ITEMS IN AFP WITH MESH TERM:
Common Conditions of the Achilles Tendon - Article
ABSTRACT: The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Aging and increased activity (particularly velocity sports) increase the chance of injury to the Achilles tendon. Although conditions of the Achilles tendon are occurring with increasing frequency because the aging U.S. population is remaining active, the diagnosis is missed in about one fourth of cases. Injury onset can be gradual or sudden, and the course of healing is often lengthy. A thorough history and specific physical examination are essential to make the appropriate diagnosis and facilitate a specific treatment plan. The mainstay of treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and nonsteroidal anti-inflammatory drugs, but physical therapy, orthoties, and surgery may be necessary in recalcitrant cases. In patients with tendon rupture, casting or surgery is required. Appropriate treatment often leads to full recovery.
ABSTRACT: Primary care physicians must be able to recognize wrist and hand injuries that require immediate attention. A complete history and physical examination, including assessment of distal limb function, are essential. Hemorrhage control is necessary in patients with vessel lacerations and amputations. Amputations require an understanding of the indications and contraindications in the management of the amputated limb. High-pressure injection injuries and compartment syndromes require a high index of suspicion for early recognition. Infectious entities include "fight bite," open fractures, purulent tenosynovitis, animal bites, and retained foreign bodies. Tendon disruptions should be recognized early to optimize management.
ABSTRACT: There is a common misconception that symptomatic tendon injuries are inflammatory; because of this, these injuries often are mislabeled as tendonitis. Acute inflammatory tendinopathies exist, but most patients seen in primary care will have chronic symptoms suggesting a degenerative condition that should be labeled as "tendinosus" or "tendinopathy." Accurate diagnosis requires physicians to recognize the historical features, anatomy, and useful physical examination maneuvers for these common tendon problems. The natural history is gradually increasing load-related localized pain coinciding with increased activity. The most common overuse tendinopathies involve the rotator cuff, medial and lateral elbow epicondyles, patellar tendon, and Achilles tendon. Examination should include thorough inspection to assess for swelling, asymmetry, and erythema of involved tendons; range-of-motion testing; palpation for tenderness; and examination maneuvers that simulate tendon loading and reproduce pain. Plain radiography, ultrasonography, and magnetic resonance imaging can be helpful if the diagnosis remains unclear. Most patients with overuse tendinopathies (about 80 percent) fully recover within three to six months, and outpatient treatment should consist of relative rest of the affected area, icing, and eccentric strengthening exercises. Although topical and systemic nonsteroidal anti-inflammatory drugs are effective for acute pain relief, these cannot be recommended in favor of other analgesics. Injected corticosteroids also can relieve pain, but these drugs should be used with caution. Ultrasonography, shock wave therapy, orthotics, massage, and technique modification are treatment options, but few data exist to support their use at this time. Surgery is an effective treatment that should be reserved for patients who have failed conservative therapy.
ABSTRACT: Improper diagnosis and treatment of finger injuries can cause deformity and dysfunction over time. A basic understanding of the complex anatomy of the finger and of common tendon and ligament injury mechanisms can help physicians properly diagnose and treat finger injuries. Evaluation includes a general musculoskeletal examination as well as radiography (oblique, anteroposterior, and true lateral views). Splinting and taping are effective treatments for tendon and ligament injuries. Treatment should restrict the motion of injured structures while allowing uninjured joints to remain mobile. Although family physicians are usually the first to evaluate patients with finger injuries, it is important to recognize when a referral is needed to ensure optimal outcomes.
Commonly Missed Orthopedic Problems - Article
ABSTRACT: When not diagnosed early and managed appropriately, common musculoskeletal injuries may result in long-term disabling conditions. Anterior cruciate ligament tears are some of the most common knee ligament injuries. Slipped capital femoral epiphysis may present with little or no hip pain, and subtle or absent physical and radiographic findings. Femoral neck stress fractures, if left untreated, may result in avascular necrosis, refractures and pseudoarthrosis. A delay in diagnosis of scaphoid fractures may cause early wrist arthrosis if nonunion results. Ulnar collateral ligament tears are a frequently overlooked injury in skiers. The diagnosis of Achilles tendon rupture is missed as often as 25 percent of the time. Posterior tibial tendon tears may result in fixed bony planus if diagnosis is delayed, necessitating hindfoot fusion rather than simple soft tissue repair. Family physicians should be familiar with the initial assessment of these conditions and, when appropriate, refer patients promptly to an orthopedic surgeon.
Management of Chronic Tendon Injuries - Article
ABSTRACT: Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.