Inducing Ulnar Nerve Function while Eliminating Claw Hand and Reducing Chronic Neuropathic Pain.

Ulnar nerve injury induces chronic neuropathic pain and is frequently devastating due to loss of cupping the hand around objects (finger clawing) and diminished grip strength. There is little chance of restoring good function, eliminating finger clawing, or reducing the pain. A novel technique was tested for its efficacy in promoting ulnar nerve function and reducing finger clawing and chronic neuropathic pain. A 25-year-old subject presented 5.7 months after a wrist gunshot that created three nerve gaps proximal to the deep ulnar nerve branch. He sought restoration of function due to developing ulnar nerve injury-induced claw hand and increasingly severe chronic neuropathic pain. After resection of the scarred nerve tissue, each gap was 10 cm long. The gaps were bridged with two nonreversed sural nerve grafts within a PRP-filled NeuroMend collagen tube (Collagen Matrix, Oakland, N.J.). Some axons regenerated entirely across all three 10-cm-long repaired nerve gaps, restoring excellent topographically correct sensitivity of S4, including two-point discrimination of 4 mm, good M4 motor function, and full ROM. The ulnar nerve injury-induced finger clawing was eliminated, and the chronic neuropathic pain of 7 was reduced to 0 on a 0-10 validated scale and did not return over the following 3.75 years. Thus, this novel technique induces good sensory and motor function, despite repairing three 10-cm-long nerve gaps while eliminating ulnar nerve injury-induced hand clawing and chronic neuropathic pain. Further studies are required to determine whether the effects were due to PRP.

Return-to-Competition Progression After Exertional Heat Stroke in an Adolescent Runner: A Case Report.

A 14-year-old runner indigenous to the tropics collapsed during his first 10-km race in a hot and humid climate. Dizziness, stumbling, and loss of consciousness were symptoms of exertional heat stroke. Two days postcollapse, blood tests revealed elevated hepatic transaminases consistent with hepatic injury. We discuss the return-to-competition progression, which included a gradual increase in exercise duration, initially in a cool and then in a tropical climate, and 2 field-based (wet-bulb globe temperature > 29.0°C) running evaluations that simulated the environmental conditions and training intensity the athlete would encounter in his sport. The thermoregulatory results guided the training progression, his tolerance to running in the heat improved, blood values normalized, and he was cleared to compete in a tropical climate. This exploration case report presents a novel field-based protocol that replicates the physiological demands of training in the tropics to evaluate thermoregulatory responses during exercise-heat stress in young runners after exertional heat stroke to facilitate a safe return to competition.

Evidence for isokinetic and functional testing in return to sport decisions following ACL surgery.

The rupture and reconstruction of the anterior cruciate ligament (ACL) of the knee are associated with an increased risk of functional instability, a reduction in sports performance, and a higher risk of future additional injuries. Competitive athletes who participate in sports that require pivoting, cutting, and jumping are at particularly high risk for ACL rupture. The return to sport progression continuum after surgery includes sports-specific rehabilitation, evaluation of strength and function, gradual participation in exercise training with progressively challenging activities in the field of play, participation in sports at a lower level, and finally a return to preinjury-level sports competition. This narrative review evaluates the evidence that supports the use of quadriceps and hamstrings isokinetic strength testing and sports-specific functional skills assessments to evaluate progress with rehabilitation after ACL surgery. Strength evaluations, hop tests, agility tests, and the limb symmetry index are described, as well as the associations of quadriceps and hamstrings muscle strength and functional test results with successful return to sports and the risk of ACL graft rupture and contralateral knee injuries. Suggestions for future research directions are presented including the importance of presurgery testing, standardization of test batteries, and comparison of test results with normative data.

Functional Recovery following Repair of Long Nerve Gaps in Senior Patient 2.6 Years Posttrauma.

Sensory nerve grafts are the clinical "gold standard" for repairing peripheral nerve gaps. However, reliable good-to-excellent recovery develops only for gaps less than 3-5 cm, repairs performed less than 3-5 months posttrauma, and patients aged less than 20-25 years. As the value of any variable increases, the extent of recovery decreases precipitously, and if the values of any two or all increase, there is little to no recovery. One 9-cm-long and two 11-cm-long nerve gaps in a 56-year-old patient were repaired 2.6 years posttrauma. They were bridged with two sensory nerve grafts within an autologous platelet-rich plasma-filled collagen tube. Both were connected to the proximal ulnar nerve stump, with one graft end to the distal motor and the other to the sensory nerve branches. Although presurgery the patient suffered chronic level 10 excruciating neuropathic pain, it was reduced to 6 within 2 months, and did not increase for more than 2 years. Motor axons regenerated across the 9-cm gap and innervated the appropriate two measured muscles, with limited muscle fiber recruitment. Sensory axons regenerated across both 11-cm gaps and restored normal topographically correct sensitivity to stimuli of all sensory modalities, including static two-point discrimination of 5 mm, and pressure of 2.83 g to all regions innervated by both sensory nerves. This novel technique induced a significant long-term reduction in chronic excruciating neuropathic pain while promoting muscle reinnervation and complete sensory recovery, despite the values of all three variables that reduce or prevent axon regeneration and recovery being simultaneously large.

Rehabilitation Management of Rotator Cuff Injuries in the Master Athlete.

Rotator cuff (RTC) injuries are common in master athletes, especially overhead athletes. Risk factors include aging and degeneration as nonmodifiable and volume of activity, muscle weakness, and loss of motion as modifiable. The clinical presentation involves limited range of motion (ROM), pain at rest and at night. Injury classification into traumatic versus nontraumatic and tendinopathy, partial or full-thickness tears helps to establish a treatment plan. RTC injury rehabilitation protocols are criteria-based, multimodal, and divided into four phases. The acute phase addresses pain, inflammation, ROM, and RTC protection. The recovery phase addresses kinetic chain abnormalities, flexibility, and strength, and the functional phase involves exercises directed toward specific sport activities. Return to sports is based on clinical recovery, kinetic chain principles, and adequate sports technique. Nonsurgical management is recommended in most cases, and surgical management is considered if symptoms progress, especially for full-thickness tears.

Comparison of the pattern of injuries in children and adult athletes. The first 10 years experience at the Olympic Training Center.

OBJECTIVES: The purpose of this study was to compare the pediatric and adult populations that receive treatment in our Inter-disciplinary Clinic to distinguish possible differences in their sports practice and the nature of their sports injuries. BACKGROUND: With increasing frequency, younger children are getting involved in competitive or recreational sports. Due to the level of participation in competitive athletics and the inherent risk such participation seems to imply, it has become apparent that consideration must be given to the injury problems associated with sports. METHODS: The patient population studied includes recreational and competitive athletes. All new cases seen between April 1988 and April 1997 were included. Before 1990, all data was collected retrospectively from medical charts and after 1990 it was collected prospectively. RESULTS: Of the total of 2579 patients seen, 1368 (53%) were under 21 years of age and 1211 (47%) were 21 or older. The most frequent practiced sports in both populations were baseball (17.6% in children, 15.1% in adults), track and field (12.9%, 13.4%) and basketball (12.1%, 10.8%) and the most commonly affected anatomical areas were the knee (29.8%, 32.9%) and the shoulder (16.6% and 14.7% respectively). Injuries were mostly chronic (63.6% and 72.1%), traumatic in nature (48.1%) in children and mostly overuse lesions (46.6%) in adults. The most common diagnoses in both populations was tendinitis (21.5% and 23.7%) and first degree strains. Conservative treatment was given regardless of age. CONCLUSIONS: The role of the rehabilitation interdisciplinary team is gaining growing importance in the therapy of children and adults with sport injuries. Further research to better understand the pattern of athletic injuries in the pediatric population is essential for effective injury prevention, treatment and rehabilitation.

Complex regional pain syndrome in pediatric sports: a case series of three young athletes.

SETTING: Outpatient Sports Medicine Clinic. PATIENTS: Three adolescent young female athletes who developed clinical findings compatible with complex regional pain syndrome (CRPS) after lower extremity trauma. INTERVENTION: Based on the clinical picture, the patients were identified and treated with physical therapy, which included desensitization techniques, stress loading, edema control, early mobilization and electrical stimulation. It was combined with pharmacotherapeutic measures such as non-steroidal anti-inflamatories, oral corticosteroids and gabapentin. One of the patients required serotonin selective reuptake inhibitors, opioid analgesics and acupuncture as an adjunctive treatment. RESULTS: All three patients had involvement of the lower extremities, with a degree of pain and edema exceeding the expected for the nature of their injury. They exhibited a good response to conservative treatment, with physical therapy playing a significant role on the treatment plan. One of the patients, whose diagnosis and treatment was delayed due to late referral, had a more severe presentation and protracted recovery. CONCLUSION: CRPS is a challenging disease that may affect young active and athletic patients. In this population, early clinical suspicion and aggressive treatment may lead to excellent clinical results and the avoidance of invasive procedures or long-term disability. Laboratory and imaging studies should be used to discard other conditions with clinical presentations similar to CRPS.

Rehabilitation update for the anterior cruciate ligament injured patient: current concepts.

The anterior cruciate ligament is an intra-articular structure of the knee essential for both static and dynamic stability. It is commonly injured during sports activities by a noncontact mechanism. Several modifiable and nonmodifiable risk factors predispose athletes to this injury, especially females. Early diagnosis and rehabilitation play an important role in its management, including both conservative and surgical treatment. Even though no specific guidelines are available in regards to which is the best alternative, criteria such as pain, instability episodes, secondary structures injuries, and pre-injury level of activity should be considered. Rehabilitation protocols for both conservative and surgical reconstruction are available and recommended approach to avoid complications. However, injury prevention protocols emphasizing on modifiable risk factors seem to be the next big step in management for the anterior cruciate ligament.

Patterns of injuries in athletes evaluated in an interdisciplinary clinic

The pattern of sports injuries appears to be population-specific. The purpose of the present study is to describe 1750 injuries evaluated between April 1988 and April 1994 in our Olympic Training Center Interdisciplinary Sports Injury Clinic. Our patient population included elite and recreational athletes of both sexes between the ages of 7 and 71 years. Males comprised 73 per cent of the patient population and approximately 80 per cent of the injuries corresponded to the 10 to 29 age range. The most frequent sports in males were baseball (21.9 per cent ) and basketball (15.9 per cent ) and in females were track and field (17.1 per cent ) and gymnastics (15.1 per cent ). Most injuries (52 per cent ) were traumatic in nature, chronic (71.6 per cent ), and occurred during training sessions (57.4 per cent ). The most commonly affected anatomical areas were the knee (31.2 per cent ) and shoulder (15.5 per cent ). The most common diagnoses were tendinitis (25.4 per cent ), and first degree strains (11.8 per cent ) and sprains (9.3 per cent ). Finally, treatment strategies included medications (61.0 per cent ), physical therapy (48.9 per cent ), relative rest (35.7 per cent ), and home exercise programs (35.2 per cent ). The variety of musculoskeletal disorders seen in combination with the frequent use of conservative treatment confirms the importance of an interdisciplinary approach to sports injuries

Fitness and the disabled

With improved long term survival of the disabled patient the incidence of cardiovascular disease is increasing in this population. One important factor is the low levels of physical activity of disable individuals. Disabled patients respond similarly to their able bodied counterparts to raining programs of a frequency, intensity, and duration which permit improving their level of fitness. Training programs should include aerobic and streghening exercises with goals of reducing the risk of cardiovascular disease and increasing the level of funcitonal independence. This review will discuss the rationale for inproving fitness levels in the disabled as well as exercise testing and training in this population