Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg.

Leg pain in athletes has many aetiologies. The clinician must strive to specifically define the clinical problem in order to administer the appropriate treatment for the athlete's condition. Clinical conditions in the leg causing symptoms in athletes include chronic exertional compartment syndrome (CECC), tendinitis, medial tibial stress syndrome, stress fractures, fascial defects, musculotendinous junction disruptions (tennis leg), popliteal artery entrapment syndrome, effort-induced venous thrombosis and nerve entrapment. Appropriate diagnostic studies are needed to allow accurate diagnosis. A work-up might include radiographs, bone scans and compartment pressure measurement. Many of these conditions relate to overuse and training errors. Conservative measures including rest, activity modification and rehabilitation will permit a gradual return to participation in sports. Some problems such as CECC, popliteal artery entrapment syndrome and nerve entrapment may require surgical intervention to allow the resolution of symptoms. Clinicians should be familiar with the range of problems causing leg pain in order to prescribe specific treatment for each athlete.

Fibromyalgia syndrome in children--an outcome study.

OBJECTIVE: To assess the outcome of fibromyalgia syndrome (FM) in a 30-month followup study of children with FM. METHODS: In the original study to assess the prevalence of FM in healthy schoolchildren, we found 21 children with FM and an additional 7 fulfilling the point count criterion only (11 of 18). Fifteen of the 21 and all 7 were recruited for a 2nd assessment in our present study. In all children, a count of 18 tender points (TP) was conducted by thumb palpation. Tenderness of 9 of the TP sites as well as 4 control point sites was further assessed using a Chatillon dolorimeter. All children were questioned concerning the presence of widespread pain or aching. Children were considered to have FM if they met the American College of Rheumatology criteria for diagnosis. RESULTS: After 30 months, 11 of the 15 children with FM (73%) were no longer fibromyalgic. The mean point count of the 15 children significantly decreased from 12.5 to 4.6 (p < 0.001). The mean tenderness threshold of the 9 tender sites increased from 2.4 to 3.4 kg (p < 0.01), and the mean tenderness threshold of the 4 control sites increased from 4.1 to 5.6 kg (p < 0.05). Of the 7 children initially fulfilling the point count criterion only, none had developed FM. Their mean point count decreased from 11.4 to 3.4 (p = 0.001), and their mean tenderness thresholds increased from 2.7 kg to 3.9 kg (p = 0.001) at tender sites and from 4.3 kg to 6.8 kg (p < 0.001) at control sites. CONCLUSION: We suggest that the outcome of FM in children is more favorable than in adults. More followup studies are needed to clarify the longterm outcomes of FM in children and adults.

Effect of anterior cruciate ligament deficiency on economy of walking and jogging.

The metabolic cost of walking and jogging following injury to the anterior cruciate ligament is unknown. Economy of motion refers to the oxygen consumption for a submaximal work rate. The purpose of this study was to compare the economy of walking and jogging of an anterior cruciate ligament-deficient population with that of a control population without orthopaedic abnormalities. Steady-state oxygen consumption was measured in 30 patients and 98 controls while they were on a treadmill at various speeds. Deficiency of the anterior cruciate ligament was diagnosed arthroscopically. The patients also were tested for isokinetic knee extension-flexion strength, hip flexion, and abduction and adduction strength and underwent arthrometric measurement of anterior tibial displacement. The patients had a statistically significant increase in oxygen consumption when jogging at 160.9 m/min (p = 0.007); however, there was no significant effect of anterior cruciate ligament deficiency on economy at the other speeds tested. The patients had significant deficits in strength of all muscle groups tested. Steady-state oxygen consumption at 160.9 m/min tended to be inversely related to the deficit of strength of knee flexion (r = -0.44, p = 0.07). Arthrometric measurements and chronicity of injury were unrelated to steady-state oxygen consumption. These data indicate that anterior cruciate ligament deficiency increases oxygen consumption during jogging. In long-distance running, this decreased economy translates into significant additional caloric requirements, which may result in earlier fatigue.

Peripheral nerve injuries in athletes. Treatment and prevention.

Peripheral nerve lesions are uncommon but serious injuries which may delay or preclude an athlete's safe return to sports. Early, accurate anatomical diagnosis is essential. Nerve lesions may be due to acute injury (e.g. from a direct blow) or chronic injury secondary to repetitive microtrauma (entrapment). Accurate diagnosis is based upon physical examination and a knowledge of the relative anatomy. Palpation, neurological testing and provocative manoeuvres are mainstays of physical diagnosis. Diagnostic suspicion can be confirmed by electrophysiological testing, including electromyography and nerve conduction studies. Proper equipment, technique and conditioning are the keys to prevention. Rest, anti-inflammatories, physical therapy and appropriate splinting are the mainstays of treatment. In the shoulder, spinal accessory nerve injury is caused by a blow to the neck and results in trapezius paralysis with sparing of the sternocleidomastoid muscle. Scapular winging results from paralysis of the serratus anterior because of long thoracic nerve palsy. A lesion of the suprascapular nerve may mimic a rotator cuff tear with pain a weakness of the rotator cuff. Axillary nerve injury often follows anterior shoulder dislocation. In the elbow region, musculocutaneous nerve palsy is seen in weightlifters with weakness of the elbow flexors and dysesthesias of the lateral forearm. Pronator syndrome is a median nerve lesion occurring in the proximal forearm which is diagnosed by several provocative manoeuvres. Posterior interosseous nerve entrapment is common among tennis players and occurs at the Arcade of Froshe--it results in weakness of the wrist and metacarpophalangeal extensors. Ulnar neuritis at the elbow is common amongst baseball pitchers. Carpal tunnel syndrome is a common neuropathy seen in sport and is caused by median nerve compression in the carpal tunnel. Paralysis of the ulnar nerve at the wrist is seen among bicyclists resulting in weakness of grip and numbness of the ulnar 1.5 digits. Thigh injuries include lateral femoral cutaneous nerve palsy resulting in loss of sensation over the anterior thigh without power deficit. Femoral nerve injury occurs secondary to an iliopsoas haematoma from high energy sports. A lesion of the sciatic nerve may indicate a concomitant dislocated hip. Common peroneal nerve injury may be due to a direct blow or a traction injury and results in a foot drop and numbness of the dorsum of the foot. Deep and superficial peroneal nerve palsies could be secondary to an exertional compartment syndrome. Tarsal tunnel syndrome is a compressive lesion of the posterior tibial nerve caused by repetitive dorsiflexion of the ankle--it is common among runners and mountain climbers.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic Knee Pain in Active Adolescents Don't Forget the Uncommon Causes.

In brief Chronic knee pain among active brief adolescents may be caused by a wide spectrum of conditions that range from generally benign, self-limited disorders, such as Osgood-Schlatter disease, to malignant osteosarcoma. Benign disorders account for the majority of knee pain in the adolescent athlete, and most causes are readily diagnosed. However, recognizing and treating the less common-often more serious-causes of chronic knee pain may be a greater challenge.

Brachial plexus injuries.

Brachial plexus injuries are not uncommon in sports. Knowledge of anatomy and neurophysiology is important to permit accurate diagnosis and institution of compressive treatment. Traumatic injuries can be caused by traction and compression. Unusual conditions such as acute brachial neuritis may also occur. Safe return to sports is permitted when strength party is achieved and rehabilitation is completed following neural recovery.

Rehabilitation of the injured athlete.

An increase in the rate of injuries has accompanied the boom in sports participation among children and adolescents. Accurate diagnosis, prompt treatment, and comprehensive rehabilitation are keys to the safe return of the young athlete to sports. Reacquisition of flexibility, strength, and endurance forms the basis of reconditioning. A graded reacclimatization to the demands of the sport allows the athlete to attain the preinjury level of skill. Psychological ramifications of injury such as fear, anger, and depression are to be expected and must be dealt with appropriately.

Femoral shaft stress fractures in athletes.

Stress fractures of the femoral shaft in athletes occur most commonly in the proximal third of the femur. They can, however, also be found in the mid- or distal third. Conservative treatment is highly successful in healing these fractures without complications. Athletes can usually return to activity in 8 to 14 weeks. Recognition of the symptoms characteristic of these fractures (vague thigh pain, diffuse tenderness, no trauma) will assist early diagnosis. Early definitive diagnosis can be made by radionuclide scanning or later, by plain radiography, if symptoms have been present for a sufficient period. Diagnosis is not limited to novice runners since runners with significant mileage, or baseball or basketball players, can develop femoral shaft stress fractures.

Stress fractures.

In general stress fractures can be readily diagnosed and easily treated. However, the clinician must always be alert to the unusual fracture or the uncommon potential complication. Prevention of stress fractures is certainly an achievable goal if attention is paid to training techniques, equipment, and athletic surfaces.

Acute brachial neuropathy in athletes.

Acute brachial neuropathy is an uncommon etiology of shoulder pain and disability. It can, however, present in association with athletic activity and therefore must be included in the differential diagnosis of athletes with such symptomatology. Findings that should alert the examiner to the possible presence of acute brachial neuropathy include 1) onset with noncontact as well as contact sports, 2) rather acute onset of pain without specific inciting trauma, 3) persistent, often severe pain that continues despite rest, 4) patchy brachial plexus and/or peripheral nerve involvement, and, 5) dominant arm predominance of symptoms and signs. Electromyography and nerve conduction studies often can confirm the diagnosis. Treatment begins with rest and continues through a rehabilitation phase. Followup of athletes with acute brachial neuropathy discloses that weakness may persist in the affected muscles. Absolute strength parity may be difficult to achieve, so permission to participate in athletics must be given on a case by case basis.

Overuse Injuries In Children and Adolescents.

In brief: Athletic injuries among children often fall into the category of overuse, with mechanisms similar to overuse injuries in adults. However, the implications for young, growing athletes are much different because the growth plates are involved, resulting in such problems as traction apophysitis and Little League elbow. Early, appropriate intervention, which sometimes includes cessation of certain athletic activity, can prevent potential long-term complications in growing athletes.

Osteoid osteoma in a cervical pedicle. Resection via transpillar approach.

Lesions in the pedicles of the cervical spine are both a diagnostic and technical challenge. An osteoid osteoma of the pedicle of the fourth cervical vertebra occurred in a 17-year-old girl. Resection of the tumor adjacent to the dura medially and the vertebral artery anterolaterally was accomplished via a transpillar approach. The transosseus approach preserved the facet joints and posterior elements and obviated the need for an interbody fusion.

Correction of chin-on-chest deformity in ankylosing spondylitis through a fracture site. A case report.

Correction of flexion deformity is possible in patients with a fracture through the ankylosed spine. In a 68-year-old man the correction was sustained by skull tong traction, while the neurologic condition was monitored. Posterior fusion may improve stability as the bone of patients with ankylosing spondylitis tends to be osteoporotic.

Inframeniscal approach for arthroscopic resection of tears of the posterior one-third of the medial meniscus.

Arthroscopic resection of tears of the posterior third of the medial meniscus may be difficult. Meniscectomy by use of routine portals superior to the meniscus is difficult in knees in which valgus stress does not allow access to the posterior meniscus. The operation may be facilitated by the use of portals inferior to the meniscus. This inframeniscal approach avoids the problem of excessive scuffing, possible medial collateral ligament sprain, and the need for a posterior medial portal.

The profile for prevention of musculoskeletal injury.

The musculoskeletal injury prevention profile has three components, namely, the performance demands of the sport, the risk factors, and the individual musculoskeletal examination. The examination consists of a history including the patient's exercise equipment and program, diet, and medication as well as a physical examination designed to quickly elicit areas that may harbor orthopedic pathology.

Salvage of bilateral knee arthroplasties with Pseudomonas infection. A case report.

The treatment of infection after knee arthroplasty presents difficult medical and technical problems. Adequate control of the infection by appropriate antibiotic treatment and arthrodesis is no longer the only alternative to surgical management of the infected implant. Successful reimplantation can be achieved, although the quality of arthroplasty is often inferior to that of noninfected per primam arthroplasty.

Arthroscopic meniscectomy: a follow-up report.

Eighty patients who underwent arthroscopic meniscectomy were interviewed and examined 12 to 24 months postoperatively. Twenty-seven (34%) of the patients rated their knees as normal, and 46 (58%) of the patients rated their knees as improved. Seventy-nine percent of the patients were pain free at the time of followup. Patients with poor results were likely to have significant degenerative disease or instability. Sixty-five percent of the patients returned to their original sport. Factors limiting patients' return to sports after meniscectomy included instability, patellofemoral disease, and degenerative arthritis.