[Molecular repair mechanisms using the Intratissue Percutaneous Electrolysis technique in patellar tendonitis]. / Mecanismos moleculares de reparación mediante la técnica Electrólisis Percutánea Intratisular en la tendinosis rotuliana.

OBJECTIVE: To investigate the molecular mechanisms of tissue response after treatment with the Intratissue Percutaneous Electrolysis (EPI(®)) technique in collagenase-induced tendinopathy in Sprague-Dawley rats. METHODS: Tendinopathy was induced by injecting 50 µg of type i collagenase into the patellar tendon of 24 Sprague Dawley rats of 7 months of age and weighting 300 g. The sample was divided into 4 groups: the control group, collagenase group, and two EPI(®) technique treatment groups of 3 and 6 mA, respectively. An EPI(®) treatment session was applied, and after 3 days, the tendons were analysed using immunoblotting and electrophoresis techniques. An analysis was also made of cytochrome C protein, Smac/Diablo, vascular endothelial growth factor and its receptor 2, as well as the nuclear transcription factor peroxisome proliferator-activated receptor gamma. RESULTS: A statistically significant increase, compared to the control group, was observed in the expression of cytochrome C, Smac/Diablo, vascular endothelial growth factor, its receptor 2 and peroxisome proliferator-activated receptor gamma in the groups in which the EPI(®) technique was applied. CONCLUSIONS: EPI(®) technique produces an increase in anti-inflammatory and angiogenic molecular mechanisms in collagenase-induced tendon injury in rats.

Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study.

OBJECTIVE: To assess whether athletes with strength imbalance of the hip musculature would be more likely to require treatment for low back pain (LBP) over the ensuing year. DESIGN: The study population included 163 National Collegiate Athletic Association Division I college athletes (100 males and 63 females) undergoing preparticipation sports physicals. Institutional review board approval was obtained to acquire and analyze hip muscle strength data. A commercially available dynamometer (Chatillon, Lexington, KY) incorporated into a specially designed anchoring station was used for testing the hip extensors and abductors. The maximum force generated for the hip abductors and extensors was used to calculate a percentage difference between the right and left hip extensors and abductors. Treatment of athletes by the athletic trainers for LBP unrelated to blunt trauma over the ensuing year was recorded. RESULTS: Of all athletes, 5 of 63 females and 8 of 100 males required treatment for LBP. Logistic regression analysis indicated that for female athletes, the percentage difference between the right and left hip extensors was predictive of whether treatment for LBP was required over the ensuing year (P = 0.05). There was no significant association noted for the percentage difference between the right and left hip abductors in females and for the percentage difference between both the right and left hip abductors and right and left hip extensors in males requiring treatment for LBP. CONCLUSIONS: These data support our results from our previous cohort study, adding validity to the concept of hip muscle imbalance being associated with LBP occurrence in female athletes. This research further supports the need for the assessment and treatment of hip muscle imbalance in individuals with LBP.

Tarlov cyst as a rare cause of S1 radiculopathy: A case report.

A 37-year-old female physician presented with a chief complaint of left posterior thigh pain, which began insidiously approximately 4 months before her initial examination. Initially, she had been evaluated by her physician, and magnetic resonance imaging (MRI) was ordered. The MRI scan was reported to be within normal limits, with the exception of minimal disc bulging at L4-5. She had received physical therapy with little benefit and was referred for physiatric assessment. Review of the patient's original MRI scan showed the presence of perineurial (Tarlov) cysts within the sacral canal at the level of S2, with compression of the adjacent nerve root. Subsequent electrodiagnostic testing showed axonal degeneration consistent with an S1 radiculopathy. Tarlov cysts can be a rare cause of lumbosacral radiculopathy and should be considered in the differential diagnosis of radicular leg pain.

The crossed femoral nerve stretch test to improve diagnostic sensitivity for the high lumbar radiculopathy: 2 case reports.

The femoral nerve stretch test (FNST) is commonly used to assess high lumbar radiculopathy. It may be falsely positive secondary to tight or injured muscles of the anterior thigh, and to osseous or joint pathology in and about the hip. We report on the crossed FNST, which may improve the specificity of the FNST. Two cases that occurred within 2 months are presented. The physical examinations suggested high lumbar radiculopathy, which was confirmed by both the FNST and crossed FNST. The crossed FNST may thus be a valuable screening test that further supports a diagnosis of upper lumbar radiculopathy. Further study is necessary to identify its prevalence in the assessment of the high lumbar radiculopathy.

Phlebotomy-related lateral antebrachial cutaneous nerve injury.

Although phlebotomy is a common and widespread procedure, the medical literature provides limited information in terms of the documented complications of venipuncture. Documentation of phlebotomy-related nerve injuries is even more limited. The authors present a case report of a phlebotomy-induced lesion of the lateral antebrachial cutaneous nerve. According to our literature search, this is the first case in which electrodiagnostic studies were used to document venipuncture-related injury of the lateral antebrachial cutaneous nerve. Specific electrodiagnostic testing is used to definitively diagnose this rare injury and to track recovery. Electrodiagnostic testing can be helpful in evaluating cases of sensory disturbance after phlebotomy.

Effect of topical heat on electromyographic power density spectrum in subjects with myofascial pain and normal controls: a pilot study.

OBJECTIVE: To investigate the influence of superficial heat on the fatigue cascade of the upper trapezius muscle in subjects with myofascial pain and matched normal controls. DESIGN: In a prospective randomized block crossover pilot study, eight female subjects, ages 20-35 yr, with upper trapezius muscle trigger points and eight matched female control subjects without pain were studied. Subjects performed six 100-sec shoulder shrug contractions to fatigue, with subjects randomly chosen to receive heat during the first three or last three trials. The initial median frequency and the slope of the median frequency decline were calculated from the data. RESULTS: In the subjects with pain, the slope of the median frequency was elevated in ambient room temperature as compared with controls. There was no difference in slope of the median frequency under heated conditions. Heat application in controls before fatiguing exercise caused an increase in initial median frequency, whereas exercise before heat treatment resulted in a significantly lower initial median frequency. Subjects with myofascial pain had no significant change in initial median frequency. CONCLUSIONS: Heat seems to have a positive effect on muscle function in normal individuals when applied before exercise. Subjects with myofascial pain respond differently to exercise and heat challenge, which suggests a difference in their muscle physiology.

Portable dynamometer anchoring station for measuring strength of the hip extensors and abductors.

OBJECTIVE: To assess the reliability of a specially designed dynamometer anchoring station in the measurement of hip muscle strength. DESIGN: Prospective study using test-retest design. SETTING: Outpatient clinic setting. PARTICIPANTS: Ten subjects, ages 25 to 35yrs. MAIN OUTCOME MEASURES: Using the apparatus, three consecutive measures were recorded for hip abduction and extension by an inexperienced examiner. Two weeks later, the same subjects were retested, with the evaluator blinded to the initial results. In both the test and retest, average and maximal values of strength were calculated for each muscle. Reliability of the device was assessed by computing the intraclass correlation coefficients and coefficients of variation (CVs). RESULTS: Intraclass correlation coefficients ranged from .94 to .98. The average CV for the maximal and average abduction strength had values of 4.77% and 4%, respectively. The maximal and average extension strength had average CV values of 8.06% and 7.83%, respectively. CONCLUSION: This specially designed dynamometer anchoring station has been found to be highly reliable in the measurement of hip girdle strength and has the advantage of easy adjustability and portability for large-scale screenings. This device enhances the reliability of the dynamometer, which may be subject to considerable variability when applied by hand to the powerful hip girdle musculature.

A study of post-traumatic shingles as a work related injury.

BACKGROUND: After chicken pox, the herpes varicella-zoster (HVZ) virus may remain dormant in the dorsal root ganglion until later reactivation causes shingles, characterized by painful dysesthesias and cutaneous vesicular eruptions along a unilateral dermatome. Shingles as a work-related injury has not been previously addressed in the medical literature. Case History We present a 50-year old female hospital employee who, while working, sustained an acute, traumatic hyperextension injury to her right wrist, hand, and fingers. Although she initially responded to treatment for flexor tendinitis, she suddenly developed shingles in the right C5-C6 dermatomes. She was treated with famcyclovir and her skin lesions resolved, but post-herpetic neuralgia persisted. CONCLUSIONS: It was felt that her shingles was causally related to her occupational injury since trauma (previously reported to precipitate shingles) was her only risk factor and the timing and location of the lesions corresponded closely to the occupational injury. In addition to appropriately diagnosing and treating their patients, workers' compensation physicians often must determine if a particular condition was caused by the original work-related incident. Clinicians who treat trauma patients and injured workers should be aware of post-traumatic shingles and understand the causal relationship of this uncommon but clinically important phenomenon.

The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.

OBJECTIVE: To determine the relationship of previous lower extremity (LE) injury and/or low back pain (LBP) on hip abduction and extension strength. DESIGN: Cohort study of college athletes at time of preparticipation screening physical. SETTING: An NCAA Division I college. PARTICIPANTS: Two hundred ten college athletes (140 males and 70 females) from an NCAA Division I school. MAIN OUTCOME MEASURES: Mean and maximal hip abduction and extension strengths were recorded using a specially designed dynamometer anchoring station. Previous injury to the LE or LBP in the past year was recorded via personal interview at the time of screening and verified by review of previous injury records. RESULTS: A significant difference in side-to-side symmetry of maximum hip extension strength was observed in female subjects who reported LE injury or LBP as compared to those who did not. Side-to-side difference in hip strength, however, did not differ between male athletes, regardless of reported LE injury or LBP status. CONCLUSION: Female athletes appear to have a differing response of the proximal hip musculature to LE injury or LBP, as compared with their male counterparts. Research is under way to further validate these findings. CLINICAL RELEVANCE: This study provides some reasoning to support the screening of hip strength during the preparticipation physical, as it may be important in the prevention of LE injury and LBP in collegiate athletes.

Greater trochanter enthesopathy: an example of "short course retinoid enthesopathy": a case report.

Irreversible skeletal changes have been described in patients with dermatologic disorders treated with isotretinoin (Accutane), a synthetic vitamin A derivative. Although retinoids were developed to avoid toxicity associated with vitamin A, skeletal lesions and rheumatologic consequences are possible hazards of isotretinoin treatment. Enthesopathy is one of the potential musculoskeletal sequelae and is characterized by pathologic, sometimes painful changes at the insertion sites (entheses) of tendons, ligaments, and articular capsules into bone. We report a patient who was referred secondary to an extended history of bilateral hip region pain. She was subsequently found to have a greater trochanteric enthesopathy. A detailed patient history revealed past use of Accutane for cystic acne. The subsequent treatment course, including medications, corticosteroid injections, physical therapy, and activity modifications, is described and the pertinent literature is reviewed. We believe that patients who are prescribed isotretinoin should be warned about this potential pathologic condition at the initiation of treatment and that physicians who are treating patients with a history of Accutane use should be suspicious of underlying enthesopathies as the etiology behind pain of musculoskeletal origin.

Salon sink radiculopathy: a case series.

Cervical radiculopathy can be diagnosed on physical examination with the Spurling test, which narrows neural foramina via neck extension along with coupled rotation and side-bending. In the presence of cervical radiculopathy, this test can reproduce radicular symptoms by transmitting compressive forces to affected nerve roots as they traverse the neural foramina. Treatment of cervical radiculopathy includes patient education to avoid obvious postures that exacerbate radicular symptoms and to assume positions that centralize discomfort. A potentially harmful position to which many patients are unwittingly subjected at least several times per year occurs when their hair is being shampooed in a salon sink before a haircut. This posture causes neck extension and is combined with rotation and side-bending as the patient's head is being manipulated during the shampooing. When the stylist then also applies a mild compressive force while shampooing the patient's hair, hyperextension of the neck is produced. We present two patients with cervical radiculopathy that was significantly exacerbated after the patient's hair had been shampooed in a salon sink; subsequently, these patients required oral administration of steroids. These cases illustrate that patients with suspected or known cervical radiculopathy should be forewarned to avoid this otherwise seemingly innocuous activity.

Electromyography in craniomaxillofacial trauma.

BACKGROUND AND PURPOSE: Electromyography is used in conjunction with clinical diagnosis to determine the presence and extent of craniofacial injuries; it is also an aid in prognosis of recovery. This article reviews the neural pathophysiology following trauma and the basic principles of electrodiagnostic testing; such understanding helps to determine indications for electrodiagnostic testing. METHODS AND MATERIALS: Electrodiagnostic techniques can detect and differentiate the degree of injury. There are three major categories of nerve injury--neurapraxia, axonotmesis, and neurotmesis. In neuropraxic injuries, stimulation distal to the lesion will continue to elicit a response indefinitely; in more severe injuries, axonal degeneration begins within 3 to 5 days postinjury. RESULTS AND/OR CONCLUSIONS: Electromyography may be used as a valuable adjunct to traditional forms of diagnosis and prognosis. The accuracy of electrodiagnostic data reported in the literature ranges from 50% to 67% in some studies and 77% to 90% in others. Studies with larger patient populations and longer follow-up periods are required.

High lumbar disc: diagnostic and treatment dilemma.

The high lumbar disc refers to a disc herniation involving the upper lumbar discs (L2-4). Radiculopathy caused by an upper lumbar disc is occasionally difficult to diagnose secondary to ambiguous presenting symptoms. Once accurately diagnosed, the treatment program is straight-forward but specific for the high nerve root pathology. A series of three cases of high lumbar radiculopathies managed with an aggressive conservative approach are presented. This case series will review the diagnostic and treatment strategies that are useful in the identification and management of a high lumbar radiculopathy. Various pitfalls in the management of these cases are reviewed, all of which may worsen the patient's clinical situation. A high index of suspicion is necessary to elucidate this entity.