Youth running consensus statement: minimising risk of injury and illness in youth runners.

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

Torsional Anatomy of the Lower Limb: The Appearance of Anatomy in Hemispastic Position.

OBJECTIVE: The aim of the study was to determine whether there are relevant anatomical variations to the typical injection sites for antispasticity procedures in the lower limb. METHODS: Sonographic images were obtained at traditional injection locations for spasticity in the lower limb. Images were recorded in neutral and contracted postures. Doppler imaging was obtained for sites that contained vasculature. The images were analyzed, and schematics were created that highlighted relevant findings. RESULTS: The adductor longus in commonly used injection sites was close to vasculature making accidental injection of the latter a higher risk. The sciatic nerve was vulnerable to injections at the proximal biceps femoris injection side if injected too deeply. Hamstring injection sites can be adjusted to the midline to improve accuracy. The proximity of the tibial nerve to the flexor hallucis longus and the deep fibular nerve to the extensor hallucis longus puts these nerves at risk for accidental injection. DISCUSSION: Contracted posture results in altered positions of lower extremity muscles that could lead to inadvertent neurovascular injection or decreased efficacy with injections. Findings in this study may be helpful for planning and executing injections to reduce spasticity in the lower extremity. CONCLUSIONS: Sonographic imaging allows a better localization of muscles associated with spasticity and can instruct the clinician to alter usual injection pathways. This article documents visual evidence that previous assumptions for injection strategies require updating.

Procedure-Oriented Torsional Anatomy of the Hand for Spasticity Injection.

OBJECTIVES: To provide musculoskeletal ultrasound (MSKUS) images of hand anatomy in the position of hemiparetic flexion as a reference for spasticity injections. After a stroke, spasticity can result in anatomic distortion of the hand. Spasticity may require treatment with botulinum toxin or phenol injections. Anatomic distortion may decrease the accuracy of injections. Standard anatomic references are of limited utility because they are not in this spastic hemiparetic position. There presently is no anatomic reference in the literature for these spastic postures. This study is part three of a series examining torsional anatomy of the body. DESIGN: Ultrasound (US) images were obtained in a healthy subject. The muscles examined included the lumbricals and the flexor pollicis brevis. A marker dot was placed at each dorsal and palmar anatomic injection site for these muscles. The US probe was placed on these dots to obtain a cross-sectional view. A pair of US images was recorded with and without power Doppler imaging: the first in anatomic neutral and second in hemiparetic spastic positions. In addition, a video recording of the movement of the muscles during this rotation was made at each site. RESULTS: On the palmar view, the lumbricals rotated medially. On dorsal view, the lumbricals can be seen deep to the dorsal interossei muscles, with spastic position, and they become difficult to identify. The flexor pollicis brevis (FPB) muscle contracts with torsion, making abductor pollicis brevis (APB) predominately in view. DISCUSSION: The anatomic location of the lumbrical muscles makes them difficult to inject even with ultrasound guidance. However, recognizing the nearby digital vasculature allows for improved identification of the musculature for injection purposes. The FPB muscle also can be identified by its adjacent radial artery lateral to the flexor pollicus longus tendon. CONCLUSION: Normal anatomy of hand can become distorted in spastic hemiparesis. Diagnostic ultrasound is able to discern these anatomic locations if the sonographer is competent in recognizing the appearance of normal anatomy and is skilled in resolving the visual changes that occur in spastic hemiparesis. The authors hope this series of images will increase the accuracy, safety, and efficacy of spasticity injections in the hand.

Cardiac arrest during long-distance running races.

BACKGROUND: Approximately 2 million people participate in long-distance running races in the United States annually. Reports of race-related cardiac arrests have generated concern about the safety of this activity. METHODS: We assessed the incidence and outcomes of cardiac arrest associated with marathon and half-marathon races in the United States from January 1, 2000, to May 31, 2010. We determined the clinical characteristics of the arrests by interviewing survivors and the next of kin of nonsurvivors, reviewing medical records, and analyzing postmortem data. RESULTS: Of 10.9 million runners, 59 (mean [±SD] age, 42-13 years; 51 men) had cardiac arrest (incidence rate, 0.54 per 100,000 participants; 95% confidence interval [CI], 0.41 to 0.70). Cardiovascular disease accounted for the majority of cardiac arrests. The incidence rate was significantly higher during marathons (1.01 per 100,000; 95% CI, 0.72 to 1.38) than during half-marathons (0.27; 95% CI, 0.17 to 0.43) and among men (0.90 per 100,000; 95% CI, 0.67 to 1.18) than among women (0.16; 95% CI, 0.07 to 0.31). Male marathon runners, the highest-risk group, had an increased incidence of cardiac arrest during the latter half of the study decade (2000-2004, 0.71 per 100,000 [95% CI, 0.31 to 1.40]; 2005-2010, 2.03 per 100,000 [95% CI, 1.33 to 2.98]; P=0.01). Of the 59 cases of cardiac arrest, 42 (71%) were fatal (incidence, 0.39 per 100,000; 95% CI, 0.28 to 0.52). Among the 31 cases with complete clinical data, initiation of bystander-administered cardiopulmonary resuscitation and an underlying diagnosis other than hypertrophic cardiomyopathy were the strongest predictors of survival. CONCLUSIONS: Marathons and half-marathons are associated with a low overall risk of cardiac arrest and sudden death. Cardiac arrest, most commonly attributable to hypertrophic cardiomyopathy or atherosclerotic coronary disease, occurs primarily among male marathon participants; the incidence rate in this group increased during the past decade.

Procedure Oriented Torsional Anatomy of the Forearm for Spasticity Injection.

UNLABELLED: : This is the second in a series of articles related to the concept of "torsional" anatomy. The objective of this article is to provide musculoskeletal ultrasound (MSKUS) anatomy of the forearm in the position of hemispastic flexion as a reference relevant to needle procedures. METHODS: The MSKUS images were obtained in a healthy human subject. Marker dots were placed over common injection sites in the forearm for spasticity. The MSKUS probe was centered over each dot to obtain a cross-sectional view. A pair of MSKUS images was recorded for each site: the first in anatomic neutral and second in hemiparetic spastic position. The images were compared side to side. In addition, a video recording was made at each site to track the movement of the muscles and nerves during internal rotation. RESULTS: The pronator teres (PT) rotated medially and the brachialis and biceps tendon rotated in view. In addition, the median nerve became more superficial. The flexor carpi radialis rotated medially and was replaced by PT and the median nerve. The flexor carpi ulnaris and flexor digitorum profundus rotated medially and were replaced by the flexor carpi radialis, PT and median nerve. The flexor digitorum superficialis was replaced by the brachioradialis, extensor carpi radialis brevis, and radial nerve. The brachioradialis was replaced by the extensor carpi radialis brevis and extensor digitorum communis. DISCUSSION: Intended muscle targets rotate out of view and injection range. These are replaced by other muscles and nerves that could inadvertently be injected. This potentially could result in both increased complications and decreased efficacy of the procedure. CONCLUSIONS: It is hoped that this series of images will increase the accuracy and safety of needle placement for spasticity injections in the forearm.

Procedure-oriented torsional anatomy of the proximal arm for spasticity injection.

UNLABELLED: This is the first in a series of papers related to the new concept of "torsional" anatomy. The objective of this article is to provide musculoskeletal ultrasound (MSKUS) anatomy of the upper arm in the position of hemispastic flexion as a reference relevant to needle procedures. METHODS: The MSKUS images were obtained in a healthy human subject. A pair of MSKUS images was recorded for each level: the first in anatomic neutral and second in hemispastic position. RESULTS: At the proximal 1/3 level of the upper arm, the pectoralis major rotated out of view. At the middle of the upper arm, the biceps rotated medially, and the brachialis rotated from far lateral to the middle of the screen. At the distal 1/3 level of the upper arm, the radial nerve rotated more anteriorly. At the distal 1/6 level of the upper arm, the biceps shifted and was replaced by the brachialis and brachioradialis. The radial nerve also rotated more anteriorly and superficially. DISCUSSION: With torsion, it is possible that intended muscle targets, such as the pectoralis, are missed, and unintended targets, such as the radial nerve, are accidentally injected in the upper arm. CONCLUSIONS: It is hoped that this series of images will increase the accuracy and safety of needle placement for spasticity and nerve block injections in the proximal upper arm.

Musculoskeletal Injuries and Regenerative Medicine in the Elderly Patient.

Regenerative medicine has gained increasing popularity in its clinical applications, particularly in the field of musculoskeletal medicine. Regenerative medicine, a broad term, can be thought of as a particular medical strategy that strives to rebuild and restore diseased tissue to normal physiologic tissue baseline. Simply put, regenerative strategies augment the body's innate physiology to heal pathologic processes. This article focuses on specific regenerative strategies and the uses of them for common pathologies in the aging adult, including platelet-rich plasma, mesenchymal stem cells, viscosupplementation, and prolotherapy.

Musculoskeletal ultrasound of the ankle and foot.

Despite the tendency for injuries of the foot and ankle to be readily localized at physical examination, the examiner is advised to perform an ultrasound examination when indicated with a routine and systematic approach. This allows for comprehensive evaluation of all the relevant structures and affords the necessary experience to recognize abnormal anatomy when it is present. Musculoskeletal ultrasound examination strongly complements other diagnostic tools used in the diagnosis and treatment of foot and ankle pathology.

Risk factors for exercise-associated hyponatremia in non-elite marathon runners.

OBJECTIVE: Describe risk factors for lower post-race [Na+] and exercise-associated hyponatremia (EAH) (serum [Na+]<135 mmol/L) during marathon running. DESIGN: Prospective observational study. SETTING: Houston Marathon 2000-2004. PATIENTS: Ninety-six runners from EAH research projects. INTERVENTIONS: Observational. MAIN OUTCOME MEASUREMENTS: Pre-race and post-race measurements: serum [Na+], weight, and fluid ingestion. RESULTS: Twenty-one runners (22%) met criteria for EAH, and 87% of subjects had lower post-race [Na+] compared to pre-race [Na+]. Lower post-race [Na+] and larger [Na+] decrease were related to lower pre-race [Na+], less weight loss during the race, and more fluid cups consumed. Increased fluid consumed correlated with slower finish time, male gender, and warmer temperature. Less weight loss correlated with lower pre-race weight, more fluid consumed, and slower finish time. Losing less than 0.75 kg increased the risk of becoming hyponatremic 7 fold (RR=7.0; CI 1.8 to 26.6) compared to those who lost more than 0.75 kg. Women consumed fluid at a significantly lower rate than men (P=0.04). Estimated mean fluid balance for women was positive and significantly higher than men's negative fluid balance (P<0.0001). Fluid balance became more positive as finish time increased and pre-race weight decreased. CONCLUSIONS: Lighter and slower runners have more positive fluid balance. Losing>0.75 kg of body weight during a marathon is advisable in order to decrease the risk of EAH. Runners should measure their sweat rate and monitor weight changes as part of their fluid consumption plan.

Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnosing and managing the injured worker with low back pain.

UNLABELLED: This self-directed learning module highlights the evaluation and management of the injured worker with low back pain (LBP). This chapter reviews the importance of recognizing the physiologic implications of a lifting injury and evaluating its structural etiology in a worker with LBP. A review of the steps required to make an accurate diagnosis is included. Justifying restrictions and prescribing therapeutic intervention is summarized. OVERALL ARTICLE OBJECTIVE: To be able to provide a step-by-step plan for evaluating, treating, and safely returning to work the injured worker with LBP.

Industrial medicine and acute musculoskeletal rehabilitation. 3. Cumulative trauma disorders of the upper limb in computer users.

UNLABELLED: This self-directed learning module highlights various cumulative trauma disorders of the upper limb that may be seen in computer users. The biomechanics and ergonomics of computer users are addressed in relationship to specific neurologic and musculoskeletal conditions within the neck and upper limbs. In addition to a general overview of these conditions, a case presentation is used to show the evaluation and treatment of a computer user who has carpal tunnel syndrome and concomitant de Quervain tenosynovitis. OVERALL ARTICLE OBJECTIVES: (a) To review the important anatomic and ergonomic basis for upper limb cumulative trauma disorders in computer users and (b) to provide an example of evaluation and treatment.

Industrial medicine and acute musculoskeletal rehabilitation. 2. Acute cervical spine and shoulder injuries in the industrial setting.

UNLABELLED: This self-directed learning module highlights the underlying anatomy and biomechanics of the cervical spine and shoulder as a basis for developing a differential diagnosis of contributing pathology in an industrial injury. This includes components of the history, examination, and appropriate diagnostic testing that are necessary to develop an optimal rehabilitation plan. Treatment options are reviewed and include medications, therapy, selective injections, and return-to-work programs in the industrial setting. OVERALL ARTICLE OBJECTIVES: (a) To be able to identify neck and shoulder pathology, (b) to effectively evaluate cervical spine and shoulder injuries, and (c) to rehabilitate acute cervical spine and shoulder injuries in the industrial setting.

Industrial medicine and acute musculoskeletal rehabilitation. 4. Evaluation and management of the injured worker with a lower-extremity injury.

UNLABELLED: This self-directed learning module highlights the importance of recognizing the relationships between multiple, concurrent joint injuries in the lower extremity of an injured worker. This chapter focuses on evaluating the lower extremity and devising a rehabilitation program that incorporates the entire kinetic chain. Further recommendations for return to work are discussed. OVERALL ARTICLE OBJECTIVES: (a) To accurately recognize and diagnose coexisting injuries in the lower extremity and (b) to devise an evaluation and treatment program enabling the worker to return to work.

Industrial medicine and acute musculoskeletal rehabilitation. 5. Effective medical management of industrial injuries: from causality to case closure.

UNLABELLED: This self-directed learning module highlights the physician's role in treating industrial injuries, from the initial causality determination to the eventual case closure. It is part of the chapter on industrial medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The article reviews important factors in determining whether an injury is work-related, particularly in the presence of preexisting, underlying conditions. The article addresses the roles of functional capacity examinations and work-hardening programs in facilitating successful return to work. Interactions are outlined between work return and nonwork activities of daily living, as well as financial and psychologic barriers that may impede work return. Legal issues regarding independent medical examinations and depositions are reviewed. Guidance is offered for identifying those relatively few injured workers who may require referral for surgical or other consultations. OVERALL ARTICLE OBJECTIVES: (a) To review the important medical, administrative, and legal challenges involved in treating injured workers and to describe strategies that physiatrists use to overcome effectively these challenges.