Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes.

BACKGROUND: Chronic adductor enthesopathy is a well-known cause of groin pain in athletes. Currently, percutaneous nonselective adductor tenotomies give mixed results and not always predictable outcomes. HYPOTHESIS: A selective partial adductor longus release as treatment for recalcitrant chronic adductor longus enthesopathy provides excellent pain relief with a prompt and consistent return to preinjury levels of sport. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All athletes were assessed in a standard way for adductor dysfunction. They received radiographs and a specifically designed magnetic resonance imaging groin study protocol. Only professional athletes who received a selective partial adductor release were included. Pain and functional improvement were assessed with the visual analog scale (VAS) pain score and time to return to sport. RESULTS: Forty-three professional athletes (39 soccer and 4 rugby) with chronic adductor-related groin pain were treated with a selective partial adductor release. The average follow-up time was 40.2 months (range, 25-72 months). Forty-two of 43 athletes returned to their preinjury level of sport after an average of 9.21 weeks (range, 4-24 weeks; SD, 4.68 weeks). The preoperative VAS score improved significantly (Wilcoxon signed-rank test, P < .001) from 5.76 ± 1.08 (range, 3-8) to 0.23 ± 0.61 (range, 0-3) postoperatively. CONCLUSION: A selective partial adductor longus release provides excellent pain relief for chronic adductor enthesopathy in professional athletes with a consistent high rate of return to the preinjury level of sport.

Results of accelerated postoperative rehabilitation using novel "suture frame" repair of Achilles tendon rupture.

The management of Achilles tendon rupture is a much-debated subject. In recent years, there has been much interest in early postoperative mobilization. We present the results of our Achilles tendon repair technique and accelerated rehabilitation program. The technique we propose uses the strength of a 1-loop polydioxanone "suture frame" to enable restoration of the tendon length, immediate positioning of the foot in a near-plantigrade position, and an accelerated rehabilitation program. We followed up 15 cases of Achilles tendon rupture treated with this technique. The initial follow-up was a review of case notes and a telephone questionnaire. All patients were subsequently invited for a clinical follow-up visit, and 11 patients (68.75%) attended. No cases of infection or repeat rupture occurred. The return to work (mean 5.6 weeks) and return to sport (mean 4.8 months) were relatively rapid. Regarding overall satisfaction on a scale of 0 to 10, the median was 9 (range 8 to 10). Of the 11 patients who attended the clinical follow-up visit, the mean American Orthopaedic Foot and Ankle Surgery ankle-hindfoot score was 94.5 points (range 83 to 100). The Achilles rupture repair scores (including isokinetic muscle strength) were good or excellent in all but 1 patient, whose result was fair. Of the 11 patients, 10 reported complete satisfaction with their outcome. Our technique with accelerated rehabilitation is safe and effective in the management of acute Achilles tendon rupture. It facilitates an early return to work and recreational sports, with excellent overall patient satisfaction.

Arthroscopic removal of a plastic soft drink bottle cap in the knee: a case report.

We report a rare case of late knee locking after an open knee injury in a polytrauma patient with a pelvic fracture and a contralateral femoral artery injury. Once the life and limb threatening injuries were addressed, debridement and washout of the knee wound was performed. X-rays and subsequent CT revealed only an undisplaced patella fracture. The patient presented 6 months later to a knee surgeon with recurrent locking. An arthroscopy was performed and a 10 mm plastic soft drink bottle cap was retrieved leading to the immediate resolution of symptoms without complications.Open knee injuries require thorough debridement washout and joint assessment. Late locking should raise the suspicion of an intra-articular loose or foreign body. Arthroscopy is an excellent first line tool in the diagnosis and late management of this unusual problem.

An unusual case of enthesophyte formation following an adductor longus rupture in a high-level athlete.

We present a case of a high-level rugby player with severe groin pain following a partial rupture of his left adductor longus enthesis during a game. Conservative treatment proved unsuccessful and the athlete had persistent symptoms, affecting his quality of life and ability to play sports. Further assessments revealed a large bony spur/enthesophyte at adductor longus origin. The patient underwent a successful surgical resection of the active bone formation.

Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections.

BACKGROUND: Adductor dysfunction can cause groin pain in athletes and may emanate from the adductor enthesis. Adductor enthesopathy may be visualized with magnetic resonance imaging and may be treated with entheseal pubic cleft injections. We have previously reported that pubic cleft injections can provide predictable pain relief at one year in competitive athletes who have no evidence of enthesopathy on magnetic resonance imaging and immediate relief only in patients with findings of enthesopathy on magnetic resonance imaging. In this follow-up study, we attempted to determine if the same holds true for recreational athletes. METHODS: We reviewed a consecutive case series of twenty-eight recreational athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. A period of conservative treatment had failed for all of these athletes. The adductor longus origin was assessed with magnetic resonance imaging for the presence or absence of enthesopathy. All patients were treated with a single pubic cleft injection of a local anesthetic and corticosteroid into the adductor enthesis. The patients were assessed for recurrence of symptoms at one year after treatment. RESULTS: On clinical reassessment five minutes after the injection, all twenty-eight athletes reported resolution of the groin pain. Fifteen patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and thirteen patients (Group 2) had findings of enthesopathy on magnetic resonance imaging. At one year after the injection, five of the fifteen patients in Group 1 had experienced a recurrence; these recurrences were noted at a mean of fourteen weeks (range, seven to twenty weeks) after the injection. Four of the thirteen patients in Group 2 had experienced a recurrence of the symptoms at one year, and these recurrences were noted at a mean of eight weeks (range, two to nineteen weeks) after the injection. Overall, nineteen (68%) of the twenty-eight athletes had a good result following the injection. Of the remaining nine athletes, two were treated successfully with repeat injection; therefore, overall, twenty-one (75%) of the twenty-eight athletes had a good result after entheseal pubic cleft injection. CONCLUSIONS: Most recreational athletes with adductor enthesopathy have pain relief at one year after entheseal pubic cleft injection, regardless of the findings on magnetic resonance imaging. There were similarities between this group of recreational athletes and the competitive athletes in our previous study, in that the adductor enthesis was the source of pain and entheseal pubic cleft injection was a valuable treatment option. The main difference was that, in this group of recreational athletes, magnetic resonance imaging evidence of adductor enthesopathy did not correlate with the outcome of the injection.

Trigger finger presenting secondary to leiomyoma: a case report.

INTRODUCTION: WE PRESENT A PREVIOUSLY UNDESCRIBED ENTITY: trigger finger secondary to a leiomyoma. This is the first time such a case has been reported and highlights the fact that common conditions can sometimes present secondary to rare diseases. CASE PRESENTATION: A 39-year-old Caucasian man presented with a fairly typical presentation of trigger finger. During surgical treatment, the lesion was excised and sent for histology, which showed tissue consistent with a leiomyoma. The patient made an uneventful recovery. CONCLUSION: Trigger finger is a common condition that is usually easily diagnosed and managed. However, it is important to appreciate that uncommon conditions, such as leiomyoma, can present with what is sometimes considered trivial disease, and one should always consider the differential diagnoses even when faced with relatively benign conditions.

Persistent symptoms following non operative management in low grade MCL injury of the knee - The role of the deep MCL.

Incomplete injuries (grade I or II) to the medial collateral ligament (MCL) of the knee are common and usually self limiting. Some patients complain of chronic medial knee pain following injury. We highlight the importance of anatomical investigation of these patients and evaluate a successful treatment technique. A consecutive case series of 34 patients with chronic pain following grade I/II MCL injury were reviewed. Injury prevented sporting activity, and examination revealed thickening and tenderness of the MCL. The knee was assessed by MRI. All patients had radiological evidence of injury to the superficial and deep MCL, with thickening, scarring and tearing. Patients were treated with ultrasound guided injection of local anaesthetic and steroid into the deep MCL and clinically reassessed. They were allowed to return to sport immediately. They were assessed for recurrence of symptoms with a postal questionnaire. Four were excluded from follow up. Four were lost. All patients reported an immediate and sustained resolution their medial knee pain. At mean follow up of 20.4 months (range 11-38 months) all were back to their pre-injury level of work. Twenty five (96%) had immediate and sustained return to sporting activity. Twenty one (81%) reported no change in level of sporting function. In patients with persistent medial joint pain following grade I/II MCL sprain, pain from the deep MCL must be considered. MRI will confirm the diagnosis, exclude coexistent pathology and localise the lesion within the deep MCL. A single corticosteroid injection provides an excellent clinical outcome 20 months post injection.

Synovial osteochrondomatosis of the talonavicular joint: a case report.

Synovial osteochondromatosis is a condition of unknown etiology affecting articular synovium, characterised by the formation of osteochondral nodules. Occurrences in the foot and ankle are rare. To our knowledge, this condition has never previously been described in the talonavicular joint. In the following article, we present two cases and review the literature regarding this condition.

Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections.

BACKGROUND: Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids. METHODS: We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms. RESULTS: On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p < 0.001) at a mean of five weeks (range, one to sixteen weeks) after the injection. CONCLUSIONS: A single entheseal pubic cleft injection can be expected to afford at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of enthesopathy on magnetic resonance imaging.

Detecting patient allergy: beware the LIE.

INTRODUCTION: Allergy detection is important in surgical patients. Historically, the focus has been on drug allergies. There is increasing focus on non-drug allergy, specifically latex, iodine and elastoplast. PATIENTS AND METHODS: The practice and knowledge of 24 pre-registration house officers was evaluated, with regard to patient allergy. For the second phase of the study, the cohort of 367 consecutive patients presenting to the orthopaedic pre-assessment clinic was prospectively assessed. RESULTS: This prospective study demonstrates that standard history-taking misses a large number (38%) of such allergies. CONCLUSIONS: With regard to allergy detection, we are living a LIE (by ignoring latex, iodine, elastoplast allergy). We suggest junior doctors should employ the mnemonic LIED (latex, iodine, elastoplast and drugs) when taking a medical history.

Partial rupture of the distal semitendinosus tendon treated by tenotomy--a previously undescribed entity.

Hamstring strains are common. They are usually treated conservatively, with good results. Thus far, the only subset of patients who have been considered for surgery are those with complete avulsions of the attachments. We describe a new clinical entity: partial rupture of the distal semitendinosus tendon; which has failed to settle with conservative treatment; and has been successfully treated by tenotomy.