Injections of the Hand and Wrist: Part II. Carpal Tunnel Syndrome, Ganglion Cyst, Intersection Syndrome, Triangular Fibrocartilage Complex Injury, and de Quervain Tenosynovitis.

Family physicians are well-positioned to provide injections for patients who have wrist pain, especially when initial treatments such as nonsteroidal anti-inflammatory drugs and rest fail. Although corticosteroid injections can offer pain relief, possible risks (e.g., infection, cartilage damage, skin depigmentation) should be discussed. Techniques and procedures for injections vary. Studies have shown significant improvement in carpal tunnel syndrome severity over 12 weeks using ultrasound-guided injections compared with landmark-guided injections. Ganglion cyst aspiration can be helpful for patients with significant symptoms, although more than 50% of ganglion cysts may recur within a year. Corticosteroid injections of ganglion cysts do not appear to produce additional benefits to aspiration. Intersection syndrome is an overuse injury; management involves rest, adjustment of activities, use of braces, nonsteroidal anti-inflammatory drugs, and physical or occupational therapy. For symptoms not improved by these methods, an ultrasound-guided glucocorticoid injection may be administered. Treatment options for a triangular fibrocartilage complex injury include immobilization, kinesio taping, relative rest, and analgesics; corticosteroid injection may relieve acute inflammatory pain. De Quervain tenosynovitis is treated conservatively with palpation- or ultrasound-guided corticosteroid injection, splinting, occupational therapy, and activity modification.

[Treatment and diagnosis of overuse injury in the Achilles tendon]. / ABC om Kronisk hälsene­smärta ­ diagnos och behandling.

Achilles tendinopathy is a common overuse injury, especially among runners. It should be divided into midportion Achilles tendinopathy and insertional Achilles tendinopathy, as the treatments are different. Achilles tendinopathy is a clinical diagnosis, which includes a combination of pain, swelling and stiffness. If pain is located 2-6 cm above the insertion to the calcaneus, it is considered a midportion tendinopathy. Pain located more distally, close to the insertion, is defined as insertional tendinopathy. Both midportion and insertional Achilles tendinopathies are primarily treated with physiotherapy during three to six months. Exercise has the highest level of evidence and is more successful in midportion Achilles tendinopathy. Insertional tendinopathy more often requires surgical treatment, with removal of bony exostosis and chronically inflamed bursa.

Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans.

BACKGROUND: Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes. METHODS: Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared. RESULTS: Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics. CONCLUSIONS: RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lesiones deportivas por sobreuso en niños y adolescentes / Sports injuries due to overuse in children and adolescents

La actividad deportiva en niños y adolescentes ha presentado un aumento sostenido en nuestro país en los últimos años; esto ha generado un aumento de las lesiones deportivas por sobreuso. Éstas pueden tener múltiples orígenes, dependiendo de la edad y la actividad del paciente. La mayoría son de manejo conservador, sin embargo, algunas requieren manejo quirúrgico. Lo más importante es la prevención de estas lesiones mediante el uso de equipo apropiado, regulando la intensidad y tipo de entrenamiento y tratando precozmente las lesiones.

Sports activity in children and adolescents has presented a sustained increase in our country in recent years, generating an increase in sports-related overuse injuries. These injuries vary in nature, depending on the patient ́s age and level of training. Most are conservatively managed; although, some will require surgical treatment. It is important, however, to try to prevent these injuries by using appropriate equipment, regulating the intensity and type of training and treating injuries early

Overuse Knee Pain in the Pediatric and Adolescent Athlete.

Overuse knee pain is common in young athletes. There are many potential overuse injuries which present with insidious onset of pain that can challenge sports medicine providers, including Osgood-Schlatter's disease, patellofemoral syndrome, osteochondritis dissecans, and stress fractures. The differential diagnosis of insidious onset knee pain also includes malignancies, infections, and rheumatologic issues. A thorough history and physical examination can guide the treating provider in making a diagnosis and appropriate treatment plan. Although not always necessary, imaging is often helpful in overuse knee pain, and laboratory workup may be necessary. Conservative treatment is often the first recommendation in the management of overuse knee pain in young athletes, and this may include activity modification, ice, anti-inflammatory medications, bracing, and physical therapy. This review summarizes common overuse knee injuries seen in pediatric and adolescent athletes.

Overuse syndrome of the hand and wrist in musicians: a systematic review.

We systematically searched medical publication databases for articles in English on upper extremity overuse syndrome in musicians. We focused on non-specific pain disorders, including diagnostic definitions, epidemiology, pathophysiology, risk factors, symptoms, treatment, and prevention. We included 42 out of 156 identified articles. The point prevalence of playing-related musculoskeletal disorders ranges from 37% to 47% in musicians with the hand and wrist among the most commonly affected areas, and the lifetime prevalence is reported as high as 89%. Leading symptoms are pain, weakness, stiffness, and loss of control. Intense repetitive use during practice, or before an audition or concert, recent changes in conductors or teachers, psychological stress, the effort of holding a weighty instrument, wrong technique, and joint laxity have all been identified as risk factors. The need for prevention is highlighted. Today's therapy is mostly based on individual rehabilitation programmes rather than on long-term rest. However, treatment remains predominantly based on beliefs rather than on evidence. The entire subject needs intensive future research.

Reflexoterapia podal para lombalgia aguda ocupacional: ensaio clínico randomizado duplo cego / Foot reflexology for acute occupational low back pain: a double-blind randomized clinical trial / Reflexoterapia podal para lumbago agudo ocupacional: ensayo clínico aleatorizado doble-ciego

OBJETIVO: Comparar os efeitos da reflexoterapia podal no alívio da lombalgia aguda ocupacional da equipe de enfermagem. MÉTODO: ensaio clínico randomizado, controlado, duplo-cego. Participaram 36 profissionais efetivos, randomicamente alocados. A coleta de dados foi realizada com a Escala Visual e Analógica de intensidade da dor, antes e depois das aplicações do protocolo de reflexoterapia e Questionário para Lombalgia, aplicado no início e fim da pesquisa. Para normalidade da amostra utilizou-se o teste Shapiro Wilk; teste Qui-quadrado ou Exato de Fisher para verificar a significância da associação entre variáveis categóricas; teste de Wilcoxon (dados não paramétricos) e teste t (dados paramétricos). RESULTADO: reflexoterapia podal apresentou efeito significativo (p=0,000) nas etapas de intervenção para alívio da intensidade da dor lombar aguda, tanto no escore do EVA, quanto no Questionário para Lombalgia (p=0,0002). CONCLUSÕES: a reflexoterapia apresentou efeitos estatisticamente significativos na redução da lombalgia aguda dos profissionais da Enfermagem

AIM: To compare the effects of foot reflexology in relieving acute occupational low back pain in the nursing team. METHOD: randomized, controlled, double-blind clinical trial. Participants included 36 randomly allocated, effective professionals. Data collection was performed with the Visual and Analogue Scale of pain intensity, before and after the applications of the reflexotherapy protocol and Questionnaire for Low Back Pain, applied at the beginning and end of the research. For normality of the sample the Shapiro Wilk test, Chi-square test or Fisher's exact test was used to verify the significance of the association between categorical variables; Wilcoxon test (non-parametric data) and t-test (parametric data). RESULT: reflexotherapy showed significant effect (p=0.000) in the intervention stages to alleviate the intensity of acute low back pain, both in the VAS score and in the Low Back Pain Questionnaire (p=0.0002). CONCLUSIONS: reflexotherapy showed statistically significant effects on the reduction of acute low back pain in Nursing professionals.

OBJETIVO: Comparar los efectos de la reflexoterapia podal en el alivio del lumbago agudo ocupacional del equipo de enfermería. MÉTODO: ensayo clínico aleatorizado, controlado, doble-ciego. Participaron 36 profesionales efectivos, asignados aleatoriamente. El muestreo se realizó con la Escala Visual y Analógica de intensidad del dolor, antes y después de las aplicaciones del protocolo de reflexoterapia y con el Cuestionario para Lumbago, aplicado al inicio y fin de la investigación. Para normalizar la muestra se utilizó el test Shapiro Wilk; test Chi-cuadrado o Exacto de Fisher para verificar la significancia de la asociación entre las variables categóricas; test de Wilcoxon (datos no paramétricos) y test t (datos paramétricos). RESULTADO: La reflexoterapia podal presentó efecto significativo (p=0,000) en las etapas de intervención para aliviar la intensidad del dolor lumbar agudo, tanto en el escore del EVA, como en el Cuestionario para Lumbago (p=0,0002). CONCLUSIONES: La reflexoterapia presentó efectos estadísticamente significativos en la reducción del lumbago agudo de los profesionales de Enfermería.

An unusual mechanism of coracoid fracture in a beginner golfer.

Golfers may injure themselves as a result of repetitive asymmetrical loads exerted on the body by poor swing mechanics. If the repetitive sub-maximal loading is not removed, this repetitive loading will exceed the adaptive capacity of bone, eventually resulting in a stress fracture. Stress fracture of the scapula due to golfing is extremely rare. Only two cases of acromion fracture have been reported. A rare case of nontraumatic coracoid fracture in a 50-year-old female beginner golfer is reported here. The mechanism of injury is also discussed. Level of evidence Level IV.

[Running and causes of running-related injuries].

Running is one of the most popular sports among the adult Danish population. Overuse injuries of the knee, such as runners knee, jumpers knee, patello-femoral pain syndrome and patello-femoral pre-arthrosis, are common and cause reduction of the health beneficial physical activity. Treatment should primarily focus on adjustment of training habits and physiotherapeutic guided rehabilitation. Other treatment options include changing landing pattern during running, corticosteroid injections, non-steroid anti-inflammatory drugs and ultimately surgery.

Hypothenar hammer syndrome in an office worker.

Hypothenar hammer syndrome (HHS) is an uncommon cause of unilateral Raynaud's phenomenon, splinter haemorrhages and hypothenar weakness. The typical patient is a male blue-collar worker who uses their hypothenar eminence to hammer objects as part of their work. The distal ulnar artery beyond Guyon's canal is superficial and vulnerable to blunt trauma. CTA and MRA are common initial investigations and can suggest the diagnosis. DSA is the gold standard imaging modality and offers therapeutic opportunities. Management is controversial, but unless there is critical digital ischaemia, conservative treatment is first line.

Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study.

PURPOSE: The incidence of groin pain in athletes is steadily increasing. Symptomatic pubic overload with groin pain and aseptic osteitis pubis represent well-known and frequently misdiagnosed overuse injuries in athletes. This study investigated the benefits of standardised non-surgical treatment for swift return-to-football. METHODS: In a prospective double-blinded controlled study, 143 amateur football players with groin pain as well as radiological signs and clinical symptoms of pubic overload were analysed for 1 year. Two randomised study groups participated in an intensive physical rehabilitation programme, either with or without shock wave therapy. The control group did not participate in any standardised rehabilitation programme but only stopped participating in sports activity. Follow-up examinations took place 1, 3 months and 1 year after the beginning of therapy. Endpoints were visual analogue scale (VAS), functional tests, the time of return-to-football, recurrent complaints and changes in the MR image. RESULTS: Forty-four football players with groin pain and aseptic osteitis pubis were randomised into two study groups; 26 received shock wave therapy, 18 did not. Clinical examination showed pubic overload as a multi-located disease. Players receiving shock wave therapy showed earlier pain relief in the VAS (p < 0.001) and returned to football significantly earlier (p = 0.048) than players without this therapy. Forty-two of 44 players of both study groups returned to football within 4 months after the beginning of therapy and had no recurrent groin pain within 1 year after trauma. Fifty-one players of the control group returned to football after 240 days (p < 0.001), of whom 26 (51%) experienced recurrent groin pain. Follow-up MRI scans did not show any effect of shock wave therapy. CONCLUSION: Non-surgical therapy is successful in treating pubic overload and osteitis pubis in athletes. Shock wave therapy as a local treatment significantly reduced pain, thus enabling return-to-football within 3 months after trauma. Early and correct diagnosis is essential for successful intensive physiotherapy. LEVEL OF EVIDENCE: I.

Failure of Autologous Chondrocyte Implantation.

Long-term results of autologous chondrocyte implantation and matrix-assisted autologous chondrocyte transplantation in the knee are satisfying, but not enough attention has been paid to the evaluation of failures. Thus, a systematic review of the literature was performed, underlining a failure rate in the 58 included articles of 14.9% among 4294 patients, most of them occurring in the first 5 years after surgery, and with no difference between autologous chondrocyte implantation and matrix-assisted autologous chondrocyte transplantation. Failures are very heterogenously defined in the current literature. A widely accepted definition is needed, and a comprehensive definition taking into consideration the patient's perception of the outcome, not just the surgeon's or researcher's point of view, would be advisable. Finally, there is no agreement on the most appropriate treatment of failures, and further studies are needed to give better indications to properly manage patients failed after cartilage procedures. LEVEL OF EVIDENCE: Level IV.

Problems With Large Joints: Shoulder Conditions.

The shoulder is the most mobile joint in the body. It requires an extensive support system to create mobility while providing stability. Although there are many etiologies of shoulder pain, weakness, and instability, most injuries in the shoulder are due to overuse. Rotator cuff tears, labral tears, calcific tendinopathy, and impingement often result from chronic overuse injuries. Acute injuries include dislocations that can cause labral tears or other complications. Frozen shoulder refers to a typically benign condition of restricted range of motion that may spontaneously resolve but can cause prolonged pain and discomfort. The history combined with specific shoulder examination techniques can help family physicians successfully diagnose shoulder conditions. X-ray imaging typically is sufficient to rule out more serious etiologies when evaluating patients with shoulder conditions. However, imaging with magnetic resonance imaging (MRI) study or ultrasonography for rotator cuff tears, and MRI study with intra-articular contrast for labral tears, is needed to confirm these diagnoses. Corticosteroid injections and physical therapy are first-line treatments for most shoulder conditions. Surgical options typically are reserved for patients for whom conservative treatments are ineffective, and typically are performed arthroscopically.

Ankle Impingement Caused by an Intra-articular Plica: A Report of 2 Cases.

UNLABELLED: Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Study.

Current evidence of extracorporeal shock wave therapy in chronic Achilles tendinopathy.

Chronic Achilles tendinopathy has been described as the most common overuse injury in sports medicine. Several treatment modalities such as activity modification, heel lifts, arch supports, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading are known as standard treatment mostly without proven evidence. After failed conservative therapy, invasive treatment may be considered. Extracorporeal shock wave therapy (ESWT) has been successfully used in soft-tissue pathologies like lateral epicondylitis, plantar fasciitis, tendinopathy of the shoulder and also in bone and skin disorders. Conclusive evidence recommending ESWT as a treatment for Achilles tendinopathy is still lacking. In plantar fasciitis as well as in calcific shoulder tendinopathy shock wave therapy is recently the best evaluated treatment option. This article analysis the evidence based literature of ESWT in chronic Achilles tendinopathy. Recently published data have shown the efficacy of focused and radial extracorporeal shock wave therapy.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).

Current concepts of shockwave therapy in stress fractures.

Stress fractures are common painful conditions in athletes, usually associated to biomechanical overloads. Low risk stress fractures usually respond well to conservative treatments, but up to one third of the athletes may not respond, and evolve into high-risk stress fractures. Surgical stabilization may be the final treatment, but it is a highly invasive procedure with known complications. Shockwave treatments (ESWT), based upon the stimulation of bone turnover, osteoblast stimulation and neovascularization by mechanotransduction, have been successfully used to treat delayed unions and avascular necrosis. Since 1999 it has also been proposed in the treatment of stress fractures with excellent results and no complications. We have used focused shockwave treatments in professional athletes and military personnel with a high rate of recovery, return to competition and pain control. We present the current concepts of shockwave treatments for stress fractures, and recommend it as the primary standard of care in low risk patients with poor response to conventional treatments.

Hypothenar hammer syndrome.

The diagnosis of hypothenar hammer syndrome (HHS) should be considered in the case of hand ischemia in people who occupationally or recreationally use the hypothenar region literally as a “hammer”. Routine diagnostics should consist of physical examination including Allen’s test, acral plethysmography and duplex sonography. According to the prevailing opinion angiography remains the «gold standard test¼ for establishing the diagnosis of HHS. Early diagnosis allows more effective therapeutic strategies and is important to prevent long-term negative medical sequelae. Several basic principles apply to all patients, for example hand protection and smoking cessation. The optimal treatment options, particularly the indication for surgery, remain controversial due to a lack of sound data from case series or prospective randomized trials.

Sports-related overuse injuries in children.

Increased intensity of sports activities combined with a decrease in daily physical activity is making overuse injuries in children more common. These injuries are located mainly in the epiphyseal cartilage. The broad term for these injuries is osteochondrosis, rather than osteochondritis, which more specifically refers to inflammatory conditions of bone and cartilage. The osteochondrosis may be epiphyseal, physeal, or apophyseal, depending on the affected site. The condition can either be in the primary deformans form or the dissecans form. While there is no consensus on the etiology of osteochondrosis, multiple factors seem to be involved: vascular, traumatic, or even microtraumatic factors. Most overuse injuries involve the lower limbs, especially the knees, ankle and feet. The most typical are Osgood-Schlatter disease and Sever's disease; in both conditions, the tendons remain relatively short during the pubescent grown spurt. The main treatment for these injuries is temporary suspension of athletic activities, combined with physical therapy in many cases. Surgery may be performed if conservative treatment fails. It is best, however, to try to prevent these injuries by analyzing and correcting problems with sports equipment, lifestyle habits, training intensity and the child's level of physical activity, and by avoiding premature specialization. Pain in children during sports should not be considered normal. It is a warning sign of overtraining, which may require the activity to be modified, reduced or even discontinued.