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Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Gymnast wrist pain presents a difficult diagnostic and therapeutic challenge. Here, we present a new case of extensor tendon impingement in an elite gymnast. To our knowledge, there is no similar report in the literature.
OBJECTIVE: To determine if Active Release Technique (ART) protocols could be used as an effective way to influence strength and muscle inhibition in the quadriceps muscles of athletes with anterior knee pain. DESIGN: Pilot clinical outcome study. METHODS: The sample consisted of 9 athletes (4 male athletes, 5 female athletes) who were identified as suffering from unilateral anterior knee pain. A Biodex dynamometer and the interpolated twitch technique were used to determine isometric strength and inhibition in the quadriceps muscles, respectively. The treatment intervention consisted of the Active Release Technique treatment protocols for anterior knee pain. The experimental leg and contralateral leg were tested pretreatment and posttreatment, and the experimental leg was tested a third time approximately 20 minutes posttreatment. RESULTS: Knee extensor moments were calculated by multiplying the moment arm by the forces measured by the Biodex dynamometer. Percentage of muscle inhibition was calculated by dividing the interpolated twitch torque (ITT) by the resting twitch torque (RTT), that is (ITT/RTT*100). A repeated measures analysis of variance (ANOVA) was used to compare pretreatment and posttreatment values for strength and muscle inhibition for the experimental and contralateral knees. The results showed no statistical significance. CONCLUSION: ART protocols did not reduce inhibition or increase strength in the quadriceps muscles of athletes with anterior knee pain. Further study is required.
OBJECTIVE: To discuss the assessment, diagnosis and chiropractic management of a patient with sacroiliac joint dysfunction (SIJ) complicated by psoas major snapping hip syndrome (coxa saltans interna). CLINICAL FEATURES: A 32-year-old male marathon runner experienced low-back and left hip pain without radiation accompanied by a "popping" in the anterior hip. He ran approximately 100 to 150 km/wk for the prior 3 years. He had stopped running for the previous 3 weeks because of worsening and consistent pain. INTERVENTION AND OUTCOME: Treatment consisted of side posture SIJ "diversified" manipulation and myofascial release to the psoas muscle twice weekly for 2 weeks. The patient was also taught proprioceptive neuromuscular facilitation exercises of the psoas and iliotibial band muscles. He was instructed to substitute swimming instead of running on a daily basis. Reassessment at 3 weeks found the patient without pain in his hip or back and no clicking or popping in his left hip. CONCLUSION: Clinicians should consider that runners who present with coexisting SIJ dysfunction and internal snapping hip syndrome may benefit from the combined management of both conditions.
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We examined cytokines in rat median nerves following performance of a high repetition reaching and grasping task at a rate of 8 reaches/min for up to 8 weeks. IL-1alpha, IL-1beta, TNF-alpha, IL-6 and IL-10 were analyzed by immunohistochemistry. Double-labeling immunohistochemistry for ED1, a marker of phagocytic macrophages, was also performed. We found increased immunoexpression of IL-6 by week 3, increases in all 5 cytokines by week 5. This response was transient as all cytokines returned to control levels by 8 weeks of performance of a high repetition negligible force task. Cytokine sources included Schwann cells, fibroblasts and phagocytic macrophages (ED1-immunopositive). These findings suggest that cytokines are involved in the pathophysiology of repetitive motion injuries in peripheral nerves.
Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present-but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.
Lateral epicondylosis is a degenerative overuse tendinopathy involving the extensor tendons of the forearm, predominantly the extensor carpi radialis brevis, in the region of the lateral epicondyle of the elbow. The Orthopaedic Research Institute-Tennis Elbow Testing System (ORI-TETS) is designed to record objective measurements of force generated with a simulated chair pick-up test. Interrater reliability of the ORI-TETS was excellent, with high intraclass correlation coefficients (ICCs) for right arm mean peak force of 0.93, left arm mean peak force of 0.84, right arm mean total force of 0.93, and left arm mean total force of 0.86. The ORI-TETS also demonstrated excellent intrarater reliability, with ICCs ranging from 0.9 to 0.97. The relative technical error of the ORI-TETS for all measurements ranged from 5.8% to 7.2%. Testing patients with lateral epicondylosis (N = 16) and comparing analog pain scores with ORI-TETS testing demonstrated a strong negative relationship between the two parameters (Spearman rho, -0.87 to -1.0). Thus, the ORI-TETS is a reliable and reproducible testing system for the forearm extensors. The testing system is inexpensive, takes 5 minutes to perform, and demonstrates good predictive value for objectively assessing patients with lateral epicondylosis. This system could be used for routine clinical monitoring of patients with lateral epicondylosis.
The purpose of this study was to determine the biomechanical and anthropometric factors contributing to elbow valgus torque during pitching. Video data of 14 youth pitchers throwing fastballs were used to calculate shoulder and elbow kinematics and kinetics. Peak elbow valgus torque averaged 18 Nm and occurred just before maximal shoulder external rotation. The magnitude of valgus torque was most closely correlated with the thrower's weight. When subject weight and height were controlled for, maximum shoulder abduction torque and maximum shoulder internal rotation torque were most strongly associated with elbow valgus torque, accounting for 85% of its variance (P <.001). When only kinematic variables were considered, maximum shoulder external rotation accounted for 33% of the variance in valgus torque. Given that the biomechanical variables correlated with peak valgus torque are not easily modifiable, limiting the number of innings pitched is likely the best way to reduce elbow injury in youth pitchers.
The first case of an aneurysm of the femoral artery occupationally exposed to a vibratory tool is described. A 72-year-old man with a right common femoral artery aneurysm had had an occupational history of putting a "breaker," which breaks concrete into pieces by means of powerful vibration, on the right groin for more than 10 years. The patient underwent aneurysmectomy and graft replacement, with reconstruction of the deep femoral artery. Pathologic examination of the resected aneurysm revealed fibrosis and lipid deposition in the intima, well-maintained elastic fibers without disruption in the media, and thickened adventitia, in place of the typical findings of atherosclerosis.
Digital artery embolization and ulnar artery thrombosis are consequences of repetitive trauma and can lead to digit loss and debility from ischemia and cold intolerance. We postulate that an arterial autograft is a theoretically superior conduit to traditional saphenous vein, and report reconstruction with inferior epigastric artery. Three adult male smokers, ages 39 to 49 years, had severe digital ischemia and cold-induced vasospasm. Arteriograms confirmed occlusion of the distal ulnar artery without direct perfusion of the superficial palmar arch, distal digital artery embolization, and normal proximal vasculature. All reconstructions were performed from the distal most patent ulnar artery at the wrist to the superficial palmar arch (1 patient) or sequentially to the involved common digital arteries (2 patients), with inferior epigastric artery. Handling characteristics and size match between the arterial autografts and bypassed arteries was excellent. Patency has been confirmed with duplex scanning at follow-up of 8 to 24 months, with resolution of cold intolerance and successful digital preservation.
We present the case of a 28-year-old competitive runner with iliotibial band (ITB) friction syndrome associated with a synovial cyst. Magnetic resonance imaging (MRI) did not demonstrate a fluid collection. However, open exploration revealed a large cyst beneath the ITB arising from the capsule of the knee proximal to the lateral meniscus. The cyst disappeared on extension. The pre-operative MRI scan may have revealed the cyst, if it had been taken with the knee flexed.
Pathology of the sesamoid bones have been rarely described in the literature especially those of the index. We present the case of a 45 years old amateur tennis player who presented with pain on the radial border of the index finger at the level of the metacarpophalangeal joint. The clinical examination and the operative findings allow us to conclude that the symptoms were due to tendinitis of the flexors of the index associated with fracture of the sesamoid and cartilaginous degenerative changes. We also present a review of the literature.
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Iliotibial band friction syndrome (ITBFS) is a common injury of the lateral aspect of the knee particularly in runners, cyclists and endurance sports. A number of authors suggest that ITBFS responds well to conservative treatment, however, much of this opinion appears anecdotal and not supported by evidence within the literature. The purpose of this paper is to provide a systematic review of the literature pertaining to the conservative treatment of ITBFS. A search to identify clinical papers referring to the iliotibial band (ITB) and ITBFS was conducted in a number of electronic databases using the keyword: iliotibial. The titles and abstracts of these papers were reviewed to identify papers specifically detailing conservative treatments of ITBFS. The PEDro Scale, a systematic tool used to critique randomized controlled trials (RCTs), was employed to investigate both the therapeutic effect of conservative treatment of ITBFS and also to critique the methodological quality of available RCTs examining the conservative treatment of ITBFS. With respect to the management of ITBFS, four RCTs were identified. The interventions examined included the use of non-steroidal anti-inflammatory drugs (NSAIDs), deep friction massage, phonophoresis versus immobilization and corticosteroid injection. This review highlights both the paucity in quantity and quality of research regarding the conservative treatment of ITBFS. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of ITBFS. Future research will need to re-examine those conservative therapies, which have already been examined, along with others, and will need to be of sufficient quality to enable accurate clinical judgements to be made regarding their use.
Tendon overuse injuries are common athletic and occupational problems. When studying mechanisms that cause these injuries, inherent complexities associated with controlling in vivo loading necessitates alternative approaches such as in vitro organ culture. Current devices for loading explants in organ culture, whether custom-built or commercial, have various deficiencies in their loading capability, control mechanism and strain assessment. To overcome these shortcomings, an advanced tissue loading device with video strain analysis capabilities was developed for investigating overuse injuries and its performance/calibration were evaluated. Two tests were used to assess the ability of the system to create and monitor mechanical changes with overuse. Overuse loading significantly increased strains and decreased strength, showing the ability of this system to create and monitor tissue damage. Furthermore, the device design allows for its use in a standard incubator. Coupled with custom loading and data collection programs, this system is suitable for long-term overuse injury studies.
In this paper the current theories on how osteoarthritis (OA) may be initiated and progressed is described. This is done in relation to the biomechanical events that would predispose the joint to the degenerative process, as well as further progression of the process within an 'OA' cycle. The relationship between the types of loading to the type of joint damage that occurs is discussed. Subsequently the influence on the rate at which OA progresses from the trauma, is presented within a hypotheses matrix. For the type of tissue damage, four phases are distinguished, phase I: superficial cells or matrix only, phase II: deeper chondral region, phase III: the tidemark or calcified region, and phase IV: subchondral bone region. The biomechanical event (A) is stipulated as having a possibility of six outcomes. (A3) is the direct damage to the calcified cartilage near the tidemark that leads most rapidly into the cycle for OA to develop and progress. Another three outcomes (A1, A2 and A4) involve damage to regions other than the calcified cartilage near the tidemark. These three outcomes involve the cells or matrix, chondral or subchondral regions. It is hypothesised that damage involved in one of these three outcomes results in all likelihood to a new level of joint deficiency or vulnerability. This new predisposition could lead to A3 type outcome and directly into the OA progression cycle or result in more A1, A2 or A4 type outcomes which remains out of the OA cycle. The biomechanical events are therefore used to predict the risk of mechanically driven OA and the rapidity in which it progresses in relation to joint loading.
Research on atrial fibrillation (AF), a common heart arrhythmia in the elderly, over many decades has resulted in a literature of more than 16,000 articles indexed in Medline. An exploratory Medline search was conducted in which the subheadings for epidemiology and etiology of AF were combined to form a small subset of the initial records. Further computer-assisted selection led to a few articles that reported an unexpectedly high prevalence of AF in groups of otherwise healthy middle-aged endurance runners and other athletes. Why athletes should be unusually susceptible to AF is mysterious and puzzling. Because relatively few articles are about both AF and endurance exercise, a computer was used first to create a list of important terms that these two separate literatures had in common. Several inflammation-related terms, including C-reactive protein (CRP) and interleukin-6, were on that list. Further searching and literature analysis revealed that excessive endurance exercise or overtraining can lead to chronic systemic inflammation and, separately, that there is a solid association between CRP and AF and that anti-inflammatory agents have been reported to lower CRP and ameliorate AF. No articles were found that brought together all three concepts - AF, inflammation, and exercise. The following hypothesis is plausible, readily testable, and apparently novel: Older athletes diagnosed with AF but otherwise healthy who have engaged in rigorous aerobic endurance exercise for more than a decade will have CRP levels that are higher than those of a similar population of athletes without AF. Corroboration of this hypothesis would then justify a prospective clinical trial of anti-inflammation therapy. It is of particular interest to extend recent studies of inflammation in AF to athletes; athletic behavior that can induce inflammation may contribute to understanding the origins of AF.
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