Shoe inserts and PFS

1. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

2. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: A randomised clinical trial
3. http://d-med.com/orthaheel/Knee_Pain.html#

• secrets of medical success: this was a great set of advice that may seem obvious.
• Slower recovery after 2-incision surgery

Hyperdense bones can be the result of

• osteopetrosis
  
• hypervitaminosis D,
  
• hypoparathyroidism,
  
• myelofibrosis,
  
• Paget disease,
  
• lead toxicity,
  
• diffuse skeletal metastasis of breast or prostate cancer,
  
• pseudohypoparathyroidism,
  
• fluoride toxicity,
  
• beryllium toxicity,
  
• sickle cell disease,
  
• leukemia.
  
• 1 case report describes abnormal bone modeling and increased bone density, with histologic features of drug-induced osteopetrosis, in a 12-year-old boy treated with bisphosphonates.

Completely unrelated to medicine are
hulk vs wolverine
chevelle
folliculitis (eeewwww)

Uhthoff's phenomenon

Thanks to dr. patel for pointing this out.

C7 to Flexor Carpi Ulnaris?

According to Dumitru, there are two "communicating branches" in the majority of brachial plexi. One of them is a connection between the medial and lateral pectoral nerves. The second is referred to as "lateral root of the ulnar nerve" which is present in 43 to 92% of brachial plexus dissections. This suggests that it is not an anomaly but a major portion of the brachial plexus ignored in standard descriptions. This arises from the lateral cord, communicates with the medial branch of the medial cord to the median nerve, and the continuation of this connection to the ulnar nerve itself. This is an explanation for the contribution from C7 to the ulnar.

NESS L300

Effects of a New Radio Frequency–Controlled Neuroprosthesis on Gait Symmetry and Rhythmicity in Patients with Chronic Hemiparesis

Claimed to have improved gait rhythm and symmetry over 5 years after the stroke. Could be effective for our patients?

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder

"Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation."

Bisphosphonate Therapy Linked to Risk for Severe Musculoskeletal Pain

January 8, 2008 — Temporary or permanent discontinuation of bisphosphonate therapy should be considered in patients who present with severe musculoskeletal pain, the US Food and Drug Administration (FDA) warned healthcare professionals yesterday. Overlooking bisphosphonate therapy as a causal factor may delay diagnosis, thereby prolonging pain and/or impairment and the use of analgesics. In contrast with the acute-phase response that sometimes accompanies initial exposure to bisphosphonate therapy, some patients experience severe and sometimes incapacitating bone, joint, and/or muscle pain that begins months or years later.

Autoimmune effects of medications.

It's common medical knowledge that autoantibodies are associated with the use of certain medications. We memorize the small list of board relevant meds that cause lupus-like symptoms. More have been reported and they're common: minocycline, tnf alpha biologics, aromatase inhibitors, sulfasalazine and statins.

Although many patients develop autoantibodies, only a minority develop autoimmune-like diseases. The development of autoantibodies alone is not sufficient reason to discontinue the medication. Patients treated with medications such as tumor necrosis factor inhibitors and minocycline who develop an apparent 'flare' of the disease should be evaluated for the possibility of drug-related lupus. Rechallenge with minocycline might be useful in order to confirm a diagnosis of minocyclinerelated lupus. Clinical trial data indicate that patients who receive aromatase inhibitors can develop arthralgias and arthritis, although no data regarding the development of autoantibodies have been reported. Patients with pre-existing thyroid autoantibodies are more likely to develop autoimmune thyroid disease when treated with interferon-α than patients with no pre-existing condition.

Memories of Jim (Off topic)

It's now 1:30 a.m. on January 21, 2008. I received two phone calls from my buddy Gary. I missed both of them. Maybe it was fortunate. The voicemail said that Jim McLean had passed this weekend during the snowboarding accident in Colorado. I saw that Jim's brother Justin had also left a message so I called him back. I actually started to get just a slight bit of emotion coming through my voice. I told him that I would be available at any time to help the family and to pass on the information to his residents and programs.

Jim and brother Justin. I came upstairs and replayed Gary's voicemail on speakerphone. Monica began sobbing loudly. I comforted her and then walked away so that I could talk Gary and clear my head. Gary sounded a little lost in his voice. It seemed he had all this emotion and intention but no clear outlet with which to produce something. We spoke in tones and inflections as if nothing had happened. But the content was clearly corrupted by the news we had just taken in. Gary had taken care of calling all of Jim’s co-residents etc. At this point he was trying to figure out how to pay tribute to Jim McLean as an outlet. I figured I would try to do the same.

Jim's residency-class picture. I first was aware of Jim during residency when he was approaching the insurance reps during our Kessler resident lunch hour. I heard him say that he lives in the same town as me and in no time we became study partners. He had become habituated to studying at Starbucks so I honored his request the first time. He was determined to read the Braddom textbook from cover to cover within his first year. He was working on understanding/memorizing the anatomy of the limbs. I was studying an article by Asa Wilbourne on radiculopathy. In order to understand something I have to be able to teach it, and he was soaking up every bit of what I was telling him. I think he was sold on the idea of studying with me and therefore respected my wishes to try studying at my parents house.

What really sealed the deal for our studying there, were the endless bountiful meals offered by my parents. Even they were impressed with the frequency and amplitude of portions ingested by Jim with a huge grin on his face. My parents used to love feeding him. It seemed to all of us that his gut was an inexhaustible infinite receptacle of food. His classmate Gary, was known to be a competitive eater in his pre-medical life. It was widely accepted that everyone should get their food from the buffet table before Gary and Jim had a chance to deplete the resources. (I suppose he had to eat like a champ in order to do the training of a champ.)

Whatever we studied that first day in my basement, required that I printed out my notes. Jim found this to be a bit excessive and he did not hesitate to tell me so. I showed him the process that I went through and he was doubly sure that this was not something he was going to explore. To him, it just did not seem to justify the time spent. The next day he showed me what he had studied in a handout format. He had completely co-opted my style and was taking it to the next step. He went handout crazy after that and served as the source of positive competitive spirit for me.

He took in all of my advice but was very careful not to let any of the negative aspects of it slow him down. I remember being amazed at how diplomatically he could get me to do things without my knowledge of it at the time for example, it is well known that I am physically quite lazy. But somehow he got me to help him move out of his apartment with two other people who clearly were not averse to physical activity. I still can’t believe that happened in retrospect.

Jim and Sally at an event (photo by Casey ODonnell).

I remember one day when we were studying in my parents basement and he sat down at my drum kit. He started to play something that caught my attention. He had played percussion in his middle school band. I immediately saw the potential rock drummer in him. By treating rock drumming as a math problem, I was able to teach him enough to play a few songs at the program's graduation party. He attacked this task with the same intensity, drive, and comprehensiveness that he did everything else. No one could believe that he was holding his own on a stage with a bunch of musicians with years of experience.

Jim drumming at Kessler graduation (photo by Jenfu Cheng)

Jim was an excellent multitasker. He simultaneously participated in a number of potentially publishable research projects, trained for the Ironman competition, set up the Ironman as a fundraiser for children, worked on a curriculum to teach electrodiagnostic evaluation to residents, tutored medical students and still made the time to talk on the phone with friends, have a relaxed dinner with my family, and keep his dating life active. He somehow did all of this without spreading himself too thin. His reputation was so ingrained among the people who knew him that it was not uncommon to hear people say "Look, I'm no Jim McLean" when trying to imply that a specific task or number of tasks seemed potentially overwhelming.

I designed this cover for the last of many manuals/study guides created by Jim.
It's hard to explain to people outside our field what it means to be prolific
in this way. Most of us don't even read a full manual, let alone write more than one.

I remember one day that he rang my doorbell and was soaking wet. I remarked that I didn't realize how torrentially it must've been raining. He corrected me, told me it was beautiful outside, the dripping wetness was actually his perspiration after riding his bike from four towns over. He then laid down on my new microfiber sofa which now has a Jim McLean body sized discoloration where he had lain. J

Jim Mclean displaying an impressive hematoma after a biking accident
(ie sliding at god knows how many mph on a metal grate bridge).

He was truly fearless. To call him a gentle soul would be a mischaracterization. He had a gentle aura which contrasted his aggressive physique and assertive ambition. We had very different backgrounds and aesthetics yet he was able to see beyond those things when dealing with me. In that way I was able to gain a strong friendship in my life.

Jim and I were very close for two years. This is the kind of closeness that one rarely finds in adulthood... it's the kind that requires many hours a week spent in the same room, with the same goals, and the same urgency to achieve them. People knew this. One friend joked when he saw our new house "which of these is Jim's bedroom?" I enjoy the guilty vice of taunting my friends to the point of aggravation. Jim never let this get to him. There was only one time that I was really able to get under his skin but I can't count it as a victory because we later found out that he was severely hypoglycemic at that moment.

Happy smiling Jim AFTER the hypoglycemia was sated by
chocolatey goodness (yes, those are girlscouts cookies)
BEFORE it he was going to unleash on me
the wrath of his front headlock!

Right now I'm a little numb. It hit me very very hard when I heard of his passing but seconds later it was gone. His life was already packed with twice the experiences and accomplishments at the end of most people's lives. Despite this, there was so much more that Jim had left to give to the world. This is the definition of tragic. I'm really going to miss him.

2 noteworthy articles:

• Daily Record.com
  
• Video from Fox
  

Other Links to the Story:

• Link to first Local Newspaper Announcement in Rocky Mountain News
• Denverpost.com
• Kansas City.com
• Summit Daily
  
• Kansas.com
• NJ.com
• Denverpost.com
• KJCT8.com
• 9news.com
• thedenverchannel.com
• gazette.com
• vaildaily.com
• bnd.com
• gazetteoutthere.blogspot.com
• kake.com
• hdnews.net
• msnbc.msn.com
• ksn.com
• Kansas.com
  
• Rutgers
• Flow Wrestling
  

• In England they found advice and manual therapy or advice alone to be more cost effective than ultrasound (duh!)
• Hemiarthroplasty was found to have better outcome compared to internal fixation in 222 femoral neck fractured patients in Norway.
• Radial contrast-enhanced CT can detect acetabular labrum injury almost as well as MRI (confirmed by arthroscopy). So go ahead and use it when MRI is contraindicated.
• Vitamin D Deficiency in Residents of Academic Long-Term Care Facilities Despite Having Been Prescribed Vitamin D. Elovic and Heath reviewed the link between Vit D deficiency and musculoskeletal pain.

Shoulder adhesive Capsulitis

I wish I could read this article in its entirety. I can't tell if there is any appreciable benefit or not.
I'm going to need to review this at some point.

Random Stuff: Lasers, Vitamins, and worthless PT

Zoledronic acid
A bisphosphonate used for hypercalcemia of malignancy.
NEJM recommends infusion to improve morbidity and mortality after hip fracture.
Has a well established safety profile.

Meta Analysis of Ca Vit D to prevent fractures and bone loss in age 50 and over:
"Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

"Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended."
Vitamin C reduces lipid peroxidation, scavenges hydroxyl radicals, protects the capillary endothelium, and inhibits vascular permeability. They assert that Complex regional pain syndrome type I or reflex sympathetic dystrophy which is treated symptomatically, and the clinical focus is on prevention. Major trauma can overwhelm homeostasis, lead to systemic inflammatory response syndrome and multiple-organ distress syndrome. This may parallel burn wounds and the development of CRPS because of the inflammatory reaction and the involved microangiopathy involving a cascade of deterioration and exaggeration of a similar process. High dose Vit C in early burn resuscitation has reportedly significantly reduced resuscitation fluid volume requirements, wound edema, severity of respiratory dysfunction, vascular permeability. This stuff reminds me of Jack's "molecular helmet."

Low level laser therapy for nonspecific low-back pain.6 reasonalbe quality RCTs showed some short-term and intermediate-term evidence of pain relief with LLLT, compared to sham therapy for subacute and chronic low-back pain. No difference disability and insufficient evidence for lumbar range of motion. Relapse rate was significantly lower than control.

Bracing after ACL reconstruction: "This study represents a systematic review of the Level I evidence (12 RCTs) to determine if appropriate evidence exists to support brace use. We found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use..."

Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial: "As compared with no therapy, physiotherapy following first-time disc herniation operation is effective in the short-term. Because of the limited benefits of physiotherapy relative to "sham" therapy, it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery, but psychological factors may contribute substantially to the benefits observed." This is quite a claim.

Jones Fx, RFA, Knee Bursae, Diabetic Amyotrophy

Jones Fracture is a frx at base of fifth metatarsal at metaphyseal-diaphyseal junction not to be confused with the much more common 5th metatarsal styloid avulsion, os peroneum, or stress fracture (chronic jones). Conservatively treat (if minimally displaced, is 3 months old, and radiographs show frx w/o evidence of non-union) with non-wt-bearing cast for 6-8 wks .

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Pes Anserine bursitis good ol emedicine does an okay job. They mention some of the 12 bursae i always talk about.
See my document about Knee Bursae

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Radiofrequency neurotomy for neck pain: an excellent study in N Engl J Med. 1996 Dec 5;335(23):1721-6. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. This paper tells you about the procedure as well.

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Diabetic Amyotrophy: One of the best reviews of this is the podcast with Dr. Dyck where he discusses his article "Diabetic and Nondiabetic Lumbosacral Radiculoplexus Neuropathies: New Insights into Pathophysiology and Ttreatment." Muscle & Nerve. 2002 Apr;25(4):477-91. It is a usually monophasic & unilateral lumbosacral radiculoplexus neuropathy associated with weight loss, begins focally with pain (excruciating in thigh, hip, buttocks muscles) but evolves into widespread, bilateral paralytic disorders. There may be prolonged pain and weakness leading to wheelchair-dependence. Nerve injury and microvasculitis seen (motor>autonomic and sensory ischemic injury). Immune-modulating therapies may be beneficial.

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Can you say Articularis Genus?

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Other Topics from Today

Parkinson's Disease:
Spinal Stenosis:
Spondylolisthesis:
Crossed Adductor Reflex:
Fibromyalgia
Proprioception
Sciatica vs. sciatic nerve injury vs. common peroneal nerve injury