News Category: General

Given the aging of America and rising numbers of women with fractures from osteoporosis, it’s time to review this topic. In this article, current understanding of risk factors, screening, and treatment for postmenopausal osteoporosis are summarized. The goal is to reduce modifiable risk factors and prevent osteoporosis as much as possible.

The loss of estrogen as a result of menopause (cessation of the menstrual cycle) can lead to decreased bone mineral density. The concern is that 30 to 50 per cent of postmenopausal American women have a bone fracture.

One way to prevent this from happening is to identify women who are at high risk for osteoporosis. Risk factors that can be changed include cigarette smoking, alcohol abuse, low body weight, and use of steroids.

As part of the screening process, bone density can be tested. Current guidelines recommend all postmenopausal women 65 years old and older should have bone density tests done. And any woman of any age who is postmenopausal with bone loss for any reason should be tested, too. For example, this would include women who go into menopause as a result of a hysterectomy.

Once a woman has been diagnosed with osteoporosis, treatment can begin. Daily intake of calcium is important. The formation of new bone requires sufficient calcium. The woman must get enough vitamin D to help the body absorb the calcium. Many calcium supplements include both calcium and Vitamin D to help with this.

Studies have not been able to show that the risk of bone fracture is less with vitamin and mineral supplementation. To offset this risk, physical activity and exercise is needed. But not just any kind of exercise is advised. Weight-bearing and resistance exercises are required. The contraction of muscles and pull of tendons on the bone is what stimulates bone growth.

There are also new drug treatments available. Women who should consider the pharmacologic approach include those who have had osteoporotic vertebral fractures or low bone density scores (- 2.5 or less). Testing for bone density is done with dual-energy X-ray absorptiometry (DXA). This screening technology measures bone density throughout the entire body.

Drug treatment is also considered for women with T-scores between -2.0 and -2.5 who have other significant risk factors. This would include thin women with low body mass index (BMI). A personal or family history of hip fracture (or other fragility fracture) are additional risk factors to consider.

Drugs used to prevent or treat osteoporosis include bisphosphonates, calcitonin, raloxifene, and parathyroid hormone (PTH) teriparatide. Each one of these medications has its own actions and indications. The two broad categories are antiresorptive and anabolic agents.

Antiresorptive agents keep bone from being dissolved or absorbed by the body. Bisphosphonates, raloxifene, and calcitonin are examples of antiresorptive agents. Anabolic treatment increases bone formation rather than preventing bone resorption. PTH teriparatide is the only anabolic agent approved by the FDA for this purpose so far.

The decision as to which drug to use can be complex. It must be made by the physician with the patient based on the woman’s history, current physical and mental health, cost, and ease of treatment doses. Some drugs are taken in pill (oral) form. Others are given under the tongue, in the nose, or injected into the muscle.

Each pharmacologic agent has its own advantages and disadvantages. Some can be used as a preventive and treatment of osteoporosis. Others have just one function either as a preventive or treatment option. Some have side effects such as stomach upset, irritation of the esophagus, difficulty swallowing, or jaw osteonecrosis (death of bone tissue).

Women should be advised and cautioned how to take the medication. They should also be instructed what to look for and when to report any side effects. All of these guidelines will continue to be reviewed and revised as new research evidence comes available. Updates such as the information in this article will help keep patients and practitioners up-to-date.

Physical therapists often help patients feel how much weight they should place on the foot up through the leg after surgery. Limiting weight-bearing is important after some surgical procedures. For optimal healing, tissue must be protected and shouldn’t be overloaded. This is very important after autologous chondrocyte implantation (ACI).

ACI is a way to remove normal cartilage cells from the patient’s joint and grow new cells from them in the lab. The new cells are used to repair a defect (hole) in the surface of the joint. The postoperative rehab program starts off with limited and controlled weight-bearing.

There are a variety of ways to help the patient limit weight-bearing. Limb-load monitors, pressure insoles, and force monitoring platforms are possible but not always available. Using a bathroom scale to approximate the allowed weight is the easiest and least expensive method. But how accurate is this approach?

In this study, scientists use a standard bathroom scale to train patients to put partial weight on the leg after ACI. Each patient was given proper instructions and training first. Everyone was taught how to put 20, 40, 60, and 80 per cent of their body weight on the leg using a bathroom scale. In a typical rehab program, weight-bearing is gradually increased over a period of five to eight weeks. A forearm crutch is used on the opposite side to help offload weight.

In this program, patients must learn, retain, and reproduce the desired load while standing and walking. After practicing each of these weight loads, a force platform was used to measure ground reaction forces. Ground reaction forces refer to the force that goes through the foot, up the leg, and to the knee. Seven days later, everyone was re-assessed.

The researchers compared actual weight-bearing to the levels used during training. Pain levels and frequency were also monitored. They found that everyone used more body weight than prescribed or expected. This was true at all levels of weight-bearing and across all trials.

Accuracy was better after seven days, but still more than desired. The greatest improvement over the seven-day period was seen in the group applying 20 per cent of body weight. In general, accuracy did improve as more weight was allowed. In other words, greater accuracy occurred at 80 per cent weight bearing compared with 20 per cent.

The authors point out that there could be many other factors affecting the success of accurate weight-bearing. The role of pain, swelling, and muscle weakness has not been investigated. Mental state and physical fragility after surgery must also be taken into consideration. And we don’t really know what the long-term effects of weight-bearing are on cartilage protection and development of repair tissue.

For now, it is advised that until further research is done to answer these questions, it may be best to provide patients with more weight-bearing training after ACI. This is especially true for patients who are expected to place low loads (e.g., 20 per cent of body weight) using a touch toe technique. The success of the ACI may depend on it.

Further studies are needed to identify how the graft is affected by progressive weight-bearing programs. Is accuracy of weight-bearing even needed to prevent overloading the healing tissue? And if so, for how long? One week? Six weeks? The information gained from this type of research could be applied to patients after other orthopedic surgery affecting the joints of the lower extremity.

Workers injured on the job become Workers’ Compensation (WC) claimants. The goal in rehab is to get them back to work as soon as possible. Employers bear the indirect costs of work disability while the WC system covers the direct cost of care. Both sides want to see a quick turn around time with maximal recovery possible.

For this reason, WC claimants’ progress is evaluated and measured with a variety of tools. In this study, researchers looked at the validity of the Patient-Specific Functional Scale (PSFS) for this group of patients.

The hope is to find a tool that measures both ability to return-to-work and ability to enjoy recreational, family, and personal activities. Workers are more functional and able to return-to-work faster when they are able to perform well at work tasks while also pursuing personal interests. In the Workers’ Compensation world, return-to-work is also known as time to claim closure.

The PSFC is a self-report questionnaire filled out by the individual. It can be used by patients with a wide range of musculoskeletal problems. It has tested out well when used with neck and low back pain patients. Studies show that it is able to detect clinical change and is more responsive than other tests available.

Since Workers’ Compensation claimants often have many different problems, this tool might be suitable for them. This is the first time it has been used to test for limitations and barriers to recovery in WC patients.

The test asks WC patients to list three activities that are difficult or impossible to do because of their injury. Then they rate (from zero to 10) their ability to perform each activity. Zero means they can’t do it at all. Ten is the level they were at before the injury or accident. If none of the three activities were work-related, then they were asked to list at least one work activity in this category.

Each WC claimant also completed three other measures of pain, general health, and perceived disability. These included the Pain Disability Index (PDI), Visual Analog Scale (VAS), and the Short Form-36 (SF-36).

The researchers compared the PSFS scores to the scores from the three other tests. They looked at scores for patients who were able to return-to-work successfully. The idea was to find factors that might predict functional limitations in WC patients. The time it took to go through rehab and rate of injury recurrence were also recorded.

The authors found that the PSFS does provide useful predictions of return-to-work capacity. It’s an easy, low-cost test to administer. And even though WC claimants were asked to include at least one work-related activity that they had difficulty with, it was really the non-work-related items that were most predictive of return-to-work.

It appears that the PSFS appeals to patients because it includes personal areas that are important to them. By listing the three most difficult activities, they are able to discuss areas that cause them the most problems — even when these are at home and not at work.

The results of this study support the use of the PSFS as a valid and meaningful measure of disability for WC claimants. Further study is needed to find predictive factors or indicators of functional limitations in workers after injury or accident.

The National Osteoporosis Foundation (NOF) is constantly keeping watch on research related to osteoporosis. As a result of compiled evidence, they have come out with a new Guide to Prevention and Treatment of Osteoporosis.

The new guidelines take into consideration different target groups. The guidelines now address African Americans, Asians, Latinos, and older men. This is a new step from previous recommendations that were just aimed at white postmenopausal women.

The new NOF guide gives doctors a way to assess fracture risk. This information is very helpful when deciding what kind of treatment is best. Anyone with low bone mass who is at risk for fracture needs treatment. A program of exercise, supplements, and osteoporosis medications is often advised.

Some of the main risk factors for fractures include older age, sex (female), personal history of fracture, and low body mass index. Bone mineral density (BMD) tests provide additional information on risk. Testing with quick results is now possible in the doctor’s office.

The NOF encourages all healthy adults to follow this program for osteoporosis prevention:

For years, doctors and physical therapists have relied on palpation to identify trigger points (TrPs) in muscles. TrPs are areas of hyperirritable tissue. When pressed, they cause painful patterns. Each muscle has its own unique TrP pattern.

But recent research has brought the assumption that palpation is a reliable way to diagnose this problem. Part of the problem is that the testing isn’t reproducible. That means the results aren’t the same when the patient is tested more than once or if two different examiners conduct the same test.

In this study, researchers from the Institute of Sports Science and Clinical Biomechanics in Denmark review all the studies done on the reproducibility of manual palpation for trigger points. They came across quite a few problems.

First, not everyone uses the same terms to describe TrPs or their findings. Second, different criteria are used to identify TrPs. Sometimes the presence of local tenderness is a positive finding. Other studies used pain referral patterns as the defining test for a trigger point. And of all the studies reviewed, no one looked at the same muscles. This makes comparing the results of one study to another invalid.

Most of the studies were judged to be of poor quality and design. The way patients were selected and studied was not random or objective. Many studies only used two examiners to determine reproducibility. The authors say this simply isn’t enough to reduce chance results.

The amount of pressure applied to test the muscles was also different from study to study. And in the clinic, the diagnosis usually requires a global assessment. This means touch, observation, and patient feedback are used to diagnosis trigger points. Palpation is not the only tool used to identify trigger points. None of the studies reviewed included any of these other exam techniques.

The authors did find that there was some evidence that reproducibility exists for three muscles in particular. These included the trapezius, gluteus medius, and quadratus lumborum. But the evidence was weak and further research is needed to study this area of patient care.

Antibiotic beads have been used to treat bone and soft tissue infections for the last 30 years. Antibiotics are mixed into a cement mixture and formed by hand into round balls called beads. The beads are placed inside a wound and changed every two weeks.

In this report, surgeons from the University of Illinois develop a better way to form and mold antiobiotic beads. They were able to make smaller, more uniform (size and shape) beads.

The authors describe the step-by-step process and method used to make smooth, round antibiotic beads. They used a four-millimeter cake decorator’s mold to form the beads. The beads were placed in silicone trays, which were easier to remove from compared with plastic bead-making trays.

There are many advantages to this method of bead making. The smoother, more uniform size and shape of beads resulted in fewer problems with the wound. Operating room staff were exposed to fewer toxic fumes because the process was much faster than rolling them by hand.

Smaller beads made it possible to fill the wound area more completely and more evenly. Patients did not report any pain from sharp or irregular edges of the beads. Combining the antibiotics as needed in the operating room is a big advantage for the patient.

The technique described in this article simplifies and improves the production of antibiotic beads. Improved local antibiotic delivery and less discomfort to patients make this process noteworthy.

Physical therapists use a variety of modalities to help with pain and inflammation. Iontophoresis is one modality that pushes a steroid drug through the skin to the inflamed area. The idea is to deliver the steroid antiinflammatory to the local area. This way the patient can avoid the side effects of an oral drug.

It’s not clear how well or how fast iontophoresis works. Numerous animal studies have been done using monkeys, horses, rabbits, pigs, and rats. But animal skin and human skin are very different and can’t be compared directly. Human studies are difficult to conduct because it isn’t easy to examine the tissue once the treatment is done.

In this study, the authors asked two questions. Does the thickness of the patient’s skin make a difference? What is the effect of time on the absorption of the drug? For example, does the drug go through the skin right away? Or does it take awhile to cross as much as it’s going to?

This study was very unique. Patients were treated with iontophoresis right before having anterior cruciate ligament (ACL) reconstructive surgery. The steroid used was Dexamethasone sodium phosphate (DEX-P). DEX-P was infused through the skin right before the ACL operation.

The semitendinosus hamstrings tendon was treated. Then during the ACL operation, the tendon was removed (a routine part of ACL reconstruction). The tissue samples were sent to the lab and analyzed. The amount of DEX-P absorbed by the tendon was measured.

For half of the samples, there was no measurement of DEX-P found at all. The reason for this is unknown. It’s possible (though not likely) that the target tissue (tendon) was missed. In other samples, the amount of DEX-P increased as time went by.

The authors suggest that if iontophoresis works by electropulsion, then this should not happen. The electric charge drives the steroid through the skin. There shouldn’t be a delayed response with this mechanism. This finding suggests there may be a different way the drug is getting across the skin. Perhaps it passes through by diffusion or by the blood flow.

Further studies are needed to find out why some patients absorbed the DEX-P and others didn’t. The two groups of patients were very similar in most ways. The position used during the iontophoresis was the same. The temperature in the preoperative suite where they received the iontophoresis was the same. They all had the same surgery to remove the tendon. It’s possible that activity level before the procedure was different and that made the difference.

The skin thickness did not seem linked to absorption. Some patients with thick skin had the highest levels of DEX-P in the tendon. And some patients with the thinnest layer of skin had the lowest levels.

The authors conclude that iontophoresis can help transmit DEX-P through the skin. But it doesn’t do so for everyone. Why it works for some patients but not for others remains unknown.

At the present time, it’s not clear if the amount (dosage) that crossed over was enough to create an antiinflammatory response. More studies are needed to better understand how iontophoresis works and who can benefit from it.

There still remains many things we don’t know about the condition called fibromyalgia syndrome (FMS). It’s not a disease, but rather, a group of symptoms that occur together. Pain is the most distressing symptom but patients can have a wide range of other problems. These may include poor sleep, joint and/or muscle pain, headaches, and fatigue (to name just a few).

In this article, the basic science of FMS is presented. Conditions that can be confused with fibromyalgia are listed. Regional triggers that may induce (bring on) fibromyalgia are also discussed.

FMS is often accompanied by one of many other conditions such as rheumatoid arthritis, thyroid problems, or cancer. Five key issues are the main focus of this review:

There are many kinds of tests that can be done to diagnose rheumatoid arthritis (RA). X-rays, CT scans, MRIs, and lab tests all have some value. Physicians must choose carefully to avoid unnecessary costs while still getting an accurate diagnosis.

Early identification of RA is important now that there are drug therapies that can prevent joint damage when used right away. Once erosion of the joint cartilage occurs, irreversible disability can happen. To avoid this, early diagnosis and treatment of this condition is very important.

In this article, rheumatology experts review early warning signs of RA. And they offer an update on testing procedures for quick and accurate diagnosis. Patients with pain, swelling, and warmth in the small joints of the hands and feet are suspected of RA. A positive family history of RA is a red flag.

Blood tests for rheumatoid factor and a positive anti-CCP test give early clues to the presence of RA. Antibodies against cyclic citrullinated peptide (CCP) are specific for RA.

A positive anti-CCP test is possible in many people with RA before they have any symptoms. In fact, a positive anti-CCP test is a predictive risk factor for damaging joint erosive disease later in the disease process.

Other serologic (blood) markers for RA include C-reactive protein (CRP) and genetic markers such as human leukocyte antigen (HLA). Elevated CRP is not an early warning sign, but is present when inflammation occurs. Testing for a particular HLA called the HLA-DR4/DR1 cluster may help predict severity of disease. This test is still experimental. It isn’t available yet on a routine basis.

X-rays are easy and readily available but they only show structural damage after the fact, rather than before. Still, baseline images can be digitally stored and retrieved later for comparison to measure disease progression.

MRIs and ultrasound (US) are much better at identifying soft tissue changes and joint pathology early in the disease process. Although more expensive, neither of these tests exposes the patient to ionizing radiation.

Studies show that bone erosion shows up on MRIs a full year before they are seen on X-rays. And MRIs can help show progressive changes in patients without symptoms who are taking disease-modifying antirheumatic drugs (DMARDs). This gives the physician a chance to change the drug dose in order to prevent further joint damage.

Currently, MRIs are not routinely used in this way. More study is needed to justify the cost. Specific guidelines need to be developed for its use in clinical practice. For now, it remains a research tool.

A more practical imaging tool may be ultrasound. It’s safe, noninvasive, and portable. It is also less expensive than CT scans or MRIs. It’s more sensitive than standard X-rays. In the hands of a well-trained health care professional, ultrasound can give an accurate picture of joint pathology. In Europe, it is used when X-rays are negative but the physician suspects RA. It can also be used to monitor effectiveness of drugs.

Physicians and patients are often confused about when and how to treat gout. In this review article, Dr. P. A. Simkin from the division of rheumatology (University of Washington – Seattle) offers an update and an explanation for the control of gout.

Diagnosis is made with arthrocentesis and X-rays. Arthrocentesis refers to removing some of the fluid in the affected joint and analyzing it for the telltale urate crystals present in many cases of gout. The absence of these crystals does not mean the patient doesn’t have gout. But the presence does confirm the diagnosis.

Diet is the first, and most important, key to preventing gout. It’s clear that the increased number of food products containing high-fructose corn syrup is a factor. Since World War II (when foods were restricted), the number of cases of gout has increased every year.

Restricting carbohydrates, especially containing corn syrup may prevent this painful, arthritic condition. Restricting alcoholic beverages (especially beer) and limiting wine is also advised. Obesity is also a risk factor for gout. Some foods and beverages can help the body rid itself of excess uric acid (cause of gout). These include ascorbic acid (vitamin C), dairy products, and coffee.

For many years physicians have advised patients to avoid foods with high purine content. Increased purine results in an increase in the uric acid that causes gout. Too much intake of sweetbreads, anchovies, and lentils was considered part of the problem. But diet alone is not enough to control the arthritis associated with gout. Other approaches to treatment are also needed.

Aspiration (removing fluid from the joint) provides decompression. This means it takes pressure off the nerves and soft tissues around the joint. Pain relief and preventing infection are the main goals of aspiration. The pathway or track caused by needle insertion actually provides a vent for fluid to drain. It may prevent rupture of the joint capsule.

Urate lowering medications such as allopurinol or probenecid are used to lower urate crystal levels. Drugs can also help dissolve crystal deposits from the tissues. A nonsteroidal antiinflammatory drug is often prescribed to help with pain and reduce the risk of inflammation.

Once the gout is under control, patients often stop seeing the doctor. However, even people with well-controlled gout should have regular follow-up and education to reinforce the hows and whys of treatment. Periodic measures of serum uric acid concentration should be taken. The risk of flare-ups is less when the uric acid levels are low (below six mg/dL).

Rheumatology is the study of rheumatic conditions. Most people think of arthritis as the main rheumatologic disorder. But there are many rheumatologic conditions and they are on the rise.

Besides osteoarthritis (OA) and rheumatoid arthritis (RA), common rheumatologic and related conditions include gout, fibromyalgia, lupus, and systemic sclerosis. Carpal tunnel syndrome (CTS), neck and back pain can also be arthritic-related conditions.

A special group of rheumatic conditions affecting tendons, bones, and joints is called spondyloarthropathy. This includes ankylosing spondylitis, Reiter’s syndrome, reactive arthritis, and psoriatic arthritis.

According to the National Arthritis Data Workshop (NADW), more and more people are being affected by these conditions. For example, there’s been a 43 per cent increase in the number of people affected by gout. OA has increased by 29 per cent and is expected to rise to 44 per cent by the year 2030.

Only RA has decreased in incidence. No one knows the reason for this decline or for the sudden increase in all other rheumatic diseases. The aging of America can account for some, but not all, of these increases.

Many organizations are busy tracking this problem and looking for solutions. The National Center for Chronic Disease Prevention and Health Promotion offers updates on this problem. They can be contacted by email at arthritis@cdc.gov or by telephone at (770) 488-5464.

Many experts say there are lots of benefits in doing Tai Chi exercise. For example, Tai Chi can help older adults maintain balance and strength needed to prevent falls. But there are very few studies to examine the movements used in Tai Chi.

In this report, the results are presented from comparing the biomechanics of Tai Chi gait in healthy elders to young adults and to normal walking in older adults. Electromyography (EMG) of the leg muscles during Tai Chi was recorded for young and old Tai Chi practitioners.

Single-stance (standing on one leg), double stance (standing on two legs), and leg swing were analyzed. Amount of hip and knee flexion and time in each position were measured. Amount of muscle activation was also viewed in relation to the amount of time the person was in each position.

The author used a variety of tools to measure everything. Besides the EMG, a handheld dynamometer was used to measure knee extensor strength. Infrared sensitive cameras recorded movement. Two force plates in the walkway recorded ground reaction forces during regular walking and while doing Tai Chi movements in a forward direction.

The results showed quite a difference in biomechanics between a Tai Chi forward movement, Tai Chi gait, and normal walking between young and old. This is the first study to show age-related differences in movement during Tai Chi.

The main difference was noticed during the single-stance phase. The older group stayed on that leg less time with less hip and knee motion. Muscles of the leg were activated for less time.

These results are in agreement with other studies that show elders have trouble controlling trunk motion from side to side when standing on one leg. They tend to narrow their base of support, take small steps, and stay on each leg less time than younger adults.

With these changes in gait position, muscle activation patterns changed, too. This finding supports the idea that there is reduced muscle strength in older adults because of changes in muscle activation patterns, not the other way around. Slower pace and deeper knee flexion (lower center of gravity) are linked with change in muscle activation patterns. Weakness leading to falls may be the result of these changes.

Tai Chi has the capability of increasing strength and balance as a way to improve balance and prevent falls. A Tai Chi practice may also improve walking patterns among elders. The final result may be walking with more knee flexion, a lower center of gravity, and with greater efficiency and stability.

The author points out that only Tai Chi gait (walking movement) was analyzed in this study. Different results might be seen with Tai Chi motions that include trunk rotation, turns, kicking, and pushing down.

Stem cell research has generated much controversy over the last few years. But scientists have found a way to harvest adult stem cells from muscle biopsy. These cells can be used to repair articular (joint) cartilage, muscle, and bone. They can also be genetically altered to contain special growth factors to speed up healing.

The uses of such a discovery are far ranging. In the future, it may be possible to heal muscular diseases that have no cure. There is hope that disabling conditions such as arthritis can be slowed, altered, or even stopped. Stem cells can be harvested from an adult donor but not easily.

It’s not always easy to tell which cell is a stem cell with the potential to become healthy muscular tissue. Right now scientists are focusing on bone marrow as a source of adult stem cells for orthopedic problems. They are easy to isolate. Once in the lab, marrow-derived stem cells are multipotent. This means they can produce many different kinds of cells such as cartilage cells, fat cells, bone cells, and muscle cells.

The disadvantage of using bone marrow stem cells is that it requires a painful bone marrow biopsy. And only a small number of cells are found in each sample. That’s why some researchers have turned to using muscle-derived stem cells (MDSCs). There are plenty of them and they are easy to harvest. Biopsy to retrieve them is minimally invasive. Given the right conditions, MDSCs are also multipotent.

The authors of this article describe how stem cells are retrieved, grown in the lab, and then used in tissue engineering. The use of MDSCs to repair defects in articular cartilage and bone and to repair skeletal muscle injury is discussed. MDSCs may play a big role in healing skeletal muscle injuries. Besides being multipotent, they survive a long time.

Stem cell research is still in its early stages of development but growing fast. The potential for regeneration of old and diseased tissues is very real. Future studies will focus on ways to use stem cells for musculoskeletal conditions. There is even hope that MDSCs can be used to repair heart tissue. Trials are already underway to use MDSCs for women with stress-induced urinary incontinence. Scientists will study which patients would benefit the most from each application of stem cell harvest.

In this review article on osteoporosis, Dr. E. M. Lewiecki from the New Mexico Clinical Research and Osteoporosis Center brings us up to date on the diagnosis and treatment of this condition. Specific topics discussed included:

High school and college wrestlers suffer injuries second only to football players. In an effort to prevent and reduce wrestling injuries, the overall rates and patterns of injuries must be collected. Trends in injuries can be determined with studies repeated over a period of years.

In this study, data on wrestling-related injuries was collected for one academic year. Both high school and college wrestlers were included. The goal was to calculate and compare rates of injuries between these two groups. Risk factors for injuries were also compared.

Data from national Internet-based surveys was used from the 2005-2006 school year. Two reporting systems were included: the High School Reporting Information Online (RIO) and the NCAA Injury Surveillance System (ISS).

All injuries occurred during practice or matches. Medical care was required. And the wrestler was unable to wrestle for one or more days after the injury.

Data on the rate and type of skin infections was also collected since these make up a large number of adverse events that occur with wrestling. Here’s what they found:

Many people with chronic muscle pain have a condition called myofascial pain syndrome (MPS). Pain over a large area with muscle tenderness is common. Trigger points (TrPs) are the main finding with this condition. TrPs are hypersensitive nodules that can be felt in a muscle. TrPs can be active or latent. Active means they cause a painful pattern when the muscle is at rest. Latent means the TrP must be palpated (rubbed or pressed) to cause symptoms.

In a previous study, these same authors found out that chemicals released during inflammation are present around the active TrPs. And they discovered that the chemical mix around latent TrPs also changes over time.

In this study, muscle tissue was compared for active TrPs, latent TrPs, and normal tissue. A very thin needle was inserted into the muscle. Tiny amounts of tissue were removed and analyzed. Two muscles were tested: the upper trapezius (in the neck and upper shoulder) and the gastrocnemius (calf). The gastrocnemius was an uninvolved muscle far away from the influence of the upper trapezius.

Various measures tested and compared included pH (measure of acidity); substance P (present with painful conditions); and levels of immune cells linked with inflammation. Immune-based inflammatory cells included bradykinin, tumor necrosis factor (TNF), and interleukins. Concentrations of other biochemicals, peptides, and hormones were also tested.

The authors described in detail the equipment and method used to collect the tissue samples.The specific tests used to analyze the samples were also discussed. These included capillary electrophoresis, electrochromatography, and nine other analyses used for each specific chemical being studied.

Results showed lower pH for the active TrP muscles. There were also higher levels of all substances tested in the active TrP muscles. Results for the muscle tissue with latent TrPs were similar to normal muscle tissue. This study confirms the fact that biochemicals known to be present with pain and inflammation are elevated around TrPs.

The fact that these substances were present (but not as much) in normal tissue was important. The authors suggest this may mean that substances normally associated with pain and fatigue can be present in areas of muscle other than around TrPs.

Muscle activity requiring oxygen delivery, muscle contraction, and relaxation may generate these chemicals. When they reach an elevated level, then tenderness and referred pain from TrPs may occur. It’s also possible that the increased levels of biochemicals signal pain receptors. Then pain receptors send pain messages through the spinal cord to the brain.

This way of studying TrPs does not harm the muscle or cause further pain and TrPs. The researchers will continue to study muscle pain related to TrPs in an effort to find more effective ways to treat and prevent them from developing.

Today’s orthopedic surgeons don’t use cast immobilization as often as they used to. Newer surgical techniques have made it possible to repair bone fractures using metal plates, rods, screws, and wires.

When casting materials are used, care must be taken to avoid problems and complications. In this article, surgeons are reminded of the many precautions required in treating patients with cast immobilization.

First, beware of high-risk patients. These include anyone who can’t communicate or talk, patients who are in a coma, and very young or developmentally delayed patients.

Anyone with decreased or abnormal sensation must be watched carefully. Children and adults with spasticity are also at increased risk for problems, especially pressure sores.

Both plaster and fiberglass materials are used for casts. The pros and cons of these materials are reviewed in detail. Plaster is less expensive and easier to mold. But it is heavier and not water resistant. Heat is generated when the plaster sets up. Patients can get burned during the process.

Fiberglass materials are lightweight but strong. There isn’t as much ability to mold the cast to the patient. It is possible to bathe and even swim with these casts. A special waterproof liner must be used. Burns are less likely and X-rays show up better with fiberglass casts.

The surgeon decides which type of material to use with each patient. Type of injury and the age and needs of the patient are considered. The length of time the cast is going to be used is also important.

When serial casts are used, plaster is usually preferred. Serial casts are often used with infants who have clubfoot. The foot is moved as close to the normal position as possible and held in place by a cast. At the end of a short time, the cast is removed. The foot is aligned again and recast. This process is repeated until the deformity is corrected.

Tips for applying the cast are provided. Casting techniques for a well-molded cast that doesn’t irritate the soft tissues are also offered. Safety of the patient is the top priority. The person applying the cast must be patient with the process.

For example, the right water temperature must be used with plaster materials. Using a warmer temp to speed up the setting time is not advised. And the plaster must set or cure before the patient’s limb can be placed on a support frame or pillow.

There are many details to pay attention to during the casting process. Just the right amount of tension is needed to unroll fiberglass materials. Just the right amount of padding must be used to avoid pressure sores. Care must be taken to avoid imprints in the cast while it is setting up.

The authors offer many, many tips for proper casting technique. Risks and ways to avoid complications are also reviewed. Once the cast is applied, the patient must be monitored for problems. Any complaint should be attended to. Pain, swelling, or numbness are red flag symptoms.

The final step is cast removal. This requires equal care and attention. An oscillating saw is usually used to cut the cast material. Saw burns can occur leaving unsightly scars. If the cast is thick and the saw blade is dull, enough heat can be generated to cause a skin burn.

There is a trend toward removable splinting to avoid some of these complications with fixed casts. Taking the splint off as directed by the surgeon allows the patient or family to inspect the limb.

Some patients are better candidates than others for this type of treatment. The surgeon takes all the risk factors into consideration when deciding the best way to properly immobilize a limb for complete healing.

In this article, orthopedic surgeons review the most common causes of bike injuries to the lower extremities (legs). Proper bicycle design, size, and seat position are described. Training and technique needed to prevent injuries are also outlined.

The knee is the site of most bicycling injuries caused by overuse. Knee pain caused by patellofemoral syndrome (PFS) is also referred to as cyclist’s knee. Pain of this type occurs along the bottom edge and underneath the patella (kneecap).

Pressure from the patella against the bone underneath is the most common cause of PFS. Hill climbing, riding in high gears, and a cadence that’s too slow are some of the risk factors for this type of compression on the joint cartilage. Over time, shear and load cause damage to the cartilage behind the knee. This condition is called chondromalacia.

Other knee injuries include hip bursitis, patellar tendinitis, quadriceps tendinitis, or iliotibial band syndrome (ITBS). The ITB is a band of thick fibrous connective tissue. It begins at the pelvic crest and then crosses the hip and knee to its insertion point on the tibia (lower leg).

Injuries of the lower leg can also occur. Achilles tendinitis, compartment syndrome, and metatarsalgia are the most commonly reported lower leg injuries.

Compartment syndrome is a build-up of pressure inside the soft tissues in the front of the lower leg or in the calf. Metatarsalgia is pain across the ball of the foot. It is caused by repeated load during pedaling.

Many injuries occur as a result of malalignment of the patient’s anatomy. But bicycle seat height, training intensity, poor foot position, and rigid shoes can contribute to these problems. Of course, unexpected trauma is another potential cause of cycling injuries.

The authors suggest it is possible to prevent predictable injuries due to repetitive motion. Each competitive cyclist should be evaluated for proper bicycle fit and alignment. Using the correct pedals and with proper technique is equally important. Rider position and the right training program can also help avoid injuries.

When nontraumatic injuries do occur, conservative care with rest and physical therapy are the first forms of treatment. Most repetitive, load, postural, and equipment-related injuries can be avoided or at least treated successfully without surgery.

Steroid injections can be used to diagnose and treat nerve compression in the wrist and foot. Carpal tunnel syndrome (CTS) can cause burning pain, numbness, and/or tingling in the thumb and first two fingers.

Pressure on the median nerve as it goes through the carpal tunnel is the underlying problem. The carpal tunnel is a space between the bones of the wrist and the retinaculum ligament across the wrist. There is usually enough room for the nerves to pass through this area undisturbed.

A similar problem called tarsal tunnel syndrome (TTS) can occur in the ankle and foot. Pressure on the tibial nerve can also cause ankle pain and pain, numbness, or tingling along the bottom of the foot.

Corticosteroid injection can bring relief from the symptoms. It is both a pain reliever and an antiinflammatory. Injections serve as a treatment and a diagnostic tool. If the wrist or ankle symptoms are eliminated by injection, then the problem was most likely nerve compression.

The authors review supplies needed for the procedure. They present surface anatomy to help the surgeon find the tunnel and locate the nerve. The patient’s position is important. Once the patient is placed in the best position, the skin is numbed and the injection is given.

Specific steps are included such as proper sterilization, angle of needle insertion, and proper length to advance the needle. Injection of the tendon can be avoided using proper patient positioning and stopping if there is any pain, numbness, or resistance.

If problems occur, the needle can be pulled back out and redirected. Patients should be told that their symptoms may get worse at first. This doesn’t last. It’s caused by the extra fluid of the steroid that has been pumped into the tunnel area.

This article was one of a dozen in a series describing the most commonly injected joints and bursae. Eight more of these procedural reviews will be presented in future publications of this journal.

Early diagnosis of rheumatoid arthritis (RA) is very important. Damage to the joints is occurring Even before symptoms start. Making the diagnosis and starting treatment early can help preserve function and prevent disability.

In this article, two rheumatologists (doctors specializing in RA) review the problems doctors face in making the diagnosis soon enough. They also discuss tests that are used to identify patients with RA.

The authors point out that the American College of Rheumatology’s (ACR) Criteria for the Classification of RA are outdated. Improved technology for lab testing and advanced imaging have made it possible to identify the disease sooner.

Studies show that patients with RA have the best results when the disease is treated within the first year of symptoms. Patients should be sent to a rheumatologist or arthritis clinic if they have any of the following symptoms: