Cold weather training: a risk factor for Achilles paratendinitis among recruits.

In a prospective study of risk factors for Achilles tendinopathy among four induction cycles of infantry recruits, 95 out of 1405 recruits, (6.8%) were found to suffer from Achilles tendinopathy. In more than 94% of the cases, the tendinopathy was considered to be paratendinitis. Training season had a statistically significant effect on the incidence of Achilles paratendinitis with 3.6% suffering in the summer and 9.4% in the winter (p = .001). This increased risk for Achilles paratendinitis in cold weather outdoor training can be explained by a fall in temperature of the Achilles paratenon whose membranes are rich in mucopolysaccharides and serve as a lubricant for gliding of the tendon and epitenon. Decreased temperature may increase the viscosity of the lubricant and thereby increases friction and risk for Achilles paratendinitis. This same relationship illustrates why "warming up" before exercising may be important in lowering the incidence of Achilles paratendinitis.

Incremental diagnostic value of 99mTc methylene diphosphonate bone SPECT in patients with patellofemoral pain disorders.

Painful disorders of the patellofemoral joint are one of the most frequent complaints in orthopaedic and sports medicine. The purpose of this study was to assess the value of single photon emission computed tomography (SPECT) bone imaging compared with arthroscopy in the differential diagnosis of anterior knee pain. Twenty-seven patients with chronic anterior knee pain and 27 age matched control patients were examined prospectively. All patients underwent a detailed clinical history and a thorough physical examination of the knee. Planar and SPECT knee scintigraphy was performed using 99mTc methylene diphosphonate (99mTc-MDP). Subsequently, arthroscopic examination of all three compartments of the affected knee was performed. The association between the scintigraphic findings and arthroscopy was examined statistically. Planar and SPECT scintigrams were classified as follows: focal or diffuse uptake in the patella only (eight patients), uptake in the patella and a corresponding focus in the distal femur (12 patients), and uptake in the patella associated with linear increased activity along the distal femur (six patients). One patient had no patellofemoral SPECT abnormalities. Six of eight patients with isolated increased patellar activity were diagnosed with chondromalacia of the patella, while 2/8 patients had arthroscopic findings unrelated to patellofemoral abnormalities. Seven of 12 patients with corresponding uptake in the patella and distal femur were diagnosed with patellofemoral arthritis. Eleven other patients with corresponding patellar and femoral activity were diagnosed with increased lateral patellar compression syndrome. In these patients the patellar foci were always lateral, and they separated during flexion of the knee. Seven patients had further scintigraphic findings in addition to patellofemoral abnormalities, unsuspected clinically. Nine of 27 patients in the control group (33%) had either focal or diffuse increased patellar uptake. Compared to arthroscopy SPECT imaging had a sensitivity of 100% for patellofemoral abnormalities and a specificity of 64% (negative predictive value, 100%; and positive predictive value, 72%). The overall observed agreement between SPECT and arthroscopy was 81% (kappa=0.63). It is concluded that SPECT imaging of the knee is highly sensitive for the diagnosis of patellofemoral abnormalities. SPECT significantly improves the detection of maltracking of the patella and the ensuing increased lateral patellar compression syndrome. This information could be used to treat patellofemoral problems more effectively.

Comparison of mortality and myocardial infarction rates in stable angina pectoris with and without ischemic episodes during daily activities.

The prognostic significance of ischemic changes during daily activities was assessed in 56 patients with stable angina pectoris. All patients had positive results on the treadmill stress test and angiographic evidence of significant coronary artery disease. Forty-three (77%) had ischemic episodes on Holter monitoring during everyday activities. During the follow-up period (mean 2 years), there were 6 deaths and 6 myocardial infarctions among the 43 patients with ischemic episodes, compared with none among the 13 patients without such changes (p less than 0.03). All 14 patients referred for coronary bypass surgery belonged to the group with ischemic episodes (p less than 0.02). The extent of coronary disease, the treadmill test parameters, and the duration and frequency of ischemia during daily activities were identical in the patients with and without subsequent cardiac events. Patients with only symptomatic ischemic episodes or those with both silent and symptomatic episodes had a frequency of cardiac events similar to that of patients with only silent episodes. Thus, it seems that patients with stable angina pectoris and ischemic episodes during daily activities have a worse prognosis than patients free from such episodes.

Prognostic significance of ischemic episodes in patients with previous myocardial infarction.

This study assessed the prognostic significance of ischemic changes during daily activity as recorded by ambulatory electrocardiographic monitoring in a group of 224 low-risk postinfarction patients. Of the 224 patients studied, 74 (33%) had transient ischemic episodes on Holter monitoring. During the 28 months of follow-up the frequency of cardiac events (cardiac death, reinfarction, hospitalization for unstable angina, balloon angioplasty or coronary bypass surgery) was 51% among those with ischemic episodes on Holter monitoring, compared with 12% in those without such changes (p less than 0.0001). The 74 patients with positive results in their exercise tests and Holter monitoring had a 51% event rate, compared with 20% among the 44 patients with a positive exercise test result but negative Holter results (p less than 0.001). The event rate in those without ischemic changes either on the exercise test or on Holter was only 8.5%. Among patients with good (greater than 40%) or reduced (less than 40%) left ventricular ejection fraction, those with transient ST depression on Holter had a significantly higher cardiac event rate compared with those without it. A similar event rate was found in patients with only silent, only symptomatic and with silent and symptomatic ischemic episodes.

Clinical outcome of silent myocardial ischemia.

Asymptomatic coronary artery disease can be detected by an abnormal electrocardiogram at rest, by a positive exercise test result unaccompanied by pain, or by the demonstration of silent ischemic episodes during daily activities. However, the clinical outcome of patients with silent myocardial ischemia has not yet been clearly defined. In a study of 356 patients with documented coronary disease--211 of whom had previous myocardial infarction--the prognostic information of spontaneous ST-segment depression was found to be independent of that associated with a positive exercise test result, ejection fraction, and extent of arteriographically documented coronary artery disease. Patients with asymptomatic ischemia had a higher coronary event rate than those without ischemia. Cardiac event rates followed a similar pattern for patients with silent, symptomatic and mixed ischemia--whether or not there was previous myocardial infarction.