A Case of Confounding Back Pain.

BACKGROUND Acute back pain is common in primary care settings (>60% lifetime prevalence). Patients can also have associated red flag signs, such as fever, spinal tenderness, and neurologic deficits, that warrant further evaluation and investigation to optimize diagnosis and treatment. CASE REPORT A 70-year-old man with a history of benign prostatic hyperplasia and hypertension sought care for midthoracic back pain. He had been recently admitted to the hospital for sepsis from a urinary tract infection (UTI) caused by multidrug-resistant (MDR) Escherichia coli. Initial treatment was conservative management with physical therapy, given the lack of red flag signs on physical examination and the likelihood that his pain was musculoskeletal, resulting from immobilization during hospitalization. At follow-up, thoracic spine radiography showed no fracture or other acute abnormalities. After persistent pain, he underwent magnetic resonance imaging, which showed T7-T8 osteomyelitis and discitis with substantial paraspinal soft tissue involvement. Computed tomography-guided biopsy showed MDR E. coli, which indicated hematogenous spread from his recent UTI. Pharmacologic treatment included intravenous ertapenem for 8 weeks, with consideration for discectomy if later indicated. This case highlights the value of maintaining a broad differential diagnosis and high alert for red flag symptoms during routine office visits with a chief concern of back pain. CONCLUSIONS A high clinical suspicion for vertebral osteomyelitis must be maintained for patients with acute back pain associated with red flag signs. Detailed assessment with appropriate investigations and close follow-up is recommended to support the diagnosis and to allow timely management to prevent complications.

ACR Appropriateness Criteria® Malignant or Aggressive Primary Musculoskeletal Tumor-Staging and Surveillance: 2022 Update.

Malignant or aggressive primary musculoskeletal tumors are rare and encompass a wide variety of bone and soft tissue tumors. Given the most common site for metastasis from these primary musculoskeletal tumors is to the lung, chest imaging is integral in both staging and surveillance. Extrapulmonary metastases are rarely encountered with only a few exceptions. Following primary tumor resection, surveillance of the primary tumor site is generally recommended. Local surveillance imaging recommendations differ between primary tumors of bone origin versus soft tissue origin. This document consolidates the current evidence and expert opinion for the imaging staging and surveillance of these tumors into five clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Is There a Correlation Between Reported Knee Pain and Fluid at the Distal Insertion of the Iliotibial Band in Runners?

Objective To determine whether there is a correlation between pain and the amount of fluid present at the distal insertion of the iliotibial band (ITB) in runners, as measured by USG. Method Our retrospective cross-sectional study evaluated 100 male and female runners prior to the start of a race. A valid and reliable questionnaire collected demographic, pain, and training data. If a runner reported knee pain, a numeric pain rating scale was used to record the degree of pain. Participants then underwent USG on both knees to determine the presence or absence of fluid at the distal insertion of the ITB. Result We found no statistically significant correlations of fluid measurements with pain score, running experience in years, or age. In addition, we found no other differences in fluid measurements between those with and without knee pain or between the sexes. Conclusions Our findings indicate that the presence or absence of fluid at the distal insertion of the ITB does not correlate with knee pain in runners, regardless of age, running experience, or sex.

Gender Diversity in Primary Care Sports Medicine Leadership.

ABSTRACT: Diversity, equity, and inclusion have been recognized as important drivers of excellence and innovation in the physician workforce. Given the historical underrepresentation of women in medicine, gender diversity is of interest. In this cross-sectional study, we sought to quantify leadership representation of female physicians in primary care sports medicine settings, including primary care sports medicine fellowship programs, select sports medicine societies, and select sports medicine-related scientific journals. Data were collected by querying the corresponding web site for each fellowship program, society, and journal and analyzed in a descriptive manner. Results showed that fewer female physicians hold primary care sports medicine leadership roles than men do. This work establishes a baseline for female representation in primary care sports medicine leadership; efforts should continue to increase the presence of women in leadership positions.

Self-reported foot strike patterns and sonographic evidence of Achilles tendinopathy in asymptomatic marathon runners.

It is unknown whether ultrasound findings and symptoms of Achilles tendinopathy in runners correlate with foot strike patterns. We aimed to examine the relationships among Achilles tendon ultrasound findings in runners with or without Achilles tendinopathy, their foot strike patterns, and their training regimens. We recruited marathon runners 18 years of age or older with no history of Achilles tendon pain or surgery participating in the 2018 DONNA Marathon. Participants completed surveys and underwent Achilles tendon sonographic evaluations and were categorized by foot strike patterns. Seventy-nine runners were included; 22 (28%) with forefoot, 30 (38%) midfoot, and 27 (34%) hindfoot strike patterns. Foot strike pattern was not associated with tendon hyperaemia (P = 1.00) or hypoechogenicity (P = .97), and there was no association of cross-sectional area of the Achilles tendon with peak weekly distance while training. Sonographic characteristics of Achilles tendinopathy did not correlate with foot strike patterns or training regimens. Although not statistically significant, it is worth noting that cross-sectional area was 1 mm2 larger per every 1 kg/m2 increase in body mass index.

ACR Appropriateness Criteria® Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis: 2021 Update.

Inflammatory back pain is a hallmark feature of axial spondyloarthritis, a heterogeneous group of inflammatory disorders which affects the sacroiliac joints and spine. Imaging plays a key role in diagnosis of this disease and in facilitating appropriate treatment. This document provides evidence-based recommendations on the appropriate use of imaging studies during multiple stages of the clinical evaluation of patients with suspected or known axial spondyloarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment.

The prevalence of class 3 obesity (body mass index ≥40 kg/m2) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.

Considerations in the Care of Athletes With Attention Deficit Hyperactivity Disorder.

OBJECTIVES: Uncover literature pertaining to: (1) attention deficit hyperactivity disorder (ADHD) and how it impacts athletes; (2) ADHD medication effects; (3) regulations regarding ADHD medications; (4) approaches to conditions similar to, and occurring with, ADHD; and (5) use of stimulants. DATA SOURCES: MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Ovid interface. MAIN RESULTS: ADHD can have many effects on athletes and sports participation. Exercise has positive benefits on ADHD behaviors and players' attitudes. Athletes with ADHD can have worsened ADHD symptoms after concussions. Attention deficit hyperactivity disorder is a modifier of return to play; baseline ADHD symptoms should be used to guide management. Management should include medications, behavioral/psychosocial therapy, and academic accommodations. Behavioral therapy combined with medication is superior to behavioral treatment alone. Sustained exercise as ADHD treatment should be considered mainstay in management. Sports can increase thermogenic effects of stimulants, heat injury, and cardiac arrhythmias. Increased aggressiveness, improved pain tolerance, and decreased sense of fatigue are some attributes of stimulants that are presumed to impart some advantage to athletes, but evidence is uncertain. Attention deficit hyperactivity disorder medications may lead to myocardial infarctions, cerebrovascular accidents, paranoid psychoses, seizures, insomnia, tremors, anxiety, hypertension, and death. CONCLUSIONS: Athletes' performance and quality of life can be negatively affected by ADHD. Risks exist for those who take ADHD medications. More research is needed on the implications ADHD may have in specific sports, and on possible advantages of medication use. Potential deleterious effects of these medications should be addressed.

Managing Sports-related Concussions From Time of Injury Through Return to Play.

Sports-related concussions continue to generate widespread interest. A concussion is a complex pathophysiologic process, with or without loss of consciousness, that results in a disturbance of brain function. Risk factors include age <18 years, female sex, and history of a previous concussion. A sideline physical examination with standardized assessment tools can assist diagnosis. Management for suspected concussion begins with immediate removal from play and requires clinical follow-up. Symptoms are usually self-limited and resolve within 2 to 3 weeks. Initial treatment consists of a reduction in cognitive activity and physical rest. A stepwise return-to-play protocol, taking into consideration state laws, with a gradual increase in activity until the athlete is able to perform full activity without symptoms should be followed. Neuropsychologic testing may be used as a tool in management. For prolonged concussion, physical rehabilitation or medications for headaches, mood, or sleep disturbance may be required. Education, rule changes, and equipment improvements may assist in prevention. The long-term consequences of concussions are not fully understood and merit additional research.