Ankle Sprains: Evaluation, Rehabilitation, and Prevention

Ankle sprains affect athletic populations at high rates. Athletes who suffer an ankle sprain frequently go on to develop persistent symptoms, resulting in significant resources spent toward treatment, rehabilitation, and prevention. A thorough clinical evaluation is necessary to ensure an accurate diagnosis and appropriate treatment prescription. This narrative review aims to present an approach to evaluation of high and low ankle sprains for athletes of all levels. The authors review the current evidence for ankle sprain treatment and rehabilitation. Strategies for prevention of recurrent sprains and return to play considerations also are discussed.

Toward a Consensus for Musculoskeletal Ultrasonography Education in Physical Medicine and Rehabilitation: A National Poll of Residency Directors

OBJECTIVES

The aims of the study were to evaluate integration of musculoskeletal ultrasonography education in physical medicine and rehabilitation training programs in 2014-2015, when the American Academy of Physical Medicine & Rehabilitation and Accreditation Council for Graduate Medical Education Residency Review Committee both recognized it as a fundamental component of physiatric practice, to identify common musculoskeletal ultrasonography components of physical medicine and rehabilitation residency curricula, and to identify common barriers to integration.

DESIGN

Survey of 78 Accreditation Council for Graduate Medical Education-accredited physical medicine and rehabilitation residency programs was conducted.

RESULTS

The 2015 survey response rate was more than 50%, and respondents were representative of programs across the United States. Most programs (80%) reported teaching musculoskeletal ultrasonography, whereas a minority (20%) required mastery of ultrasonography skills for graduation. Ultrasonography curricula varied, although most programs agreed that the scope of resident training in physical medicine and rehabilitation should include diagnostic and interventional musculoskeletal ultrasonography, especially for key joints (shoulder, elbow, knee, wrist, hip, and ankle) and nerves (median, ulnar, fibular, tibial, radial, and sciatic). Barriers to teaching included insufficient expertise of instructors, poor access to equipment, and lack of a structured curriculum.

CONCLUSIONS

Musculoskeletal ultrasonography has become a required component of physical medicine and rehabilitation residency training. Based on survey responses and expert recommendations, we propose a structure for musculoskeletal ultrasonography curricular standards and milestones for trainee competency.

Popliteal Artery Entrapment Syndrome-Return to Sport Considerations: A Case Report

This is a case of a 19-year-old female collegiate field hockey player with left leg pain, numbness, and tingling. A comprehensive workup including dynamic ultrasound, magnetic resonance imaging (MRI), and magnetic resonance angiogram (MRA) revealed a type VI functional popliteal artery entrapment syndrome (PAES). There are many options for treatment of functional PAES including activity modification, botulinum toxin injection, and surgery. To the authors' knowledge there is no published return to sport recommendation for postsurgical functional PAES. This report highlights alternative treatment options and proposes a postsurgical return to play rehabilitation protocol in functional PAES. LEVEL OF EVIDENCE: V.

Regenerative Sports Medicine: Past, Present, and Future (Adapted From the PASSOR Legacy Award Presentation; AAPMR; October 2016)

Regenerative medicine has shown dramatic expanse and evolution in the past decade. Within that milieu, physiatrists are taking an active role in research, clinical care delivery, and education. The purpose of this review is to provide a balance among evidence, theory, experience, clinical trends, and the foreseeable future. We focus on the literature that reports the research with the best methodology in each practice area, recognizing that the level of evidence varies substantially among different treatment modalities and conditions. The following elements are included: an overview of the evolution of currently available regenerative techniques, evidence base for each available modality (prolotherapy, platelet rich plasma, bone marrow aspirate concentrate and stem cells, adipose-derived stem cells, and amniotic tissue products), general principles in the application of these treatments, and discussion and a vision of what lies ahead. We expect that practitioners will use this review to facilitate clinical decision making and to provide a core knowledge base to assist when counseling patients. LEVEL OF EVIDENCE: IV.

The Current State of Musculoskeletal Ultrasound Education in Physical Medicine and Rehabilitation Residency Programs

BACKGROUND

Exposure to musculoskeletal ultrasound (MSUS) is now a mandatory component of physical medicine and rehabilitation (PM&R) residency training. However, reports on the extent of the implementation and efficacy of MSUS education are lacking in the literature.

OBJECTIVE

To determine the extent to which PM&R residencies are implementing MSUS education.

DESIGN

Cross-sectional.

SETTING

Institutional.

PARTICIPANTS

Thirty-six of the 78 United States PM&R residency programs accredited by the Accreditation Council for Graduate Medical Education.

METHODS

All 78 programs were solicited with an online survey via the residency program director and coordinator in July 2014. The 25 questions on the survey were aimed at determining program MSUS educational characteristics and their effectiveness.

MAIN OUTCOME MEASURES

Description of teaching methods used for MSUS, residency demographics, characteristics of MSUS faculty expertise, and faculty-perceived competency in MSUS examinations and procedures among residents. Data were analyzed using both descriptive statistics and tests for independence to identify correlations between program characteristics and resident MSUS competency.

RESULTS

A response was received from 36 of the 78 residency programs (46.2%). Of the 36 residency programs that responded, 97.2% provide exposure to MSUS (a figure that drops to 44.9% when nonrespondents are included); 61% had mandatory MSUS training (28.2% when including nonrespondents); and 44.4% had a formal curriculum (20.5% when including nonrespondents). The most common MSUS educational tools used were lecture (88.9%), outpatient clinic (86.1%), and hands-on workshops (86.1%). Sixty-one percent of responding programs evaluate residents with formal assessment tools. Overall, faculty at 38.8% and 44.4% of programs believed that at least 50% of residents who graduate are competent in diagnostic and interventional MSUS, respectively. These rates were significantly associated with the use of formal assessment.

CONCLUSION

MSUS education is growing in PM&R, but many programs still have not adopted a formal educational curriculum. Formal assessment to evaluate resident MSUS skills significantly improves faculty-perceived MSUS competency.

Myofascial pain syndrome treatments

Myofascial pain syndrome (MPS) is a regional pain disorder caused by taut bands of muscle fibers in skeletal muscles called myofascial trigger points. MPS is a common disorder, often diagnosed and treated by physiatrists. Treatment strategies for MPS include exercises, patient education, and trigger point injection. Pharmacologic interventions are also common, and a variety of analgesics, antiinflammatories, antidepressants, and other medications are used in clinical practice. This review explores the various treatment options for MPS, including those therapies that target myofascial trigger points and common secondary symptoms.

Regenerative injection therapy for osteoarthritis: fundamental concepts and evidence-based review

Regenerative therapy involves the injection of a small volume of solution into multiple sites of painful ligament and tendon insertions (entheses) and adjacent joint spaces, with the goal of reducing pain and ostensibly promoting tissue repair and growth. Dextrose and platelet-rich plasma solutions have been shown to increase expression of growth factors in vivo and have shown promising clinical results in the treatment of tendinosus. In the treatment of osteoarthritis, small clinical trials and case series to date suggest safety, symptomatic improvement, and functional improvement at up to a year of follow-up; however, most of these studies are uncontrolled. Given the methodological limitations of clinical research on regenerative injections for osteoarthritis to date, this treatment should be considered only after execution of a comprehensive assessment and treatment plan, including optimization of biomechanics, weight loss, cardiovascular exercise, resistance training, and judicious use of more established topical, oral, and injectable medications.

The aging spine in sports

1. Masters athletes may experience low back pain from multiple sources. Masters athletes with discogenic back pain should avoid or modify sports with combined rotational and compressive forces; individuals with facet-mediated pain should avoid or modify sports with excessive extension and rotation. 2. Optimization of flexibility, strength, endurance, and core control is critical. Sports specific training, realistic goal setting, and counseling are of maximal importance. 3. Overall, the health benefits of continued sports and athletic participation outweigh the potential risks of spinal degeneration in middle-aged athletes. There is little correlation between radiographic appearance of the spine and symptoms; therefore, symptoms should serve as the primary guide when determining activity modifications. Overall, masters athletes should be encouraged to remain active and fit to enhance their quality of life and reduce the risk of cardiovascular disease.

Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial

OBJECTIVE

To compare the efficacy of prolotherapy versus corticosteroid injection for the treatment of chronic lateral epicondylosis.

DESIGN

A prospective, randomized controlled, double-blinded study.

SETTING

Academic, tertiary, outpatient, rehabilitation hospital.

PARTICIPANTS

Twenty-four subjects with clinically determined chronic (ie, lasting 3 months or longer) lateral epicondylosis were recruited. All subjects noted pain intensity levels significant enough to prevent the participation in activities, such as playing racquet sports or lifting heavy objects.

METHODS

Subjects were assigned to receive either prolotherapy or corticosteroid injection for treatment of chronic lateral epicondylosis. Each subject underwent injection at baseline followed by a second injection 1 month later.

OUTCOME MEASUREMENTS

Visual analog scale (VAS) self-rating of pain, quadruple visual analog scale (QVAS), and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were measured at baseline and at 1, 3, and 6 months' follow-up.

RESULTS

Within each group, the analysis demonstrated statistically significant improvements in both VAS and DASH within the prolotherapy group with significant changes noted from baseline to 3 months (VAS: Δ2.38; 95% confidence interval [95% CI] 1.04-3.71, P = .004 and DASH: Δ19.89; 95% CI 5.73-34.04, P = .01), and baseline to 6 months (VAS: Δ2.63; 95% CI 0.61-4.62, P = .017 and DASH: Δ21.76; 9% CI 7.43-36.09, P = .009) after initial treatment, as well as in the QVAS from baseline to 3 months. The steroid group demonstrated a clinically and statistically significant change for DASH only at both 3-month (Δ13.33; 95% CI 0.68-25.99, P = .04) and 6-month (Δ15.56; 95% CI 1.30-29.81, P = .04) follow-up. Comparison of the subjects completing the study revealed no significant differences between the prolotherapy and the corticosteroid group for change in VAS, QVAS, or DASH, although the study lacked sufficient power to draw conclusions from this finding. Eighty-three percent of the subjects were satisfied with their overall improvement during the course of the study, without significant differences revealed between groups. Aside from injection-associated pain, no adverse reactions were reported. Seventeen subjects completed study protocol.

CONCLUSIONS

Both prolotherapy and corticosteroid therapy were generally well tolerated and appeared to provide benefit of long duration. Small sample size precludes determining whether one therapy is superior to the other. Larger, controlled trials appear feasible and warranted on the basis of these findings.

Evidence-informed management of chronic low back pain with prolotherapy

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum

Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.

Soft tissue determinants of low back pain

Low back pain is one of the complaints most commonly seen in the clinical setting. Correctly or incorrectly, these patients are often given the diagnosis of fibromyalgia, myofascial pain syndrome, disk herniation, or some other label. It is important to recognize the soft tissue causes of low back pain and understand how they can be most appropriately diagnosed and managed. Nonligamentous disorders of the low back region may occur in isolation or in combination with underlying discogenic, ligamentous, and facet-mediated causes of pain. Therefore, in order to fully evaluate and treat a patient with low back pain, it is necessary to consider and address these soft tissue conditions. This paper reviews soft tissue causes of low back pain and discusses how they are most appropriately diagnosed and managed.

Functionally Oriented Rehabilitation Program for Patients with Fibromyalgia

OBJECTIVE

To evaluate function and disability in patients with fibromyalgia before and after participation in a functionally oriented, multidisciplinary, 8-wk treatment program.

DESIGN

A total of 23 patients who met American College of Rheumatology criteria for the diagnosis of fibromyalgia were enrolled in the study. Outcome measures included: range of motion, 6-min walk test, a modified Fibromyalgia Impact Questionnaire, a modified SF-36 Physical Functioning Scale, and the Fibromyalgia Health Assessment Questionnaire. Pretreatment and posttreatment scores were analyzed using paired t tests.

RESULTS

All subjects completed the program, and there were no reported injuries. Three subjects failed to complete the survey instruments at the conclusion of the study. Intention to treat analysis including these subjects was carried out but did not significantly change results. For the remaining subjects (n = 20), a significant improvement was found on the Physical Functioning Scale (P = 0.01). Trends toward improvement on the Fibromyalgia Impact Questionnaire (P = 0.40) and Fibromyalgia Health Assessment Questionnaire (P = 0.14) were seen but did not achieve statistical significance. Range of motion testing revealed significant improvements in lumbar spine extension (P < 0.001), straight-leg raise (P < 0.001), cervical spine flexion (P < 0.01), cervical spine rotation (P < 0.05), and cervical spine side bending (P < 0.05). Distance traveled during the 6-min walk test increased significantly (P < 0.01), whereas perceived exertion as measured by the Borg scale did not change. There were no injuries or other adverse consequences of the program.

CONCLUSIONS

This study utilized multiple functional outcome measures to demonstrate improved function and decreased disability in patients with fibromyalgia. Our patients reported significantly improved physical function after participation in the 8-wk intensive multidisciplinary treatment program. This progressive, functionally based exercise training program was well tolerated by all participants and outlines an effective exercise prescription for patients with fibromyalgia. Fibromyalgia patients in this study responded favorably to a treatment program that focused on function instead of pain.

Treatment of Fibromyalgia, Myofascial Pain, and Related Disorders

Chronic muscle pain is a common complaint among patients who seek care for musculoskeletal disorders. A spectrum of clinical presentations exists, ranging from focal or regional complaints that usually represent myofascial pain syndromes to more wide spread pain that may meet criteria for a diagnosis of fibromyalgia. This article addresses the epidemiology, pathophysiology, and clinical management of myofascial pain syndrome and fibromyalgia. These conditions are challenging to treat and require physiatrists to be aware of the wide range of pharmacologic, rehabilitative,and psychosocial interventions that can be helpful.

Musculoskeletal aspects of pregnancy

Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.