MR imaging in tarsal tunnel syndrome.

Magnetic resonance imaging was used to demonstrate the normal anatomy of the tarsal tunnel in two volunteers and to evaluate 33 feet in 27 patients with tarsal tunnel syndrome. The tarsal tunnel is a fibroosseous channel extending from the ankle to the midfoot, through which the medial tendons and the posterior tibial neurovascular bundle pass. Tarsal tunnel syndrome is a compression neuropathy of the posterior tibial nerve or one of its branches and may be caused by a variety of pathologic lesions. Magnetic resonance imaging demonstrated a mass lesion in five feet, dilated veins or varicosities in eight feet, fracture or soft tissue injury in five feet, fibrous scar in two feet, flexor hallucis longus tenosynovitis in six feet, and abductor hallucis muscle hypertrophy in one foot. Six feet were normal on MR imaging. The findings of MR imaging were confirmed in 17 of 19 patients that went to surgery. Magnetic resonance is useful for localizing lesions within the tarsal tunnel and for determining the lesion extent and relationship to the posterior tibial nerve and its branches.     

改良微创胫后神经减压术治疗跗管综合征

目的探讨改良微创胫后神经减压手术（显微镜结合关节镜技术）治疗跗管综合征。方法采用独创的单切口微创胫后神经减压手术对跗管综合征患者进行手术治疗,术中采用与屈肌支持带和拇展肌之间的平行于屈肌支持带的直切口,在显微镜和关节镜下同时对胫后神经主干及其分支进行满意松解,同时显著减轻了手术损伤。结果患者足底疼痛麻木症状均明显缓解120侧,缓解14侧患肢,麻木缓解28侧,缓解程度达85%以上,胫神经传导速度明显上升。结论微创胫后神经减压手术为跗管综合征的治疗提供了一条有效的新途径。     

Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment

The purpose of this study was to clarify the efficacy of conservative treatment in athletes with severe low back pain and spondylolysis, especially focusing on returning to original sporting activities. One hundred and four athletes (96 males and eight females), who consulted our sports medicine clinic during the 11-year period between September 1991 and October 2002 because of low back pain with an apparent defect of the pars interarticularis on plain radiographs, were subjected to conservative treatment. The mean age of the patients was 20.7 years. Of all the patients, 40 (38.5%) discontinued sporting activities due to severe low back pain, and were conservatively treated with activity restriction and antilordotic lumbosacral bracing, aimed at relieving low back pain by achieving stability of the fracture partly associated with fibrous union. After their low back pain was markedly reduced, the brace was removed and then individual training to return to the original sporting activities was started. Thirty-five patients (87.5%) could return to their original sporting activities in an average of 5.4 months (range: 1.0-11.5 months) after the onset of treatment, and could continue the activities for at least 6 months despite non-bony union. These results suggest that the outcome of conservative treatment with activity restriction and bracing appears to be satisfactory in controlling symptoms and returning to original sporting activities. Randomized controlled trials or comparative follow-up studies are needed to confirm our results.     

MR imaging of the tarsal tunnel and related spaces: normal and abnormal findings with anatomic correlation

The tarsal tunnel syndrome may be caused by extrinsic or intrinsic pressure on the posterior tibial nerve or its terminal branches. The specific symptoms depend on the extent of nerve involvement, and compression distal or proximal to the tarsal tunnel may result in variants of the syndrome. To define better the capability of MR imaging for evaluating this entity, we performed MR imaging on three normal subjects and correlated the images with cryomicrotome sections. Six patients with symptoms suggestive of tarsal tunnel syndrome also were studied with MR. In all normal subjects, MR images showed the flexor retinaculum and the structures passing deep to the retinaculum: the tibialis posterior tendon, flexor digitorum longus tendon, flexor hallucis longus tendon, and the posterior tibial neurovascular bundle. The medial calcaneal sensory branch(es) and the medial and lateral plantar nerves also were delineated. Mechanical causes of compression were shown in all six symptomatic patients. The pathologic entities included two neurilemomas, tenosynovitis involving all three tendons, a ganglion cyst arising from the flexor hallucis longus tendon sheath, posttraumatic fibrosis, and post-traumatic fibrosis with associated posttraumatic neuroma. The MR findings were confirmed surgically in five cases. MR imaging can accurately depict the contents of the tarsal tunnel and the courses of the terminal branches of the posterior tibial nerve. In our small series, MR imaging accurately showed the lesions responsible for tarsal tunnel syndrome.     

Painful heel: MR imaging findings.

Heel pain is a common and frequently disabling clinical complaint that may be caused by a broad spectrum of osseous or soft-tissue disorders. These disorders are classified on the basis of anatomic origin and predominant location of heel pain to foster a better understanding of this complaint. The disorders include plantar fascial lesions (fasciitis, rupture, fibromatosis, xanthoma), tendinous lesions (tendinitis, tenosynovitis), osseous lesions (fractures, bone bruises, osteomyelitis, tumors), bursal lesions (retrocalcaneal bursitis, retroachilleal bursitis), tarsal tunnel syndrome, and heel plantar fat pad abnormalities. With its superior soft-tissue contrast resolution and multiplanar capability, magnetic resonance (MR) imaging can help determine the cause of heel pain and help assess the extent and severity of the disease in ambiguous or clinically equivocal cases. Careful analysis of MR imaging findings and correlation of these findings with patient history and findings at physical examination can suggest a specific diagnosis in most cases. The majority of patients with heel pain can be successfully treated conservatively, but in cases requiring surgery (eg, plantar fascia rupture in competitive athletes, deeply infiltrating plantar fibromatosis, masses causing tarsal tunnel syndrome), MR imaging is especially useful in planning surgical treatment by showing the exact location and extent of the lesion.     

Sports-related injuries in elderly men still active in sports.

By means of a questionnaire with a complementary interview and physical examination, the site and nature of sports injuries were investigated over a 10-year period (1977-1987) in 97 elderly athletes (age range 70-81 years). The athletes were still active in training and competition with a mean competition background of 15 years. Of the subjects studied 30 were strength/power athletes and the remaining 67 endurance athletes. Altogether we found 273 sports-related injuries (169 acute and 104 overuse injuries). Of the injuries 75% had occurred in the lower extremities. The most commonly injured part of the body was the knee (20% of all cases). Sprains of the thigh and knee were the most frequent types of acute injury. In most cases the treatment prescribed was rest and physiotherapy. Surgery had been necessary in ten cases (3.7% of all injuries). Mean withdrawal from normal sporting activity had, in general, been 2-3 weeks. Of the injuries, one in five had, however, lasted over several years causing some disability during sporting activities.     

Posterior tibial nerve entrapment at the ankle

Compression of the posterior tibial nerve of the ankle, also known as tarsal tunnel syndrome (TTS), is being seen withincreasing frequency in athletes, particularly runners. For this reason, it behooves the sports medicine professional to be well informed about this condition. TTS is caused by either extrinsic or intrinsic pressure on the posterior tibial nerve or its terminal branches. The syndrome, although analogous to carpal tunnel syndrome, is much less common. The most common symptoms of TTS are numbness and burning pain in the medial heel and foot. The condition is often difficult to differentiate from plantar fasciitis. Electrodiagnostic studies, including nerve conduction studies and electromyography, help confirm the diagnosis. Conservative measures are usually unsuccessful, and surgical decompression of the tarsal tunnel is generally regarded as the treatment of choice.     

Sudden cardiac death among general population and sport related population in forensic experience

PurposeThe goal of the study was to assess the causes and analyze the cases of sudden cardiac death (SCD) victims referred to the department of forensic medicine in Lausanne, with a particular focus on sports-related fatalities including also leisure sporting activities. To date, no such published assessment has been done nor for Switzerland nor for the central Europe.MethodsThis is a retrospective study based on autopsy records of SCD victims, from 10 to 50 years of age, performed at the University Centre of Legal Medicine in Lausanne from 1995 to 2010. The study population was divided into two groups: sport-related (SR) and not sport-related (NSR) SCDs.ResultsDuring the study period, 188 cases of SCD were recorded: 166 (88%) were NSR and 22 (12%) SR. The mean age of the 188 victims was 37.3 ± 10.1 years, with the majority of the cases being male (79%). A cause of death was established in 84%, and the pathology responsible for death varied according to the age of the victims.In the NSR group, the mean age was 38.2 ± 9.2 years and there was 82% of male. Coronary artery disease (CAD) was the main diagnosis in the victims aged 30–50 years. The majority of morphologically normal hearts were observed in the 15–29 year age range. There was no case in the 10–14 year age range.In the SR group, 91% of victims died during leisure sporting activities. In this group the mean age was 30.5 ± 13.5 years, with the majority being male (82%). The main cause of death was CAD, with 6 cases (27%) and a mean age of 40.8 ± 5.5 years. The youngest victim with CAD was 33 years old. A morphologically normal heart was observed in 5 cases (23%), with a mean age of 24.4 ± 14.9 years. The most frequently implicated sporting activities were hiking (26%) and swimming (17%).ConclusionIn this study, CAD was the most common cause of death in both groups. Although this pathology most often affects adults over 35 years of age, there were also some victims under 35 years of age in both groups. SCDs during sport are mostly related to leisure sporting activities, for which preventive measures are not yet usually established. This study highlights also the need to inform both athletes and non athletes of the cardiovascular risks during sport activities and the role of a forensic autopsy and registries involving forensic pathologists for SR SCD.     

Nerve entrapment of the foot and ankle in runners

In the 10 years 1972 through 1982, the senior author performed 21 operations on 15 runners with persistent foot and ankle pain. The operative procedures involved decompression of peripheral nerves in the foot and ankle, consisting of release of soft tissues in the tarsal tunnel and foot or removal of abnormal bony excrescences that were irritating these nerves. All 15 runners had good to excellent results and all returned to their preinjury running status, including the competitive athletes. Foot and ankle pain is best treated conservatively, but when signs and symptoms culled from a careful history and physical examination reflect a nerve entrapment syndrome, surgical intervention has its place in the armamentarium of the surgeon.     

Sports and physical activity after cementless total hip arthroplasty with a minimum follow‐up of 10 years

The present retrospective cohort study was conducted to compare sporting activity levels before and a minimum of 10 years after primary cementless total hip arthroplasty (THA). A consecutive series of 86 patients with a mean age at surgery of 52 years (range, 21–60 years) was evaluated 11 years after surgery (range, 10–12 years). Pre‐ and post‐operative sporting activities were assessed at routine follow‐up using the University of California, Los Angeles activity score and the Schulthess Clinic sports and activity questionnaire. Post‐operative health‐related quality of life was measured using the Short‐Form 36 (SF‐36) questionnaire and compared with age‐matched reference populations from the SF‐36 database. Eleven years after THA, 89% of preoperatively active patients had returned to sport. Comparing sports activity preoperatively (before the onset of symptoms) and 11 years after THA, no significant difference was found for the mean number of disciplines or session length. A significant decline in high‐impact activities was observed, while participation in low‐impact activities significantly increased. Health‐related quality of life compared well against a healthy age‐matched reference population and was significantly higher than in a reference group of patients with osteoarthritis. The majority of patients were able to maintain their physical activity level in the long term after primary cementless THA, compared with the activity level before the onset of restricting osteoarthritis symptoms. However, a change in disciplines toward low‐impact activities was observed.     

Effect of school age sports on leisure time physical activity in adults: The CORDIS Study

PURPOSE: Data evaluating the impact of various types of childhood physical activity on adult leisure time physical activity (LTPA) are inconsistent. The purpose of this study was to evaluate the influence of organized childhood sporting activities on LTPA as an adult in a cohort of industrial workers. METHODS: The frequency of current LTPA, defined as a half hour or more of activity at least once per week, of 3687 industrial workers in the Cardiovascular Occupational Risk Factors in Israel Study (CORDIS) cohort was the outcome variable. We analyzed the association of organized school age sports with adult LTPA, using a multiple logistic regression model, after adjusting for sociodemographic variables including current occupational factors. RESULTS: Participating in organized school age sporting activities predicted LTPA as an adult [adjusted odds ratio (OR) 3.55, 95% confidence intervals (95% CI) 2.97-4.23]. This association was consistent in the various subgroups of marital status, age, smoking, shift work, body mass index, and religious observance. CONCLUSIONS: Organized school age sporting activities influenced future LTPA in this cohort. Attempts to promote these activities may lead to increased levels of LTPA in adults.     

Nerve disorders in dancers

Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.     

Carpal cysts in hemodialysis patients

A new type of amyloidosis due to beta 2-microglobulin depositions has been recently described in long-term hemodialysis patients. This systemic complication mainly affects the osteoarticular system, with diffuse articular symptoms; among them carpal tunnel syndrome is the most frequent. The syndrome etiopathology is unknown, even though many causal factors have been identified, among which the repeated use of non-biocompatible dialytic membranes. The authors conducted a retrospective study of 138 hemodialysis patients, with mean dialytic age of 79.3 months, to evaluate both incidence and evolution of bone cysts involving the carpal bones. Bone cysts were detected in the hands of 18.8% of the patients at the beginning of dialytic treatment; their incidence was over 50% after 10 years of treatment. Their size and number showed a rapid progression after the 6th year of hemodialysis, and their features were not related to osteodystrophic bone lesions. The carpal tunnel syndrome appeared after several years and its incidence was 7.9%; a direct correlation was demonstrated with the size of carpal bone cysts. The influence of hemodialysis membrane type on the occurrence of hemodialysis-related amyloidosis was strong, but not exclusive.     

Laparoscopic repair of groin pain in athletes

BACKGROUND: There has been increasing interest regarding the cause and treatment of groin pain in athletes. The most common finding is a deficiency of the posterior wall of the inguinal canal, often repaired with bilateral inguinal myorrhaphy. HYPOTHESIS: Laparoscopic repair will offer a shorter convalescent period and better results as compared with open myorrhaphy. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Between October 1993 and October 2002, 131 athletes with groin pain unrelieved after 2 to 8 months of conservative management underwent bilateral laparoscopic repair with the transabdominal preperitoneal technique for hernias. In 123 (94%) patients, physical examination revealed a dilated external ring, unilateral or bilateral, of the inguinal canal, and in 8 patients (6%) it was normal. RESULTS: During laparoscopy, a deficiency of the posterior inguinal wall was seen in all athletes. All patients left the hospital 24 hours after the procedure, discontinued oral analgesics within 72 hours of surgery, and were back to full sporting activities within 2 to 3 weeks. Four patients (3%) complained of thigh pain. After a mean follow-up of 5 years (range, 4 months to 10 years), there was 1 recurrence (0.76%). CONCLUSIONS: Laparoscopic repair is an efficient method for the treatment of groin pain originating from a deficiency of the posterior inguinal wall, having fast recovery and excellent long-term results.     

Tarsal coalition in the young athlete

Twenty young athletes with tarsal coalition were studied. There was a total of 26 feet including 15 cases of calcaneonavicular bars, 9 cases of talocalcaneal bars, 1 talonavicular bar, and 1 mixed. Twenty-five feet had bar resection. Calcaneonavicular bar resection is the recommended procedure for the adolescent who presents with a painful tarsal coalition. The talocalcaneal synostosis resection has been mentioned in the literature as yielding poor results. This was not true in my series. The eight cases of talocalcaneal coalition presented all had improvement in motion and decreased pain after surgical excision of the bar.     

Continuity and change in sporting and leisure time physical activities during adolescence

OBJECTIVES: To map the pattern of involvement in physical activities by adolescents at ages 15 and 18 years. METHODS: Data from a longitudinal cohort study were used. Participants in the Dunedin Multidisciplinary Health and Development Study provided information about their sporting and similar physical activities during the 12 months before study assessments at ages 15 and 18 years. RESULTS: Total participation time at age 18 was 63% of that reported at age 15. Mean participation time for girls decreased from 7.5 hours a week to 4.3 hours a week (p<0.001) whereas for boys it decreased from 11.7 hours a week to 7.8 hours a week (p<0.001). At both ages, boys spent significantly more time in physical activity than girls. More time in physical activity at age 18 was reported by participants who judged their fitness higher than their peers (odds ratio (OR) 1.7: 1.2, 2.5), those who played sport for their school (OR 1.8: 1.3, 2.4), and those reporting very good self assessed health (OR 1.4: 1.0, 1.8) at age 15. The overall median number of activities decreased from seven at age 15 to three at 18. Boys were involved in more activities at age 15 but there was no sex difference at age 18 in the number of different activities reported. CONCLUSION: Although involvement in school sporting activities and high levels of fitness in mid-adolescence may protect against marked reductions in physical activity in late adolescence, social and organisational factors are also likely to be important. There is a need for innovative approaches to health promotion which will encourage adolescents to maintain higher levels of physical activity after they leave school.


     

Coagulation parameters in senior athletes practicing endurance sporting activity

AIM: Physical activity is practiced more and more by middle-aged people. We studied the behavior of the coagulation system before and after near-maximum, specific and standardized exercise tests in 2 groups of senior athletes. METHODS: The subjects of the study were 2 groups of athletes over 40 years of age (ranging 41 to 60 years): 10 rowers and 10 marathon runners. The data were compared with 10 controls (ranging in age from 40 to 71 years) tested on the cycle ergometer. The first group (rowers) was tested on a rowing machine; the second group (marathon runners) performed a maximal exercise on the treadmill. All subjects were tested to a maximal level of cardiovascular and muscular exertion and cardiac and respiratory parameters were monitored. The following coagulation tests were performed before and after maximal exercise: prothrombin time (PT), partial activated thromboplastin time (PTT), fibrinogen (FBG), antithrombin III (ATIII), protein C (PC), protein S (PS), prothrombin fragment 1+2 (F1+2), tissue activator of plasminogen (t-PA) and its inhibitor (PAI). All subjects performed a complete maximal specific test. RESULTS: The results showed all individuals produced a significant increase of FBG, PT and PTT activities and a lowering trend for PC and PS inhibitors after maximal exercise testing. ATIII levels increased significantly in trained subjects. After the test, data regarding fibrinolysis showed higher t-PA levels in athletes as compared with controls. PAI levels indicated a more marked decrease in athletes. The F1+2 showed a moderate but significant increase in the control group. CONCLUSIONS: Coagulative tests showed an increase in procoagulant and fibrinolysis parameters in all the groups but the increased fibrinolytic activity in trained athletes indicates a protective factor and greater vascular efficiency. The results demonstrate that sporting activity practiced by middle-aged people accelerates fibrinolytic activity in conditioned subjects. In conclusion, physical activity benefits the coagulation system particularly as regards fibrinolysis.     

Dermatologic problems in athletes

The skin diseases observed in athletes are common dermatologic problems that are related specifically to the individual skin type, hereditary factors, age, sex, environment, and sporting activity. Early recognition and treatment of these skin diseases permit the athlete to continue participation without disability or reduced performance.     

Carpal tunnel syndrome in athletes

Carpal tunnel syndrome is the most frequent peripheral compression neuropathy found in sporting activities. The recent introduction of endoscopic methods to release the transverse carpal ligament has generated renewed interest in the clinical, social, and economic issues relating to this pervasive condition. This report reviews the most common open, minimum open, and endoscopic techniques used in the operative treatment of carpal tunnel syndrome.     

跖管综合征的诊断及治疗

目的　探讨跖管综合征的原因、临床表现及诊断 ,并报道其治疗效果。方法　对 18例 (2 1足 )跖管综合征的患者进行了手术治疗 ,术前Takakura指数为 3～ 7分 ,平均 6 4分 ;术中发现腱鞘囊肿 15例 (17足 ) ,胫后静脉淤血、静脉曲张 2例 (3足 ) ,脂肪瘤 1例 (1足)。结果　术后随访 0 5～ 17年 ,平均 7 3年 ,症状均消失 ,无复发。Takakura指数为 9～ 10分 ,平均 9 7分。结论　跖管综合征临床上较为少见 ,原因复杂 ,临床表现多样 ,易误诊、漏诊 ;对非手术治疗效果不佳的患者 ,手术治疗可取得较好的效果。