Comparative Analysis of Predetermined Axillary Crutch Length Settings to Individualized Fittings.

Axillary crutches are the most common assistive devices given to individuals with musculoskeletal injuries in an acute care setting. Nurses are frequently the care provider fitting injured individuals with crutches. This study compared the crutch length determined by the crutch manufacturer's height setting with the crutch length attained after applying a standard clinical protocol for crutch fitting. A total of 116 adults with lower extremity injuries were enrolled. Self-reported height was documented as well as initial crutch length as indicated by the numbers on the push-button feature of the crutches. Subject height with and without shoes was measured. Proper crutch length was then determined using the method described by Bauer et al. (1991). No change between the initial and adjusted crutch settings was made in 43% of the subjects. Change was made in 57% of the subjects: lengthening in 40% and shortening in 17% of subjects. This study revealed the predetermined crutch settings are unreliable and should simply be used as a starting point during a personalized fitting.

Assessing Lateral Ankle Sprains With a New Arthrometer.

BACKGROUND: Lateral ankle sprains are a common musculoskeletal injury across a variety of activities. Researchers have sought to identify a method to objectively assess joint laxity with a device that is simple to use and affordable. AIM: The purpose of this study was to assess the use of an ankle arthrometer on individuals with ankle sprains. METHODS: The participant was evaluated by the physician and the degree of ankle sprain was identified. In the prone position, the arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each). Both clinicians were blinded to the data of the other. RESULTS: There were 30 participants, 10 in each group (uninjured, grade 1 sprain, grade 2 sprain). Mann-Whitney U testing found significant differences between the control and grade I ankle sprain groups (P < .001), the control and grade II ankle sprain groups (P < .001), and the grade I and grade II ankle sprain groups (P = .004). There was ±0.31-mm difference in anterior translation between healthy ankles, whereas there was 1.11- and 2.16-mm difference between ankles in grade 1 and grade 2 sprains, respectively. CLINICAL APPLICATION: Despite the manual anterior drawer test being convenient, the subjectivity makes it unreliable. This study is consistent with prior literature about the difference in translation (millimeters) between the uninjured and injured ankles corresponding to the magnitude of ankle laxity. This study also contributes to the evolving evidence to support the relationship of a ratio of measures (injured/uninjured) as an objective measure of laxity. These comparisons to the individual's healthy ankle mitigate the variability of the normative values. The use of an arthrometer to assess ankle joint laxity enhances the objectivity of patient assessment throughout the recovery process. LEVELS OF EVIDENCE: Level III.

Primary leiomyosarcoma of the distal tibia: A case report.

The authors present an unusual case of a leiomyosarcoma of the distal tibia. Leiomyosarcoma tumors typically originate from smooth muscle tissue. It is rare for it to derive from bone and even rarer to be found in a bone of the lower limb. Given this extreme rarity in addition to nonspecific findings on plain film radiographs and magnetic resonance imaging (MRI), biopsy was needed in this case. It was only through immunochemistry staining that a definitive diagnosis was made. As such, this case is an illustrative example of an aggressive, though rare, primary lesion of the bone which should be considered in the differential diagnosis of a lytic intramedullary lesion. This case also highlights the need for careful evaluation of imaging features suggesting a potentially aggressive lesion requiring appropriate work up in a timely fashion.

Os Intermetatarseum and Polymetatarsia Without Polydactyly: A Case Report.

Nontraumatic bony abnormalities of the foot occur at different rates, according to the literature. However, it is uncommon to see rare variations presenting together in one patient. This article discusses two less common anomalies: fused os intermetatarseum and polymetatarsia without polydactyly. Etiology, symptomology, diagnosis, and treatment are reviewed, in addition to the relationship of the two conditions to each other. We then discuss a case where both anomalies are present at the same time in a 17-year-old patient.

Extra-articular synovial chondromatosis of the ankle: Unusual case with radiologic-pathologic correlation.

Extra-articular synovial chondromatosis is a rare entity in the foot and ankle. We present a case of a 49-year-old female who presented for evaluation of a palpable concern following trauma; which was found to represent synovial chondromatosis. This case demonstrates the multimodality imaging findings, including ultrasound and MRI, with histopathologic correlation.

Does Immobilization Affect Braking Time?

BACKGROUND: Despite the importance to patients of driving, no well-established guideline exists to help either the patient or the physician determine when it is safe for the patient to return to driving. Previous studies have recommended 6 weeks postoperatively before patients can return to driving safely. Several scientific studies have found the nationally recommended safe brake time standard to be 1.25 sec (1,250 msec), looking at brake reaction time (BRT) in all types of patients, surgical and nonsurgical. METHODS: This is a prospective study assessing BRT after individuals are placed in various forms of immobilization (controlled action motion [CAM] boot, surgical shoe). The study also tested whether BRT is different when using the left foot to brake, with immobilization of the right foot. RESULTS: All 29 male and 71 female participants in this study (mean age, 35.49 years) were capable of driving and were not currently being treated for any foot or ankle conditions. No differences were found regarding age, sex, and use of assistive devices. The mean BRT while wearing a CAM boot was 713 msec, while using the left foot to brake (CAM boot on the right foot) was 593.86 msec, and while wearing a surgical shoe was 626.32 msec. CONCLUSIONS: Although most of the study participants were below the nationally recommended safe brake time standard, it was found that not all of the participants fell within these parameters.

Spontaneous Fracture of the Os Peroneum With Rupture of the Peroneus Longus Tendon.

Rupture of the peroneus longus tendon with or without an associated os peroneum fracture is rare and uncommonly encountered in the published data. Owing to the infrequent nature, a high index of suspicion is required. Otherwise, the opportunity for the injury to result in a delayed or missed diagnosis is increased. We report the case of a 39-year-old male with spontaneous rupture of the peroneus longus tendon and associated fracture of the os peroneum. The spontaneous rupture and fracture were diagnosed from the history, physical examination, and imaging findings. The patient elected to undergo operative repair, with excellent results, full recovery, and full return to normal function.

DISTAL FIBULAR STRESS FRACTURE IN A FEMALE RECREATIONAL RUNNER: A CASE REPORT WITH MUSCULOSKELETAL ULTRASOUND IMAGING FINDINGS.

BACKGROUND AND PURPOSE: This case report describes a physical therapist's use of diagnostic ultrasound imaging in the decision making process used to refer a patient to a physician for a suspected fibular stress fracture. The purpose of this case report is to 1) describe the history, subjective examination, and objective examination findings of a fibular stress fracture, 2) describe the ultrasound findings associated with a fibular stress fracture, and 3) describe the decision making process of a physical therapist in the decision to refer the patient to a medical physician for further work-up. CASE DESCRIPTION: A 52-year-old female recreational runner with a recent increase in running intensity self-referred to a physical therapist with a 19-day history of lateral lower leg pain. Examination revealed relatively normal ankle range of motion, mild weakness of ankle invertors and evertors, no increase in pain with resisted muscle tests of the ankle, and tenderness to palpation over the fibularis brevis muscle and distal fibula. Diagnostic ultrasound examination of the fibularis muscles revealed cortical irregularity of the distal third of the fibula in the location of tenderness. OUTCOMES: The physical therapist used the abnormal ultrasound findings, running history, symptoms, and physical examination for differential diagnosis, and decided to refer the patient to a physician for further examination. Radiographs revealed a fibular stress fracture. Follow-up ultrasound imaging demonstrated a mixed hypoechoic-hyperechoic appearance of the fibular cortex typical of healing fracture and the presence of bony callus. DISCUSSION: Diagnostic ultrasound imaging is increasingly being used by physical therapists to guide rehabilitation. Ultrasound imaging of musculotendinous structures may display adjacent bone. Physical therapists should be knowledgeable of normal and abnormal bony ultrasound imaging findings. Abnormal ultrasound findings may be one sign indicating the need to refer a patient for consultation by a physician.

Heel lipoma mimicking plantar fasciitis in a ballroom dancer.

The present case illustrates a lipoma as an unusual cause of heel pain. A 64-year-old female ballroom dancer presented with 8 months of pain that was unresponsive to previous treatment of plantar fasciitis. Magnetic resonance imaging revealed a heel lipoma. Her pain was fully resolved after surgical excision. Soft tissue tumors should be included in the differential diagnosis of heel pain, especially when symptoms and treatment response do not follow the typical course of plantar fasciitis.

Distal fibula metastasis of cholangiocarcinoma.

Cholangiocarcinoma is a rare disease with a reported incidence in the United States of 1 to 2 cases per 100,000 population. These cancers have a high mortality rate because most are locally advanced at presentation. Cholangiocarcinoma most commonly advances locally and regionally by invading the lymph nodes. In rare cases, it has been noted that cholangiocarcinoma can metastasize to bone, with a preponderance for the axial skeleton. Herein, we describe what we believe to be the first clinical report of an acral bone metastasis from metastatic cholangiocarcinoma.

The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures.

BACKGROUND: The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula. It occurs from violent twisting of the ankle that characteristically causes ligament damage and severe instability. Most patients complain of significant ankle pain but very little pain over the fracture. The clinical and radiographic examination is usually directed to the ankle region; and the proximal fibula is often ignored. OBJECTIVE: The authors intend to show the ease of missing the proximal fibular fracture when the clinical examination is directed to the ankle region. They discuss the importance of palpating the proximal fibula and ordering appropriate radiographs. CASE STUDIES: The authors report on 5 patients who presented to the Emergency Department, where the Maisonneuve fracture was missed despite having ankle radiographs taken. All patients required open reduction and internal fixation. CONCLUSION: The Maisonneuve fracture injury pattern causes untoward consequences if not promptly recognized and treated. To avoid misdiagnosis, the proximal fibula should be examined in all patients with ankle injury.

MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria.

BACKGROUND: Achilles tendon ruptures are common in middle-aged athletes. Diagnosis is based on clinical examination or imaging. Although MRI is commonly used to document ruptures, there is no literature supporting its routine use and we wondered whether it was necessary. QUESTIONS/PURPOSES: We (1) determined the sensitivity of physical examination in diagnosing acute Achilles ruptures, (2) compared the sensitivity of physical examination with that of MRI, and (3) assessed care delays and impact attributable to MRI. METHODS: We retrospectively compared 66 patients with surgically confirmed acute Achilles ruptures and preoperative MRI with a control group of 66 patients without preoperative MRI. Clinical diagnostic criteria were an abnormal Thompson test, decreased resting tension, and palpable defect. Time to diagnosis and surgical procedures were compared with those of the control group. RESULTS: All patients had all three clinical findings preoperatively and complete ruptures intraoperatively (sensitivity of 100%). MR images were read as complete tears in 60, partial in four, and inconclusive in two patients. It took a mean of 5.1 days to obtain MRI after the injury, 8.8 days for initial evaluation, and 12.4 days for surgical intervention. In the control group, initial evaluation occurred at 2.5 days and surgical intervention at 5.6 days after injury. Nineteen patients in the MRI group had additional procedures whereas none of the control group patients had additional procedures. CONCLUSIONS: Physical examination findings were more sensitive than MRI. MRI is time consuming, expensive, and can lead to treatment delays. Clinicians should rely on the history and physical examination for accurate diagnosis and reserve MRI for ambiguous presentations and subacute or chronic injuries for preoperative planning. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.