Samuel Dekel

Patellofemoral Pain Syndrome: Validity of Clinical and Radiological Features

Data regarding validity of clinical and radiographic findings in diagnosing patellofemoral pain syndrome are inconclusive. We prospectively assessed how sensitive and specific key patellofemoral physical examination tests are, and evaluated the prevalence of physical examination and radiographic findings. Sixty-one infantry soldiers with patellofemoral pain syndrome and 25 control subjects were evaluated. The sensitivity of the patellar tilt, active instability, patella alta, and apprehension tests was low (less than 50%); specificity ranged between 72% and 100%. Although the prevalence of positive patellar tilt and active instability tests was significantly greater in subjects with patellofemoral pain syndrome, there were no significant differences between the groups in the results of the other two tests. Soldiers with patellofemoral pain syndrome presented with increased quadriceps angle, lateral and medial retinacular tenderness, patellofemoral crepitation, squinting patella, and reduced mobility of the patella. There were no differences between the groups in the prevalence of lower limb and foot posture alignment and knee effusion. Plain radiography showed increased patellar subluxation in soldiers with patellofemoral pain syndrome. Other radiographic measures (sulcus angle, Laurin angle, Merchant angle, and Insall-Salvati index) were similar in both groups. We provide evidence regarding the validity of clinical and radiographic features commonly used for diagnosing patellofemoral pain syndrome. Physical examinations were more useful than plain radiography.Level of Evidence: Diagnostic study, Level I. See the Guidelines for Authors for a complete description of levels of evidence.

Control of knee coronal plane moment via modulation of center of pressure: A prospective gait analysis study

OBJECTIVES Footwear-generated biomechanical manipulations (e.g., wedge insoles) have been shown to reduce the magnitude of adduction moment about the knee. The theory behind wedged insoles is that a more laterally shifted location of the center of pressure reduces the distance between the ground reaction force and the center of the knee joint, thereby reducing adduction moment during gait. However, the relationship between the center of pressure and the knee adduction moment has not been studied previously. The aim of this study was to examine the association between the location of the center of pressure and the relative magnitude of the knee adduction moment during gait in healthy men. METHODS A novel foot-worn biomechanical device which allows controlled manipulation of the center of pressure location was utilized. Twelve healthy men underwent successive gait analysis testing in a controlled setting and with the device set to convey three different para-sagittal locations of the center of pressure: neutral, medial offset and lateral offset. RESULTS The knee adduction moment during the stance phase significantly correlated with the shift of the center of pressure from the functional neutral sagittal axis in the coronal plane (i.e., from medial to lateral). The moment was reduced with the lateral sagittal axis configuration and augmented with the medial sagittal axis configuration. CONCLUSIONS The study results confirm the hypothesis of a direct correlation between the coronal location of the center of pressure and the magnitude of the knee adduction moment.

The Use of Three-Dimensional Computed Tomography in Evaluating Snapping Scapula Syndrome

This article evaluates imaging of the scapula and scapulothoracic joint in patients with snapping scapula syndrome. Between 1990 and 1996, a total of 20 patients (10 men and 10 women) with snapping scapula syndrome were evaluated. Diagnosis was based on patient complaints and physical examination findings. There were 26 affected scapulae (6 patients had bilateral presentation). Imaging of the scapula included plain radiography, computed tomography (CT), and 3-dimensional computed tomography (3-D CT) reconstruction. Plain radiography revealed bony incongruity between the anterior aspect of the scapula and the chest wall in 7 scapulae, CT revealed such incongruity in 19 scapulae, and 3-D CT revealed incongruity in all 26 scapulae. Treatment was conservative, consisting of nonsteroidal anti-inflammatory drugs, a physiotherapy program, and subscapular injection of a local anesthetic and steroids. In 5 patients who responded poorly to conservative treatment, the region responsible for the snapping was resected. Pain relief and resolution of the snapping were complete following surgery in 4 patients, while pain and crepitation persisted in the fifth. Three-dimensional CT is recommended as the main imaging modality in the evaluation of any patient with snapping scapula syndrome who is a candidate for surgical intervention.

Safety and Efficacy of Dietary Agmatine Sulfate in Lumbar Disc‐associated Radiculopathy. An Open‐label, Dose‐escalating Study Followed by a Randomized, Double‐blind, Placebo‐controlled Trial

Objective. Agmatine, decarboxylated arginine, was shown in preclinical studies to exert efficacious neuroprotection by interacting with multiple molecular targets. This study was designed to ascertain safety and efficacy of dietary agmatine sulfate in herniated lumbar disc-associated radiculopathy. Study Design. First, an open-label dose escalation study was performed to assess the safety and side-effects of agmatine sulfate. In the follow-up study, participants diagnosed with herniated lumbar disc-associated radiculopathy were randomly assigned to receive either placebo or agmatine sulfate in a double-blind fashion. Methods. Participants in the first study were recruited consecutively into four cohorts who took the following escalating regimens: 1.335 g/day agmatine sulfate for 10 days, 2.670 g/day for 10 days, 3.560 g/day for 10 days, and 3.560 g/day for 21 days. Participants in the follow-up study were assigned to receive either placebo or agmatine sulfate, 2.670 g/day for 14 days. Primary outcome measures were pain using the visual analog scale, the McGill pain questionnaire and the Oswestry disability index, sensorimotor deficits, and health-related quality of life using the 36-item short form (SF-36) questionnaire. Secondary outcomes included other treatment options, and safety and tolerability assessment. Results. Safety parameters were within normal values in all participants of the first study. Three participants in the highest dose cohort had mild-to-moderate diarrhea and mild nausea during treatment, which disappeared upon treatment cessation. No other events were observed. In the follow-up study, 51 participants were randomly enrolled in the agmatine group and 48 in the placebo. Continuous improvement of symptoms occurred in both groups, but was more pronounced in the agmatine (analyzed n = 31) as compared with the placebo group (n = 30). Expressed as percent of baseline values, significantly enhanced improvement in average pain measures and in quality of life scores occurred after treatment in the agmatine group (26.7% and 70.8%, respectively) as compared with placebo (6.0% [P </= 0.05] and 20.0% [P </= 0.05], respectively). No treatment-related adverse events were noted. Conclusions. Dietary agmatine sulfate is safe and efficacious treatment for alleviating pain and improving quality of life in lumbar disc-associated radiculopathy. Study Registration. ClinicalTrials.gov Protocol Registration System Identifier: NCT00405041.

Meralgia paresthetica: A retrospective analysis of 79 patients evaluated and treated according to a standard algorithm

Background The efficacy of various treatment modalities in meralgia paresthetica (MP) is not established. We retrospectively evaluated the management of spontaneous MP (i.e. MP not secondary to trauma or surgery) according to a standard algorithm. Methods Initial management included oral medications, rest, and reduction of aggravating factors. Non-responders underwent a diagnostic local anesthetic nerve block test. Patients who responded with transient symptomatic relief were treated by local infiltration of corticosteroids. Surgical intervention was reserved for patients with positive nerve block test, who did not respond to nonoperative measures. Results A negative nerve block test ruled out the diagnosis of MP in 6/86 patients. Of 79 patients with MP, 21 responded to the initial nonoperative treatment and 48 patients responded to local corticosteroids. 3 of the remaining 10 patients underwent surgery (nerve transection 2, neurolysis 1). During an average of 3 (1–13) years of follow-up, symptoms consistent with MP did not recur in any of the 72 patients in whom symptoms had resolved after treatment. Interpretation The algorithm used proved to be useful in the management of spontaneous meralgia paresthetica.

Whiplash injury--a retrospective study on patients seeking compensation

The purpose of this cohort study is to evaluate the objective long-term findings and the final outcome of a population suffering from whiplash-associated disorders (WAD) after rear-end car collision and claiming legal compensation. Eight hundred and sixty-six patients after whiplash injury were followed up on average 32 months post-trauma. All patients had clinical examination and radiographs performed on the day of the accident and at follow up. MRI, CT scan, bone scan, electromyographic (EMG) tests were performed upon request of the treating physician and correlated by the authors with the clinical findings. Cervical pain was the most common complaint (96%). Radiating pain to one side of the upper limbs or the shoulder was also very common (36 and 24%, respectively). Chin to chest test was found to be a strong indicator in differentiating between the less severe (grades 1 and 2) to more severe (grades 3 and 4) WAD patients. In 10% of the patients with normal radiographic findings, degenerative changes were found at follow up. CT scan and MRI did not add to patient diagnosis, except for those patients suffering from degenerative changes and decreased range of motion (RoM). Based on our findings the initial radiograph taken in the emergency room was the best imaging modality and probably the only one needed routinely following whiplash injury. Although this is a special subgroup of patient seeking compensation, the overall prognosis is favorable in all grades of WAD injury and there is no need for further diagnostic expenditures.

Traumatic separation of the symphysis pubis during pregnancy : a case report

OBJECTIVE To present an unusual case of traumatic extensive separation of the symphysis pubis during pregnancy and rationale for mode of treatment. DESIGN Diagnosis for etiology of public and lower back pain following trauma in a 37-year-old woman in an advanced stage of pregnancy. METHODS Physical examination and plain anterioposterior X-rays. CONCLUSION Extensive traumatic separation of the symphysis pubis might result from a very forceful descent of the fetal head against the pelvic ring upon the mothers accidental falling. Propitious timing of a caesarian section permits the option of open reduction and internal fixation.

Whiplash injury: is there a role for electromyographic studies?

IntroductionThis retrospective study was undertaken to assess the value of carrying out baseline and follow-up electromyography (EMG) for patients with whiplash-associated disorders (WAD, grades I and II) after they had undergone rear-end car collisions, and to determine if there is any agreement with clinical and imaging (CT and MRI) findings.Materials and methodsWe carried out a retrospective review of 330 patients seeking compensation after rear-end car collisions. The treating physician referred all patients for EMG studies in the post-injury follow-up period and for additional CT scans and MRIs. All patients underwent physical and X-ray examination by the senior author (SD), and 75 patients with persistent radicular complaints were referred again for EMG studies. The results of the association between patient complaints, clinical examination, and EMG, CT and MRI studies are reported.ResultsWe sought but failed to find any correlations between 354 EMG results with those of 278 CT scans and 75 MRIs. Both subjective complaints and early vs late EMG abnormalities showed statistical agreement and persistency of findings only at disc level C7/D1.ConclusionsOur data indicate that follow-up EMG studies for patients with WAD do not contribute any useful information for patient management.

Longstanding knee joint preserved functional outcome following medial femoral condyle resection. A case report.

Giant cell tumor of the bone (GCT) is a relatively uncommon benign aggressive tumor that occurs near the articular surface of major joints. Standard treatment of GCT is comprised of local resection followed by local adjuvant therapy. Unicondylar osteoarticular resection is usually followed by a reconstructive procedure to restore the biomechanical demands of the joint. The present report describes a patient with satisfactory knee stability and functional outcome 32 years following medial femoral condyle resection with no reconstructive arthroplasty.