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.
"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)
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.
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
4-year-old patient comes to the ED for an unrelated complaint and you notice that his knees appear to be touching while his ankles remain apart.
Genu Varum or “knock knees” may be caused by Infantile Blount’s disease
-A progressive pathologic condition causing genu varum in children between ages 2 to 5
- Centered at the tibia
-Bilateral in up to 80%
-More common in boys
-Leg length discrepancy
- Articular incongruity
Risk factors: Early walkers (<1 year), overweight, large stature, Hispanic and African American
Results in disruption of normal cartilage growth at the MEDIAL aspect of the proximal tibia while LATERAL growth continues normally
May complain of knee soreness or subjective instability
On physical exam
Focal angulation of the proximal tibia
Lateral thrust during stance phase of walking (brief lateral shift of proximal fibula and tibia)
No tenderness or effusion
Imaging: Plain film shows varus deformity of the proximal tibia with medial beaking (beak like appears of bone) and downward slope of the proximal tibia metaphysis (increased metaphyseal-diaphyseal angle)
https://paleyinstitute.org/wp-content/uploads/blounts1.jpg
Treatment depends upon the age of the child and the severity
Successful in up to 80%
Note: In adolescent variant bracing is ineffective and surgery is only treatment
: Genu varum is normal in children <2 years old and becomes neutral at 14 months
DDX: Physiologic varus, Rickets
9-year-old male left hand dominant, presents with left elbow pain.
He is a future “star pitcher,” says his coach dad. “Doc, I bet you didn’t know that although only 10% of people throw with their left hand almost a 1/3rd of MLB pitchers are lefties. He is 3x more likely than a righty to pitch in MLB.” “Maybe I’m asking him to throw too much.”
Hx: Lateral elbow pain and “stiffness” worse with activity that is better with rest
PE: Lateral elbow tenderness (capitellum) with slight (approx. 20 degrees) decreased loss of extension. Minimal swelling noted.
Dx: Panner's disease refers to osteochondrosis of the capitellum (similar to Legg Calve Perthes). Likely due to AVN from repetitive trauma. May also be due to endocrine disturbances.
Affects the dominant elbow of boys between the ages of 5 and 10
Associated with the repetitive trauma of throwing or gymnastics.
Must be differentiated from osteochondrosis dissecans which occurs in the older child >13yo when the ossification of the capitellum is complete
Radiology:
The articular surface of the capitellum may appear irregular or flattened with areas of radiolucency (43%). Loose bodies not seen with Panners, much more likely with OCD lesions.
Treatment: Ice and NSAIDs. Avoid pitching/gymnastics etc. until full radiographic and clinical healing. If significant pain and/or swelling place patient in long arm posterior splint for 7-10 days. Resolution may take several months and up to one year.
A recent study investigated the association between concussion and subsequent mental health conditions in a pediatric population.
Retrospective cohort study. Pediatric patients aged 5 to 18 years who presented to an ED, PCP or mental health practitioner from April 2010, to March 2020, in Ontario, Canada.
Primary outcome: Time to first diagnosis with a mental health condition during follow-up
Secondary outcomes: 1) self-harm 2) psychiatric hospitalization 3) death by suicide.
Mental health conditions: anxiety and neurotic disorders, adjustment reactions, behavioral disorders, mood and eating disorders, schizophrenia, substance use disorder, suicidal ideation, and disorders of psychological development.
Study group, almost 450,000 patients. Age and sex matching between those with concussion and those who experienced an orthopedic injury.
A significant association (P < .001) was found between concussion and mental health conditions
A significant association emerged between concussion and self-harm and psychiatric hospitalization
No association with suicide
Conclusion: Concussion was significantly associated with risk of mental illness, psychiatric hospitalization and self-harm but not death by suicide.
Concussed patients had an almost 40% higher rate of mental health conditions compared to controls (adjusted hazard ratio 1.39)
Take home: Screen patients who return to the ED with post concussive symptoms for mental health symptoms/concerns and provide appropriate awareness for parents
The knee is one of the most commonly affected joints from osteoarthritis (OA).
Patients will complain of knee pain, swelling and stiffness.
This leads to disability as it interferes with walking, using stairs at home and getting in and out of chairs and the bath without assistance.
Increasing incidence due to aging of the general population and rising rates of obesity.
Patients frequently present to the ED for knee pain and imaging is often obtained.
Diagnosis of knee OA can be made with an appropriate history and imaging that shows osteophytes and joint space narrowing.
The best views for knee OA include 1) PA weight-bearing & 2) 45 degree of knee flexion
https://d3i71xaburhd42.cloudfront.net/6f8ce215fb4bcd153a478187c9a6a2ae652a5fc4/250px/1-FigureI-1.png
Note: Weight-bearing radiographs will demonstrate greater joint space narrowing than non-weight-bearing radiographs
Of the 3 compartments of the knee, the medial tibiofemoral compartment is most commonly affected > patellofemoral compartment > lateral tibiofemoral compartment.
Examples of knee OA
https://roberthowells.com.au/wp-content/uploads/2016/04/A00212F02.jpg
https://orthoinfo.aaos.org/link/e7e6933819db4020bc2f3822c45c538f.aspx
Quadriceps contusion
Mechanism: Blunt trauma from ball, helmet, stick
Usually to the central region
Damage to highly vascular area of the muscle and to local blood vessels can cause hematoma formation
Typical trauma history and pain worse with muscle activation (knee flexion)
Physical exam: Bruising, tenderness, palpable mass/hematoma
Goals of care: Minimize intramuscular bleeding
Treatment: NSAIDS, crutches, unique type of immobilization
Attempt to increase resting length of the quadriceps muscle to facilitate early healing and return to function
Note: Left untreated, large contusions may result in myositis ossificans
Hamstring Injury
Prevalence varies by sport ranging from 8 to 25 percent with a high recurrence rate frequently during the ensuing sport season, usually in next 2 months but may extend up to one year!
Highest in sports that involve rapid acceleration and deceleration
3 highest risk sports - football and men’s and women’s soccer
Average time lost 17-21 days
Injury much less common in younger athletes
The hamstring is composed of three muscles: the biceps femoris, semitendinosus, and semimembranosus.
Primarily involved in knee flexion and hip extension
Biceps femoris is most commonly injured
https://www.ncbi.nlm.nih.gov/books/NBK539862/figure/article-28873.image.f1
Simple grading system using 3 grades
Grade 1 – mild strain
Grade 2 – Partial tear
Grade 3 – Complete tear
Proximal injuries are more common than distal injuries, occurring at the musculotendinous junction
Avulsion fractures of the ischium occur rarely occur in adults but may occur in skeletally immature athletes
https://radiopaedia.org/cases/ischial-tuberosity-avulsion
When watching a sporting event you will see the athlete grab the buttock or upper thigh. They usually cannot return to play. Most grade 2 or 3 injuries will require crutches. If seeing them the following day significant bruising may be seen.
Numerous modifiable and non-modifiable risk factors have been identified including:
*Weakness of ipsilateral quadriceps or contralateral hamstring, hamstring, hip & quadriceps tightness/poor flexibility, poor warm-up, sudden increased training volume and muscle fatigue.
*Older age (risk increase may begin as early as age 23)
Prior hamstring injury (up to 6x increased risk)
**Premature return to sport increases the risk of reinjury
Differential Diagnosis: Lumbar radiculopathy, sciatic nerve irritation or compression, stress fracture of femur.
Refer to sports medicine/orthopedics for avulsion injuries, complete proximal complete tears and partial or complete distal tears
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