Franklin E. Caldera

Cell therapy for the degenerating intervertebral disc

Spinal conditions related to intervertebral disc (IVD) degeneration cost billions of dollars in the US annually. Despite the prevalence and soaring cost, there is no specific treatment that restores the physiological function of the diseased IVD. Thus, it is vital to develop new treatment strategies to repair the degenerating IVD. Persons with IVD degeneration without back pain or radicular leg pain often do not require any intervention. Only patients with severe back pain related to the IVD degeneration or biomechanical instability are likely candidates for cell therapy. The IVD progressively degenerates with age in humans, and strategies to repair the IVD depend on the stage of degeneration. Cell therapy and cell-based gene therapy aim to address moderate disc degeneration; advanced stage disease may require surgery. Studies involving autologous, allogeneic, and xenogeneic cells have all shown good survival of these cells in the IVD, confirming that the disc niche is an immunologically privileged site, permitting long-term survival of transplanted cells. All of the animal studies reviewed here reported some improvement in disc structure, and 2 studies showed attenuation of local inflammation. Among the 50 studies reviewed, 25 used some type of scaffold, and cell leakage is a consistently noted problem, though some studies showed reduced cell leakage. Hydrogel scaffolds may prevent cell leakage and provide biomechanical support until cells can become established matrix producers. However, these gels need to be optimized to prevent this leakage. Many animal models have been leveraged in this research space. Rabbit is the most frequently used model (28 of 50), followed by rat, pig, and dog. Sheep and goat IVDs resemble those of humans in size and in the absence of notochordal cells. Despite this advantage, there were only 2 sheep and 1 goat studies of 50 studies in this cohort. It is also unclear if a study in large animals is needed before clinical trials since some of the clinical trials proceeded without a study in large animals. No animal studies or clinical trials completely restored IVD structure. However, results suggest cause for optimism. In light of the fact that patients primarily seek medical care for back pain, attenuating local inflammation should be a priority in benchmarks for success. Clinicians generally agree that short-term back pain should be treated conservatively. When interventions are considered, the ideal therapy should also be minimally invasive and concurrent with other procedures such as discography or discectomy. Restoration of tissue structure and preservation of spinal motion are desirable.

High-Resolution Median Nerve Sonographic Measurements Correlations With Median Nerve Conduction Studies in Healthy Adults

To study relationships between median wrist and forearm sonographic measurements and median nerve conduction studies.

Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome

Background: The current literature indicates that hip abduction weakness in female patients is associated with ipsilateral patellofemoral pain syndrome (PFPS) as part of the weaker hip abductor complex. Thus, it has been suggested that clinicians should consider screening female athletes for hip strength asymmetry to identify those at risk of developing PFPS to prevent the condition. However, no study to date has demonstrated that hip strength asymmetry exists in the early stages of PFPS. Purpose: To determine whether hip abduction strength asymmetry exists in female runners with early unilateral PFPS, defined as symptoms of PFPS not significant enough to cause patients to seek medical attention or prevent them from running at least 10 miles per week. Study Design: Controlled laboratory study. Methods: This study consisted of 21 female runners (mean age, 30.5 years; range, 18-45 years) with early unilateral PFPS, who had not yet sought medical care and who were able to run at least 10 miles per week, and 36 healthy controls comparably balanced for age, height, weight, and weekly running mileage (mean, 18.5 mi/wk). Study volunteers were recruited using flyers and from various local running events in the metropolitan area. Bilateral hip abduction strength in both a neutral and extended hip position was measured using a handheld dynamometer in each participant by an examiner blinded to group assignment. Results: Patients with early unilateral PFPS demonstrated no significant side-to-side difference in hip abduction strength, according to the Hip Strength Asymmetry Index, in both a neutral (mean, 83.5 ± 10.2; P = .2272) and extended hip position (mean, 96.3 ± 21.9; P = .6671) compared with controls (mean, 87.0 ± 8.3 [P = .2272] and 96.6 ± 16.2 [P = .6671], respectively). Hip abduction strength of the affected limb in patients with early unilateral PFPS (mean, 9.9 ± 2.2; P = .0305) was significantly stronger than that of the weaker limb of control participants (mean, 8.9 ± 1.4; P = .0305) when testing strength in a neutral hip position; however, no significant difference was found when testing the hip in an extended position (mean, 7.0 ± 1.4 [P = .1406] and 6.6 ± 1.5 [P =.1406], respectively). Conclusion: The study data show that early stages of unilateral PFPS in female runners is not associated with hip abduction strength asymmetry and that hip abduction strength tested in neutral is significantly greater in the affected limb in the early stages of PFPS compared with the unaffected limb. However, when tested in extension, no difference exists. Further studies investigating the early stages of PFPS are warranted. Clinical Relevance: Unlike patients with PFPS seeking medical care, early PFPS does not appear to be significantly associated with hip abduction strength asymmetry.

Diagnosing adductor muscle avulsion at the symphysis pubis with ultrasound.

ABSTRACTA 58-yr-old woman presented after experiencing left hip and groin pain for 1 mo. She denies any history of trauma, falls or any bruising, or history of sports injury or extreme physical exertion before her symptoms. On ultrasonography, she was found to have an avulsion tear at the origin of the adductor muscles, predominantly involving the adductor longus and brevis muscles. The treatment course was conservative: nonsteroidal anti-inflammatory drugs for pain control and physical therapy for muscle strengthening and balance improvement. Upon follow-up, she demonstrated significant improvement and resolution of her pain.

Patellofemoral Syndrome—A Term to Be Avoided: Response

Dear Editor: On behalf of the International Patellofemoral Study Group, we appreciate the work that went into the preparation of the article ‘‘Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome?’’ from your January 2016 issue. This study addresses an important issue. We regret, however, the use of the term ‘‘patellofemoral pain syndrome,’’ a term that has gradually supplanted ‘‘chondromalacia’’ but in itself defies definition. A medical syndrome reflects a specific combination of symptoms, signs, imaging findings, and/or serum values (eg, nephrotic syndrome, Marfan syndrome). No such well-defined combination exists for ‘‘patellofemoral pain syndrome.’’ Patients complain of pain, and in our opinion, this in and of itself does not justify the application of the term ‘‘syndrome.’’ Moreover, the use of ‘‘patellofemoral pain syndrome’’ suggests to a patient (and health care professionals) that a specific diagnosis has been made. Not surprisingly, and as previously noted, nearly every study on patients with patellofemoral syndrome puts forth a different meaning and a different set of inclusion/ exclusion criteria. Therefore, by and large, every study evaluates a different population, and these studies cannot be meaningfully compared to each other. The study in question is no exception and does not clearly define the ‘‘syndrome.’’ As best as we can understand, their definition is ‘‘pain in the front of the knee or behind the kneecap that occurs with running, prolonged sitting, or when climbing stairs’’ and which is associated with ‘‘tenderness of the medial or lateral patellar facets,’’ ‘‘pain with compression of the patella into the femoral condyles,’’ and ‘‘anterior knee pain with single-leg squat.’’ It might have been more clear as well to restate the tenderness findings as being present on palpation of the medial retinaculum and lateral retinaculum because direct palpation of the patellar facets is, of course, not possible in the office. We respectfully urge authors and editors to avoid the term ‘‘patellofemoral pain syndrome.’’ It would promote clearer thinking if authors instead substituted a more precise diagnosis when possible or simply stated the symptom being studied (eg, ‘‘anterior knee pain’’). We do appreciate your journal’s willingness to recognize this problem as worthy of attention and study. As a leader in sports medicine research, AJSM has the opportunity here to set a standard for clear thinking in understanding this issue.

Acute achilles tendinopathy diagnosed with ultrasound.

A 72-yr-old woman presented with a complaint of left ankle pain, which was 4 of 10 on the visual analog scale. Ultrasound (US) evaluation of the left posterior and the left lateral ankle was obtained using high-resolution gray scale and color Doppler imaging (Figs.1 and 2). The sonographic evaluation demonstrated marked thickening of the Achilles tendon with heterogeneous echogenicity. Numerous foci of calcifications and marked hyperemia were noted within the tendon. These findings represent severe tendinopathy of the Achilles tendon. After failing multiple conservative therapies, the patient opted for a surgical debridement of her Achilles tendon. Her symptoms improved after finishing postoperative physical therapy. Tendinopathy is often considered to be a chronic degenerative condition, but there are acute exacerbations or Bflare-ups[ that can occur at any age. The cause of degeneration of the tendon is recurrent microtrauma and inadequate healing caused by the relative hypovascularity of the tendon. As the tendon becomes damaged, it becomes thickened, inelastic, and fibrotic. The differential diagnosis of Achilles tendon pain includes Achilles tendinopathy and rupture, calcaneal bursitis, and calcaneal apophysitis. In individuals with Achilles tendinopathy, pain is described as burning, located 2Y6 cm above the posterior calcaneus. In individuals with a tendon rupture, they describe their pain as severe and acute in nature, with some hearing a Bpop[ before the onset of pain. Absence of pain does not rule out rupture. Treatment of Achilles tendinopathy generally consists of avoiding intense physical activities, applying ice, using nonsteroidal anti-inflammatory drugs, and supporting the Achilles tendon with a heel lift when appropriate. Achilles tendinopathy is a clinical diagnosis, but changes in the tendon may be seen on radiologic imaging. US is a rapidly performed examination with greater resolution than that of magnetic resonance imaging (MRI) and allows dynamic evaluation of the tendons and the muscles. The use of US continues to increase for the evaluation of the musculoskeletal system. It is an attractive option to help diagnose Achilles tendon injuries because of the lower cost than that of MRI, lack of ionizing radiation,

Poster 156 Newly Diagnosed Uncommon Isolated Posterior Tibialis Tenosynovitis in a Ballet Dancer: A Case Report

Disclosures: A. J. Haig, Ownership or partnership: Haig et al., Consulting LLC; Non-remunerative positions of influence, The International Rehabilitation Forum; The International Society for Physical and Rehabilitation Medicine; Non-remunerative positions of influence; The University of Michigan. Objective: While reversal of pathophysiology and improvement in capacity are important intermediate goals of many medical, surgical, and rehabilitation interventions, the improvement of actual participation in the community is the ultimate goal for most patients. Activity monitors can now measure daily walking participation. Since the principal impairment from neurogenic claudication is walking the current study hopes to examine factors that impact the ratio of walking participation:capacity (P:C) in that population and control groups. Variation in P:C ratio may disclose barriers to full participation that are psychological or social. Design: Prospective, controlled, NIH-funded trial. Setting: University clinic. Participants: Persons age 50-85 with clinician-diagnosed mechanical back pain, neurogenic claudication, and asymptomatic volunteers. Interventions: 6-minute walk test (capacity), 7 day activity monitor (participation), masked physical examination, multiple standardized surveys. Main Outcome Measures: Relationship of variables to the P:C ratio, defined as (average daily steps on activity monitor )/( steps taken during the 6 minute walk test). Results: 29 claudicants, 27 mechanical back pain and 33 asymptomatic volunteers completed the trial, with P:C ratios of 9.7 (s.d. 7.3), 9.3 (s.d. 3.9) and 10.7 (s.d. 5.6), respectively. The P:C ratio did not relate (P .05) to medical issues (diagnosis, visual analog pain, Pain Disability Index, McGill, obesity, age, sex), psychosocial issues (education, Tampa kinesiphobia scale, CESD Depression scale) or any SF-36 quality of life component. Conclusions: Surprisingly this extensive evaluation did not find factors that relate to optimization or diminution of participation, given a certain level of disability. In a larger group, in other populations, or in other diseases, parameters that alter the P:C ratio might help guide rehabilitation.

Poster 188 Careful Consideration of Medial Patellar Retinaculum. A Rare Presentation of a Partial Sprain: A Case Report

pain. Program Description: This patient presented with a 4-year history of left groin and medial thigh pain that started insidiously without any trauma. The pain was worse with prolonged walking, stair climbing, and squatting. Initial AP/lat radiographs were normal. He was diagnosed with an inguinal hernia; however, during surgery, no hernia was found. He was evaluated for an upper lumbar radiculopathy by his PCP. He was treated for an adductor strain with injections and therapy that provided minimal relief. His pain persisted and he was referred to our clinic. Setting: Veterans Affairs outpatient clinic. Results: Positive hip impingement signs were noted on examination. Magnetic resonance arthrogram demonstrated femoral head asphericity, mildly increased angle, and a small tear within the superior labrum at the chondral-labral junction. His history, physical examination, and imaging findings were consistent with femoroacetabular impingement (FAI) with a resulting labral tear. Discussion: FAI has been reported in 10% of the general public, and it plays a role in development of early hip osteoarthritis. This diagnosis is often missed, and the average time from symptom onset to proper treatment is 30 months. Plain AP/lat radiographs are often normal. Hip internal rotation of 15° or 45° of flexion may help with the sensitivity of the radiographs but magnetic resonance arthrogram is quickly becoming the standard imaging. Asphericity of the femoral head, decreased head-neck offset, and a labral tear are often demonstrated. Nonoperative management often only provides temporary relief. Open or arthroscopic surgery often provides good pain relief with a quick return to activity. Conclusions: This case illustrates that standard imaging of the hip can be falsely negative in patients with FAI. This may lead to an incorrect diagnosis, unnecessary interventions, and unnecessarily high medical costs. Early recognition can prevent disability related to early onset of hip DJD and labral tears. In any young patients with a complaint of hip and/or groin pain, FAI should be high on the differential diagnosis.

Poster 454 A Patient With Spinal Epidural Mass Effect Refusing Surgical Intervention: A Case Report

bladder, or sexual dysfunction. Diagnosis is made by MRI of the spine. Treatment options include open surgical ligation or resection of the malformation, endovascular occlusion, spinal radiation, or a combination of these techniques. Conclusions: We present a rare case of a patient with a thoracic spinal arteriovenous malformation. Clinicians should be aware of this entity and should consider further imaging of the spine in patients presenting with lower extremity weakness and a normal lumbar MRI.

Poster 186 Avulsion of the Adductor Muscle at the Symphysis Pubis Diagnosed With Ultrasound: A Case Report

admitted to acute inpatient rehabilitation. She demonstrated decreased balance with gait secondary to quadriceps weakness. After 10 days of therapy, she achieved modified independence with transfers and ambulation by using a rolling walker. Setting: A tertiary care hospital. Results: At 6 weeks after surgery, electromyography and nerve conduction studies revealed axonal injury to the femoral nerves bilaterally. At 12 weeks after surgery, the patient noted significant improvement in her lower extremity strength. Hip flexion was 4 /5 bilaterally, right knee extension was 4 /5, and left knee extension was 4/5. She progressed to ambulation by using a cane in the community. Discussion: Lithotomy positioning can lead to bilateral femoral neuropathy due to prolonged hip flexion, extreme hip abduction, and external rotation. This position may not only compress the femoral nerve but also stretch it beneath the inguinal ligament, which results in demyelinating or axonal nerve injuries. This complication may be prevented by modifying posture and decreasing operating time. Conclusions: Bilateral femoral neuropathy is a rare complication of prolonged surgery in the lithotomy position. Clinicians should timely recognize this condition and promptly initiate a comprehensive rehabilitation program to address the significant functional impairments and associated psychological stress.