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By Q. Gambal. Kentucky Christian College.

MUSCLE STRAIN INJURY NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Animal studies demonstrate that nonsteroidal anti- Muscle strain is the most common injury sustained in inflammatory drugs (NSAIDs) reduce the inflamma- sports order 5mg eldepryl free shipping medicine 6 clinic. This type of muscle injury can range from tory response associated with muscle strain injury but CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 57 may delay complete healing of the muscle tissue PATHOPHYSIOLOGY (Nikolaou et al cheap 5 mg eldepryl overnight delivery symptoms ketosis, 1987; Obremsky et al, 1994). The High tension over a small cross-sectional area (seen in indication for the use of these drugs in muscle strain eccentric muscular contraction) results in cytoskeletal injury is unclear. This stimulates nociceptors within the Muscle strengthening is an important factor in the muscle resulting in the production of pain recovery of injured muscle and the prevention of rein- (Armstrong, 1984). This is most likely owing to exer- athlete with a muscle strain injury should not return to cise-induced production of endorphins or other alter- competition until complete muscle strength and con- ations in neural pathways (Armstrong, 1984). There is MUSCLE STRETCHING AND WARM-UP still continued muscle tissue damage with repetitive Muscle is viscoelastic material, and passive stretching exercise but to a progressively lesser extent. The dis- can reduce stress for a given muscle length (Taylor comfort associated with this tissue damage, however, et al, 1990). These studies suggest the similar effects in an exercise-induced muscle injury importance of stretching and warm-up in the preven- model as they do in other muscle injury models. Additional studies are needed before MUSCLE CONTUSION INJURY definitive conclusions can be made. These injuries most frequently DELAYED MUSCLE SORENESS involve the lower extremity muscle groups, such as the quadriceps, gastrocnemius, or anterior muscles of Delayed muscle soreness is defined as skeletal muscle the lower leg (Best, 1997). Loss of muscle strength, loss of joint range of lowed by persistent swelling and warmth, a firm mass, motion, tenderness, and elevated muscle enzymes are and continued loss of motion. Immobilization Versus Mobilization The cramp begins as a fasciculation from a single of Contused Muscle focus within the muscle and then spreads throughout a. Electric evidence suggests that the source faster healing without further tissue damage while of the abnormal activity is coming from the nerve prolonged immobilization results in muscle atro- within the muscle (Best, 1997). In addition, early mobilization results in Hypokalemia and hypocalcemia have also been impli- increased tensile stiffness of contused muscle and cated (Best, 1997). Military Academy Athletes with repeated episodes of cramping should demonstrate that a brief period of immobilization undergo evaluation for electrolyte or endocrine disor- (24–48 h) with the involved muscle in a lengthened ders. TENDON INJURY AND REPAIR Tendon injuries are secondary to direct trauma (lacer- PHARMACOLOGIC TREATMENT ations) or tensile overload. The etiology of this abnor- mal bone formation is unclear but is related to the Tendons consist primarily of type I collagen fibrils, a degree of muscle injury, the region injured (quadri- proteoglycan matrix, and relatively few fibroblasts. Type I collagen consists of two alpha-I polypeptide muscle is subjected to trauma (Beiner and Jokl, 2001). These three chains Clinically there is usually tenderness, swelling, loss of are organized into a triple helix stabilized by motion, persistent warmth, and a firm mass in the area hydrogen and covalent bonds (Wood et al, 2000). The collagen triple helix molecules are aligned in ographically evident by 4 weeks and resembles a quarter-staggered arrangement to make up the mature bone by 6 months (Best, 1997). Surgical resection, if oppositely charged amino acids and contributes to necessary, should be delayed until the osteoblastic the tendon’s strength. The microfibrils are then arranged in a parallel, well ordered, and densely packed fashion. MUSCLE CRAMPS The microfibrils are combined with a proteoglycan and water matrix to form collagen fascicles. The Muscle cramps commonly affect both athletes and tendon consists of groupings of these fascicles sur- nonathletes. The gastrocnemius muscle and ham- rounded by connective tissue that contains blood strings are most commonly involved but cramping can vessels, nerves, and lymphatics (Wood et al, 2000). CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 59 The insertion of tendons onto bone is usually via four decreased flexibility, and joint laxity), age, gender, zones: tendon, fibrocartilage, mineralized fibrocarti- weight, and predisposing diseases (Almekinders, lage, and bone. Synovial fluid within the errors (over training, rapid progression, fatigue, run- sheath assists in tendon gliding. Tendons that are not ning surface, and poor technique), and equipment enclosed in a sheath (Achilles tendon) are covered by problems (footwear, racquets, and seat height) a paratenon. Tendons sus- PATHOPHYSIOLOGY taining compressive loads exhibit increased proteo- Repetitive load on a tendon that results in 4–8% strain glycan levels, larger proteoglycan molecules, and causes microscopic tendon fiber damage.

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Retroverted hip Astonishingly discount eldepryl 5mg without a prescription symptoms 4 weeks, dislocated hips in MMC patients hard- 3 A pronounced and fixed external rotation can cause ret- ly show any significant restriction of movement order 5mg eldepryl free shipping medicine dictionary prescription drugs. If functional impairment is present this can be we have never had to implement therapeutic measures in corrected by a femoral osteotomy. By contrast, we have observed that centered joints are much more frequently associ- Hip dislocation ated with functionally relevant restriction of movement. The dislocation of the hip in myelomeningocele results Reconstruction therefore involves the risk of producing a from the combination of diminished sensation around worse scenario than with the dislocated hip. The patients want to be able to take part in the same activities Surgical approach enjoyed by children of the same age without neurological As with spastic locomotor disorders, the reconstruction disorders. They stress their joints by adopting extreme of the hip involves the correction of the deformities of the positions (for example they really throw their legs around acetabulum and femur and open reduction. An iliopsoas during transfer activities) and thereby constantly over- transfer is not performed for lateral and dorsal disloca- stretch the joints. With ventral dislocations, the transferred iliopsoas there is no pain reaction to stimulate the already weak- helps keep the head in the acetabulum. However, an ilio- ened, or even absent, dynamic joint stabilizers into action. Again as with spastic locomotor disorders, the post- A neurogenic hip dislocation can even occur inside operative management involves a hip spica, followed by the uterus. One or both hips are then dislocated at birth, nocturnal positioning orthoses. The reconstruction of and the sonographic finding is compatible with that in the hip can be repeated if necessary. A patients have required recentering of the hip up to 3 dislocation groove may even be detected at this stage times. It is advisable, therefore, to wait until the skeleton during arthrography. Dislocations are common in cases is adequately developed before performing the first pro- of flaccid paresis (up to 80%), while the frequency cedure to correct the deformities. Recentering on its own, in myelomeningocele depends on the neurological level without correction of the acetabulum, has little prospect involved: L1/L2: 30%, L3: 36%, L4: 22%, L5: 7%, S 1: of long-term success. Other authors have reported higher rates: L1/L2: 50%, The main complication, apart from infections and the L3 and L4: 75% [21, 41]. In contrast with other underlying neurological disor- Treatment ders, this is relatively common with myelomeningoceles. Conservative treatment We have observed isolated cases although the ossification Conservative treatment offers almost no prospect of suc- was never functionally relevant. The alternative to hip re- cess since it cannot ensure dynamic stabilization of the construction is to leave the hip dislocation and adapt the hip. This involves stabilization of the hip with an orthosis and, for a unilateral dislocation, offset-! Treatment with the Pavlik harness is contraindicated ting the leg-length discrepancy. In muscular dystrophies and spinal muscular atrophies, muscle power is progressively lost. The patients therefore Dislocations at 3 years of age or older: While the inherent require hyperextension at the hip in order to be able to ability to walk does not correlate with the centering of the stand passively in the ligamentous apparatus. Flexion hips [16, 20, 44], patients with successfully operated hips contractures are disabling at this stage as they can lead to show functional improvement. Unilateral hip disloca- the premature loss of the ability to walk and stand. These tions can lead to a pelvic obliquity requiring treatment must be corrected, concurrently with other contractures, [13, 20]. Functional deformities in muscular dystrophies Deformity Functional benefit Functional drawbacks Treatment Abduction/ – Loss of ability to walk and stand Campbell operation external rotation Flexion – Flexion contracture Physical therapy ⊡ Table 3. Structural deformities in muscular dystrophies Deformity Functional benefit Functional drawbacks Treatment Flexion contracture – Crouching position (loss of ability Lengthening of hip flexors to walk and stand), hyperlordosis Hip dislocation – Instability, restricted mobility, Head resection, Schanz osteotomy pelvic obliquity padding.

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This tests the extensor carpi radialis longus discount eldepryl 5mg without a prescription medicine 1975 lyrics, extensor carpi radialis brevis trusted 5mg eldepryl symptoms jet lag, and extensor carpi ulnaris mus- Photo 7. This tests the patient’s flexor carpi radialis muscle, which is innervated by the median nerve (C7); and the flexor carpi ulnaris muscle, which is inner- vated by the ulnar nerve (C8–T1). Despite the multiple nerve involve- ment, wrist flexion is predominately mediated by C7. Then have the patient abduct and adduct their fingers against resist- ance. Test the integrity of the patient’s anterior interosseous nerve by having the patient make the “OK” sign (Photo 10). If the patient has an anterior interosseous neuropathy, the patient will be unable to make the “OK” sign (Photo 11). Table 1 lists the major movements of the hand and wrist, along with the involved muscles and their innervation. The C6 dermatome is tested over the dorsal aspect of the first proximal phalanx; the C7 der- matome is tested over the dorsal aspect of the third proximal phalanx; and the C8 dermatome is tested over the dorsal aspect of the fifth proximal phalanx. Test for the radial nerve sensory distribution in the 60 Musculoskeletal Diagnosis Photo 10. Plan Having completed your history and physical examination, you have a good idea of what is wrong with your patient’s wrist and hand. Here is what to do next: Suspected carpal tunnel syndrome Additional diagnostic evaluation: Electrodiagnostic studies should be performed if the diagnosis is in doubt or if surgery is considered. Treatment: Conservative care, including activity modification and splinting in the neutral position, are the cornerstones of first-line treat- ment. Tendon gliding exercises and corticosteroid and anesthetic injec- Wrist and Hand Pain 61 Table 1 Primary Muscles and Innervation for Wrist and Finger Movement Major muscle Primary muscles Primary nerve movement involved innervation Wrist extension 1. In patients with refractory symptoms, surgical release is very effective. Treatment: Often the only treatment necessary is reassurance and avoidance of the offending activity. Caution must be exer- cised with corticosteroid injections because subcutaneous injections may result in skin hypopigmentation. After one or two corticosteroid and anesthetic injections into the sheath, 90 to 95% of patients report sat- 62 Musculoskeletal Diagnosis Photo 12. X-rays, including antero- Wrist and Hand Pain 63 posterior (AP) and lateral views, should be obtained. Treatment: Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, heat, and physical therapy are all first- line treatments. Treatment: A combination of splinting and corticosteroid and anes- thetic injections is effective in more than 95% of patients. Treatment: First-line treatment includes rest, NSAIDs, splinting, and physical therapy. Surgical release may be necessary in patients who do not respond to more conservative measures. Treatment: If the ganglion cyst is asymptomatic, then simple reas- surance may be all that is necessary. If the cyst becomes symptomatic or if it is aesthetically unacceptable to the patient, aspiration or surgi- cal excision may be performed. Additional diagnostic evaluation: X-rays, including AP, lateral, ulnar deviation, and oblique views (depending on the fracture sus- pected), should be obtained. Computed tomography and/or magnetic resonance imaging are also often necessary. Special consideration: Patients with snuffbox tenderness but nega- tive radiographs should be treated with 2 weeks of a thumb spica fol- lowed by repeat X-rays to rule out scaphoid fracture because of the risk of avascular necrosis. As in the cervical spine, because the diagnostic and therapeutic approach to radicular and nociceptive pain is very different, it is important to dis- tinguish them during the history and physical examination. Understanding the language of low back pain is as important as under- standing the language of neck pain. You may wish to briefly review the principles and terminologies discussed at the beginning of Chapter 1. In the lumbosacral spine, radicular symptoms are caused by an intervertebral disc bulge, protrusion, extrusion, or sequestration that compresses and inflames a nerve root in approximately 98% of all cases. Other causes of radicular symptoms emanating from the lumbo- sacral spine include disc osteophytes, a buckled ligamentum flavum, zygapophysial (Z)-joint hypertrophy, and other causes of lumbosacral spinal stenosis.

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