Joseph Ihm

Eccentric training for the treatment of tendinopathies

Tendinopathy can result from overuse and is experienced in the affected tendon as pain with activity, focal tenderness to palpation, and decreased ability to tolerate tension, which results in decreased functional strength. While tendinopathy often occurs in those who are active, it can occur in those who are inactive. Research has shown that an eccentric exercise program can be effective in the treatment of tendinopathies. The earliest studied was the Achilles tendon, and subsequent studies have shown benefits using eccentric exercises on other body regions including the patellar tendon, proximal lateral elbow, and rotator cuff. In this article, we review the research on using an eccentric exercise program in the treatment of painful tendinopathy and proposed mechanisms for why eccentric exercises are effective in treating this and then finish by providing a general framework for prescribing an eccentric exercise program to those with a symptomatic tendinopathy.

Injectable Medications for Osteoarthritis

Osteoarthritis is one of the most frequent and chronic conditions that affect the U.S. population. Use of intra‐articular injections is one of the established treatment options available in the nonoperative care for the management of symptomatic osteoarthritis. Common injectable medications include corticosteroids, hyaluronic acid, and other less traditional compounds (for example, botulinum toxin). Corticosteroids work by anti‐inflammatory and antinociceptive actions. Corticosteroids have been shown to decrease pain and symptoms associated with osteoarthritis for up to 3 weeks. Hyaluronic acid has an unclear mechanism of action, but it is thought to promote the restoration of hyaluronic acid within an osteoarthritic joint. The efficacy of hyaluronic acid is modest and is most beneficial between 5 and 13 weeks after treatment. Other injectable compounds have been studied and include botulinum toxin type A, which has been theorized to work as an antinociceptive agent. One must be aware of the potential adverse effects associated with these medications. For all of these injectable treatments, the placebo effect must not be overlooked, because it has be demonstrated in multiple studies that these medications provide similar relief of pain when compared with placebo. Image guidance with ultrasound or fluoroscopy may be considered when performing intra‐articular injections to improve accurate placement of medication.

Proximal wrist extensor tendinopathy

Proximal wrist extensor tendinopathy, which is also known as tennis elbow, is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon. It occurs commonly in certain athletes but can also occur in people with jobs that require repetitive movements of the hand and upper limb. In most cases the tendon involved shows no signs of inflammation or tendonitis, but instead shows fibroblasts, vascular hyperplasia, and disorganized collagen. Diagnosis is often made by history and physical exam alone. Most people respond to conservative measures including activity modification, analgesics, manipulation of tissue, and exercise. In some cases, an injection of corticosteroid or botulinum toxin may be used. Surgery is rarely needed.

ACGME Sports, ACGME Pain, or Non-ACGME Sports and Spine: Which Is the Ideal Fellowship Training for PM&R Physicians Interested in Musculoskeletal Medicine?

R.J. is a third-year physical medicine and rehabilitation resident. She has a strong interest in general musculoskeletal medicine, including spine care and interventional procedures. She envisions a practice that is a mixture of acute and chronic musculoskeletal and spine injuries, with the ability to see all age groups, from young patients with acute traumatic injuries to patients with age-related degenerative changes. She plans on doing electromyograms for her own patients as well as interventional procedures in the lumbar spine and peripheral joints by using fluoroscopy and ultrasound. She wants to be a clinician educator at an academic physical medicine and rehabilitation program due to her love of teaching. She plans on going to a fellowship for additional training and possibly certification. Her coresidents have told her that she will only be able to perform fluoroscopic spine procedures after her fellowship if she completes an Accreditation Council for Graduate Medical Education (ACGME) pain medicine fellowship. She is concerned that there are ACGME requirements for a pain fellowship that she has no interest in, for example, cancer pain. She also does not think that she wants to be a “pain physician.” She likes the idea of an ACGME sports medicine fellowship, but her goals are general musculoskeletal and spine care and not necessarily sideline coverage. She also has been told that sports medicine board certification is essential for an academic job in a physical medicine and rehabilitation department. Several non-ACGME fellowships, some even at academic institutions, do fulfill her educational goals, but she is worried that she may not be able to get a job or even get credentialed to preform interventional procedures after engaging in such a fellowship. E. Kano Mayer, MD, will argue that a non-ACGME fellowship may better suit her educational desires. Joe Ihm, MD, and Joel Press, MD, will argue that she should do an ACGME sports medicine fellowship. David Sibell, MD, will argue she should consider an ACGME pain fellowship. Guest Discussants:

Resistance exercise: How much is enough?

Multiple organizations recommend that resistance exercise be part of an adult health and fitness regimen. Extensive research has been done over the years on how to appropriately use a resistance exercise program to increase strength and power for general health and improve athletic performance. This article will review the literature on the components of a resistance exercise program and the recommendations for increasing strength and power in healthy adults.

Rehabilitation Strategies for the Athletic Individual with Early Knee Osteoarthritis.

Knee osteoarthritis (OA) is a major cause of disability in the United States. The condition has most commonly been associated with elderly sedentary individuals; however, it also can affect those who participate in regular athletic activities. The diagnosis and management of these individuals can be challenging because of both their higher level of physical activity and their overall athletic goals. Treatment requires an appropriate exercise regimen, rehabilitation program, and education of both the athlete and the coach. The focus of our article is to provide an up-to-date overview of the evaluation and management of the athletic individual who presents with symptomatic early knee OA, in particular, the nonsurgical rehabilitation treatment options available to the practitioner and the evidence to support these recommendations.

Platelet-Rich Plasma Versus an Eccentric Exercise Program for Recalcitrant Lateral Elbow Tendinopathy

A 48-year-old male, left handedominant air conditioning repairman has a 3-month history of persistent pain in his left elbow. He does not report any traumatic precipitating incident. He is now having difficulty performing his work duties, especially gripping and lifting. In addition, he has had to stop playing recreational tennis and golf. His initial treatment was physical therapy, including therapeutic ultrasound, friction massage, and use of a counterforce strap. After 8 sessions and minimal improvement in his pain, he was referred to a sports medicine specialist. The pain averages 5 out of 10 on a visual analog scale (VAS) and is usually a deep ache, but at times it is sharp. Examination showed no obvious inflammation of common extensor origin. Tenderness was present over the lateral epicondyle, and gripping reproduced the pain. The Cozen test (resisted wrist extension with an extended and pronated elbow) and resisted middle finger extension were positive for pain. The patient was diagnosed with chronic lateral elbow tendinopathy. Given his lack of improvement with physical therapy, the patient is requesting a more aggressive approach. Dr Joseph Ihm will argue that an eccentric exercise strengthening program should be implemented to provide long-term relief. Drs Kenneth Mautner and Joseph Blazuk will argue that an injection of platelet-rich plasma (PRP) is warranted in this patient to optimize and restore his long-term function.

Poster 319 An Unexpected Presentation and Treatment for Unilateral “Foot Drop” in a Triathlete: A Case Report

(47.3%) showing intra-articular flow. Fifteen injections were performed using the posterior approach, and 4 (30.8%) had intra-articular flow. There was no statistically significant difference between the anterior and posterior approaches regardless of physician level of experience. Conclusion: The results of this study suggest that image guidance is an important utility for accurate navigation into the glenohumeral joint space. Although the experienced physician had a significantly higher accuracy rate with blind GHJ injections than those physicians at the fellowship level, the experienced physician still missed the intra-articular space on initial attempt more than 30% of the time. Neither the anterior nor the posterior approach proved to be significantly more accurate for blind GHJ injections regardless of provider experience.