Strategies to Promote Racial Healthcare Equity in Pain Medicine: A Call to Action.

In the past several years, many national events have illuminated the inequities faced by the Black community in all aspects of life, including healthcare. To close the gap in healthcare equity, it is imperative that clinicians examine their practices for disparities in the treatment of minority patients and for racial injustice and take responsibility for improving any issues. As leaders in pain medicine, we can start by improving our understanding of healthcare disparities and inequities among racial and ethnic minorities and translating that knowledge into a cultural transformation to improve the care of those impacted. In this paper, we identify the areas of medicine in which pain assessment and treatment are not equitably delivered. As we acknowledge these disparities, we will highlight reasons for these incongruences in care and clarify how clinicians can act to ensure that all patients are treated equitably, with equal levels of compassion.

Sonographically Guided Plantaris Tendon Release: A Cadaveric Validation Study.

BACKGROUND: The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described. OBJECTIVE: To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Procedural skills laboratory in a tertiary medical center. SUBJECTS: Twenty unembalmed cadaveric knee-ankle-foot specimens (10 right, 10 left) obtained from 16 donors (6 male, 10 female) ages 55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2 ). METHODS: After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendon-Achilles tendon interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateral-to-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury. MAIN OUTCOME: Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection. RESULTS: All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures. CONCLUSION: Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically guided PT release in patients with suspected PT-mediated Achilles region pain syndromes. LEVEL OF EVIDENCE: IV.

Differential Plantaris-Achilles Tendon Motion: A Sonographic and Cadaveric Investigation.

BACKGROUND: Differential motion between the plantaris and Achilles tendons has been hypothesized to contribute to pain in some patients presenting with Achilles tendinopathy. However, objective evidence of differential Achilles-plantaris motion is currently lacking from the literature. OBJECTIVE: To determine whether differential, multidirectional motion exists between the plantaris tendon (PT) and Achilles tendon (AT) as documented by dynamic ultrasound (US) and postdissection examination in an unembalmed cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Procedural skills laboratory in a tertiary medical center. SUBJECTS: Twenty unembalmed knee-ankle-foot specimens (9 right, 11 left) obtained from 6 male and 10 female donors ages 55-96 years (mean 80 years) with body mass indices of 14.1-33.2 kg/m2 (mean 22.5 kg/m2). METHODS: A single, experienced operator used high-resolution dynamic US to qualitatively document differential PT-AT motion during passive ankle dorsiflexion-plantarflexion. Specimens were then dissected and passive dorsiflexion-plantarflexion was repeated while differential PT-AT motion was visualized directly. MAIN OUTCOME MEASUREMENTS: Presence or absence of multidirectional differential PT-AT motion. RESULTS: All 20 specimens exhibited smooth but variable amplitude multidirectional differential PT-AT motion. Whereas US readily demonstrated medial-lateral and anterior-posterior PT motion relative to the AT, differential longitudinal motion was only appreciated on dissection and direct inspection. Many specimens exhibited partial or complete encasement of the PT between the gastrocnemius portion of the AT and the soleus aponeurosis. CONCLUSION: Some degree of multidirectional differential PT-AT motion appears to be a normal phenomenon, and PT motion can be evaluated sonographically in both the medial-lateral and anterior-posterior directions. The existence of normal differential PT-AT motion suggests that alterations in PT motion or repetitive stress within the PT-AT interval may produce symptoms in some patients presenting with Achilles region pain syndromes. The PT should be evaluated in all patients presenting with Achilles, plantaris, or calf pain syndromes. Future research would benefit from the development of a sonographic classification system for PT anatomy and motion with the goal of differentiating normal versus pathologic states and identifying risk factors for symptom development. LEVEL OF EVIDENCE: IV.