Ischial apophysis injuries in athletes

Pathogenesis and Diagnosis of Proximal Hamstring Tendinopathies

The proximal hamstring complex is a highly vulnerable area that is especially prone to injury. Proximal hamstring tendinopathies (PHTs) remain challenging in diagnosis, treatment, rehabilitation, and prevention due to a large variety of different injuries, slow healing response, persistent symptoms, and functional impairments. PHTs are often misdiagnosed or underdiagnosed, leading to delayed treatment and therapy failure. In addition, many athletes are at a high risk of PHT recurrence, a leading cause of prolonged rehabilitation and impaired individual performance. Until now, there have been no clear criteria for the diagnosis and classification of PHT. Tendinopathies can be graded based on their symptoms and onset. Additionally, radiological characteristics exist that describe the severity of tendinopathies. The diagnosis usually includes a battery of pain provocation tests, functional tests, and imaging to ensure a proper classification. Understanding the specific tasks in the pathogenesis and diagnostic process of PHT requires knowledge of functional anatomy, injury pattern and pathophysiological mechanisms as well as examination and imaging techniques. This work provides a structured overview of the pathogenesis and diagnostic work-up of PHT, emphasizing structured examination and imaging to enable a reliable diagnosis and rapid treatment decisions.

Traumatic avulsion of the anterior superior and inferior iliac spines in adult: A case report

Introduction

Avulsion fractures of the anterior superior and inferior iliac spines are rare fractures. They are mostly observed in adolescents during sports accidents, traumatic forms are even more exceptional.

Case report

Here we report a case of simultaneous and homolateral avulsion fractures of both anterior superior and anterior inferior iliac spines in a 35-year-old male adult after a motorcycle accident. Surgical treatment using an open reduction and fixation of the two spines was performed with very good functional outcomes. Surgical management of iliac spine avulsion fractures allows recovery of the subsequent level of sports activity in most cases.

Conclusion

Avulsion fractures of the anterior superior and inferior iliac spines are rare fractures. Surgical management of iliac spine avulsion fractures allows recovery of the subsequent level of sports activity in most cases. Orthopedic treatment is still used for the management of this type of injury, thus comparative studies are needed to refine the criteria for surgery.

Focused Extracorporeal Shock Wave Therapy for Ischial Apophysitis in Young High-Level Gymnasts

OBJECTIVE

We aimed to investigate the effect and safety of extracorporeal shock wave therapy (ESWT) on ischial apophysitis (IA) in young high-level gymnasts. We hypothesized that ESWT would be safe and effective in alleviating pain.

DESIGN

Retrospective case series.

SETTING

Funabashi Orthopedic Hospital.

PATIENTS

The subjects were 18 high-level gymnasts (mean age of 13 years) with a chief complain of chronic buttock pain diagnosed with IA.

INTERVENTIONS

Ten patients received only physiotherapy (PT), whereas 8 received both PT and ESWT to the ischial tuberosity. The basic protocol for ESWT was to use an energy dose of 0.20 mJ/mm 2 or less with 3000 shots per session at 4-week intervals.

MAIN OUTCOME MEASURES

We investigated whether PT and ESWT relieved the pain and allowed the patient to return fully to gymnastics. Based on radiographs at the last observation, we examined whether early closure of the apophyseal line of the ischium and around hip joint on the affected side occurred.

RESULTS

In the PT group, pain was relieved in 2 of 10 patients. In the ESWT group, pain was relieved and full return to gymnastics was possible in all 8 patients. None of the patients showed early closure of the apophyseal line.

CONCLUSIONS

Extracorporeal shock wave therapy can be a safe and effective treatment option for IA in young high-level gymnasts.

Treatment of Acute Bony Avulsion of Ischial Tuberosity With Cortical Screw Fixation

Displaced bony avulsion of the hamstring origin is a rare condition that necessitates surgical treatment. This article describes the surgical treatment of acute apophyseal separation of the ischial tuberosity via open reduction and internal fixation with cortical screws.

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment

BACKGROUND

We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis.

METHODS

We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed.

RESULTS

We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon.

CONCLUSIONS

We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

Scaphoid Cortical Desmoid in a Snowboarder With Persistent Wrist Pain

A 28-year-old man presented to our clinic with persistent left wrist pain. Three months earlier, he had fallen on an outstretched hand while snowboarding. Initial radiographs showed no fractures or dislocations; however, magnetic resonance imaging revealed evidence of a dorsal projection from the scaphoid waist. There was no evidence of a scaphoid wrist fracture, scapholunate ligament disruption, or injury. The final diagnosis was avulsive cortical irregularity or cortical desmoid, which pertains to new bone formation at sites of muscle insertion. The literature has identified cases found in the deltoid, latissimus dorsi, adductor magnus muscles, and gastrocnemius insertion; however, it has never been reported in the scaphoid region. The proposed mechanism, in this case, is the repetitive pull on the radioscaphoid ligament. Avulsive cortical irregularities are benign conditions that mimic malignant conditions radiologically and microscopically. It is therefore important not to mistake this lesion for more worrisome lesions such as osteosarcoma or fibrosarcoma to avoid unnecessary procedures. In the incidental setting, no further imaging is necessary. If the patient presents with pain, atypical radiographical findings, or a suspicion of malignancy, a magnetic resonance image can provide valuable information and confirmation of diagnosis.

Avulsion fracture of the ischial tuberosity treated with the suture bridge technique: a case report

Background

In cases of avulsion fracture of the ischial tuberosity in which the bone fragments are substantially displaced, nonunion may cause pain in the ischial area. Various surgical procedures have been reported, but achieving sufficient fixation strength is difficult.

Case presentation

We treated a 12-year-old male track-and-field athlete with avulsion fracture of the ischial tuberosity by suture anchor fixation using the suture bridge technique. The boy felt pain in the left gluteal area while running. Radiography showed a left avulsion fracture of the ischial tuberosity with approximately 20-mm displacement. Union was not achieved by conservative non-weight-bearing therapy, and muscle weakness persisted; therefore, surgery was performed. A subgluteal approach was taken via a longitudinal incision in the buttocks, and the avulsed fragment was fixed with five biodegradable suture anchors using the suture bridge technique.

Conclusions

Although the majority of avulsion fractures of the ischial tuberosity can be treated conservatively, patients with excessive displacement require surgical treatment. The suture bridge technique provided secure fixation and enabled an early return to sports activities.

Apophysitis of the Ischial Tuberosity: A Case Report

Introduction

Sports-related recurrent injuries (microtrauma and trauma) of the apophyses are common in children and adolescents and could result in specific pathologies. One of them is the apophysitis or apophysiolysis of ischial tuberosity (Valtancoli or Kremser's disease) due to contraction of hamstrings, in sports with sudden accelerations and decelerations.

Case Report

We present the case of a male athlete who complained of pain in the left buttock and difficulty walking after a 3months old reported trauma with pain and hematoma in his left thigh, during a kick with his contralateral leg. Due to a radiographic finding of a suspicious lesion near his left ischial tuberosity, an extensive investigation that included computed tomography, magnetic resonance imaging, bone scintigraphic scan, and blood analysis followed the diagnosis of apophysitis of the ischial tuberosity was determined and the proposed non-surgical treatment had satisfactory results.

Conclusion

The diagnosis of apophysitis of ischial tuberosity is usually delayed but has a good response to the appropriate treatment.

Operative treatment of pelvic apophyseal avulsions in adolescent and young adult athletes: a follow-up study

INTRODUCTION

Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes.

MATERIALS AND METHODS

Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up.

RESULTS

Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes.

CONCLUSIONS

Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery.

LEVEL OF EVIDENCE

Case series, IV.

Surgical treatment of two adolescent athletes with dislocated avulsion fracture of the anterior superior iliac spine (ASIS)

INTRODUCTION

Avulsion fractures of the anterior superior iliac spine are rare. Therefore, evidence-based treatment guidelines do not exist. The therapeutic options are either conservative treatment or surgical intervention. The decision depends on grade of dislocation, age of the patient, and his sportive demands and competitive requirements.

MATERIALS AND METHODS

We present the cases of two young athletes suffering from traumatic avulsion fractures of the anterior superior iliac spine. In both cases, the musculotendinous unit (sartorius muscle and tensor of the fascia lata) remained attached to the loose dislocated fragment. Both patients were treated by means of open reduction with a new surgical technique using suture anchors.

RESULTS

Both patients were pain-free 4 weeks after surgery and had full range of motion. They were able to return to their preoperative sportive activity levels 10 weeks after surgery. No complications were reported at final follow-up 18 months postoperatively.

CONCLUSION

Operative treatment of avulsion fracture of the ASIS using suture anchors shows excellent clinical outcome and a short convalescence period. The patients achieve their preinjury sportive levels within 3 months.

Orthopedic emergencies: a practical emergency department classification (US-VAGON) in pelvic fractures

Trauma is one of the leading causes of death before the age of 40 years and approximately 5% of patients with trauma who require hospital admission have pelvic fractures. This article updates the emergency department classification of pelvic fractures first described in 2000. This information is of practical value to emergency physicians in identifying the potential vascular, genitourinary, gastrointestinal, orthopedic, and neurologic complications and further assists them in the initial evaluation and treatment of patients with pelvic fractures.

Surgical management of traumatic avulsion of the ischial tuberosity in young athletes

OBJECTIVE

Complete traumatic avulsion of the ischial tuberosity in young athletes is rare, and the optimal treatment is unclear. The purpose of this article is to present our experience and the efficacy of surgical repair of avulsions of the ischial tuberosity with bony dislocation of more than 2 cm and to discuss the complex postoperative rehabilitation.

METHODS

Three young athletes sustained complete avulsion of the ischial tuberosity with bony dislocation during different sport activities (long jump, soccer, sprinting). The age at the time of injury ranged from 13.8 to 15 years. All underwent surgical repair with reattachment of the hamstring muscle complex to the origin on the ischium. The time from injury to repair varied from 2 to 22 weeks. All patients underwent a specific postoperative rehabilitation program. Follow-up ranged from 12 to 24 months.

RESULTS

All athletes had improved with surgery and had good subjective and objective functional results. One patient needed operative revision 1 day after primary repair because of suture loosening because of excessive muscle contractions during wake up after general anesthesia. Finally, all returned to their preinjury sport at the same level.

CONCLUSIONS

Young athletes with traumatic avulsion of the ischial tuberosity and dislocation of more than 2 cm benefit from operative repair. Good results were achieved in all cases on the basis of functional recovery and patient satisfaction. Chronic complaints could be avoided, and also return to sport was possible. Surgery under spinal anesthesia is recommended.

Ischial apophyseal avulsions: proximal hamstring repair with bony fragment excision

BACKGROUND

Avulsion injury of the hamstring muscles from their origin on the ischium is an uncommon injury. In persons aged 14 to 25 years, such an avulsion may include detachment of an epiphyseal fragment at the growth plate of the ischial apophysis. The literature suggests that surgery is not necessary unless there is a large displacement of the fragment. The objective of this report is to present evidence that treatment planning should be based on symptoms, regardless of displacement.

METHODS

Between July 1998 and July 2002, 3 consecutive patients with avulsion of the immature ischial apophysis were evaluated by the senior author. In each case the bony fragment was excised and the hamstrings were reattached to the ischium with suture anchors. All patients were assessed postoperatively by biodex strength testing.

RESULTS

The average age of the patients was 15 years and the average time to repair was 7 months from the time of injury. The average retraction was 3.7 cm. The average follow-up period was 78 months. The average strength was 86% and the average power was 100% compared with the contralateral side at the final follow-up. In all 3 cases pain was relieved, and with adequate rehabilitation normal strength was regained and the subjects returned to sport. There was one complication involving an activity-related peroneal nerve palsy. This was treated by neurolysis with good functional return.

CONCLUSIONS

The 3 cases presented here suggest that treatment should be planned on the basis of pain and disability rather than pathology, and that surgical treatment can effectively address a chronic condition. Each case requires an individualized treatment plan and should include a consideration of the patient's functional goals.

Orthopaedic magnetic resonance imaging challenge: apophyseal avulsions at the pelvis

Apophyseal avulsion injuries of the hip and pelvis are frequent athletic injuries in children and adolescents, most commonly associated with explosive movement or sprinting. This article details typically encountered apophyseal injuries and their appearance on magnetic resonance imaging.

Posterior thigh compartment syndrome as a result of a basketball injury

Acute compartment syndrome of the thigh is a serious although rare occurrence that was sparsely documented in the orthopedic literature until Schwartz et al reported on a series of 21 cases. Although classically associated with high-energy femur fracture, thigh contusion, or the use of military anti-shock trousers, compartment syndrome of the thigh has recently been diagnosed in seemingly low-energy injuries. A complete hamstring avulsion from its ischial origin during routine ambulation and rupture of the quadriceps tendon after a low-energy fall have been shown to result in compartment syndrome. In light of the potential medicolegal ramifications surrounding the diagnosis of compartment syndrome, emergency room consultations to rule out compartment syndrome are on the rise. Specifically, the time to fasciotomy was found to be linearly related to indemnity payment, and a fasciotomy performed within 8 hours was uniformly associated with a successful defense. This article describes a case of a 29-year-old healthy man who developed posterior thigh compartment syndrome as a result of an intrasubstance tear of the biceps femoris muscle sustained while attempting a lay-up during a recreational basketball game. His posterior thigh compartment pressure measured 70 mm Hg and he required emergent posterior thigh compartment fasciotomy.

Avulsion of the proximal hamstring origin

BACKGROUND

The torn hamstring is a common athletic injury. The purpose of the present study was to review the clinical presentation of this injury, the diagnostic imaging findings, the surgical technique of reattachment, and the likely clinical outcome of surgery for the treatment of avulsion of the proximal hamstring origin.

METHODS

Seventy-two consecutive reconstructions in seventy-one patients with avulsion of the proximal hamstring origin were performed at a single center. The mean age at the time of the operation was 40.2 years. The mean duration of follow-up was twenty-four months, and all patients with a minimum duration of follow-up of six months were included. There were no exclusions. Patients were independently reviewed, and the mean postoperative isotonic hamstring strength was compared with that on the uninjured side.

RESULTS

Waterskiing was the most frequent cause of injury (twenty-one cases). The mean time between the injury and the operation was twelve months. The most common pathological finding was a complete avulsion of the proximal hamstring origin (sixty-three cases; 87.5%), with a mean retraction of 7 cm (range, 0 to 20 cm). The mean postoperative isotonic hamstring strength measured 84% (range, 43% to 122%) and the mean postoperative hamstring endurance measured 89% (range, 26% to 161%) when compared with the values on the contralateral side.

CONCLUSIONS

It is important to distinguish proximal hamstring origin avulsions (for which we recommend early surgical repair) from the majority of hamstring muscle injuries (which respond well to nonoperative treatment). The present study suggests that, in cases of complete avulsion with hamstring retraction, a delay in surgical repair renders the repair more technically challenging, may increase the likelihood of sciatic nerve involvement, increases the need for postoperative bracing, and reduces postoperative outcome in terms of hamstring strength and endurance. Once the nature of the injury has been established, the surgical treatment of hamstring origin avulsions has predictable and satisfactory results.

Complete proximal hamstring avulsions: a series of 41 patients with operative treatment

BACKGROUND

Complete proximal hamstring avulsions can cause considerable morbidity and are often associated with significant functional loss.

HYPOTHESIS

Early surgical treatment leads to better results than does surgery in the chronic phase.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-one patients (21 men and 20 women) with a complete proximal hamstring avulsion were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result of the surgical treatment.

RESULTS

The mean follow-up was 37 months (range, 12-72 months). Nineteen patients were rated as having an excellent result and 10 patients a good result. In 5 patients, the result was classified as moderate and in 7 patients poor. In the patients with an excellent or good result, the delay from the injury to surgery averaged 2.4 months, whereas in patients with a moderate or poor result, the delay averaged 11.7 months. The difference was statistically significant (P < .001).

CONCLUSION

Excellent or good results can often be expected with surgery, and considerable improvement of symptoms may be achieved even in chronic cases. According to the results, early operative treatment in complete proximal avulsions of the hamstring muscles gives better results than does late surgery and is therefore recommended.

Sports-related acute and chronic avulsion injuries in children and adolescents with special emphasis on tennis

Acute and chronic sports-related muscle and tendon injuries are not infrequent in youngsters. In particular, the physis is prone to trauma as it constitutes the weakest part of the immature skeleton. The type of sports activity determines the location of the lesion. Most commonly, apophyses of the hip and pelvis are subject to avulsion. The purpose of this paper is to give a short overview of the pathogenesis, location, prevalence and imaging characteristics of acute and chronic avulsion injuries in the immature skeleton, with special emphasis on tennis-related injuries. Tennis-related injuries particularly involve apophyses of the ischial tuberosity, the anterior inferior or superior iliac spine and the iliac crest.

Diagnosis and management of posttraumatic piriformis syndrome: a case study

OBJECTIVE

The aim of this study is to describe the clinical management of a young male patient with sciatica symptoms that developed after an avulsion of the ischial tuberosity. This is a rare injury, but complications may occur.

CLINICAL FEATURE

A 19-year-old patient developed sciatica 6 months after a football injury. The patient described his symptoms as a shooting pain from the buttock to the lateral part of the foot, along the back of his thigh and calf, sometimes accompanied by paresthesia. Physical examination showed restricted hip range of motion and a positive Bonnet's test. X-ray analysis revealed a bony overgrowth of the right ischial tuberosity.

INTERVENTION AND OUTCOME

A treatment plan was designed to decrease the pain level, increase sacroiliac and lumbar joint mobility, and augment muscular extensibility. The patient received 20 treatments over a period of approximately 3 months. Complete recovery was observed 5 months later.

CONCLUSION

Although many differential diagnoses were contemplated, it is most likely that changes in muscular tension and gait pattern, resulting from the ischial tuberosity avulsion, contributed to overuse of the piriformis muscle leading to a piriformis syndrome.

Partial rupture of the distal semitendinosus tendon treated by tenotomy--a previously undescribed entity

Hamstring strains are common. They are usually treated conservatively, with good results. Thus far, the only subset of patients who have been considered for surgery are those with complete avulsions of the attachments. We describe a new clinical entity: partial rupture of the distal semitendinosus tendon; which has failed to settle with conservative treatment; and has been successfully treated by tenotomy.

[Complete rupture of the proximal semimembranosus tendon. Minimally invasive surgical repair by use of a suture anchor in a rare but often underestimated injury]

Complete rupture of the proximal semimembranosus tendon is a rare injury associated with significant functional loss. Conservative treatment has proven inadequate in returning patients to their previous activity level. However, diagnosis is often delayed because of underestimation of the severity of this injury. Satisfactory results can be achieved with both early and late surgical tendon repair in the majority of cases. However, repair delayed by more than 4 weeks post trauma usually requires extended mobilisation of the injured muscle and neurolysis of the sciatic nerve. Therefore, we recommend surgical repair as early as possible. We report on the successful minimally invasive surgical repair of a complete rupture of the proximal semimembranosus tendon by use of a suture anchor 18 days after injury.

Apophysitis of the ischial tuberosity mimicking a neoplasm on magnetic resonance imaging

We present multimodality imaging features of an ischial tuberosity apophysitis in a 13-year-old boy who was an active baseball pitcher. Roentgenography of the pelvis and computed tomography showed mild irregularity in the inferior margin of the left ischial tuberosity. T1-weighted MRI showed a wide area with low signal intensity in the left ischial body; T2-weighted fat-suppression images showed areas with markedly high signal intensity in the ischial apophysis and body and the surrounding periosteum; contrast-enhanced T1-weighted fat-suppression MRI showed that the ischial body, surrounding periosteum, and origin of the hamstring muscles strongly enhanced; technetium-99m scintigraphic scans showed increased isotope uptake in the entire ischial body. Histological specimens obtained from the bone showed increased osteoblastic activity, edema, and proliferation of benign spindle cells and small vessels in the bone marrow spaces. In the present case, because MR imaging demonstrated extensive signal abnormalities involving the apophysis, periosteum, and intramedullary portion of bone, a neoplasm could not be excluded, and a biopsy was undertaken.

MR imaging of sports-related hip disorders

Hip arthroscopy is being used increasingly for the diagnosis and treatment of hip disorders. MR imaging performed with appropriate technical considerations may aid not only in preoperative planning but in the appropriate selection of patients, which tends to lead to better postoperative results. Although the painful hip is imaged most commonly by radiography, MR imaging is considered the next imaging test of choice for evaluation of most common hip abnormalities in athletes, including labral injuries, ligament injuries, osteochondral injuries, fractures, bursitis, and musculotendinous injuries. MR arthrography can be a particularly useful technique for dedicated assessment of hip joint internal derangements.

Imaging of sports-related muscle injuries

Muscle derangements in athletes have a wide variety of causes, treatments, and prognoses. Given that the cause and severity of sports-related injuries may be difficult to determine clinically in some cases, MR imaging is utilized increasingly to evaluate muscle injuries in athletes. After reviewing useful MR imaging techniques, this article focuses on MR imaging of the most common causes of muscle pain and disability in athletes, including myotendinous strain, delayed onset muscle soreness, muscle contusion, myositis ossificans, muscle laceration, muscle herniation, and compartment syndrome. The differential diagnosis of various signal intensity abnormalities in muscle also is reviewed.

Intra-orbital foreign body: an unusual route of entry

Images

Just a pulled hamstring?

Images

Tardy sciatic nerve palsy following apophyseal avulsion fracture of the ischial tuberosity. Case report

This 4 1-year-old man presented with a 2-year history of symptoms and signs of sciatic nerve compression. Imaging studies revealed a large ossified fragment within the biceps muscle of the thigh abutting the sciatic nerve at the level of the lesser trochanter. The bony fragment resulted from an unrecognized apophyseal avulsion fracture of the ischial tuberosity, which the patient had sustained while sprinting 27 years earlier. External neurolysis of the sciatic nerve and excision of the mass led to a successful outcome.

Rectus abdominis rhabdomyolysis after sit ups: unexpected detection by bone scan

Uptake of technetium-99m methylene diphosphonate by the rectus abdominis muscle was unexpectedly found in a 29 year old man who had started to perform 30 to 40 sit ups a day for five days before the bone scan. After a week of rest, serum creatine kinase activity was still abnormal but muscle uptake of technetium-99m methylene diphosphonate had ceased. This specific muscle injury after short term sit ups as well as the resolution of the phenomenon within a week are of interest.

Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation

A case is reported of an adolescent sprinter who was chronically disabled by pain after non-operative management for an acute hamstring injury. He had sustained an avulsion fracture of the ischial apophysis with displacement of 2.5 cm. Avulsion fractures of the ischial apophysis with displacement of 2 cm or more are unusual, but they frequently result in a symptomatic non-union, and early diagnosis, open reduction, and internal fixation is to be encouraged.

Iatrogenic acute hyponatraemia in a college athlete

Hyponatraemia is one of the most common electrolyte abnormalities, leading to significant morbidity and mortality. In the most basic sense, hyponatraemia can be due to sodium loss or fluid excess. The extracellular fluid status is used to clinically divide hyponatraemia into three categories to help to determine both the cause and treatment required. Hyponatraemic patients can be categorised on the basis of their fluid status as hypovolaemic, euvolaemic, or hypervolaemic. Another distinction to make in evaluating hyponatraemia is whether the onset was acute or chronic in nature. The case presented here is iatrogenic acute hypervolaemic hyponatraemia in a college athlete. The patient presented in respiratory distress with an altered mental status after the administration of hypotonic fluids for treatment of muscle cramps. Treatment included intubation, water restriction, and furosemide, to which he responded favourably. Hyponatraemia should be in the differential diagnosis for patients presenting after intravenous fluid administration.

Hamstring strains in athletes: diagnosis and treatment

Hamstring strains are among the most common injuries (and reinjuries) in athletes. Studies combining electromyography with gait analysis have elucidated the timing of activity of the three muscles of the hamstring group; they function during the early-stance phase for knee support, during the late-stance phase for propulsion, and during midswing to control the momentum of the leg. Muscle injury, whether partial or complete, occurs at the myotendinous junction, where force is concentrated. The healing response begins with inflammation, associated edema, and localized hemorrhage. After an initial period of reduced tension, the healing muscle regains strength rapidly as long as reinjury does not occur. Although the use of anti-inflammatory medication is a keystone of treatment, a certain degree of inflammation is necessary for removing necrotic muscle fibers and rescaffolding to allow optimal recovery. The protocol of rest, ice, compression, and elevation is still the preferred first-aid approach. After a brief period of immobilization (usually less than 1 week for even the most severe strain), mobilization is begun to properly align the regenerating muscle fibers and limit the extent of connective tissue fibrosis. Concurrent pain-free stretching and strengthening exercises (beginning with isometrics and progressing to isotonics and isokinetics) are essential to regain flexibility and prevent further injury and inflammation. Readiness for return to competition can be assessed by isokinetic testing to confirm that muscle-strength imbalances have been corrected, the hamstring-quadriceps ratio is 50% to 60%, and the strength of the injured leg has been restored to within 10% of that of the unaffected leg. The only indication for surgery is a complete rupture at or near the origin from the ischial tuberosity or distally at its insertion (either soft-tissue avulsion with a large defect or bone avulsion with displacement by 2 cm).

The evaluation of pelvic injury in the female athlete

The differential diagnosis of pelvic pain and possible injury in the female athlete is quite broad and must include gastrointestinal and genitourinary aetiologies, as well as musculoskeletal injuries. These considerations reflect the anatomical complexity of the female pelvis. The pelvic bones house the lower gastrointestinal and genitourinary viscera and transmit stress from the lower extremities to the upper body. The innervation of the pelvic structures also complicates evaluation and diagnosis when somatic and visceral afferent information affects the athlete's interpretation of pain. An algorithmic approach can facilitate evaluation and rehabilitation of pelvic injuries in the female athlete in the contest of previously described mechanisms of musculoskeletal injury.

Rupture of the ischial origin of the hamstring muscles

We treated eight patients who had complete rupture of the ischial origin of the hamstring muscles. This uncommon injury results from a sudden forceful flexion of the hip joint when the knee is extended and the hamstring muscles powerfully contracted. The injuries occurred during athletic exercise in six men and two women who had a mean age of 40 years (range, 22 to 53). With prompt diagnosis and surgery the final functional results in these patients were good. If the diagnosis is delayed, it is not possible to accomplish a primary suture of the hamstring muscles to the ischial bone. Consequently, another surgical procedure will need to be performed to restore function. Unlike cases of bony avulsion of the ischial apophysis in growing children, acute complete rupture of the proximal hamstring muscles origin in adults should be treated with prompt surgery.