Walter Taylor

Peroneal tendon subluxation: the other lateral ankle injury

Ankle injuries are a frequent cause of patient visits to the emergency department and orthopaedic and primary care offices. Although lateral ligament sprains are the most common pathologic conditions, peroneal tendon subluxations occur with a similar inversion mechanism. Multiple grades of subluxation have been described with a recent addition of intrasheath subluxation. Magnetic resonance imaging is the best imaging modality to view the peroneal tendons at the retrofibular groove. Currently, point-of-care ultrasound is gaining clinical ground, especially for the dynamic viewing capability to capture an episodic subluxation. Although conservative treatment may be attempted for an acute injury, it has a low rate of success for the prevention of recurrent subluxation. Surgical procedures of various techniques have resulted in excellent recovery rates and faster return to play. The aim of this paper was to give a complete review of the current literature on peroneal tendon subluxation and to propose a clinical algorithm to help guide diagnosis and treatment. The goal of this study was to heighten clinical awareness to improve earlier detection and treatment of this sometimes elusive diagnosis.

Echocardiographic characterisation of left ventricular geometry of professional male tennis players.

Background: The cardiac characteristics of various types of athletes have been defined by echocardiography. Athletes involved in predominately static exercise, such as bodybuilders, have been found to have more concentric hypertrophy, whereas those involved in dynamic exercise, such as long distance runners, have more eccentric hypertrophy. Tennis at the elite level is a sport that is a combination of static and dynamic exercise. Objective: To characterise left ventricular geometry including left ventricular hypertrophy by echocardiography in male professional tennis players. Design: Retrospective study of screening echocardiograms that were performed on male professional tennis players. Setting: All echocardiograms were performed at the Mayo Clinic (Jacksonville, Florida, USA) between 1998–2000. Participants: A total of 41 male professional tennis players, with a mean age of 23. Results: Left ventricular hypertrophy was present in 30 of 41 subjects (73%, 95% CI: 57%–86%). The majority of players manifested eccentric hypertrophy (n = 22, 54%). Concentric hypertrophy (n = 9, 22%) and normal geometry (n = 7, 17%) were encountered with similar frequency. Only 7% (n = 3) manifested concentric remodelling. The mean thickness of both the interventricular septum and the posterior wall was 11.0 mm. The mean LVEDd was 55 mm. The mean RWT was 0.41. The mean LVMI was 130 gm/m2 and the mean EF was 64%. Five of the 41 subjects had an abnormal septal thickness of 13 mm. Conclusion: This was the first study to specifically describe the full range of echocardiographically-determined left ventricular geometry in professional male tennis players. The majority of subjects exhibited abnormal geometry, predominantly eccentric hypertrophy.

Eosinophilic fasciitis in a duathlete.

CASE REPORT A 59-year-old woman who was a world-class duathlete presented with fatigue and insidious onset of edema involving the extremities and face. Fatigue progressed over several weeks such that she was unable to run for more than 2 minutes. Four months before the onset of symptoms, she sustained a clavicle fracture requiring 8 weeks of rest. After recovery, she trained intensely for the World Duathlon Championships where she performed poorly because of intense fatigue. The patient came to our sports medicine clinic after extensive work-up by a cardiologist, neurologist, and rheumatologist. Treatment had included compressive stockings and diuretics, which had minimal effect. Her work-up before our evaluation included a negative Cardiolite stress test and computed tomography of the abdomen and pelvis. Her medical history included asthma, hypothyroidism, fibromyalgia, osteopenia, and allergic rhinitis. There was no history of Raynaud phenomenon. Medications included montelukast, azelastine nasal spray, fluticasone inhaler, salmeterol inhaler, alendronate, celecoxib, hydrochlorothiazide/triamterene, and levothyroxine. She had previously taken tryptophan but not since 1999. Physical examination was remarkable for 3+ pitting edema of the knees through the feet bilaterally and 1+ edema of the hands, with induration of the skin in the pretibial and forearm regions. No sclerodactyly was present and peripheral pulses were normal. Results of laboratory studies are summarized in Table 1. Echocardiography showed mild eccentric left ventricular hypertrophy, a mildly thickened mitral valve, and ejection fraction of 60%. Magnetic resonance imaging (MRI) of the extremities, suggested by a consulting rheumatologist, showed hyperintense signal on T2 images extending diffusely along the fascial planes and subcutaneous tissues of both calves and the right forearm, which was consistent with fasciitis (Figure 1). A biopsy specimen from the left medial gastrocnemius showed fascia with associated lymphoplasmacytic inflammation including eosinophils and associated edema and hemorrhage (Figure 2). These results were believed to be consistent with a diagnosis of eosinophilic fasciitis. Treatment was begun with prednisone (60 mg daily) and eventually included methotrexate. She was followed up by her outside rheumatologist. Methotrexate caused significant elevation of liver transaminases and was subsequently withdrawn. The prednisone was gradually tapered over 17 months. The patient has returned to highlevel duathlon training and qualified and competed in the 2004 National and World Championships for her age group.