Sonographic Assessment of Asymptomatic Patellar and Achilles Tendons to Predict Future Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: Patients with clinical tendinopathy often demonstrate significant abnormalities with ultrasound (US) imaging. Tendon abnormalities likely precede pain in these patients. The purpose of this review was to systematically evaluate the available literature regarding the utility of US imaging as a method to predict Achilles and patellar tendon pain. DESIGN: Systematic review and meta-analysis. Inclusion criteria were as follows: prospective studies of Achilles and patellar tendon pain development with baseline US measurements, follow-up clinical measurements, and English-language studies published after 2000. Exclusion criteria were prior rupture or surgery and presence of rheumatologic disorder. SETTING: N/A. PATIENTS: Athletes without Achilles or patellar tendon pain at baseline. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Risk ratios (RRs) were identified for the development of pain in those with Achilles or patellar tendon sonographic abnormalities. RESULTS: This review of 16 studies included 810 Achilles and 1156 patellar tendons from a variety of sports and demonstrated that the RR for pain development from abnormal Patellar and Achilles tendons was 6.07 [95% confidence interval (CI), 2.88-12.81; P < 0.001] and 3.96 [95% CI, 2.21-7.09; P < 0.001], respectively. The positive and negative predictive values of an abnormal US finding were 27.2% and 92.0% for the Achilles tendon and 27.2% and 93.5% for the patellar tendon, respectively. CONCLUSIONS: This systematic review and meta-analysis identified that the use of asymptomatic US scanning of the Achilles or patellar tendon has a low positive predictive value but a high negative predictive value for the future development of pain.

Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports.

OBJECTIVE: This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes. DESIGN: Observational cross-sectional study. SETTING: Three Division I institutions. PARTICIPANTS: 243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts. INTERVENTIONS: Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability. MAIN OUTCOME MEASURES: The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity. RESULTS: Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures (P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively. CONCLUSIONS: This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.

Procedural education for cancer-related pain in Pain Medicine fellowships: a national program survey.

INTRODUCTION: Cancer-related pain is ubiquitous. Targeted procedural interventions may be an important and underutilized method for improving cancer-related pain and quality of life. The goal of this study was to determine the baseline educational experience and perceived post-graduation comfort of Pain Medicine fellows in performing procedures that can be used for cancer-related pain. METHODS: Using Qualtrics, a 16-question survey was distributed to graduating fellows at accredited Pain Medicine Fellowship programs in the USA in June 2022. The fellows' experience and comfort level performing eight procedures was analyzed using summary descriptive statistics and contingency table analysis with statistical significance determined by Pearson's χ2 test. RESULTS: Survey respondents represented 30% of fellows among 44% of Pain Medicine programs during the 2021-2022 academic year. The majority of respondents reported no experience performing 7 of the 8 procedures for cancer-related pain (56.1%-90.6%). Graduating fellows reported overall comfort performing sympathetic neurolysis (65.7%), spinal cord stimulator trials (85.7%) and implantations (66.0%), but not intrathecal pump trials (36.9%) and implantations (31.3%), peripheral nerve stimulator implantations (41.7%), vertebral augmentations (31.3%), and vertebral body radiofrequency ablations (16.7%). CONCLUSIONS: Experience performing 10 or more of the surveyed procedures, personal interest in treating cancer-related pain, and attendance of cancer-related pain lectures were found to significantly increase comfortability in performing cancer-related pain procedures post graduation, whereas cadaver-based learning did not. This study highlights the need for more robust procedural education for cancer-related pain and identifies procedural experience in non-cancer patients and lectures on cancer-related pain as ways to bridge this educational gap.

Comparing fluoroscopic versus ultrasound guidance in glenohumeral joint aspiration.

BACKGROUND: Joint aspiration is a common technique used to aid in the diagnosis of glenohumeral pathology. Fluoroscopy and ultrasound are both used as image-guidance methods to increase the accuracy of the procedure. There are no prior studies comparing the ability of these two methods to obtain joint fluid. OBJECTIVE: To evaluate whether fluoroscopy or ultrasound-image guidance more often obtains fluid from the glenohumeral joint and which technique obtains a greater amount of fluid. DESIGN: Retrospective cohort study. SETTING: Single academic orthopedic clinic. PATIENTS: A total of 206 patients undergoing glenohumeral aspiration, generally to rule out infection. INTERVENTIONS: Fluoroscopic- or ultrasound-guided joint aspirations, performed by numerous physicians. MAIN OUTCOME MEASURES: Primary was the successful aspiration of at least 0.1 mL of joint fluid; secondary was the total amount of joint fluid obtained. RESULTS: There was no significant difference in rate of successful aspirations between ultrasound (69.4% successful; 95% confidence interval [CI] = 54.4%, 84.5%) and fluoroscopy (70.6% successful; 95% CI = 63.7%, 77.4%). The amounts of fluid obtained by fluoroscopy and ultrasound did not differ significantly (p = .349; mean ± standard deviation [SD] = 7.1 ± 12.6 vs. 10.0 ± 16.8 mL; median [interquartile range [IQR] = 3 [7] vs. 5 [8.75] mL). Sub-analysis showed that significantly more fluid was obtained with fluoroscopy in patients with a >35 body mass index (BMI) (adjusted mean = 7.9 mL; 95% CI = 4.3, 11.5) when compared with ultrasound (2.3 mL; 95% CI = 0.6, 4.0). CONCLUSIONS: Fluoroscopic- and ultrasound-guided aspirations of the glenohumeral joint demonstrate similar success in obtaining fluid. For nonobese patients, ultrasound guidance is typically less expensive, office-based, less uncomfortable, and allows for dynamic visualization. For obese patients, fluoroscopy appears to have an advantage with respect to the amount of fluid obtained. Prospective studies are warranted to make more robust conclusions.

Evaluation of an Ultrasound-Assisted Longitudinal Axis Lateral Crest Approach to Radiofrequency Ablation of the Sacroiliac Joint.

OBJECTIVE: The aim of the study was to evaluate the effectiveness and procedural characteristics of a novel, ultrasound/fluoroscopically guided technique (longitudinal axis sacroiliac joint radiofrequency ablation) for sacroiliac joint denervation. DESIGN: A single-arm cohort with historical cohort comparison was used in this study. METHODS: Thirty-seven participants underwent longitudinal axis sacroiliac joint radiofrequency ablation after 50% or more pain reduction after diagnostic dual-block criterion. Outcomes were the proportion of participants with 50% or more pain reduction and mean Pain Disability Quality of Life Questionnaire change. Subanalysis included longitudinal axis sacroiliac joint radiofrequency ablation procedural and fluoroscopy times compared with participants previously treated with palisade radiofrequency ablation technique. RESULTS: Primary outcome worst case analysis demonstrated a responder rate of 64.9% (95% confidence interval = 48.8%-78.2%) and 59.5% (95% confidence interval = 43.5%-73.7%) at 3 and 6 mos. There was significant decrease in mean Pain Disability Quality of Life Questionnaire at 3 (45.6 ± 9.5 to 21.4 ± 16.0, P < 0.001) and 6 mos (45.6 ± 9.5 to 23.0 ± 16.5, P < 0.001). Longitudinal axis sacroiliac joint radiofrequency ablation required more procedure time than the palisade technique (38.2 ± 7.9 vs. 32.1 ± 6.9 mins, P = 0.031) but less fluoroscopy time (35.0 ± 11.8 vs. 57.6 ± 16.8 secs, P < 0.001). CONCLUSIONS: Longitudinal axis sacroiliac joint radiofrequency ablation resulted in improvement in pain, disability, and quality of life at 3 and 6 mos. Compared with the palisade technique, longitudinal axis sacroiliac joint radiofrequency ablation required greater procedure time but less fluoroscopy time.

Aerobic Capacity According to Playing Role and Position in Elite Female Basketball Players Using Laboratory and Field Tests.

PURPOSE: To compare the aerobic capacity of elite female basketball players between playing roles and positions determined using maximal laboratory and field tests. METHODS: Elite female basketball players from the National Croatian League were grouped according to playing role (starter: n = 8; bench: n = 12) and position (backcourt: n = 11; frontcourt: n = 9). All 20 players completed 2 maximal exercise tests in a crossover fashion 7 days apart. First, the players underwent a laboratory-based continuous running treadmill test with metabolic measurement to determine their peak oxygen uptake (VO2peak). The players then completed a maximal field-based 30-15 Intermittent Fitness Test (30-15 IFT) to estimate VO2peak. The VO2peak was compared using multiple linear regression analysis with bootstrap standard errors and playing role and position as predictors. RESULTS: During both tests, starters attained a significantly higher VO2peak than bench players (continuous running treadmill: 47.4 [5.2] vs 44.7 [3.5] mL·kg-1·min-1, P = .05, moderate; 30-15 IFT: 44.9 [2.1] vs 41.9 [1.7] mL·kg-1·min-1, P < .001, large), and backcourt players attained a significantly higher VO2peak than frontcourt players (continuous running treadmill: 48.1 [3.8] vs 43.0 [3.3] mL·kg-1·min-1, P < .001, large; 30-15 IFT: 44.2 [2.2] vs 41.8 [2.0] mL·kg-1·min-1, P < .001, moderate). CONCLUSIONS: Starters (vs bench players) and guards (vs forwards and centers) possess a higher VO2peak irrespective of using laboratory or field tests. These data highlight the role- and position-specific importance of aerobic fitness to inform testing, training, and recovery practices in elite female basketball.

Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians.

BACKGROUND: Physician decision-making surrounding choices for large joint and bursa injections is poorly defined, yet influences patient safety and treatment effectiveness. OBJECTIVE: To identify practice patterns and rationale related to injectate choices for large joint and bursal injections performed by physician members of the American Medical Society for Sports Medicine (AMSSM). DESIGN: An electronic survey was sent to 3400 members of the AMSSM. Demographic variables were collected: primary specialty (residency), training location, practice location, years of clinical experience, current practice type, and rationale for choosing an injectate. PARTICIPANTS: A total of 674 physicians responded (minimum response rate of 20%). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Outcomes of interest included corticosteroid type and dose, local anesthetic type, and total injectate volume for each large joint or bursa (hip, knee, and shoulder). RESULTS: Most respondents used triamcinolone (50% to 56% of physicians, depending on injection location) or methylprednisolone (25% to 29% of physicians), 21 to 40 mg (53% to 60% of physicians), diluted with lidocaine (79% to 87%) for all large joint or bursa injections. It was noted that 36.2% (244/674) of respondents reported using >40 mg for at least one injection type. Most (90.5%, 610/674) reported using an anesthetic other than ropivacaine for at least one type of joint or bursa injection. Physicians who reported lidocaine use were less likely to report that their injectate choice was based on the literature that they reviewed (odds ratio [OR] 0.41 [0.27-0.62], P < .001). Respondents predominantly used 5 to 7 mL of total injectate for all large joints or bursae (45% to 54% of respondents), except for the pes anserine bursa, where 3-4 mL was more common (51% of physicians). CONCLUSIONS: It appears that triamcinolone and methylprednisolone are the most commonly used corticosteroids for sports medicine physicians; most physicians use 21 to 40 mg of corticosteroid for all injections, and lidocaine is the most-often used local anesthetic; very few use ropivacaine. Over one-third of respondents used high-dose (>40 mg triamcinolone or methylprednisolone) for at least one joint or bursa.

The Effectiveness of Spinal Cord Stimulation for the Treatment of Axial Low Back Pain: A Systematic Review with Narrative Synthesis.

OBJECTIVE: Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain. DESIGN: Systematic review. SUBJECTS: Persons aged ≥18 with axial LBP with or without accompanying leg pain. INTERVENTION: Traditional low-frequency, burst, or high-frequency SCS. COMPARISON: Sham, active standard of care treatment, or none. OUTCOMES: The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention. METHODS: Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality. RESULTS: Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70-87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity. CONCLUSIONS: According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.

The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis.

OBJECTIVE: Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain. DESIGN: Systematic review and meta-analysis. SUBJECTS: Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis. COMPARISON: Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection. OUTCOMES: The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery. METHODS: Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable. RESULTS: There were no studies with an internal comparison group (control group) meeting the review's definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34-61%) at one month and 55% (95% CI = 45-64%) at three months. CONCLUSIONS: Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.

Descriptive Epidemiology, Medical Evaluation, and Outcomes of Rock Climbing Injuries.

OBJECTIVE: To gather epidemiologic data on injury type, treatment, and recovery from rock climbing injuries. METHODS: Design: retrospective cross-sectional study. SETTING: web-based survey. PARTICIPANTS: rock climbers who sustained a climbing-related injury during the prior 24 months. Criteria for inclusion: aged ≥18 years; participation in rock climbing at least 4 times per year in the United States. INTERVENTIONS: none. MAIN OUTCOME MEASURES: percentage of injured climbers seeking medical care, providers seen, subspecialty referral, development of chronic problems, factors affecting return to climbing, injuries by climbing type, body region, and injury type. RESULTS: Data were collected over a 60-day period using the Research Electronic Data Capture (REDCap) survey system. Seven hundred and eight surveys were collected from 553 male and 155 female climbers. Thirteen hundred ninety seven injuries were reported, and 975 injuries were suitable for analysis. The most common provider initially seen was a primary care provider. Subspecialty referral was commonly obtained. Injury patterns differed by climbing type. The percentage of respondents that returned to climbing before their injury was fully healed was 51.1%, and 44.9% of respondents developed chronic problems related to their climbing injury. Twenty-eight percent of respondents were unable to return to their previous level of climbing performance. Several factors were associated with delayed recovery from climbing injury. CONCLUSIONS: A significant number of climbers sought healthcare after injury. A majority of climbers who sought treatment were referred to subspecialist providers. About one-half of climbers were symptomatic when they returned to climbing and developed chronic problems after injury. Factors associated with slower return to climbing included increasing age, smoking, fractures, and surgery.

Lack of Reality: Positive Self-Perceptions of Health in the Presence of Disease.

The aim of this study was to determine if adults in Central Queensland have accurate self-perceptions of health. Data were collected as part of the 2010 Central Queensland Social Survey (N = 1289). Overweight/obesity is considered a health disorder and was determined using body mass index. Disease states were determined by asking respondents if they have: heart disease, high/low blood pressure, high cholesterol, high triglycerides, thyroid disorder, diabetes, and osteopenia/osteoporosis. Self-perceptions of health were assessed by asking, "Would you say that in general your health is" poor, fair, good, very good, excellent, don't know, and no response. An accurate health perception occurred if: (1) A respondent with a disease/health disorder reported that their health was poor/fair or (2) A respondent without a disease/health disorder reported that their health was good/very good/excellent. The proportions of people with an accurate health perception by disease/health disorder were compared using a χ² test. A proportion ratio (PR) with a 95% confidence interval (CI) was calculated for each disease/health disorder. A logistic regression analysis was performed to examine the association between each disease/health disorder and health perception using gender, age, education, physical activity level, and smoking status as covariates. More than 50% of residents with each disease/health disorder reported their health to be good/very good/excellent. Residents with each disease/health disorder were less likely to have an accurate health perception than those without the corresponding disease/health disorder prior to (p < 0.001) and following adjustment of the covariates (p < 0.001). Our results suggest that overweight/obesity and prevalence of disease are not being recognized as unhealthy, which contradicts established definitions of health.

Association of Leisure-Time Physical Activity to Cardiovascular Disease Prevalence in Relation to Smoking among Adult Nevadans.

It is well known that cigarette smoking and physical activity have significant impacts on cardiovascular disease (CVD) mortality and morbidity. Meanwhile, it is of interest to understand whether physical activity protects against CVD for smokers in a similar manner as it does for non-smokers. The present study examined how leisure-time physical activity (LTPA) is associated with the prevalence of CVD in relation to smoking status among adult Nevadans, using data from the 2010 Nevada Behavioral Risk Factor Surveillance System. Of the 3,913 survey respondents, 8.5% self-reported that they had ever been diagnosed with CVD. People with a history of CVD were significantly less likely to engage in LTPA than those with no history of CVD (p < 0.05). After adjusting for common sociodemographic variables, it was revealed that people with CVD were twice more likely to not engage in LTPA than their counterparts independent of smoking status. Without taking LTPA into account, the odds of having CVD for current and former smokers was 1.87-2.25 times higher than the odds for non-smokers. Interestingly, however, if LTPA was accounted for, there was no significant difference in the odds of having CVD between current and non-smokers. These results indicate that LTPA is inversely associated with the prevalence of CVD independent of smoking status, and that regular physical activity may protect against CVD for smokers as well as for non-smokers. Physical activity, along with smoking cessation, should be promoted to better prevent and control CVD among smokers.