Chronic Exertional Compartment Syndrome Treated With Botulinum Toxin-A Yielding 36-Month Total Symptom Relief: A Case Report.

Chronic exertional compartment syndrome (CECS) can be a debilitating condition observed in athletes, including military service members. Surgical fascial release, first described in 1956, has long been a standard treatment despite symptom recurrence in up to 45% of surgically treated military service members. A 2013 case series introduced intracompartmental Botulinum Toxin-A (BoNT-A) injections as a nonsurgical CECS treatment option, demonstrating efficacy for 15 of 16 patients. At the time of this submission, two additional case reports addressing BoNT-A injections for CECS have occurred. This case report describes a U.S. Military service member treated with ultrasound-guided BoNT-A for bilateral lower leg CECS. This patient achieved pain-free activities for 36 months with one treatment. This case, coupled with additional literature, supports consideration of BoNT-A as a potential long-term, nonsurgical alternative for CECS.

Occupational Injuries in Musicians: A Literature Review.

INTRODUCTION: The U.S. Department of Defense employs more musicians than any other organization in the USA with over 6,000 musicians employed. Musculoskeletal pathologies, behavioral health disorders, hearing loss, and dystonias account for the majority of reasons a musician seek medical care. The aim of this study is to review recent medical literature documenting occupational hazards in musicians. MATERIALS AND METHODS: Authors performed a literature review of publications related to musician performance-related musculoskeletal disorders (PRMDs) and performance-related pain (PRP), behavioral health disorders, dystonias, and hearing loss, published from 2004 to 2019 PubMed. RESULTS: The search returned 174 possible articles which, after review and exclusion, yielded 88 articles. CONCLUSIONS: Medical literature suggests several risk factors for multiple disease categories. Practice time and history of PRMD/PRP were both associated with development of PRMD/PRP and focal dystonia. A history of behavioral health disorder was associated with development of focal dystonia. Clinicians should counsel their musician patients on strategies to minimize risks, and additional research is needed to identify specific causes of illnesses in musician populations.

Facile access to foldable redox-active flavin-peptide conjugates.

A convenient approach for the synthesis of foldable redox-active flavin peptide conjugates was established. A model ß-hairpin oligopeptide motif was utilized to demonstrate that azidolysine side-chains are readily functionalised with an alkyne-bearing flavine derivative. The folding equilibrium of the peptide backbone as well as the redox behaviour of the flavin moieties remains intact after the conjugation.

Point-of-Care Ultrasonography.

Point-of-care ultrasonography (POCUS) is performed by a physician at the bedside and is standard practice in obstetric, emergency, and musculoskeletal medicine. When compared with formal sonography, POCUS is equivalent in screening for abdominal aortic aneurysm and as accurate in diagnosing deep venous thrombosis. POCUS has high accuracy for diagnosing pneumonia and detecting acute decompensated heart failure but is less accurate than computed tomography for identifying pulmonary embolism. POCUS confirmation of intrauterine pregnancy rules out an ectopic pregnancy. In the third trimester of high-risk pregnancies, umbilical artery Doppler ultrasonography can improve perinatal outcomes. Musculoskeletal POCUS is used to diagnose and guide treatment of many joint and soft tissue conditions. It is as accurate as magnetic resonance imaging in the diagnosis of complete rotator cuff tears. Ultrasound guidance improves outcomes in the placement of central venous catheters and fluid drainage from body cavities and lumbar punctures. Ultrasonography can reduce the use of CT for diagnosis of appendicitis; however, negative scan results do not rule out disease. POCUS can accurately diagnose and rule out gallbladder pathology, and is effective for diagnosing urolithiasis. Focused cardiac ultrasonography can detect pericardial effusion and decreased systolic function, but is less accurate than lung ultrasonography at diagnosing acute heart failure. Limited evidence demonstrates a benefit of diagnosing testicular and gynecologic conditions. The American College of Emergency Physicians, the American Institute of Ultrasound in Medicine, the Society for Academic Emergency Medicine, the American College of Radiology, and others offer POCUS training. Training standards for POCUS have been defined for residency programs but are less established for credentialing.

Sports Medicine: Preparticipation Cardiovascular Screening and Evaluation of Adults.

Sudden cardiac death in athletes is a relatively uncommon but devastating event. To prevent such deaths, multiple national and international organizations have created preparticipation evaluation recommendations for cardiovascular screening in adult athletes, care of athletes with cardiovascular disease, and physical examinations. Preparticipation cardiovascular screening of athletes should include the American Heart Association 14-point questionnaire to assess for risk. Exercise stress testing is recommended for athletes with a moderate to high risk of coronary heart disease who want to participate in vigorous athletic activities. Routine preparticipation electrocardiogram is an area of considerable debate, although it does appear to increase early detection of some cardiac disease associated with sudden cardiac disease. An understanding of the basic aspects of initial preparticipation evaluation of adult athletes is essential for family physicians. Recommendations from evidence-based publications and guidelines should be used when available.

An Interdisciplinary, Multi-Institution Telehealth Course for Third-Year Medical Students.

PROBLEM: The American Medical Association has called for telehealth to become a core competency of medical students. Studies indicate that a principal reason physicians do not practice telehealth is lack of training, yet patient interest in and satisfaction with telehealth are high. No comprehensive U.S. undergraduate medical education curriculum teaching telehealth principles has been published. APPROACH: In February 2018, the Uniformed Services University of the Health Sciences (USU) provided an innovative telehealth training experience for third-year medical students. USU led an interinstitutional, interprofessional learner-centered course including six segments: (1) multiple-choice pretest; (2) asynchronous lectures covering telehealth history, applications, ethics, safety, military uses, etiquette, and patient considerations; (3) in-person interactive telehealth instruction including patient selection, current uses, and risk management; (4) faculty-supervised mock patient telehealth encounters; (5) hands-on diagnosis and advanced surgical procedures using telehealth equipment; and (6) multiple-choice posttest. OUTCOMES: This course was piloted with 149 third-year medical students. Students' improvement in telehealth knowledge was demonstrated through (1) 10.1% average improvement between pre- and posttest scores, (2) completion of competency-based checklists, and (3) postcourse preceptor and student feedback. Faculty feedback indicated that technology use was novel and effective based on student input. Faculty noted that students enjoyed engaging via videoconference. Of participating medical students, 119 (80%) indicated future plans to practice telehealth; several requested to be part of future telehealth courses. NEXT STEPS: Telehealth will be integrated into clinical rotations in collaboration with other institutions. As the telehealth curriculum is taught at other institutions, lessons learned will inform enhancements at USU.

Knee Pain in Adults and Adolescents: The Initial Evaluation.

Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. Initial evaluation should emphasize excluding urgent causes while considering the need for referral. Key aspects of the patient history include age; location, onset, duration, and quality of pain; associated mechanical or systemic symptoms; history of swelling; description of precipitating trauma; and pertinent medical or surgical history. Patients requiring urgent referral generally have severe pain, swelling, and instability or inability to bear weight in association with acute trauma or have signs of joint infection such as fever, swelling, erythema, and limited range of motion. A systematic approach to examination of the knee includes inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and special (provocative) tests. Radiographic imaging should be reserved for chronic knee pain (more than six weeks) or acute traumatic pain in patients who meet specific evidence-based criteria. Musculoskeletal ultrasonography allows for detailed evaluation of effusions, cysts (e.g., Baker cyst), and superficial structures. Magnetic resonance imaging is rarely used for patients with emergent cases and should generally be an option only when surgery is considered or when a patient experiences persistent pain despite adequate conservative treatment. When the initial history and physical examination suggest but do not confirm a specific diagnosis, laboratory tests can be used as a confirmatory or diagnostic tool.

Musculoskeletal Therapies: Osteopathic Manipulative Treatment.

Osteopathic manipulative treatment (OMT) is being used increasingly in the United States. OMT techniques can be categorized as direct, using an activating force to move tissue through range-of-motion barriers; indirect, disengaging dysfunctional body parts away from restrictive barriers; and combined techniques. Evidence supports the effectiveness of this therapy in management of musculoskeletal conditions, particularly for low back pain, but is limited for many other conditions. Physician opinion, patient reporting, and student attitudes about OMT primarily are positive, but rates of OMT use vary across different US regions. Adverse effects are rare but include cauda equina syndrome, lumbar disk herniation, fracture, and hematoma or hemorrhagic cyst. Contraindications to OMT primarily involve conditions that increase bleeding risk or compromise bone, tendon, ligament, or joint integrity. National organizations have issued recommendations and guidelines recommending OMT as a first-line noninvasive therapy for low back pain after self-care. OMT is covered by many health insurance companies and training is available for allopathic physicians. Patient referrals should be made to appropriately credentialed physicians after consideration of supporting evidence and patient interest.

Plantar Fascia Rupture: Ultrasound to Facilitate Recognition.

Plantar fascia rupture in the absence of previous diagnosis of plantar fasciitis, corticosteroid injection, or injury is a rare occurrence with only 7 case reports in the literature since 1978. This is a case of spontaneous plantar fascia rupture in a 38-year-old active-duty US military member with current considerations in musculoskeletal ultrasound, other radiologic imaging, treatment, and followup of this diagnosis.

Sacroiliac Joint Dysfunction in the Athlete: Diagnosis and Management.

Sacroiliac joint (SIJ) dysfunction is a common cause of low back pain in the athlete, especially in sports with repetitive, asymmetric loading. Complex anatomy and broad pain referral pattern make diagnosis difficult. Identifying three or more positive physical examination maneuvers for the SIJ improves examination sensitivity and specificity. Imaging is rarely helpful in establishing the diagnosis but is often used to rule out other pathology. Conservative management with activity modification, medication, physical therapy, manipulation and bracing is first line treatment. After at least 6 weeks of conservative efforts or if pain limits the athlete's tolerance of these measures, diagnostic and therapeutic intra-articular or periarticular injections or nerve blocks can be used. Radiofrequency ablation is recommended as the next approach for treatment. When all other options have been exhausted, surgical management can be considered. For athletes, once the underlying dysfunction is adequately addressed, gradual progression to full participation is encouraged.

Treatment of Acute Carpal Bone Fractures.

Carpal bone fractures are common hand fractures that can be complicated by concomitant damage to surrounding structures, chronic comorbidities, or delays in diagnosis. This article provides an overview of wrist anatomy, an expedited review of the athlete's presenting condition, and a systematic approach to the evaluation of the wrist. Recommended treatment plans are based on a review of the literature and an evidence-based approach to imaging studies. It is imperative that sports medicine providers be aware of current literature for carpal bone fractures and collaborate with other medical subspecialties and the athlete to provide recommendations for a safe return to play.