Nonoperative Management of Chronic Exertional Compartment Syndrome: A Systematic Review.

Although nonoperative treatment options for chronic exertional compartment syndrome (CECS) are often used in clinical practice, supporting evidence is limited. The objective of this study was to systematically review the literature for nonsurgical treatment options for CECS of the lower leg. The literature search identified seven articles describing in total four different treatment options: massage, gait changes, chemodenervation, and ultrasound-guided (USG) fascial fenestration. Pertinent studies were in the form of case series and one case report, which limited the robustness of the data. Nevertheless, all four treatment options have little to no reported adverse effect profiles and can be considered in clinical practice. In addition, gait changes and USG fascial fenestration were found to have continued effect at 1 and 1.5 years, respectively.

Approach to the patient with noninflammatory musculoskeletal pain.

Musculoskeletal pain is one of the most common presenting symptoms at the pediatrician's office. Etiology ranges from benign conditions to serious ones requiring prompt attention. This article addresses entities that present as musculoskeletal pain but are not associated with arthritis. The most common nonarthritic conditions are benign limb pain of childhood (growing pains), hypermobility, overuse syndromes with or without skeletal abnormalities, malignancies, and pain amplification syndromes. The| initial decision process, diagnosis, and treatment options for each of these conditions are discussed.

Athletic osteitis pubis.

Athletic osteitis pubis is a painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis. The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction. The differential diagnosis for osteitis pubis is extensive and includes many other syndromes resulting in groin pain. Imaging, particularly in the form of MRI, may be helpful in making the diagnosis. Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. Prolotherapy injections of dextrose, anti-inflammatory corticosteroids and a variety of surgical procedures have been reported in the literature with varying efficacies. Future studies of athletic osteitis pubis should attempt to define specific and reliable criteria to make the diagnosis of athletic osteitis pubis, empirically define standards of care and reduce the variability of proposed treatment regimens.

Stress fractures of the base of the metatarsal bones in young trainee ballet dancers.

Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients' activities and a return to dancing without pain.

The 'Bunkie' test: assessing functional strength to restore function through fascia manipulation.

It has been speculated that repetitive patterns of movement will lead to specific patterns in fascia contraction, which, if it exceeds a specific limit, will lead to injury. Therapists working in the athletic environment are challenged to find ways not only to assess and measure fascia dysfunction, but also to restore functional strength by manipulating the fascia back to its neutral position. The 'Bunkie' test was developed over a period of 12 years to measure the function of the specific fascia lines in athletes. Numerous athletes from various sports were assessed and treated. Results have shown over the years that this test can be used successfully to find the cause of and treat injuries and to determine the progress of treatment in elite and recreational athletes.

Inmovilización y movilización del niño politraumatizado / No disponible

No disponible

[Growing pains in children: myth or reality?]. / Les douleurs de croissance chez l'enfant existent-elles ?

"Growing pains" are a frequent problem in paediatric practice. Over the last years, their diagnostic and therapeutic approaches have changed. Other syndromes than those well-known by paediatricians are to be taken in consideration. Current treatment consists in reassurance of children and their family reactivation of patients (which means to take up a normal physical activity) and treatment of painful crisis as well as complementary therapies.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients.

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

Relação entre o relato clínico e o exame físico na avaliação de distúrbios osteomusculares relacionados ao trabalho / Realtionship between self-reported symptoms and clinical signs in the assessment of work -related musculoskeletal disorders

O objetivo deste estudo foi verificar se há relação entre o relato de indivíduos sobre os sintomas musculosqueléticos e os sinais clínicos de lesões por esforço repetitivo (LER) ou distúrbios osteomusculares relacionados ao trabalho (DORT)...

This study aimed at verifying the relationship between self-reported musculoskeletal symptoms and clinical findings of work-related musculoskeletal disorders (WRMD). One hundred and thirty-two female workers from an industrial...

Common overuse tendon problems: A review and recommendations for treatment.

There is a common misconception that symptomatic tendon injuries are inflammatory; because of this, these injuries often are mislabeled as "tendonitis."' Acute inflammatory tendinopathies exist, but most patients seen in primary care will have chronic symptoms suggesting a degenerative condition that should be labeled as "tendinosus" or "tendinopathy." Accurate diagnosis requires physicians to recognize the historical features, anatomy, and useful physical examination maneuvers for these common tendon problems. The natural history is gradually increasing load-related localized pain coinciding with increased activity. The most common overuse tendinopathies involve the rotator cuff, medial and lateral elbow epicondyles, patellar tendon, and Achilles tendon. Examination should include thorough inspection to assess for swelling, asymmetry, and erythema of involved tendons; range-of-motion testing; palpation for tenderness; and examination maneuvers that simulate tendon loading and reproduce pain. Plain radiography, ultrasonography, and magnetic resonance imaging can be helpful if the diagnosis remains unclear. Most patients with overuse tendinopathies (about 80 percent) fully recover within three to six months, and outpatient treatment should consist of relative rest of the affected area, icing, and eccentric strengthening exercises. Although topical and systemic nonsteroidal anti-inflammatory drugs are effective for acute pain relief, these cannot be recommended in favor of other analgesics. Injected corticosteroids also can relieve pain, but these drugs should be used with caution. Ultrasonography, shock wave therapy, orthotics, massage, and technique modification are treatment options, but few data exist to support their use at this time. Surgery is an effective treatment that should be reserved for patients who have failed conservative therapy.

Patellar tendinopathy.

Patellar tendinopathy is a common and serious condition in athletes. Although there have been many advances in the understanding of the histopathology, imaging, and surgical outcomes in this condition in the past decade, successful management of athletes with patellar tendinopathy remains a major challenge for both the practitioner and patient. There is a definite need for further prospective studies into etiological factors and randomized controlled trials into treatment choices.

Musculoskeletal problems of the chest wall in athletes.

Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes' bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.

Elbow injuries in golf.

Golf is not a sport known for its high injury level; however, injuries do occur. Such mishaps usually involve overuse-type injuries that are more common among amateur golfers than among professional golfers. This article attempts to provide an overview of golf injuries to the elbow, with a concentration on incidence, proper diagnosis, adequate treatment (including rehabilitation), and prevention strategies. After reading this article, primary care physicians should be able to manage most golfing injuries to the elbow.

[Musculoskeletal disorders caused by repetitive trauma of the upper limbs: a paradigm of the development of occupational diseases and industrial medicine]. / I "disturbi" muscolo scheletrici da traumi ripetuti agli arti superiori: paradigma della evoluzione delle patologie da lavoro e della Medicina del Lavoro.

The work related musculoskeletal disorders (WMSDs) are a wide range of inflammatory and degenerative disease and disorders that result in pain and functional impairment. All available definitions for WMSDS are non consistent and require in each individual case and in each group study careful identification of symptoms, signs and findings. WMSDs, as a mutifactorial work related disease, are associated to physical and psychosocial factors at work and other individual, sociocultural factors. They are therefore good paradigm for the changing occupational risks and illness and for the new methods that the occupational medicine and the preventive disciplines have to set up. The research and standardization needs appear to be more evident for framing pathogenesis, biological response and pathology of WMSDs and mainly for risk factors assessment, since suitable analytical methods are still not available. The agreement of valid standardised methods (guide lines) for the evaluation of working conditions and assessment of risk factors is required, taking due regard to the multidisciplinary approach both in biological and medical areas and in poly technical ones. Finally attention would be paid to the strategy for prevention, implementing ergonomic programmes, health surveillance, adequate training to work, aimed to primary prevention of WMSDs.

The healthy patient: empowering women in their encounters with the health care system.

Many women's expectancies when they assume the role of patient include the experiences of regression, helplessness, passivity and fear. This paper describes techniques for interrupting this negative set and for facilitating the development of a self-efficacious state in which the woman experiences herself as an active and informed participant in her encounters with medical personnel.

Repetitive strain injury. 2. Diagnostic and treatment tips on six common problems. The Goff Group.

Repetitive strain injury is caused by recurrent overuse, resulting in microtrauma to tissues. Local pain and tenderness, weakness, inflammation, and limited function are common findings. Some of the strain injuries seen most often are carpal tunnel syndrome, trigger finger, shoulder impingement syndrome, tennis elbow, thoracic outlet syndrome, and myofascial pain disorders. Often, treatment can be started at the initial visit, after systemic disorders have been ruled out. A vital step is elimination of aggravating factors, such as improper posture, inadequate attention to ergonomic factors at work, and contributory habits (e.g., jaw or hand clenching). Use of simple joint-protection measures can alleviate much of the discomfort. Appropriate self-help strategies used at home may restore flexibility and strength with a minimum of medical intervention, but pain relief must be achieved before patients can be expected to follow through with rehabilitation efforts. Use of ice packs, massage, NSAIDs, or topical pain-relief agents is often helpful. Prompt, temporary pain relief can also be achieved with injection of a local anesthetic-corticosteroid mixture. Persistent disability should prompt consideration of psychosocial factors. In addition, fraudulent claims of disability do occur. Although physicians should make every effort to support legitimate claims of work-related injury, they should also be aware of the possibility that activities outside of work (e.g., sports participation, accidental injuries) may be contributing factors.

Electromyographic biofeedback evaluation of a computer keyboard operator with cumulative trauma disorder.

This article describes a rehabilitation approach for a keyboard operator following radial tunnel decompression and release of the extensor origin of the right elbow. Prior to the patient's returning to work, a clinical electromyographic (EMG) biofeedback device was used to determine which work activities the patient should avoid or alter to reduce strain on her affected muscles. The patient was able to return to work and noticed a considerable reduction of muscle fatigue and pain in the involved muscles. A relatively inexpensive EMG biofeedback device was employed to evaluate the patient's muscles prior to returning to work. The rationale and suggestions for application of the biofeedback unit are discussed.

Evaluation and treatment of hand and wrist disorders in musicians.

Hand symptoms in musicians reflect a complex, multifactorial etiology. A multidisciplinary approach is required for proper evaluation and treatment. Good results can be achieved in most patients with localized inflammatory and overuse disorders or nerve compression syndromes. Motor control disorders and chronic pain syndromes are associated with poorer results. Early diagnosis appears to improve outcome.