Knee Extensor Mechanism Tendinopathy: Evaluation, Treatment, and Prevention.

ABSTRACT: Knee extensor mechanism tendinopathy, including patellar and quadriceps tendinopathy, is common among athletes and those involved in jumping sports. It is largely a clinical diagnosis that presents as anterior knee pain and stiffness with associated tenderness over the affected tendon. Imaging modalities, including ultrasound and/or magnetic resonance imaging, may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Focused and structured rehabilitation using eccentric or heavy slow resistance exercise in conjunction with load management is important for recovery. Adjuvant therapies (e.g., injections or surgery) may be necessary in recalcitrant cases or those with insufficient response to rehabilitation efforts. Prevention strategies focus on improving biomechanics, landing mechanism and lower-extremity balance, flexibility, and strength.

Ultrasound-guided glenohumeral joint injections for shoulder pain in ALS: A case series.

Introduction: Shoulder pain is a common secondary impairment for people living with ALS (PALS). Decreased range of motion (ROM) from weakness can lead to shoulder pathology, which can result in debilitating pain. Shoulder pain may limit PALS from participating in activities of daily living and may have a negative impact on their quality of life. This case series explores the efficacy of glenohumeral joint injections for the management of shoulder pain due to adhesive capsulitis in PALS. Methods: People living with ALS and shoulder pain were referred to sports medicine-certified physiatrists for diagnostic evaluation and management. They completed the Revised ALS Functional Rating Scale and a questionnaire asking about their pain levels and how it impacts sleep, function, and quality of life at baseline pre-injection, 1-week post-injection, 1 month post-injection, and 3 months post-injection. Results: We present five cases of PALS who were diagnosed with adhesive capsulitis and underwent glenohumeral joint injections. Though only one PALS reported complete symptom resolution, all had at least partial symptomatic improvement during the observation period. No complications were observed. Conclusions: People living with ALS require a comprehensive plan to manage shoulder pain. Glenohumeral joint injections are safe and effective for adhesive capsulitis in PALS, but alone may not completely resolve shoulder pain. Additional therapies to improve ROM and reduce pain should be considered.

Telemedicine During COVID-19 for Outpatient Sports and Musculoskeletal Medicine Physicians.

INTRODUCTION: The global pandemic due to SARS-CoV-2 has resulted in an expansion of telemedicine. Measures of quality and barriers for rapid use by patients and physicians are not well described. OBJECTIVE: To describe results from a quality improvement initiative during a rapid adoptive phase of telemedicine during the pandemic. DESIGN: Patient and physician satisfaction with synchronous audiovisual telemedicine visits was measured during the early adoptive phase (6 April 2020-17 April 2020) within the division of sports medicine in an academic Physical Medicine and Rehabilitation (PM&R) department. Patients were invited to participate in a quality improvement initiative by completing an online survey at the end of a telemedicine visit. Physicians completed a separate survey. PRIMARY OUTCOME MEASURES: Patient measures included visit type, duration of encounter, quality, and satisfaction. Physicians reported on experiences performed telemedicine. RESULTS: Surveys were completed by 119 patients (293 telemedicine encounters, response rate 40.6%) and 14 physiatrists. Telemedicine was utilized primarily for follow-up visits (n = 74, 70.6%), and the most common duration was 15 to 29 minutes. Patients rated their telemedicine visit as "excellent" or "very good" across measures (91.6%-95.0%) including addressing concerns, communication, developing a treatment plan, convenience, and satisfaction. Value of completing a future telemedicine visit was measured at 84.9%. Most reported estimated travel time saved was in excess of 30 minutes. Rate of no-show was 2.7%. Most physicians (57.1%) had no prior experience with telemedicine visits, and most were comfortable performing these visits after completing 1 to 4 sessions (71%). Nearly all physicians (92.9%) rated their telemedicine experience as very good or excellent. The key barrier identified for telemedicine was technical issues. All physicians reported plans to perform telemedicine visits if reimbursement continues. CONCLUSIONS: In summary, rapid expansion of telemedicine during the COVID-19 pandemic was well-received by a majority of patients and physicians. This suggests feasibility in rapid expansion of telemedicine for other outpatient sports medicine practices.

Patient-reported auditory handicap measures following mild traumatic brain injury.

OBJECTIVES/HYPOTHESIS: Few studies have specifically addressed auditory complaints in patients with nonblast mild traumatic brain injury (mTBI). Herein, we aimed to investigate auditory symptoms in patients following mTBI using patient-reported outcome measures. STUDY DESIGN: Retrospective analysis of prospectively collected data in a tertiary-care hospital. METHODS: The patients included those with mTBI (cases) and those without mTBI (controls). Individuals (≥18 years old) with and without mTBI were screened. Exclusion criteria included history of otologic disorders, blast injury, or occupational noise exposure. Primary outcomes included the Hearing Handicap Inventory for Adults (HHIA), Tinnitus Handicap Inventory (THI), and Hyperacusis Questionnaire (HQ). Secondary outcomes included subjective auditory complaints. RESULTS: From September 2017 to September 2018, 52 patients with mTBI and 55 controls met inclusion and exclusion criteria. The mean time between mTBI and survey intake was 70.6 months. The mean age and gender were 51.5 years old and 73% female in the mTBI group, and 46.1 years old and 56.3% female in the control group (P = .112 and P = .105, respectively). Patients with mTBI reported hyperacusis (67.3% of all mTBI patients), hearing loss (61.5%), and tinnitus (61.5%), compared to 8.3%, 12.7%, and 16.4%, respectively, for control subjects (P < .0001). The mean HHIA score in the mTBI group was 38.3 versus 8.5 in controls (P = .002). The mean THI score was 27.4 in the mTBI group and 3.1 in controls (P < .0001). The mean HQ score was 26.5 in mTBI group and 7.3 in controls (P = .001). CONCLUSIONS: Auditory symptoms and associated handicap were common in patients with nonblast mTBI compared to age-matched controls. Findings have implications for the pathophysiology and management of symptoms in this patient population. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:761-767, 2020.

The Relationship Between Body Mass Index and Fluoroscopy Time During Intraarticular Hip Injection: A Multicenter Cohort Study.

BACKGROUND: Higher body mass index (BMI) is associated with difficulty in obtaining imaging studies. While there is a small body of literature regarding the relationship between fluoroscopy time and BMI during injections for pain management, this has not been studied for intraarticular (IA) hip injections. Further, in academic training centers, trainee involvement may affect this relationship. OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during IA hip injections, both with and without involvement of a trainee. STUDY DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient musculoskeletal and pain medicine centers. METHODS: Patients who underwent fluoroscopically guided IA hip injections with encounter data regarding fluoroscopy time during the procedure and BMI were included. Mean and standard deviation fluoroscopy time were recorded. Comparisons were made between BMI categories of normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), and obese (greater than or equal to30.0 kg/m2). Statistical significance was set at P = 0.01 due to multiple comparisons. RESULTS: A total of 559 IA hip injections are represented in this cohort. Patients had a mean age of 58 (standard deviation [SD] 14) years and 63% were women. There was no significant difference in fluoroscopy time when comparing BMI categories (P = 0.02). However, when trainees were not involved in the injection, fluoroscopy times were significantly shorter with decreasing BMI category, with normal weight patients requiring the shortest fluoroscopy times (P = 0.01). LIMITATIONS: This study evaluated total fluoroscopy time, not radiation dose exposure per injection, which provides more direct and precise information with regard to provider and patient radiation exposure and overall safety. Future study of the impact of BMI on radiation dose during fluoroscopically guided IA hip injections is needed. CONCLUSIONS: Fluoroscopy times during IA hip injections increase with higher BMI categories in a statistically significant manner when performed by experienced clinicians but this relationship is not observed when injections are performed with a trainee in a teaching institution. This finding appears to be related to longer fluoroscopy time required to complete an IA hip injection in patients with lower BMI when a trainee is involved. KEY WORDS: Hip, injections, obesity, overweight, body mass index, fluoroscopy, radiation, pain.

Prevention, Evaluation, and Rehabilitation of Cycling-Related Injury.

The unique quality of the bicycle is its ability to accommodate a wide variety of injuries and disabilities. Cycling for recreation, transportation, and competition is growing nationwide, and has proven health and societal benefits. The demands of each type of cycling dictate the necessary equipment, as well as potential for injury. Prevention of cycling-related injury in both the athlete and the recreational cyclist involves understanding the common mechanisms for both traumatic and overuse injury, and early correction of strength and flexibility imbalances, technique errors, and bicycle fit.

Local, national, and service component cost variations in the management of low back pain: Considerations for the clinician.

In the past two decades, the cost associated with managing low back pain has increased significantly. Improved consciousness of how clinicians utilize resources when managing low back pain is necessary in the current economic climate. The goal of this review is to examine the component costs associated with managing low back pain and provide practical solutions for reducing healthcare costs. This is accomplished by utilizing examples from a major metropolitan area with several major academic institutions and private health care centers. It is clear that there is considerable local and national variation in the component costs of managing low back pain, including physician visits, imaging studies, medications, and therapy services. By being well informed about these variations in one's environment, clinicians and patients alike can make strides towards reducing the financial impact of low back pain. Investigation of the cost discrepancies for services within one's community of practice is important. Improved public access to both cost and outcomes data is needed.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study.

OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication. DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient pain treatment centers. SUBJECTS: Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI). MAIN OUTCOME MEASURE: Median and 25-75% Interquartile Range (IQR) fluoroscopy time. RESULTS: 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories. CONCLUSIONS: Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

Outcomes of Inpatient Rehabilitation in Patients With Simultaneous Bilateral Total Knee Arthroplasty.

BACKGROUND: The number of total knee arthroplasty (TKA) procedures performed in the United States is increasing each year, and the number of bilateral TKA procedures has also increased during the past 2 decades. However, few studies in the literature have investigated the rehabilitation outcomes of patients who undergo bilateral TKA. This study was performed to provide information on the benefits and role of inpatient rehabilitation for patients after bilateral TKA. OBJECTIVE: To investigate the functional outcomes, complications, and transfer rates of patients in the inpatient rehabilitation setting who undergo simultaneous bilateral TKA. DESIGN: Retrospective cohort study. SETTING: Freestanding inpatient rehabilitation hospital. PATIENTS: Ninety-four patients admitted to an inpatient rehabilitation hospital after simultaneous bilateral TKA from 2008-2013. METHODS: Retrospective chart review of demographic, clinical, and functional data for patients admitted to inpatient rehabilitation after simultaneous bilateral TKA. MAIN OUTCOME MEASURES: Length of stay, admission and discharge Functional Independence Measure (FIM), and FIM efficiency. RESULTS: The study included 27 male (28.7%) and 67 female (71.3%) patients aged 42.0-86.9 years, with a mean of 65.6 ± 10.2 years. Mean length of time between surgery and admission to inpatient rehabilitation was 4.5 ± 3.3 days. Mean length of stay in rehabilitation was 11.7 ± 4.2 days. Mean admission and discharge FIM scores were 87.3 ± 11.7 and 113.4 ± 4.8, respectively, with a mean FIM gain of 26.1 ± 10.5. The mean FIM efficiency was 2.33 ± 0.84. Eight patients required transfer to an acute care hospital. Complications leading to transfer to acute care facilities included sepsis, cardiac arrhythmias, knee dislocation, and suspected small bowel obstruction. Eighty-eight patients were discharged home, 4 patients were discharged to skilled nursing facilities, and 2 patients were transferred to an acute care hospital and did not return to the inpatient rehabilitation hospital. CONCLUSIONS: After undergoing simultaneous bilateral TKA, patients demonstrate functional gains when admitted to inpatient rehabilitation facilities based on FIM gains and FIM efficiency scores; 8.5% of patients in this cohort required transfer to an acute care facility as a result of complications during inpatient rehabilitation, and 93.6% of patients were discharged home.

Does Electrodiagnostic Confirmation of Radiculopathy Predict Pain Reduction after Transforaminal Epidural Steroid Injection? A Multicenter Study.

OBJECTIVE: Minimal definitive literature identifies patients with radicular pain who would benefit most from epidural steroid injection (ESI). This study investigated if electromyographic (EMG) confirmation of radiculopathy with active or chronic denervation predicts a positive treatment outcome following ESI. DESIGN: Longitudinal cohort study of adults who underwent EMG and subsequent transforaminal ESI within 6 months. The proportion of individuals who experienced >50% pain relief and mean change in daily morphine equivalents (DME) were calculated. RESULTS: 170 individuals with respective mean (Standard Deviation) age and duration of symptoms of 55 (15) years and 36 (56) months were included. Mean time to <30 day and >30 day follow-up post-injection were 18 (6) and 99 (130) days, respectively. At >30 day follow-up, a larger proportion of EMG-confirmed individuals (37.7%) reported >50% pain reduction compared to EMG-negative individuals (17.8%) (p=0.03). This was significant for lumbosacral (40% vs. 15%, p=0.01) but not cervical symptoms (p>0.05). Mean decrease in DME at long-term follow-up in EMG-confirmed compared to EMG-negative individuals trended toward significance (-4 vs. -1, p=0.11). There was no significant relationship between myotomal spontaneous activity and pain or opioid use. CONCLUSIONS: Needle EMG predicts long-term pain reduction from transforaminal ESI in patients with lumbosacral radiculopathy, regardless of the presence of active denervation.

Increased FGF-2 secretion and ability to support neurite outgrowth by astrocytes cultured on polyamide nanofibrillar matrices.

An electrospun nonwoven matrix of polyamide nanofibers was employed as a new model for the capillary basement membrane at the blood-brain barrier (BBB). The basement membrane separates astrocytes from endothelial cells and is associated with growth factors, such as fibroblast growth factor-2 (FGF-2). FGF-2 is produced by astrocytes and induces specialized functions in endothelial cells, but also has actions on astrocytes. To investigate potential autocrine actions of FGF-2 at the BBB, astrocytes were cultured on unmodified nanofibers or nanofibers covalently modified with FGF-2. The former assumed an in vivo-like stellate morphology that was enhanced in the presence of cross-linked FGF-2. Furthermore, astrocyte monolayers established on unmodified nanofibers were more permissive for neurite outgrowth when cultured with an overlay of neurons than similar monolayers established on standard tissue culture surfaces, while astrocytes cultured on FGF-2-modifed nanofibers were yet more permissive. The observed differences were due in part to progressively increasing amounts of FGF-2 secreted by the astrocytes into the medium; hence FGF-2 increases its own expression in astrocytes to modulate astrocyte-neuron interactions. Soluble FGF-2 was unable to replicate the effects of cross-linked FGF-2. Nanofibers alone up-regulated FGF-2, albeit to a lesser extent than nanofibers covalently modified with FGF-2. These results underscore the importance of both surface topography and growth factor presentation on cellular function. Moreover, these results indicate that FGF-2-modified nanofibrillar scaffolds may demonstrate utility in tissue engineering applications for replacement and regeneration of lost tissue following central nervous system (CNS) injury or disease.

Covalently attached FGF-2 to three-dimensional polyamide nanofibrillar surfaces demonstrates enhanced biological stability and activity.

Activation of fibroblast growth factor receptors (FGFRs) requires the formation of a ternary complex between fibroblast growth factors (FGFs), FGFRs, and heparan sulfate proteoglycans, which are all located on the cell surface and the basement membrane (BM)/extracellular matrix (ECM). Heparan sulfate proteoglycans appear to stabilize FGFs by inhibiting the rapid degradation of FGFs normally observed in solution. Because of the pivotal role of FGFs in proliferative and developmental pathways, a number of recent studies have attempted to engineer microenvironments to stabilize growth factors for use in applications in tissue culture and regenerative medicine. In this communication, we demonstrate that covalent linkage of FGF-2 to nanofibrillar surfaces (defined as covalently bound FGF-2) composed of a network of polyamide nanofibers resulted in the maintenance of the biological efficacy of FGF-2 when stored dry for at least 6 months at 25 degrees C or 4 degrees C. Moreover, covalently bound FGF-2 was more potent than FGF-2 in solution when measured in cellular assays of proliferation and viability using a variety of cell types. Covalently bound FGF-2 also strongly activated FGFR, extracellular signal-regulated kinase (ERK1/2), and c-fos. Hence cell-signaling molecules can be incorporated into a synthetic nanofibrillar surface, providing a novel means to enhance their stability and biological activity.

Three-dimensional nanofibrillar surfaces covalently modified with tenascin-C-derived peptides enhance neuronal growth in vitro.

Current methods to promote growth of cultured neurons use two-dimensional (2D) glass or polystyrene surfaces coated with a charged molecule (e.g. poly-L-lysine (PLL)) or an isolated extracellular matrix (ECM) protein (e.g. laminin-1). However, these 2D surfaces represent a poor topological approximation of the three-dimensional (3D) architecture of the assembled ECM that regulates neuronal growth in vivo. Here we report on the development of a new 3D synthetic nanofibrillar surface for the culture of neurons. This nanofibrillar surface is composed of polyamide nanofibers whose organization mimics the porosity and geometry of the ECM. Neuronal adhesion and neurite outgrowth from cerebellar granule, cerebral cortical, hippocampal, motor, and dorsal root ganglion neurons were similar on nanofibers and PLL-coated glass coverslips; however, neurite generation was increased. Moreover, covalent modification of the nanofibers with neuroactive peptides derived from human tenascin-C significantly enhanced the ability of the nanofibers to facilitate neuronal attachment, neurite generation, and neurite extension in vitro. Hence the 3D nanofibrillar surface provides a physically and chemically stabile cell culture surface for neurons and, potentially, an exciting new opportunity for the development of peptide-modified matrices for use in strategies designed to encourage axonal regrowth following central nervous system injury.