Estimating the size of knee effusions
While this size range is typically easily detectable on exam. This may not apply to patients who are either very muscular or obese.
If the detection of a small to moderate sized effusion would change patient management
Consider ultrasound:
As compared to MRI (sensitivity of 81.3 % and a specificity of 100 %)
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"I was kicked in the inside of my knee while it was straight (extended). Look at the x-ray and tell me if its bad"
The objective of a recent study was to analyze the injury and illness characteristics in Iron Man distance triathletes. This information is important for emergency providers who may be asked to directly assist or help coordinate race day medical care.
Intro: The Iron Man distance triathlon is one of the most challenging ultra endurance competitions in the world. 80,000 Iron Man triathletes compete internationally each year to qualify for the Ironman world championship. The race totals 140.6 miles across three legs, beginning with a 2.4 mile swim, followed by a 112 mile cycle, and is completed with a 26.2 mile run.
Retrospective cross-sectional study of medical records from Iron Man distance championship races across a 30-year period (1989-2019). The study population (10,533) consisted of all triathletes treated at mobile medical units along the race route or who presented to the medical tent for evaluation during and immediately after the event.
Mean population age of 37 with a range of 18 to 87 years.
Results: Female athletes were found to present to the medical tent more than males (P < 0.001).
The total incidence of medical encounters by age was found to be higher in both younger athletes (18 to 34 years old) and older athletes (greater than 70 years old) versus middle-aged athletes (35-69 years old) (P < 0.001).
Professional athletes have similar overall medical encounters compared with other athletes.
The busiest hours of the medical tent were between approximately 9 and 14 hours after start time (afternoon and early evening) in which approximately 73% of athletes presented for evaluation and treatment.
Once inside the medical tent 71% of athletes were discharged within an hour and 87% were discharged within 1.5 hours. Athletes were dispatched to the hospital from the medical tent area at a rate of 17.1/1000 athletes (most athletes presenting to the medical tent finished the race and few required hospital transfer).
The most common medical complaints were dehydration and nausea followed by dizziness, exhaustion, muscle cramps, and vomiting.
Blood work was collected for 30% of athletes who entered the medical tent. Of these athletes, hyponatremia was the most prevalent diagnosis and most of whom were symptomatic with symptoms such as confusion, stupor, gait disturbance, muscle weakness, headache, dizziness, fatigue, nausea and vomiting.
Beyond basic medical care, intravenous fluids were the most common medical treatment.
Conclusion: Medical events were more frequent among female athletes as well as both younger and older age categories. Gastrointestinal and exertional related symptoms were the most common complaints in the medical tent. Besides basic medical care, IV infusions were the most common treatment. Most athletes presenting to the medical tent finished the race and only a small percentage were transferred to the hospital.
The role of exercise in patients with asthma is complicated.
Asthma symptoms can worsen or be triggered by physical activity. This can lead to avoidance response. Patients with asthma are less physically active than their matched controls.
Recently, however, the role of exercise and physical activity as an adjunct therapy for asthma management has received considerable attention. There is an emerging and promising role of physical activity as a non-pharmacologic treatment for asthma. Exercise reduces inflammatory cytokines and increases anti-inflammatory cytokines thereby reducing chronic airway inflammation.
Physical activity can help improve lung function and boost quality of life. As fitness improves, asthma patients report better sleep, reduced stress, improved weight control, and more days without symptoms.
The Global Initiative for Asthma recommends twice-weekly cardio and strength training. Strength training requires short periods of exertion allowing for periods of rest and recovery. High-intensity interval training (HIIT) is a promising option for people with asthma. These types of workouts allow ventilation to recover intermittently vs conventional cardio exercises.
A 2021 study in adults with mild-to-moderate asthma found that low volume HIIT classes (three 20-minute bouts/week) significantly improved asthma control. Patients also had improved exertional dyspnea and enjoyment of exercise which will, in turn, increase the odds of further exercise.
A 2022 study compared constant-load exercise versus HIIT in adults with moderate-to-severe asthma. Exercise training lasted 12 weeks (twice/week, 40 minutes/session). Both groups showed similar improvements in aerobic fitness however the HIIT group reported lower dyspnea and fatigue perception scores and higher physical activity levels.
Conclusion: Patients with asthma should be encouraged to safely incorporate exercise in their daily lives bother for overall health benefits but also as an effective non-pharmacologic asthma treatment.
Sport related concussion has been estimated to affect almost 2 million children and adolescents in the United states annually
Patients who take longer than four weeks to recover are considered to have persistent post concussive symptoms
This diagnosis is associated with poor educational, social and developmental outcomes in pediatric patients
Following sport related concussion, patients are recommended to have an individualized aerobic exercise program
Prior studies have found that sub symptom threshold aerobic exercise safely and significantly speeds recovery from sport related concussion.
Purpose: This study attempted to answer whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden effects adherence to the prescription.
Design: Male and female adolescents aged 13 to 18 years old presenting within 10 days of injury and diagnosed with sport related concussion.
Almost all participants (94%) sustained concussion during interscholastic games or practices.
As it is known that physician encouragement can influence patient adherence to medical interventions, treating physicians in the study were blinded to study arm assignment.
Patients were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test
Adherence to prescription was determined objectively with heart rate monitors. No participants exercised above their prescribed heart rate intensity.
Patients who completed at least 2/3 of their aerobic exercise prescription were considered to be adherent
Results: 61% of adolescents met the adherence criterion
Adherent patients were more symptomatic and were more exercise intolerant (worse initial exercise tolerance) at their initial visit.
These patients were also more adherent than those with fewer symptoms and with better exercise tolerance. This likely indicates a stronger motivation for those more symptomatic patients to engage in a potentially effective intervention.
Adherent patients recovered faster than those who were not adherent (median recovery time 12 days versus 21.5 days (P = 0.016)
Adherence during week one was inversely related to recovery time and to initial exercise tolerance but not to initial symptom severity
Conclusion: Adherence to individualized sub symptom threshold aerobic exercise within the first week of sport related concussion is associated with faster recovery. The initial degree of exercise intolerance (but not initial symptom severity) affects adherence to aerobic exercise prescription in an adolescent population with sport related concussion
29 yo baseball pitcher presents with right medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Also notes mild paresthesias in 4th and 5th digits.
Ulnar collateral ligament (UCL) injury
Sprain of the UCL of the elbow can occur either as an acute injury or as the result of chronic excessive valgus stress due to throwing. This injury is seen in javelin throwers and baseball pitchers. Most recently, Angels superstar Shohei Ohtani suffered a torn UCL.
While traditionally this injury pattern was thought to occur in older, high-level pitchers (high velocity throwing), we are increasingly seeing this in younger athletes.
The repeated valgus stress of pitching leads to micro tearing and inflammation of the ligament. Over time, this leads to scarring and calcification and then ligament rupture.
This injury is more likely to happen in pitchers who “open up too soon” in their throwing motion. Fatigue related changes seen first in leg and core mechanics cause pitchers to open up earlier, increasing stress to the shoulder and the UCL of the elbow. Other risk factors include high velocity pitching, insufficient recovery time, and chronic overuse. The importance of proper pitching mechanics is very important as players whose pitching motion produces greater elbow valgus loads and shoulder external rotation torque are at increased risk for UCL tears.
Approximately one half of the torque generated during a fastball pitch is transmitted to the UCL. Well developed muscles about the elbow can dissipate enough energy that acute tearing is rare.
The athlete with a UCL sprain will complain of medial elbow pain that increases during the acceleration phase of throwing.
On examination, there is localized tenderness directly over the UCL:
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Stress testing of the UCL causes both pain and demonstrates laxity.
Moving Valgus Stress Test:
Place elbow in the “90/90” position. Apply a valgus stress while ranging elbow through full arc of flexion and extension. A positive test will reproduce apprehension, pain or instability at the UCL origin between 70 and 120 degrees.
https://www.youtube.com/watch?v=OnkkHpG3Dqg&ab_channel=RussHoff
"The normal value for the Böhler angle is between 25° and 40° 1. Although there is wide variation between individuals, there is relatively little variation between the left and right feet of a single individual 2. A reduced Böhler angle can be seen in displaced intra-articular calcaneal fractures. The degree of reduction in the Böhler angle is an indicator of the severity of calcaneal injury, and the degree to which the Böhler angle is restored at surgery is correlated with functional outcome 3."
SLAP tear/lesion – Superior labral tear oriented anterior to posterior
Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint.
Integral to shoulder stability.
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O’Brien’s test aka active compression test for superior labral pathology.
2 parts – generally performed with the patient standing.
The patient’s shoulder is raised to 90 degrees with full elbow extension and approximately 30 degrees of adduction across the midline.
Resistance is applied, using an isometric hold.
Test in both full internal and external rotation
-This alters the position and rotation of the humerus against the glenoid
A positive test is when pain is elicited when the shoulder is in internal rotation with forearm pronation (thumb to floor) and much less or no pain when in external rotation (supination).
Note: AC joint pain may test similarly but will localize to different area of shoulder
The presence of similar, reproducible deep and diffuse glenohumeral joint pain is most indicative of a true positive test.
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Multiple vision disorders may occur after concussion including injury to the systems that control binocular vision including: Convergence insufficiency and Accommodation insufficiency
In order to obtain a single binocular vision, simultaneous movement of both eyes in opposite directions is required.
To look at an object close by such as when reading, the eyes must rotate towards each other (convergence).
Convergence insufficiency is the reduced ability to converge enough for near vision and is a common visual dysfunction seen after concussion.
One of both eyes may also turn outward.
May lead to complaints with reading such as diplopia, blurry vision, eyestrain, and skipping words or losing one's place.
Patient or parent may also report other difficulties such as becoming more easily fatigued when reading, needing to squint and/or having disinterest in reading.
Take home: consider testing convergence in patients with some of these complaints in setting of acute or subacute head trauma.
The use of a fascia iliaca compartment block has been shown to reduce pain, decrease length of stay and decrease the opiate requirements for patients with hip fractures.
Check out this page on how to perform this procedure.
Fascia iliac blocks can be challenging to implement routinely in the emergency department. Studies show that 2.5% of eligible patients, despite departmental implementation, receive a block.
One recently published article showed that large scale multi-disciplinary implementation can increase the use of fascia iliac blocks. After implementation, the study team found that 54% of eligible patients received a fascia iliac block.
This article is interesting as it provides helpful resources including physician and nursing protocols for performing this block.
Adhesive capsulitis aka frozen shoulder
Definition: Gradual development of global limitation of both active and passive shoulder motion, characterized by severe pain and lack of radiographic findings
Idiopathic loss of BOTH active and passive motion (significant reduction of at least 50%)
Motion is stiff and painful especially at the extremes.
Occurs due to thickening and contracture of the shoulder capsule.
Affects up to 8-10% of people of working age.
Affects patients between the ages of 40 and 60.
Peak age mid 50s
Onset before 40 is rare (consider other diagnosis).
Affects women more than men.
Diabetes is the most common risk factor.
Patients with DM, suffer a more prolonged course and are more resistant to therapy
Also associated with thyroid disease and prolonged immobilization
Increased risk following trauma to shoulder region (rotator cuff tear, following shoulder surgery, fracture of proximal humerus)
Presents unilaterally (other shoulder may become involved in next 5 years)
Slight increased risk of non-dominant shoulder
Pt presents to the emergency department with knee pain.
You decide to ultrasound the proximal knee. You place your ultrasound probe in the midline of the knee with your probe marker towards the patient's head.
What is the diagnosis?
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The answer is a quadriceps tendon rupture with femur fracture.
Intersection syndrome
Intersection syndrome is an overuse injury of the forearm.
Pain is located approximately 2 finger breaths (4cm) proximal to the wrist joint.
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Mechanism: friction is caused by repetitive wrist extension activities
Commonly: Rowing, skiing, tennis, canoeing and weightlifting
Friction may cause crepitus with finger/wrist extension.
Tenderness, mild swelling may be present
A Baker's cyst is a common incidental finding on ultrasound reports and bedside physical exam.
Clinically, these cysts are commonly found in association with intra-articular knee disorders. Most commonly: osteoarthritis, RA and tears of the meniscus.
Sometimes Baker's cysts are a source of posterior knee pain.
In an orthopedic clinic setting, Baker’s cysts are frequently discovered on routine MRI in patients with symptomatic knee pain. They tend to occur in adults from ages 35 to 70.
Over 90% of Baker’s cysts are associated with an intraarticular knee disorder. While most frequently associated with OA and meniscal tears, other knee pathologies that have been associated include inflammatory arthritis and tears of the anterior cruciate ligament.
DDX: DVT, cystic masses (synovial cyst), solid masses (sarcoma) and popliteal artery aneurysms.
Based on cadaveric studies, a valvular opening of the posterior capsule, proximal/medial and deep to the medial head of the gastrocnemius is present in approximately 50% of healthy adult knees.
Fluid flows in one way from knee joint to cyst and not in reverse. This valve allows flow only during knee flexion as it is compressed shut during extension due to muscle tension.
Most common patient complaint is that of the primary pathology, meniscal pain for example. At times, symptoms related to the cyst are likely due to increasing size as they may report fullness, achiness, stiffness.
In one small study, the most common symptoms were 1) popliteal swelling and 2) posterior aching. Patients may complain of loss of knee flexion from an enlarged cyst that can mechanically block full flexion.
If the Baker cyst is large enough the clinician will feel posterior medial fullness and mild tenderness to palpation. The cyst will be firm and full knee extension and softer during the flexion (Foucher’s sign).
This may help with differentiation from other popliteal masses (hematoma, soft tissue tumor, popliteal artery aneurysm).
With cyst rupture, severe pain can simulate thrombosis or calf muscle rupture, (warmth, tenderness, and erythema). A ruptured cyst can also produce bruising, which may involve the posterior calf starting from the popliteal fossa and extending distally towards the ankle.
Treatment: initial treatment for symptomatic Baker cysts is nonoperative unless vascular or neural compression is present (very unlikely)
Treatment involves physical therapy to maintain knee flexibility. A sports medicine physician may perform an intraarticular knee corticosteroid injection as this has been found to decrease size and symptoms of cysts in two-thirds of patients.
For patients that fail above, refer for surgical evaluation. Inform patients that they are not undergoing ED drainage of this symptomatic cyst due to the extremely high rate of recurrence which, as a result of the ongoing presence of the untreated intraarticular pathology, results in the recurrent effusion.
Acute lower back pain is a very common emergency department presenting complaint. Over the last several years there has been impetus to move away from opioids in the management of lower back pain.
A recent systematic review investigated the pharmacologic management of acute low back pain. This review looked at RCTs investigating the efficacy of muscle relaxants, NSAIDs, and acetaminophen for the treatment of acute nonspecific lower back pain of fewer than 12 weeks duration in patients > 18 years of age. Studies that investigated the use of opioids were not considered.
18 RCTs, totaling 3478 patients were included. 54% were women. The mean patient age was 42.5 ± 7.3 years. The mean length of follow-up was 8.0 ± 5.6 days. The mean duration of symptoms before treatment was 15.1 ± 10.3 days.
Results: Muscle relaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately 1 week.
The combination of NSAIDs and acetaminophen was associated with a greater improvement than the sole administration of NSAIDs.
However, acetaminophen alone did not promote any significant improvement. Placebo administration was not effective.
Limitations: Most patients with acute LBP experience spontaneous recovery or at least reduction of symptoms, therefore, the real impact of most medications is uncertain. The present study wasn't able to distinguish among different classes of NSAIDs. A best practice treatment protocol cannot be extrapolated from this study.
Take home: In my practice, patients are treated with NSAIDs and Acetaminophen first line. I also include Licocaine patches for all patients. If there is a contraindication to NSAIDs, I treat with muscle relaxants alone.
This study highlights the lack of benefit of acetaminophen as mono therapy (which has been noted in other studies).
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.
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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.
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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.
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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.
