Patellofemoral anatomy and disease (part 1)
During normal knee flexion, the patella slides within the trochlear grove. Both (patella and the trochlear groove) are lined with articular cartilage at the patellofemoral articulation.
https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint2.jpg
Multiple forces act on the patella which can affect proper tracking: Proximately, by the quadriceps tendon, distally, by the patellar tendon, medially, by the medial retinaculum/vastus medialis and laterally by the lateral retinaculum and the vastus lateralis.
Patellofemoral OA can occur when this cartilage starts to wear and can be seen in skyline/sunrise/notch or equivalent views. OA here rarely occurs in isolation (<10%) and is usually part of medial or lateral knee OA.
https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint3.jpg
Patellofemoral pain is usually from overuse/training overload or malalignment.
Contributors to overuse involve total joint load which may have influence from training volume (total miles), intensity (competitive sports) in addition to BMI (>25) in addition to overall fitness level.
Malalignment aka abnormal patellar tracking involves both static (leg length discrepancy, hamstring tightness, etc.) and dynamic components (hip weakness, gluteus medius weakness, excessive foot pronation, etc.).
Patients with anterior knee pain should have activity modification, ice, NSAIDs (not steroids) and long-term engagement in physical therapy (>6 months) with a focus on flexibility and strengthening of lower extremity kinetic chain including the vastus medialis, gluteus medius, hip external rotators and core.
Also, consider looking for hyper supination or pronation. Foot orthotics can be of help with this.
21-year-old college softball player presents for evaluation of Left hand/wrist pain following batting practice.
She states her pinky is “tingly”
On exam, there is tenderness over her volar ulnar wrist.
You obtain an X-ray.
https://prod-images-static.radiopaedia.org/images/52314027/a662d8f338ec08ba56178463638d25_jumbo.jpeg
What’s the diagnosis?
Prolonged post-concussion symptoms are loosely defined as those lasting more than three or four weeks versus typical recovery, typically between 10-14 days.
Athletes who take longer than "typical” to recover have a challenging road of uncertainty. Medical providers are asked to make informed decisions about “normal” and expected return based on limited information.
Evaluating both athlete and parental expectations is challenging, especially when navigating difficult conversations about medical disqualification and permanently discontinuing their sport.
A 2016 study of approximately 50 patients with sports-associated concussion who had persistent symptoms lasting greater than one-month found that a collaborative multidisciplinary treatment approach was associated with significant reduction in post concussive symptoms at six months versus usual treatment.
A recent 2023 study in Neurology provides additional good news for athletes who are slow to recover from sports associated concussion. Approximately 1750 concussed collegiate athletes (diagnosed by team physician) were enrolled. In this study, slow recovery was defined as taking more than 14 days for symptoms to resolve OR taking more than 24 days to return to sport.
Approximately 400 athletes met the criteria for slow recovery (23%).
Male athletes participated primarily in football, soccer, and basketball.
Female athletes participated primarily in soccer, basketball, and volleyball.
Of the athletes who took longer than 24 days to return to play:
77.6% were able to return to play within 60 days of injury,
83.4% returned to play within 90 days, and
10.6% did not return to play at 6 months.
Slow to recover athletes averaged 35 days after injury for return to play.
This study provides valuable information for medical providers: There is an overall favorable prognosis for slow to recover concussed athletes for return to school and sport.
In a recent study in The Lancet, researchers at NIH attempted to test the hypothesis that optimal hydration may slow down the aging process.
A large proportion of people do not consume the recommended fluid amounts. This has likely become worse with our masking during the pandemic.
Previous studies in a mouse model showed that water restriction, increasing serum sodium by 5 mmol/l, shortened the mouse lifespan by 6 months which corresponds to about 15 years of human life.
Population: Data from Atherosclerosis Risk in Communities (ARIC) study: an ongoing population-based prospective cohort study in which 15,792 45-66 year-old black (African American) and white men and women were enrolled from four US communities in 1987–1989 and followed up for more than 25 years.
Variables: 15 biomarkers and serum sodium (as a proxy for the hydration habits of study participants).
They attempted to exclude people whose serum sodium could be affected by factors other than the amount of liquids they consume. After these exclusions, 11,255 participants remained in the datase.
Authors also calculated ones biologic age by sampling 15 biomarkers characterizing performance of multiple organ systems and processes: cardiovascular (systolic blood pressure), renal (eGFR, cystatin-C, urea nitrogen, creatinine, uric acid), respiratory (FEV), metabolic (glucose, cholesterol, HbA1c, glycated albumin, fructosamine), immune/inflammatory (CRP, albumin, beta 2-microglobulin).
Conclusions: The analysis showed that middle age serum sodium >142 mmol/l is associated with a 39% increased risk to develop chronic diseases (hazard ratio [HR] = 1.39, 95% confidence interval [CI]:1.18–1.63) and >144 mmol/l with 21% elevated risk of premature mortality (HR = 1.21, 95% CI:1.02–1.45). People with serum sodium >142 mmol/l had up to 50% higher odds to be older than their chronological age (OR = 1.50, 95% CI:1.14–1.96).
Limitations: Observational study. No firm conclusions without intervention studies.
Summary: Serum sodium concentration exceeding 142 mmol/l is associated with increased risk to be biologically older, develop chronic diseases and die at younger age.
Take home: Drink more water
Humor me and imagine that your birth certificate vanished, and your age was based on the way you feel inside. How old would you say you are (subjective age) versus your actual age?
In a few studies, those individuals reporting a younger subjective age had a lower risk of depression, greater mental well-being, better physical health, and a lower risk of dementia. These individuals also had improved episodic memory and executive functioning. Subjective age also predicts incident hospitalization.
Three longitudinal studies tracked more than 17,000 middle aged and elderly individuals.
Over a 20-year period, researchers tracked: Subjective age, demographic factors, disease burden, functional limitations, depressive symptoms, and physical inactivity.
Researchers found that those who felt approximately 8, 11, and 13 years older than their actual age had an 18%, 29%, and 25% higher risk of mortality, respectively. They also had a greater disease burden even after controlling for demographic factors such as education, race and marital status. Multivariable analyses showed that disease burden, physical inactivity, functional limitations, and cognitive problems, but not depressive symptoms, accounted for the associations between subjective age and mortality.
This study provides evidence for an association between an older subjective age and a higher risk of mortality across adulthood. These findings support the role of subjective age as a biopsychosocial marker of aging. This may allow for early intervention for select individuals who may have a higher association with poor health outcomes.
Your subjective age can better predict your overall health than the date on your birth certificate.
Over half of U.S. adults in the United States consume dietary supplements.
Study design: A quality improvement study using data from the FDA’s Center for Drug Evaluation and Research, Tainted Products Marketed as Dietary Supplements
Dates: 2007 through 2016.
Results: Unapproved pharmaceutical ingredients were identified in 776 dietary supplements.
146 different dietary supplement companies were involved.
Most of these products were marketed for sexual enhancement (353 [45.5%]), weight loss (317 [40.9%]), or muscle building (92 [11.9%].
157 adulterated products (20.2%) contained more than 1 unapproved ingredient.
A 2015 NEJM study estimated that 23,000 ED visits per year are attributed to adverse effects associated with dietary supplements.
Estimated 2154 hospitalizations annually.
Frequently involve young adults between 20 and 34 years of age in addition to unsupervised children.
Excluding children, almost 66% of ED visits involve herbal or complementary nutritional products and 31.8% involved micronutrients.
Products for weight loss or increased energy were commonly implicated.
Finally, herbal and dietary supplements now account for 20% of cases of hepatotoxicity in the US.
The major implicated agents include anabolic steroids, green tea extract, and multi-ingredient nutritional supplements.
Anabolic steroids (marketed as bodybuilding supplements) typically induce a prolonged cholestatic, self-limiting liver injury.
Green tea extract and many other products, in contrast, tend to cause an acute hepatitis like injury.
"The Tortoise and the Hare" fable has been used as a metaphor for the epidemiological differences between slower, low-intensity exercise versus faster, high-intensity physical activity.
"Current physical activity recommendations are predicated on the idea that both the hare and the tortoise can win the race for better health, but the provocative studies give an edge to the hare's higher-intensity approach,"
Regular physical activity is associated with significant health benefits, including decreased risk of cardiovascular disease, cancer, and all-cause mortality.
Traditional research has focused on exercise volume (150 minutes/week) over intensity.
Two recent studies looked at the benefits of shorter bouts of vigorous activity at higher intensities.
A recent large population-based cohort study of middle-aged adults used objective measurement of activity (wrist accelerometer) over self-reporting to investigate the role of exercise intensity and CV health.
Higher intensity physical activity is associated with lower rates of incident CVD.
This makes theoretical sense as greater stimulation will result in greater physiologic CV adaptations resulting in overall improved CV fitness.
For example. the authors extrapolate that an ambling 14-minute stroll has roughly the same cardiovascular benefits as an up-tempo 7-minute walk at a brisk pace.
Increasing the total amount of activity is not the only means of achieving health goals which can be met with raising overall intensity.
Vigorous physical activity is a time-efficient means to achieve overall health benefits of exercise.
A recent study (Ahmadi et al., 2022) involved 71,893 older adults with a mean age of 62.5. Authors found that quick bursts of vigorous physical activity throughout the day can lower older adults' risk of premature death by 16% to 27%, depending on daily frequency and weekly totals (from 15-20 min/week up to 50-57 min/week).
For example, doing one two-minute burst of high-intensity exercise every day for a total of 14 minutes per week was associated with an approximately 18% lower risk of all-cause mortality. The authors also found that doing as little as one to nine minutes per week of vigorous activity in quick bursts versus doing no vigorous activity was associated with significantly lower all-cause mortality risk over five years.
Exercise may not need to be a planned hour-long session at the gym for our middle-aged and older population. Accruing small amount sporadically over the day/week is an attractive option to reap the CV benefits of exercise. Existing exercise guidelines will need to be modified with future research to pinpoint the optimal exercise intensity and duration for adults in different stages of life.
Dog ownership has become more common especially during the pandemic.
Almost 70% of US households own a pet and almost half own ≥1 dogs.
There are many health benefits associated with dog ownership including: reduced risk of asthma and allergic rhinitis in children exposed to pets during early ages, improvement in symptoms of PTSD, overall wellbeing & alleviation of social isolation in elderly individuals and increased physical activity.
The main positive impact of dog ownership seems to be in relation to cardiovascular risk including an association with lower blood pressure levels, improved lipid profile, and diminished sympathetic responses to stress.
Study: A systematic review and meta-analysis (10 studies, over 3 million participants) to evaluate the association of dog ownership with all-cause mortality, with and without prior cardiovascular disease, and cardiovascular mortality. Mean follow up 10 years.
Results: Dog ownership was associated with a 24% risk reduction for all-cause mortality as compared to non-ownership (relative risk, 0.76; 95% CI, 0.67–0.86) with 6 studies demonstrating significant reduction in the risk of death.
In individuals with prior coronary events, dog ownership was associated with an even more pronounced risk reduction for all-cause mortality (relative risk, 0.35; 95% CI, 0.17–0.69). When authors restricted the analyses to studies evaluating cardiovascular mortality, dog ownership conferred a 31% risk reduction for cardiovascular death (relative risk, 0.69; 95% CI, 0.67–0.71).
The cause of this benefit is unclear. Though some activities such as the act of petting a dog has been observed to lower blood pressure levels, the mechanism for the longer survival is likely through enhanced physical activity provided by dog walking.
Conclusion: Dog ownership is associated with reduced all-cause mortality likely driven by a reduction in cardiovascular mortality. Dog ownership as a lifestyle intervention may offer significant health benefits, particularly in populations at high-risk for cardiovascular death.
Finally, meet Winston, a French bulldog who, last night, won the National Dog Show!
Opioids & NSAIDs for MSK pain in the ED: Effectiveness and Harms
Study selection: A recent systematic review in Annals of Internal Medicine attempted to evaluate the effectiveness and harms of opioids for musculoskeletal pain in the emergency department.
Included were RCTs of any opioid analgesic as compared with placebo or a nonopioid analgesic.
Conditions studied: bone injuries, soft tissue injuries, spinal pain, and mixed presentations.
Out of 2464 articles, they included 42 trials (n=6128).
Effectiveness data: Opioids were statistically but not clinically more effective in reducing pain in the short term (approximately 2 hours) versus placebo and Tylenol but were not clinically or statistically more effective than NSAIDs.
Take home: Opioids and NSAIDs may have about the same pain outcomes.
Harm data: The results on harms were very mixed. Overall, there were fewer harms with NSAIDs than opioids. However, many studies showed less of a difference. The benefit with NSAIDs due to fewer harms may be less in patients with mixed musculoskeletal conditions.
Opioids may carry higher risk for harms than placebo, Tylenol, or NSAIDs. Authors also found that an increased opioid dose may increase harms from opioids.
Limitations: Limited data on long-term outcomes and longer-term pain management
Developmental dysplasia of the hip (DDH)
Popliteal artery entrapment syndrome (PAES)
CC: Exertional lower leg pain, however, compression of posterior neurovascular structures can lead to nonspecific vascular and neurogenic symptoms.
Challenging diagnosis to make because of close overlap with chronic exertional compartment syndrome (CECS).
Anatomic PAES has a prevalence of 0.62% to 3.5% in the general population. Patients are more likely to be older be older, male, and have lower levels of activity.
Functional popliteal artery entrapment (FPAE) however has no anatomic anomaly. Sx’s are thought to be because of bulky surrounding muscle crowding with repetitive dynamic injury. This is most commonly from the medial head of the gastrocnemius. Patients are younger and more likely to be involved in athletics. Most athletes were involved in sports that put high value on repetitive plantarflexion, such as track and field (45%), soccer (25%), water sports (8%), lacrosse (6%), basketball (6%),
Sx’s: bilateral (25-75% of cases) cramping in the region of the soleus and plantar paresthesias.
Common exacerbating mechanism: ascending stairs or climbing inclines because of leg/knee position of extension with plantarflexion
In one review, 31% of patients who underwent debulking surgery for FPAES had been previously treated and extensively worked up at outside institutions for CECS, and already undergone various compartment releases.
Patients in one study underwent a dynamic CTA protocol. A positive test demonstrated normal flow in neutral position and compression or complete occlusion of the popliteal artery by the medial head of the gastrocnemius muscle against the lateral femoral condyle with provocative foot plantarflexion. Images below.
https://images.journals.lww.com/acsm-csmr/Original.00149619-202210000-00008.F1.jpeg
Nearly three-fourths of athletes limited by FPAES demonstrated full return to prior competitive levels with four compartment fasciotomy AND surgical debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle.
Pes Anserinus pain syndrome (formerly pes anserine Bursitis)
Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semi-tendinosis tendons. Insertions resemble a Goose’s foot.
An inflammatory condition of the medial knee
Location is 2-3 inches below the knee joint on the medial side
1st layer of medial compartment
https://www.dramynrajani.com/wp-content/uploads/2018/05/pes-anserine-bursitis-clinical-test.jpg
Patients complain of knee pain just below medial joint line (esp with stairs)
History may include sudden increase in running distance especially with hills (common)
Associated with obesity, tight hamstring muscles and with knee OA
PE: Tenderness to palpation of the bursa possibly with mild swelling
DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis, tibial stress fracture
Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.
Exericse as preventative medicine!
A recent cohort study of over 2,000 adults (mean age approx. 45) over approximately 11 years of follow-up investigated the association of step count with mortality.
This study found that those participants taking at least 7,000 steps per day compared to those taking fewer steps had a 50%-70% lower risk of mortality. They did not find an association with step intensity.
Another recent study investigated the dose-response association between daily step count and intensity and the incidence of all-cause dementia.
Uk based study of >78,000 adults aged 40 to 79 years with approximately 7 years of follow-up. Data from wrist accelerometer and registry-based dementia diagnoses.
Optimal step dose was 9826 steps. Minimal dose was 3826 steps (value at which the risk reduction was 50% of the observed max).
In this study, steps performed at higher intensity (112 steps/min) resulted in stronger associations.
Conclusions: A great exercise goal for middle aged and older adults is just under 10,000 steps per day to decrease risks of both overall mortality and dementia.
Limited data are available to guide recommendations re screen time after concussion.
A recent ED study looked at screen time effects on concussion recovery.
Population: 125 patients aged 12 to 25 years presenting to the ED <24h after injury. Mean age 17. Approximately 51% male.
Intervention: Patients were placed in a screen time allowed group and a screen time not allowed group for the first 48 hours. Total minutes reported after the study were 630 minutes vs 130 minutes.
Outcome: Time to symptom resolution. Patients took daily symptom scoring tests for 10 days.
Result: Screen time allowed group had a significantly longer time to recovery (8 days) vs screen time not allowed (3.5 days).
Strength: Good attempt at quantifying effects on early screen time exposure on symptom recovery in an ED population.
Weakness: This was a small study. Many patients (>25%) were lost to follow-up and it relies on symptom self-reporting.
The hip joint is a very strong and stable structure requiring great force to produce a dislocation
Most hip dislocations are posterior (80-90%)
Mechanism: MVC generating force onto an adducted flexed hip (most commonly)
Associated injuries occur both locally (acetabular fx) and distant (knee bone and ligamentous)
Significant associated injuries in >70%
The hip joint has a very precarious blood supply.
One of the risk factors for AVN is total dislocation time
<6 hours - 5% incidence
>6 hours – up to 53% incidence
Examine the sciatic nerve carefully with posterior dislocations (10% incidence)
Motor – EHL/ankle dorsiflexion
Sensory – sensation dorsum of foot
There are many reduction maneuvers including the East Baltimore Lift technique
https://www.youtube.com/watch?v=1zvelGbVn04
Demonstrated at 30 seconds in above video
Place patient supine with affected leg flexed to 90 degrees at knee and hip. 2 providers position themselves on opposite sides of the patient and each places their arm under the patient’s calf/popliteal region and their hand on the opposite providers shoulder. A 3rd person is required to stabilize the pelvis. Axial traction is generated by the providers slowly standing up. Gentle internal and external rotation can facilitate successful reduction
The radial nerve is susceptible to compressive neuropathy against the spiral grove of the humerus which can lead to neuropraxia.
When the upper arm is compressed against a chair back or bar edge sometimes from a lost battle with alcohol: Saturday night palsy.
When another individual sleeps on someone’s arm overnight compressing the radial nerve: Honeymoon palsy
From nerve compression from improper technique with crutches: Crutch palsy
If diagnosis not clear from history, DDx includes other entities that can also present with isolated wrist, thumb/finger drop
Horses: Radial verve palsy, CVA, C7 compression
Zebras: Lead toxicity, acute porphyrias (often polyneuropathy but upper extremity before lower and frequently distal extensors
Careful history and exam important in differentiating
In cases of peripheral compression against the spital groove the triceps maintains strength.
The distal extensors lose strength (wrist and fingers)
Including the thumb abduction (abductor pollicis longus is radial-innervated)
AND so will the brachioradialis
The brachioradialis (despite being a forearm flexor) has dual innervation from the radial nerve in 80% of people.
Brachioradialis strength is often preserved in a central lesion.
Best tested with arm supported on a surface in mid pronation/supination (hammer curl position) and have patient flex against resistance and evaluate muscle strength and bulk.
Head Impact Exposure and Concussion Incidence
There has been a major focus on head impact biomechanics as a cause of single-impact concussion in football.
The role of repeated subclinical (without diagnosed concussion) head impact exposure (HIE)
during the preseason and regular season may also be contributory.
There may exist individualized concussion tolerance levels. This threshold may be reduced by the burden of sustained subconcussive impacts
NCAA Division 1 football athletes sustain a median of 426 impacts over the course of a football season
652 impacts/season in high school football
Total head impact exposure during the preseason occurred at 2x the rate of the regular season
This association was investigated over 1120 athlete seasons from 6 NCAA D1 football programs across 5 years
Head Impact Telemetry was used to record head impact exposure
Elevated preseason HIE was strongly associated with preseason and in season concussion incidence
Total season HIE was strongly associated with total season concussion incidence.
Conclusion: There is a prolonged effect of HIE on concussion risk starting with preseason football.
Athletes with higher preseason HIE may have higher risk of concussion for the entire fall season.
In Practice:
In 2016, the Ivy League eliminated full contact practices from the regular season in addition to their existing limits on the amount of full contact in practice during the spring and preseason.
Currently, the NCAA has the following limitations: Teams won’t be allowed to hold full-contact practices on more than two days in a row. Each practice session is limited to only 75 minutes of full contact, in addition to a limit of two preseason scrimmages.
28-year-old male present with dorsal hand pain after “losing his temper”
On exam, you note dorsal swelling, tenderness, and deformity
AP, lateral and oblique views are obtained.
There is no rotational deformity but using the lateral view, you note that there is angulation
Measured as the shaft of the metacarpal as compared to the mid-point of the fracture fragment
Acceptable shaft angulation generally accepted to be less than 40°
Patient has greater that acceptable angulation so you have to perform closed reduction
After appropriate pain control consider the “90-90 method.”
Flex the MCP, DIP, and PIP joints to 90 degrees.
This positioning stretches the MCP collateral ligaments helping to optimize reduction
Next, apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint.
Best demonstrated below
https://www.youtube.com/watch?v=40irKoUJqsM
Download the UMEM Pearls App!
Subscribe to daily UMEM Pearls (FREE!) via:
RSS Feed
