Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners.

Objectives: To examine whether asymptomatic ultrasonographic abnormalities in the Achilles and patellar tendons in runners are associated with an increased risk of pain development.Methods: This is a longitudinal, prospective cohort study with 139 runners recruited at a half and full marathon race. Ultrasound examination of the Achilles and patellar tendons was performed bilaterally the day prior to the race. Self-reported injury data were collected at 1, 3, 6 and 12 months. 104 (74.8%) runners were included in the data analysis.Results: Ultrasonographic tendon abnormalities were found in 24.1% of the Achilles and in 23.1% of the patellar tendons prior to the race. Runners with tendon abnormality were 2-3 times more likely to develop pain within 12 months than those without (relative risk = 3.14, p = 0.010 for Achilles; relative risk = 2.52, p = 0.008 for patellar tendon). After adjusting for gender, age, years of running, average miles per week of running over a year, and pre-race pain, runners with ultrasound abnormality were about 3 times (hazard ratio = 2.89, p = 0.039 for Achilles; hazard ratio = 2.73, p = 0.030 for patellar tendon) more likely to develop pain after the race. Tendon delamination was most strongly associated with pain in both the Achilles (relative risk = 6.00; p = 0.001) and patellar tendons (relative risk = 3.81; p = 0.001).Conclusions: Structural changes in asymptomatic tendons were found in almost 25% of runners. Presence of structural changes was associated with increased development of Achilles and patellar tendon pain within one year.

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 Use of Vitamins, Supplements, Herbs, and Essential Oils in Rehabilitation.

The term, dietary supplement, refers to a broad category of products, including herbal or plant-based extracts, micronutrients, and food-based nutraceuticals. The use of supplements in clinical rehabilitation requires clear communication from patients and health care providers to understand the types of products used and their effects on health. Providers should distinguish between using micronutrient supplementation for therapeutic purposes and treatment of nutritional deficiency in patients with malnutrition syndromes. Evidence supports micronutrient and nutraceutical supplementation use to improve pain, functional status, and inflammation. There is little evidence on the use of herbal or plant-based extracts in therapeutic rehabilitation; larger studies are warranted.

Image guidance used for large joint and bursa injections; a survey study.

Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.

Infections After Large Joint or Bursa Injection: A Survey of 554 Sports Medicine Physicians.

OBJECTIVE: Despite the ubiquity of intra-articular and bursal injections for the treatment of joint pain and bursitis, relatively little literature is available on the prevalence of infection after these procedures. The aim of this study was to identify the number of infections recalled by sports medicine physicians who perform injections of large joints and bursae at least once per month. DESIGN: A survey of physician members of the American Medical Society for Sports Medicine identified the reported number of recalled infections for each large joint/bursal location. RESULTS: Of a total of 554 physicians, only 31 infections were recalled by 27 physicians. Only 4.87% of all physicians were aware of an infection after an injection during their career. On average, one infection was recalled of 170 physician-years in practice. No differences in infection rates were observed when comparing primary specialties (P = 0.281). CONCLUSIONS: This study, the largest to date, demonstrates that sports medicine physicians rarely encounter infections after large joint and bursa injections. Though rare, because of their catastrophic nature, risk mitigation strategies should be maintained.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Intra-articular Hip Injections.

BACKGROUND: Intra-articular hip injections are commonly performed for both diagnostic and therapeutic interventions. Because of the risk of damage to neurovascular structures, fluoroscopic guidance with injection of contrast material has been established as the gold standard to ensure proper needle placement into the intra-articular space. However, fluoroscopically guided intra-articular hip injections put patients at risk due to radiation exposure. OBJECTIVE: To examine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during intra-articular hip injections. DESIGN: Retrospective study. SETTING: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in PM&R and/or with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS: All patients who underwent fluoroscopically guided intra-articular hip injections between the years 2003-2014 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS: All patients received unilateral or bilateral intra-articular hip injections with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at P < .01. RESULTS: A total of 438 subjects (446 injections) were included. Mean fluoroscopy times were 17.4 ± 9.9, 17.5 ± 11.4, and 19.1 ± 13.4 seconds for normal, overweight, and obese body mass (BMI) index groups, respectively, with no significant difference between groups (P = .148). The mean radiation doses were 601 ± 690, 678 ± 558, and 1049 ± 812 mGy-cm(2), respectively (P < .001, r = 0.29). There was no association of age (P = .03), needle length (P = .34) or trainee involvement (P = .159) with fluoroscopy time. CONCLUSION: This study demonstrates that increasing BMI leads to elevated radiation dose during fluoroscopically guided intra-articular hip injections. The increased radiation experienced by patients with a larger BMI, however, is likely negligible.