Anconeus and pronation: a palpatory and ultrasonographic study.

PURPOSE: Depending on its axis, pronation varies from the radius rotation around the steady ulna to the reciprocal adduction of the radius and abduction of the ulna. While there is no question that pronator teres is a central pronation agonist, anconeus's role is not settled. The current investigation comparing palpation and ultrasonography in these two muscles during pronation along the axis capitulum-second digit evolved from a serendipitous finding in a clinical anatomy seminar. METHODS: Single-hand palpation and two-transducer ultrasonography over anconeus and pronator teres were used on ten normal subjects to investigate their contraction during pronation around the capitulum-second digit axis. These studies were done independently and blind to the results of the other. The statistical analysis between palpation and ultrasonography was performed with Cohen's kappa coefficient and the χ2 test. RESULTS: On palpation, on resisted full pronation, anconeus contracted in 8/10 subjects and pronator teres in 10/10 subjects. Without resistance, the corresponding ratios were 5/10 and 9/10. On two-transducer ultrasonography, the comparable ratios were 7/10 and 10/10, and 3/10 and 10/10. A fair concordance (Cohen's kappa = 0.21) between palpation and ultrasonography in detecting the simultaneous status of anconeus and pronator teres during resisted full pronation. Anatomic dissection illustrated the elements involved. CONCLUSIONS: Plain palpation confirmed by ultrasonography showed the simultaneous contraction of anconeus and pronator teres during resisted pronation in most of the studied subjects. The study suggests that palpation can be helpful in directly studying muscle activity during movement.

Repigmentation of hair following adalimumab therapy.

Repigmentation of canities, or age-related grey or white hair, is a rare occurrence. Generalized repigmentation of grey-white hair has been reported following inflammatory processes, and heterochromia (localized patches of hair repigmentation) is even more unusual, reported in association with medication use and malignancy. Tumor necrosis factor (TNF) inhibitors are increasingly utilized medications for inflammatory disorders, including psoriasis, rheumatoid arthritis, and inflammatory bowel disease. Hair loss, or alopecia, has been described among the side effects of these medications, but changes in hair pigmentation in association with this class of drugs have not previously been reported. We describe a patient with hair repigmentation associated with adalimumab therapy.

Examining the Forearm Intersection through Palpation and Ultrasonography.

BACKGROUND: Forearm intersection syndrome causes pain, swelling, and a rub at the dorsal distal forearm where the first extensor compartment muscles intersect with the second compartment tendons. Although primary care settings tend to treat mild cases, high-performance athletes may suffer from severe symptoms that require surgery. This proof-of-concept study aims to help detect the anatomical substrate of forearm intersection syndrome using palpation and ultrasonography when available. METHODS: Five individuals were studied using independent palpation and ultrasonography to identify the first dorsal compartment muscles and the second dorsal compartment tendons. The distances between the dorsal (Lister's) tubercle of the radius and the ulnar and radial edges of the first dorsal compartment muscles were measured to determine the location and extent of the muscle-tendon intersection. The palpatory and ultrasonographic measurements were compared using descriptive statistics and the paired t-test. RESULTS: The mean distances from the dorsal tubercle of the radius to the ulnar and radial borders of the first dorsal compartment muscles were 4.0 cm (SE 0.42) and 7.7 cm (SE 0.56), respectively, based on palpation. By ultrasonography, the corresponding distances were 3.5 cm (SD 1.05, SE 0.47) and 7.0 cm (SD 1.41, SE 0.63). Both methods showed a similar overlap length. However, ultrasonography revealed a shorter distance between the dorsal tubercle of the radius and the ulnar border of the first compartment than palpation (p = 0.0249). CONCLUSIONS: Our findings indicate that a basic knowledge of anatomy should help health professionals diagnose forearm intersection syndrome through palpation and, if available, ultrasonography.

Palpation and Ultrasonography Reveal an Ignored Function of the Inferior Belly of Omohyoid: A Case Series and a Proof-of-Concept Study.

BACKGROUND: Palpation, a traditional haptic ability, is used daily by practitioners of all medical and surgical specialties to assess patients. In the current study, one of the authors, in a routine clinical setting, was able to deduce the dynamic features of the putative inferior belly of omohyoid. This led to a proof-of-concept study that yielded results consistent with the clinical findings. METHODS: The first part of the study involved a survey of 300 rheumatic disease patients in whom the greater supraclavicular fossa was explored by palpation. While the patient kept the head straight, the clinician placed his middle three fingers 2.5-3 cm dorsal to the clavicle in the window between the sternocleidomastoid and trapezius clavicular insertions, explored the supraclavicular fossa, and palpated the paired contractile inferior belly of the assumed omohyoid during flexion in the three orthogonal planes. In the second part of the study, five normal subjects were examined in a similar manner by the same clinician and had independent ultrasonography performed on the dominant side. Descriptive statistics were used, and Yates' corrected chi-squared test was applied to certain nominal variables. Additionally, a comparative anterolateral bilateral neck dissection was performed in a cadaveric specimen. RESULTS: Both studies showed that the contractile structure was the inferior belly of omohyoid and that its contraction occurred during anterior neck flexion and was opposite to the side of neck rotation, resembling the sternocleidomastoid. CONCLUSIONS: Palpation uncovered a previously unknown function of the inferior belly of omohyoid, suggesting that physical examination of the musculoskeletal system based on palpation may lead to hypotheses worthy of exploration.

Dynamic changes in the infrapatellar knee structures with quadriceps muscle contraction. An in vivo study.

OBJECTIVE: To determine the effect of knee flexion and submaximal isometric quadriceps muscle (Q) contraction on the patellar tendon (PT), the infrapatellar fat pad (IPFP), and the deep infrapatellar bursa (IPB) from extension to full flexion. METHODS: In Study 1, the dominant knee of seven healthy subjects was studied in full extension and at 60° flexion during relaxation and Q contraction. Each knee was inspected and palpated, the transverse infrapatellar diameter was measured by plicometry, and measurements of the anteroposterior (AP) thickness of the IPFP were made by ultrasound (US). In Study 2, the dominant knee of seven healthy subjects was studied by US in full flexion, and then, at 15° decrements, down to 60° flexion during relaxation and Q contraction. Both studies had IRB approval. Results were analyzed with the Wilcoxon test and descriptive statistics. RESULTS: In Study 1, Q contraction caused straightening of the patellar tendon (PT), a statistically significant widening of the IPFP by plicometry, and an increased AP thickness of the IPFP by US, in both knee positions. In Study 2, in full knee flexion, the PT contacted the tibial cortex in all seven subjects. Upon increasing extension, the PT-tibial cortex contact was lost in all subjects nearing 90° flexion. The contraction of the Q made the concave PT straight, grew the width of the underlying IPFP, and the apron of the IPFP moved distally within the IPB in all knee positions. A small amount of bursal fluid was present in all seven subjects. CONCLUSION: Q contraction makes the IPFP bulge anteriorly, on both sides of the PT, and distally into the IPB, with possible biomechanical implications. In full knee flexion, the PT contacted the tibia, confirming a fulcrum at this site.

Musculoskeletal anatomy by self-examination: A learner-centered method for students and practitioners of musculoskeletal medicine.

BACKGROUND: The authors describe a series of learner-centered exercises, highlighting a technique in which the musculoskeletal anatomy is explored and learned through self-examination, with the examiner required to identify designated structures in both the static and dynamic state. METHODS: The technique of musculoskeletal anatomy through self-examination consists of applying knowledge of the surface anatomy of a region as it exists in the static state, to the analysis and understanding of changes that occur with movement and function of that body part. The sensory input of the examined part may contribute to the overall perception of the exercise. RESULTS: Three tables provide details that allow the reader to understand and perform the exercises describing the anatomic part explored, the physical maneuver required, the expected anatomic finding(s), and their clinical relevance. CONCLUSIONS: The authors believe that musculoskeletal self-examination provides an engaging learner-centered pedagogy that may complement that which is learned in peer or model examination. The lack of cost, the absence of intimacy barriers, and the opportunity to extend the method to further areas and functions are additional benefits of musculoskeletal self-examination as a learner-centered, self-study methodology.

Lyme arthritis: pathogenesis, clinical presentation, and management.

Arthritis is one of the most prominent features of Lyme disease, the tick-borne illness caused by Borrelia burgdorferi. Although the pathogenesis of Lyme arthritis is complex and still under study, the clinical presentation and natural history have been established by long-term observation of untreated and treated patients. This review addresses the clinical presentation of Lyme arthritis as a mono- or oligoarticular relapsing/remitting arthritis primarily affecting the large joints and describes presentations in which arthralgias rather than arthritis are seen. Strategies for diagnosis and treatment are discussed, and methods are reviewed for addressing treatment-refractory Lyme arthritis and arthralgias that may occur after treatment of Lyme disease (sometimes as a component of what is known as the post-Lyme disease syndrome).

A survey of anatomical items relevant to the practice of rheumatology: pelvis, lower extremity, and gait.

This study aimed to generate a minimum list of structural and functional anatomical items about the pelvis/hip, knee, ankle/foot, gait, and lower limb innervation, which are most relevant to the practice of rheumatology. To determine their perceived relevance to clinical practice, seven members of the Mexican Clinical Anatomy Task Force compiled an initial list of 470 anatomical items. Ten local and international experts according to a 0-10 Likert scale ranked these items. Of the original list, 101 (21.48%) items were considered relevant (global rate >40). These included 36/137 (26.27%) pelvis and hip items, 25/82 (30.48%) knee items, 22/168 (13.98%) ankle/foot items, 11/68 (16.17%) neurologic items, and 7/15 (46.66%) gait-related items. We propose that these 101 anatomical items of the lower extremity, when added to the 115 anatomic items of the upper extremity and spine we previously reported, may represent an approximation to the minimal anatomical knowledge central to the competent practice of rheumatology. The meager representation of ankle and foot items may reflect a lesser emphasis in these anatomical regions during rheumatologic training. Attention to these and related items during rheumatologic training and beyond may sharpen the rheumatologist's ability in the differential diagnosis of regional pain syndromes as well as strengthen an endangered art: the rheumatologic physical examination.

A survey of anatomical items relevant to the practice of rheumatology: upper extremity, head, neck, spine, and general concepts.

This study aimed to identify the anatomical items of the upper extremity and spine that are potentially relevant to the practice of rheumatology. Ten rheumatologists interested in clinical anatomy who published, taught, and/or participated as active members of Clinical Anatomy Interest groups (six seniors, four juniors), participated in a one-round relevance Delphi exercise. An initial, 560-item list that included 45 (8.0 %) general concepts items; 138 (24.8 %) hand items; 100 (17.8 %) forearm and elbow items; 147 (26.2 %) shoulder items; and 130 (23.2 %) head, neck, and spine items was compiled by 5 of the participants. Each item was graded for importance with a Likert scale from 1 (not important) to 5 (very important). Thus, scores could range from 10 (1 × 10) to 50 (5 × 10). An item score of ≥40 was considered most relevant to competent practice as a rheumatologist. Mean item Likert scores ranged from 2.2 ± 0.5 to 4.6 ± 0.7. A total of 115 (20.5 %) of the 560 initial items reached relevance. Broken down by categories, this final relevant item list was composed by 7 (6.1 %) general concepts items; 32 (27.8 %) hand items; 20 (17.4 %) forearm and elbow items; 33 (28.7 %) shoulder items; and 23 (17.6 %) head, neck, and spine items. In this Delphi exercise, a group of practicing academic rheumatologists with an interest in clinical anatomy compiled a list of anatomical items that were deemed important to the practice of rheumatology. We suggest these items be considered curricular priorities when training rheumatology fellows in clinical anatomy skills and in programs of continuing rheumatology education.

Teaching of clinical anatomy in rheumatology: a review of methodologies.

Clinical anatomy may be defined as anatomy that is applied to the care of the patient. It is the foundation of a well-informed physical examination that is so important in rheumatologic practice. Unfortunately, there is both documented and observed evidence of a significant deficiency in the teaching and performance of a competent musculoskeletal examination at multiple levels of medical education including in rheumatology trainees. At the Annual Meeting of the American College of Rheumatology in Boston, MA, that took place in November 2014, a Clinical Anatomy Study Group met to share techniques of teaching clinical anatomy to rheumatology fellows, residents, and students. Techniques that were reviewed included traditional anatomic diagrams, hands-on cross-examination, cadaver study, and musculoskeletal ultrasound. The proceedings of the Study Group section are described in this review.

Self-assessed efficacy of a clinical musculoskeletal anatomy workshop: A preliminary survey.

OBJECTIVE: To survey the efficacy of a practical workshop on clinical musculoskeletal anatomy held in five American countries. METHODS: A self-assessment competence questionnaire sent to participants 1-3 months after the workshop. Results were compared to the results of a practical, instructor-assessed, pre-workshop test. RESULTS: The response rate of participants was 76.4%. The overall, self-assessed competence score for anatomical items that had been included in the pre-test was 76.9 (scale 0-100) as compared to an overall score of 48.1 in the practical, pre-workshop test (p<0.001). For items that were addressed in the workshop, but not included in the pre-test, self-assessed competence was rated at 62.9. Differences in anatomical knowledge between individuals from different countries and professional groups noted in the practical pre-test were no longer present in the post-test self-assessment. CONCLUSIONS: From this preliminary data and supporting evidence from the literature we believe that our anatomy workshop provides an effective didactic tool for increasing competence in musculoskeletal anatomy.

Preworkshop knowledge of musculoskeletal anatomy of rheumatology fellows and rheumatologists of seven North, Central, and South American countries.

OBJECTIVE: To report the baseline knowledge of clinical anatomy of rheumatology fellows and rheumatologists from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay. METHODS: The invitation to attend a workshop in clinical anatomy was an open call by national rheumatology societies in 4 countries or by invitation from teaching program directors in 3 countries. Prior to the workshop, a practical test of anatomic structures commonly involved in rheumatic diseases was administered. The test consisted of the demonstration of these structures or their function in the participant's or instructor's body. At one site, a postworkshop practical test was administered immediately after the workshop. RESULTS: There were 170 participants (84 rheumatology fellows, 61 rheumatologists, and 25 nonrheumatologists). The overall mean ± SD number of correct answers was 46.6% ± 19.9% and ranged from 32.5-67.0% by country. Rheumatology fellows scored significantly higher than nonrheumatologists. Questions related to anatomy of the hand scored the lowest of the regions surveyed. CONCLUSION: Rheumatology fellows and rheumatologists showed a deficit in knowledge of musculoskeletal anatomy that is of central importance in rheumatologic assessment and diagnosis. This gap may hinder accurate and cost-effective rheumatologic diagnosis, particularly in the area of regional pain syndromes. Presently, widespread use of musculoskeletal ultrasound (MSUS) by rheumatologists may be premature, since a key component of expert-level MSUS is the integration of an accurate knowledge of anatomy with the views obtained with the ultrasound probe.

Development of the seminar.

The current issue of Reumatología Clínica is devoted to the method of teaching clinical anatomy as it applies to rheumatology. This method was developed as a response to a perceived need. It is our belief that rheumatologists are at present insufficiently trained in clinical anatomy. As a result, our diagnostic skills may fall short of their potential. Recent rheumatologic literature shows a vertiginous growth of musculoskeletal ultrasonography. In contrast to ultrasound, however, skilled, anatomy-based inspection and palpation can be mastered by all and applied in the care of all patients. It is our hope that clinical musculoskeletal anatomy will one day be a basic component in rheumatology training programs.

Clinical anatomy of the ankle and foot.

This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fasciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Morton's neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.

Clinical anatomy of the pelvis and hip.

The contents of this review may appear odd. After a brief description of the coxofemoral joint, the entities discussed include ilioinguinal neuropathy within the context of the nerves that may be damaged during lower abdominal surgery, meralgia paresthetica, piriformis syndrome with the appropriate caveats, trochanteric syndrome, "ischial bursitis" and trochanteric syndrome caused by ischemia. These cases were chosen to stress our belief that rheumatologists are first and foremost internists. We further believe that being current in other pathologies such as peripheral neuropathies and certain vascular syndromes sooner or later benefits our patients.

Clinical anatomy of the knee.

The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Baker's cyst, popliteus tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms of the structures involved and their role in knee physiology. All of the discussed structures can be identified in their normal state and more so when they are affected by disease. The wealth of information gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.

Clinical anatomy of the hand.

This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys, sesamoid bones), flexor tenosynovitis, de Quervain's syndrome, Dupuytren's contracture, some hand deformities in rheumatoid arthritis, the carpal tunnel syndrome and the ulnar nerve compression at Guyon's canal. Some important syndromes and structures have not been included but such are the nature of these seminars. Rather than being complete, we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and, in the most important part of the seminar, these pertinent items are demonstrated by cross examination of participants and teachers. Self learning is critical for generating interest and expanding knowledge of clinical anatomy. Just look at your own hand in various positions, move it, feel it, feel also your forearms while you move the fingers, do this repeatedly and inquisitively and after a few tries you will have developed not only a taste, but also a lifelong interest in clinical anatomy.

Clinical anatomy of the elbow and shoulder.

The elbow patients herein discussed feature common soft tissue conditions such as tennis elbow, golfers' elbow and olecranon bursitis. Relevant anatomical structures for these conditions can easily be identified and demonstrated by cross examination by instructors and participants. Patients usually present rotator cuff tendinopathy, frozen shoulder, axillary neuropathy and suprascapular neuropathy. The structures involved in tendinopathy and frozen shoulder can be easily identified and demonstrated under normal conditions. The axillary and the suprascapular nerves have surface landmarks but cannot be palpated. In neuropathy however, physical findings in both neuropathies are pathognomonic and will be discussed.