures are even rarer, with only a few case reports in the literature. Their presentation can easily be missed on routine workup and imaging. We present two cases of the very rare superomedial iliac bone stress fracture in athletes, an unusual location for this uncommon stress fracture. We review the available literature on this condition and provide clinical commentary on workup and treatment recommendations.

Tart Cherry Juice in Athletes: A Literature Review and Commentary.

Tart cherry (TC) juice has many antioxidant and anti-inflammatory polyphenol compounds. TC lessens pain and accelerates strength recovery after exercise and decreases blood markers of inflammation/oxidative stress. These improvements occur in both strength and endurance exercise. TC supplementation may not be optimal during the adaptation/build stage of training. However, excessive inflammatory/oxidative stress during single-day intense training/competition or multiday tournaments may delay return to peak form. In this stage, where recovery (not adaptation) is the priority, TC may be beneficial. Timing and dosage vary widely, but most studies use 8 to 12 oz (1 oz if concentrate form) twice a day, 4- to 5-d loading phase before the event, and 2 to 3 d after to promote recovery. Therefore, for an athlete who has already peaked in training and looking to improve recovery and faster return to competition, TC may be beneficial.

Rehabilitation after scapulectomy.

An 84-yr-old man presented with right posterior shoulder pain and growing mass. Shoulder range of motion was limited in forward elevation and abduction; result of the neurologic testing was normal. Radiologic workup showed an irregular mass resembling Paget's disease or sarcoma. On surgical inspection, a 16-cm hemorrhagic mass, occupying the entire scapula, was identified. Patient underwent tumor resection and scapulectomy. Postoperatively, he started a rehabilitation program. With attempted ambulation, patient exhibited strong tendencies to lean rightward, walked in circles, and risking fall. The gait abnormality could not be corrected and acute inpatient rehabilitation admission was recommended. A unique rehabilitation program was developed to correct gait deviation, improve balance, and compensate for deficits. After a comprehensive inpatient rehabilitation, the patient was successfully discharged home. We present a review of scapulectomy, postoperative care, and a recommended rehabilitation program.

Rehabilitation after intramedullary skeletal kinetic distractor implantation: a report of two cases and a suggested therapy program.

Adult limb lengthening occurs via distraction osteogenesis and traditionally involves use of an external fixator. Complications after placement of hardware often disrupt rehabilitative efforts and hinder patients' progress. A completely internal limb-lengthening device has been developed and increasingly used, and it may more commonly be seen by a physiatrist in consultation for postoperative rehabilitation. We present two cases of patients who underwent implantation of the intramedullary skeletal kinetic distractor and required acute inpatient rehabilitation. One patient had previously suffered a malunion deformity with a resultant limb shortening, and the second patient was born with a congenital leg-length inequality. Both patients had successful femoral intramedullary skeletal kinetic distractor implantation and were transferred for acute inpatient rehabilitation. Distraction occurred daily, based on the patient's level of physical activity in therapy, and was measured using a hand-held monitor. Both patients were successfully discharged home, without complications throughout the hospital stay. Knowledge of the theory and mechanism of action of the device is important to guide both the amount and type of therapy prescribed and to follow patient progress. We present general guidelines during the acute rehabilitation of a patient after intramedullary skeletal kinetic distractor surgery.

Convalescence care for seniors of lower Manhattan: an interdisciplinary outreach, rehabilitation, and education model.

The purpose of this study was to test the efficacy of an interdisciplinary geriatric outreach, rehabilitation, and education program for seniors. Community-dwelling Chinese seniors in lower Manhattan were recruited through outreach activities (17 educational workshops, three community health fairs, media interviews) and community physician referrals to offer rehabilitation services. The instrument administered at entry and exit included questions about pain intensity, quality of life, activities of daily living (ADLs), and an assessment of a variety of intrinsic and extrinsic barriers to life participation. The sample included 70 seniors (53 women) with a mean age of 70.5 +/- 7.48 years (range 60-93 years old) of whom 86% were Cantonese-speaking Chinese. The barriers-to-life participation assessment revealed cultural, communication, transportation, and physical environmental barriers as well as insufficient financial resources. Thirty-four patients who completed the program showed a significant improvement in quality of life. Patients' reports reflected a high degree of satisfaction with the program. Interdisciplinary team-oriented patient care, including a physiatrist, social worker, and rehabilitation staff, may result in good outcomes and high patient satisfaction in ambulatory community seniors.