Anterior Pain Research Articles

Perception Of Medical Practitioners Regarding Patient Referral to Physiotherapy

The purpose of this study is to give us an insight into the current perceptions held by other professionals who are currently practicing medicine regarding patient referral to physiotherapy. Methods: A self-designed Questionnaire was distributed among the medical practitioners that were currently working various hospitals and clinics which were currently operational and were located in various regions of Lahore, Punjab, Pakistan. The required questionnaires were filled within a period of 3 months. Results: Out of Total 225, 57% were males and 43% were females. Participants on the base of their specialties were 55% from general practice, 45% from medical specialties. The referral rate among the participants showed that 14% participants did not refer any patients at all, 22% Rarely referred patients, 49% referred patients sometimes and 15% participants referred on a regular basis.30% respondents referred patients with a prescription and 70% referred patients with a prescription did not believe that a physiotherapist cannot devise an action plan without proper instruction. While 53% medical doctors included a specified medical diagnosis in their and 47% that include a medical diagnosis said that this was not the cause of including it in referrals.Conclusion: It was concluded that, participants were found to have well response about the patient referral to physiotherapy, the likelihood of referral is good and majority of participants admit physiotherapy as autonomous profession and have opinion that physiotherapist are trained enough to determine the right treatment for their patients. Methods: This is an observational study; cross sectional survey with 306 estimated sample size 288 participants were respondents but remaining 18 were non respondents and data is collected from students of sports sciences department in mentioned universities using Kujala Scoring questionnaire. Data is entered and analyzed using SPSS version 21. Results: The results shows that age of participants were between 19 to 25 years. Number of male (62.15%) participants were more than female (37.85%) participants. prevalence of PFP among sports sciences students is 63.54%( N=183) with mild or no symptoms of anterior knee pain, 26.74%(N=77) with moderate symptoms and 9.72% (N=28) with severe symptoms of Patellofemoral pain syndrome. Conclusion: According to the results we concluded that there is mild or no symptoms of Patellofemoral Pain Syndrome in 63.54 % Sports Sciences Students in Lahore,26.74 % Sport Sciences Students have moderate symptoms of Anterior Knee joint Pain and 9.72% Sports Sciences Students have severe Symptoms of Patellofemoral Pain Syndrome

Subacute thyroiditis associated with thyrotoxic periodic paralysis after COVID-19 vaccination: a case report.

SummaryWe report a 26-year-old Japanese man who visited our outpatient clinic presenting fever immediately after i.m. injection of the second dose of a coronavirus disease 2019 (COVID-19) vaccine (Moderna®). At the first visit, the patient had a fever of 37.7°C and a swollen thyroid gland with mild tenderness. He was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free tri-iodothyronine, 32.3 pg/mL; free thyroxine, >7.77 ng/dL; and thyroid-stimulating hormone (TSH) < 0.01 μIU/mL), high C-reactive protein level (7.40 mg/dL), negative TSH receptor antibody, and characteristic ultrasound findings. His HLA types were A*02:01/24:02, B*15:11/35:01, Cw*03:03, DRB1*09:01/12:01, DQB1*03:03, and DPB1*05: 01/41:01. He was initially administered prednisolone 15 mg/day, following which the fever subsided. After 10 days, he developed limb weakness and could not walk. The serum potassium level decreased to 1.8 mEq/L, which confirmed the diagnosis of thyrotoxic periodic paralysis (TPP). Potassium supplementation was initiated. The muscle weakness gradually decreased. Prednisolone therapy was terminated 6 weeks after the first visit. His thyroid function returned to normal 5 months after the first visit, through a hypothyroid state. To our knowledge, this is the first reported case of TPP-associated SAT following COVID-19 vaccination. Persistent fever following vaccination should be suspected of SAT. Additionally, TPP may be associated with SAT in Asian male patients.Learning pointsFollowing coronavirus disease 2019 (COVID-19) vaccination, subacute thyroiditis may develop regardless of the vaccine type.If persistent fever, anterior neck pain, swelling and tenderness of thyroid gland, and symptoms of thyrotoxicosis are observed immediately after the COVID-19 vaccination, examination in consideration of the onset of subacute thyroiditis is recommended.HLA-B35 may be associated with the onset of subacute thyroiditis after the COVID-19 vaccination.Although rare, subacute thyroiditis can be associated with thyrotoxic periodic paralysis, especially in Asian men.Glucocorticoid therapy for subacute thyroiditis may induce thyrotoxic periodic paralysis through hypokalemia.

Medical Management of Septic Arthritis of the Sternoclavicular Joint With Extended-Spectrum Beta-Lactamase-Producing Escherichia coli: A Case Report

The sternoclavicular joint (SCJ) is an uncommon location for septic arthritis to occur in. Due to the rarity of the condition and the nonspecific symptoms, SCJ septic arthritis can be missed or mislabeled as osteoarthritis or muscle strain. Accurate history and physical examination is crucial for recognizing this condition. With the potential life-threatening complications that may ensue, SCJ septic arthritis has traditionally been managed surgically. This ranges from simple incision and drainage to resection of the joint. However, in cases where there is not enough fluid for incision and drainage, a trial of medical management with antibiotics can be attempted. We herein describe a case of a 58-year-old male who presented with nonspecific anterior chest wall and neck pain. Chest X-ray and ultrasound of the anterior chest wall was normal; however, magnetic resonance imaging (MRI) of the chest showed a small effusion without other complications. His blood cultures grew extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli, rendering this as his hematogenous source of septic arthritis. The ESBL was from a left-sided obstructing kidney stone that resulted in pyelonephritis, which was confirmed via computed tomography of the abdomen. His effusion was too minimal to drain; therefore, he was managed medically with intravenous (IV) antibiotics along with a left ureteral stent placement, and he had a full recovery. This case represents the ability for SCJ septic arthritis to be managed medically with IV antibiotics, especially when the diagnosis is caught early without complications. The role of MRI is indispensable for coming to the diagnosis, as it is capable of detecting complications that ultimately dictate management. Additionally, this case highlights the unique microorganism, ESBL-producing E. coli causing the SCJ septic arthritis, a finding that has been rarely reported in the literature as the majority of microorganisms that have been previously documented are either Staphylococcus aureus or Pseudomonas aeruginosa.

Tachycardiomyopathy Due To Hyperthyroidism: Case Report

Introduction High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Methods Descriptive, qualitative, and documentary study of the “case report” type. Case report Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Conclusion Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible. High output heart failure (HF) is one of the complications of hyperthyroidism. Some patients may evolve with reduced ejection fraction HF (HFREF) due to tachycardiomyopathy. The most prevalent arrhythmias are atrial fibrillation and atrial flutter, which, when controlled, improve HF. Hypotheses: Tachycardiomyopathy resulting from hyperthyroidism. Descriptive, qualitative, and documentary study of the “case report” type. Male, 35 years old, with no previous comorbidities, sought emergency with signs of decompensated HF associated with palpitations, hyperthermia, sweating, anterior neck pain, and extremity tremors. Thyroid with increased volume resulting from multiple nodules, without murmurs; bilateral exophthalmos; propulsive ictus with two digital pulps, in the sixth left intercostal space, irregular heart rhythm, HR 140bpm, pathological jugular venous pressure, bilateral crackles up to middle third. Lower limbs with edema + 3 / + 4. EKG in high-response atrial fibrillation rhythm reversed during hospitalization with amiodarone. ECHO with severe global LV systolic dysfunction with Simpson's ejection fraction 12%. He was discharged from the hospital with carvedilol, furosemide, amiodarone, and oral anticoagulant, being referred to primary care. Doppler ultrasonography of the thyroid showing increased volume, lobulated contours with diffuse heterogeneous parenchyma of multinodular aspect, and increased vascularity. Laboratory tests confirmed hyperthyroidism (TSH 0.008 mU / L; T4L 2.22 ng / dL; TRAB 9.58 IU / L). Optimized treatment for HF (added enalapril and spironolactone), it evolved in NYHA I, with a new ECHO after 3 months showing mild LV dysfunction with 45% EF. In a joint follow-up with endocrinology, under treatment with Methimazole, awaiting thyroidectomy. Hyperthyroidism increases metabolic demand and can lead to cardiovascular complications such as HF and atrial arrhythmias. This occurs by increasing blood volume, reducing systemic vascular resistance and reducing circulation time, triggering LV hypertrophy, and reducing myocardial contractile reserve. The hyperthyroidism with decompensated HF is a medical emergency with up to 30% mortality. It is a treatable entity, and its complications are potentially reversible.

Necrotizing fasciitis of the neck: A rare diagnostic emergency

A 76-year-old male, with no prior medical history, was referred to our hospital due to odynophagia and fever with 3 days, sudden worsening with dyspnea, drooling, edema and anterior neck pain. Physical examination revealed tachypnea, trismus, halitosis, bulging of the pharyngeal lateral walls and salivary stasis. No evidence of peritonsillar abscess or tonsil exudate was observed. Contrast-enhanced computed tomography (CT) of the neck revealed an organized collection involving both parapharyngeal and retropharyngeal with air bubbles and edema of the surrounding tissues (Figure 1). The patient was immediately admitted, started empiric broad-spectrum antibiotic therapy and submitted to an emergent surgical drainage. After securing the airway with tracheotomy, a trans-cervical drainage was performed. The drained pus had a grayish color and a foul smell. Necrotic tissue of fascia and sternocleidomastoid muscle were removed, as much as possible, without compromising vital structures. The cervical spaces were irrigated with a diluted solution of povidone-iodine and hydrogen peroxide. Penrose drains were placed and the skin was “loosely” approximated with minimal sutures. (Figure 2). Microbiology of the pus culture revealed the presence of Streptococcus constellatus, Eikenella corrodens, Prevotella buccae and Parvimonas micra.

Tietze's syndrome presenting as enthesitis diagnosed by ultrasound: A case report.

Tietze's syndrome (TS) is an inflammatory disorder characterised by painful, non-suppurative swelling in the sternocostal or sternoclavicular joint. The aetiology of TS is unknown. Herein, we described a case of isolated enthesitis in the sternocostal joint in a 42-year-old male patient whose clinical course led to the diagnosis of TS. A 42-year-old male Japanese patient (HLA-B27 negative) presented with chronic anterior chest wall pain. Mild swelling and tenderness were found in the right, third sternocostal joint (rt.3STCJ). No other arthralgia was present. Ultrasonography (US) of the rt.3STCJ showed hypoechoic thickening and power Doppler signal in the anterior radiate sternocostal ligament with mild synovial hypertrophy of the STCJ. US also depicted cortical bone erosion at the sternum with neovascularisation. Magnetic resonance imaging with T2-weighted short-tau inversion recovery showed high signal intensity in the bone marrow of the sternum and adjacent soft tissue around the rt.3STCJ. Based on these findings, TS with the enthesitis in the rt.3STCJ was diagnosed. The patient received a US-guided corticosteroid injection, and the symptoms completely resolved 10months later. Enthesitis may cause TS. US is a readily available, sensitive imaging technique useful for diagnosing TS.

Prevalence of Patellofemoral Pain Syndrome Among Sports Sciences Students In Lahore

Patellofemoral pain syndrome is characterized by severe pain around the knee cap during physical activities. Many researches have been done to describe the causes of PFP and it is found that it is multifactorial in nature. It is suggested that Patellofemoral pain can persist for many years and can cause decline in sports participation. Muscular imbalance and over activity are major causes of knee pain in Sports related PFP .Multiple management strategies are used in the intervention protocol of PFP however, more research is required to find potential causes of knee pain and its management in sport sciences. Objective: The aim of this study is to find out prevalence of Patellofemoral Pain Syndrome among Sports Sciences students in Lahore. Methods: This is an observational study; cross sectional survey with 306 estimated sample size 288 participants were respondents but remaining 18 were non respondents and data is collected from students of sports sciences department in mentioned universities using Kujala Scoring questionnaire. Data is entered and analyzed using SPSS version 21. Results: The results shows that age of participants were between 19 to 25 years. Number of male(62.15%) participants were more than female(37.85%) participants .prevalence of PFP among sports sciences students is 63.54%( N=183) with mild or no symptoms of anterior knee pain, 26.74%(N=77) with moderate symptoms and 9.72% (N=28) with severe symptoms of Patellofemoral pain syndrome. Conclusion: According to the results we concluded that there are mild or no symptoms of Patellofemoral Pain Syndrome in 63.54 % Sports Sciences Students in Lahore,26.74 % Sport Sciences Students have moderate symptoms of Anterior Knee joint Pain and 9.72% Sports Sciences Students have severe Symptoms Of Patellofemoral Pain Syndrome

A comparative analysis of topical corticosteroids and non-steroidal anti-inflammatory drugs to control inflammation and macular edema following uneventful phacoemulsification.

Purpose:To compare the efficacy of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisolone acetate in controlling inflammation and preventing cystoid macular edema (CME) after uneventful phacoemulsification.Methods:All patients who underwent uneventful phacoemulsification from December 2020 to Feb 2021 were included in the study. These were randomly assigned to receive any one anti-inflammatory agent among topical nepafenac (0.1%) [96 eyes], bromfenac (0.07%) [93 eyes], preservative-free ketorolac (0.4%) [94 eyes], nepafenac (0.3%) [96 eyes], or prednisolone acetate (1%) [91 eyes]. The efficacy of the drugs was evaluated by comparing the grade of anterior chamber (AC) cells, conjunctival hyperemia, pain score, visual acuity, intraocular pressure (IOP), and central macular thickness (CMT) at 1 and 6 weeks after surgery.Results:At 1 and 6 weeks, there was no significant difference in pain score, conjunctival hyperemia, AC cells, change in IOP, and visual acuity between the prednisolone and the NSAIDs groups, though nepafenac 0.3% was most effective. At 6 weeks, there was no significant difference in the number of patients developing subclinical CME in the prednisolone versus NSAID group. The mean increase in CMT was significantly lower in nepafenac 0.3% than prednisolone at 1 and 6 weeks (P = 0.003 and 0.004, respectively).Conclusion:NSAIDs used in isolation are comparable to prednisolone in preventing inflammation and pain after uneventful phacoemulsification. However, nepafenac 0.3% is most comparable to prednisolone and more efficacious in reducing the incidence of CME. We recommend that nepafenac 0.3% can be used as a sole anti-inflammatory agent in patients with uneventful phacoemulsification.

Cryotherapy in Anterior Cruciate Ligamentoplasty Pain: A Scoping Review.

Cryotherapy is used in individuals in the postoperative period (PO) of anterior cruciate ligament (ACL) repair, owing to its effects such as increased pain threshold, decreased cellular activity, and vasoconstriction. The aim of this study was to analyze the effect of cryotherapy on pain intensity in the immediate PO of ACL reconstruction. A scoping review was performed in the databases: Cochrane, Embase, Lilacs, LIVIVO, PEDro, PubMed, Scopus, and Web of Science; and gray literature: Google Scholar, CAPES Thesis Database, and Open Grey. PRISMA recommendation was followed. Two blinded reviewers performed the selection of studies: Phase 1-reading of titles and abstracts and Phase 2-Reading of the full texts and disagreements resolved in consensus. The references of 701 studies were identified, 603 from the main databases and 98 from the gray literature. After removal of duplicates, 387 studies were left for Phase 1-reading of titles and abstracts according to eligibility criteria and for Phase 2-28 studies for reading of full texts. Two studies were excluded: one randomized clinical trial and another sandwich study. Finally, 15 studies were included in this review. Cryotherapy is effective in reducing pain intensity because there were reductions in the scores of subjective pain scales in the immediate PO of ACL reconstruction. Cryocompression was shown to be superior to conventional cryotherapy.

Phrenic nerve schwannoma as an incidental intraoperative finding. Case report.

Introduction and importancePeripheral neuronal sheath tumors are rare lesions that can arise from the lining of the neuronal axons of any nerve in the body. Schwannomas are usually solitary and encapsulated, slow growing, predominantly benign, with a malignant transformation rate of less than 2% and very low recurrence. The phrenic nerve schwannoma is rare in the neck and usually is asymptomatic.Case presentationWe present a case of a phrenic nerve schwannoma as an incidental intraoperative finding in the study of a patient with a cervical mass of progressive growth on the right side of the neck in contact with the anterior scalene muscle and pain intermittent. Resection of the mass was done with preservation of the endoneurium. Intraoperative stimulation after resection had a proper functionality of the phrenic nerve. In the follow-up, the patient had not any damage of the function of the phrenic nerve.Clinical discussionThis tumor is generated by a deficiency of merlin with the consequent cell proliferation. The diagnostic imaging (CT or MRI) are the studies of choice. The differential diagnosis of these lesions has an impact on the presence or absence of oncological disease or progression of a previously treated one. The ideal management is surgical and the anatomical and/or functional preservation of the nerve depend of the tumor infiltration.ConclusionThe phrenic nerve schwannoma is rare in the neck. The ideal management is surgical, and this pathology must be considered in patients with masses in the Station IV and supraclavicular fossa of the neck.

Knee symptoms do not affect walking biomechanics among women 6 months after anterior cruciate ligament reconstruction.

Women with anterior cruciate ligament reconstruction report worse pain and knee-related symptoms, and also exhibit biomechanical changes that may be related to knee osteoarthritis (OA) development. This is particularly concerning as symptom state has been previously associated with knee OA development. The purpose of this study was to compare lower extremity walking biomechanics between women (age: 21.40 ± 8.54 years) experiencing clinically significant knee-related symptoms and women with acceptable symptoms 6 months following surgery. Twenty-eight women with history of primary, unilateral anterior cruciate ligament reconstruction who completed a lower extremity walking biomechanics assessment 6 months following surgery were included in this analysis. Women were dichotomized as experiencing acceptable or clinically significant knee symptoms according to Knee injury and OA Outcomes Score cut-offs described by Englund et al. Walking biomechanics were compared between women with clinically significant and acceptable symptoms using one-way analysis of covariances for involved limb biomechanics. Biomechanical variables of interest were: peak vertical ground reaction forces (vGRFs), vGRF loading rates, knee flexion angles, knee extension moments, knee adduction angles, and knee adduction moments, and gait speed. Nearly 60% of women reported clinically significant knee symptoms 6 months postoperative. There were no statistically significant differences between symptom groups for walking biomechanics and gait speed outcomes. These findings suggest patient reported knee symptoms may not be a primary influence on walking biomechanics 6 months following anterior cruciate ligament reconstruction. Though, longitudinal assessment of changes in symptom state and walking biomechanics may be warranted as poorer walking biomechanics and symptoms are indicators of knee OA.

Association between patellofemoral pain syndrome (PFPS) and muscle tightness a cross- sectional study

Background: Patellofemoral pain syndrome (PFPS) is characterized by peripatellar or retro patellar pain, as a result of changes in the physical and biochemical components of the patellofemoral joint. The main contributory factor being the load on the patellofemoral joint. The change in the flexibility of lower limb muscles is one of the factors for developing PFPS. Purpose: The aim is to find the association between muscle tightness (hamstring, quadriceps, illiotibial band, gastrocnemius, and quadratus lumborum) and PFPS on affected and unaffected sides. Study design: A cross -sectional study Methods: Subjects with PFPS were included with age 18 to 40 years having anterior, retro or peripatellar non-traumatic pain at least for a duration of 6weeks. Active knee extension test for hamstring length, ely test for rectus femoris, modified obers test for ITB length, weight-bearing lunge test for gastrocnemius, and QL muscle length were measured to assess the presence or absence of muscle tightness. A Chi Square test and phi crammer&#39;s v criteria was used to check the association and strength of the association respectively. Results: A significant strength of association was found between rectus femoris tightness (Phi-Crammer’s V =.632 p

Missing the Bull’s Eye: A Case Report of Tibialis Anterior Hernia

Objectives: Shin pain is a broad term used to describe lower leg pain. It is commonly seen in the athletic/sports population. Various conditions have been claimed to produce leg pain, and muscle herniation is one of these conditions. Muscle herniation is the protrusion of muscle through a defect in the overlying fascia. Although such herniation is common, it is often an underdiagnosed condition in the lower extremity. It usually occurs in athletes, especially in the anterior compartment of the leg, as a result of trauma or due to muscle hypertrophy secondary to strenuous exercise. Herniation diagnosis depends on its clinical presentation as it appears as a palpable soft tissue bulge through a fascia defect; radiological findings are used to confirm the diagnosis. Conservative treatment should be the initial approach, and surgery can be performed if conservative treatment fails. Methods: We present a case of symptomatic anterior lower leg pain, initially diagnosed as a psychosomatic disorder by two orthopedic physicians. However, tibialis anterior hernia in this patient was confirmed after physical examination by a physiotherapist and subsequent referral for ultrasonographic evaluation to a radiologist. The patient underwent an 8-week course of conservative treatment under the supervision of a physiotherapist. This treatment significantly improved the patient’s pain and function. Results: After eight weeks of conservative treatment using Minhaj protocol for Tibialis Anterior hernia, the patient has reported improvement in pain (reduction of score from eight to two on the NPRS scale) and function. The patient returned to his previous level of physical activity following eight weeks of rehabilitation. Discussion: Tibialis anterior hernia should be considered a differential diagnosis in chronic leg pain with palpable soft tissue protrusion. Conservative treatment can be chosen as the primary approach.

Graves’ Disease Following Subacute Thyroiditis

Subacute thyroiditis is an inflammatory thyroid disease caused by viral infection. Graves’ disease is an autoimmune thyroid disease caused by thyrotropin (TSH) receptor antibody (TRAb). Graves’ disease following subacute thyroiditis is rare, and only a few cases have been reported. A 58-year-old woman presented with anterior neck pain and swallowing difficulty. Laboratory tests showed elevated FT4, low TSH, normal TRAb, and elevated erythrocyte sedimentation rate. Thyroid ultrasonography (US) revealed focal, ill-defined hypoechoic areas in both thyroid lobes. The patient was treated with corticosteroid, and symptoms subsided after 1 month. Three months later, she complained of tremor and palpitation. Thyroid function testing showed hyperthyroidism with the positive conversion of TRAb, indicating Graves’ disease. Doppler US showed increased vascular flow in both thyroid lobes. She started treatment for hyperthyroidism with methimazole.

Infrahyoid myofascial flap transfer for the prevention of concave deformity and gustatory sweating after parotidectomy

ObjectiveConcave deformities and gustatory sweating are the most common complications that cause substantial patient dissatisfaction after parotidectomy. Various surgical methods to prevent these complications have been described. However, effective techniques have not been established, especially in patients with medium- to large-sized parotidectomy defects. We evaluated the utility of infrahyoid myofascial flap reconstruction of parotidectomy defects for the prevention of these complications. MethodsWe conducted a retrospective case series study in patients with a benign or malignant parotid tumor measuring over 4 cm who underwent immediate pedicle infrahyoid myofascial flap reconstruction after total or subtotal parotidectomy or total resection of either the superficial or deep parotid gland at our hospital. Subjective analyses of facial symmetry, postoperative concave deformities of the anterior neck, gustatory sweating, voice disorders, odynophagia, neck scarring in the parotid and anterior neck areas, sensory disorders, pain, and neck stiffness were performed using patient interview data. Objective evaluations of facial symmetry were made by the first or second author. Both analyses were performed after a follow-up of more than six months. Additionally, patient demographic data, clinicopathological factors, parotidectomy and skin incision types, flap survival, and postoperative complications were evaluated. ResultsWe included eight patients (male, n=5; mean age, 69.3 years [range, 37–93 years]). Procedures included total or subtotal parotidectomy (n=4), superficial lobe parotidectomy (n=2), and deep lobe parotidectomy with partial superficial lobe parotidectomy (n=2). Infrahyoid myofascial flaps reached the cranial tip of the parotid defect without tension, and their volume sufficiently filled the parotidectomy defect in all patients. There were no local signs of insufficient blood flow within the transferred flaps.Objective and subjective assessments were made after a mean duration of 1.2 years (range, 0.6-1.8). Postoperatively, no patient subjectively reported facial asymmetry. Objectively, facial symmetry was “good” in four patients and “fair” in four patients. No distinctly visible concave deformity in the parotid or anterior neck area occurred in any patient. Gustatory sweating occurred in one patient; this individual had the largest parotidectomy defect. Only one patient experienced donor site morbidity (mild anterior neck stiffness) related to infrahyoid myofascial flap elevation. ConclusionAlthough complete prevention of gustatory sweating was unsuccessful, infrahyoid myofascial flap reconstruction of medium- to large-sized parotidectomy defects led to postoperative facial symmetry with minimal donor site morbidity.

Botulinum toxin injections as salvage therapy is beneficial for management of patellofemoral pain syndrome

PurposePatellofemoral pain syndrome (PFPS) is a common pathology usually presenting with anterior or retropatellar pain. It is associated with a relative imbalance between the vastus medialis oblique (VMO) and the vastus lateralis (VL) muscles. This can lead to considerable morbidity and reduced quality of life (QOL). This study aims to assess the long-term functional outcome of PFPS treated with VL muscle botulinum toxin A (BoNT-A) injection.Materials and methodsA retrospective review was performed on 26 consecutive patients (31 knees) with a mean age of 50.1 years (± 19.7 years) who were treated with BoNT-A injections to the VL muscle followed by physiotherapy between 2008 and 2015. Pre- and post-treatment pain levels (numerical rating scale, NRS), QOL (SF-6D), and functional scores (Kujala and Lysholm questionnaires) were measured. Demographics, physical therapy compliance, previous surgeries, perioperative complications, and patient satisfaction levels were collected.ResultsThe mean follow-up time was 58.8 ± 36.4 months. There were significant improvements in all the examined domains. The average pain score (NRS) decreased from 7.6 to 3.2 (P < 0.01), and the Kujala, Lysholm, and SF-6D scores improved from 58.9 to 82.7 (P < 0.001), 56.2 to 83.2 (P < 0.001), and 0.6 to 0.8 (P < 0.001), respectively. Similar delta improvement was achieved irrespective of gender, age, compliance to post-treatment physical therapy, or coexisting osteoarthritis. Patients who presented with a worse pre-treatment clinical status achieved greater improvement. Prior to BoNT-A intervention, 16 patients (18 knees) were scheduled for surgery, of whom 12 (75%, 13 knees) did not require further surgical intervention at the last follow-up.ConclusionsA single intervention of BoNT-A injections to the VL muscle combined with physiotherapy is beneficial for the treatment of patients with persistent PFPS.Level III evidenceRetrospective cohort study.

COVID-19 vaccination and a severe pain in the neck

A 40-year-old woman developed malaise and severe anterior neck pain 12 hours after the second dose of COVID-19 mRNA vaccine (Pfizer/BioNTech). The pain peaked and plateaued at the fourth post-vaccination day. Her GP prescribed ibuprofen and azithromycin for presumed bacterial pharyngitis, with no avail. She visited our endocrine clinic 26 days post-vaccination with ongoing symptoms including bony aches, exhaustion, emotional lability, palpitations and hyperhidrosis. Upon general examination she was haemodynamically stable but with significant neck tenderness (visual acuity score = 8/10).

Short-Term Comparison between Resection and Preservation of the Infrapatellar Pad of Fat in Patients Undergoing Primary Total Knee Replacement

Background: Resection of infrapatellar pad of fat (IPPF) is an ordinary step performed in primary total knee joint replacement (TKR) in approximately 88% to get a clearer field and eases patellar retraction to a side away during the surgical procedure. Objectives: The aim of this study was to evaluate the preservation versus resection of the IPPF regarding postoperative pain and range of movements in patients undergoing primary TKR. Materials and Methods: This was a prospective, case series study conducted in Erbil Teaching Hospital from March 1, 2018 till December 31, 2018. A total of 28 patients who underwent primary TKR were randomly allocated into two equal groups. In the first group the pad of fat was resected, whereas in the other group the pad of fat was preserved. The follow-up period of this study was 9 months. Patients of both groups were seen and followed up in the ward in the first 5 days of admission and seen again at the outpatient clinic at weeks 2, 6, 12, 24, and 36. The anterior knee joint pain and range of movement were recorded and observed by visual analog scale (VAS) score, knee score, and knee functional score. Results: Twenty-eight patients who underwent primary TKR were included in this study. Among them, 18 patients were women (64.28%) and 10 were men (35.72%). The mean age of the patients was 63.42 years ± 4.31 years, ranging from 56 to 71 years. Improved postoperative VAS score of the IPPF resection group (6.28 ± 0.91) and preserved group (5.92 ± 0.82) were observed (P &lt; 0.045) at the 6 months of follow-up. Improvement in the degree of flexion observed in the IPPF preservation group over the resected one (P &lt; 0.0060), with either no statistical differences were noticed of the final Knee Society Scores or the functional scores of the two groups, (62.78 ± 4.91) and (50.07 ± 5.80) of the IPPF resected group, (64.57 ± 5.54) and (52.14 ± 5.08) of the IPPF preservation group with both scores (P = 0.059 and 0.850), respectively. Conclusions: Preservation over resection of the IPPF during primary TKR decreases the postoperative anterior knee joint pain. Consequently, no significant changes were observed regarding the knee joint functionality.

High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability

PurposeThe purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up.MethodsA retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis.ResultsWe identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis.ConclusionsThere is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain.Level of EvidenceLevel IV, retrospective diagnostic case series.

Genicular Nerve Anatomy and Its Implication for New Procedural Approaches for Knee Joint Denervation: A Cadaveric Study.

To verify the articular branch contributions in the human knee, delineate their anatomical variance, and outline the limitations of currently applied procedure protocols for denervation of the knee joint. A detailed anatomical dissection. Cadavers in residence at the Albert Einstein College of Medicine. In total, 24 lower extremity specimens from 14 embalmed cadavers. Human cadaveric dissections were performed on 24 lower extremities from 14 embalmed cadavers. This cadaveric study has demonstrated that the anterior knee receives sensory innervations from SMGN, SLGN, LRN, NVI, NVL, RFN, and IMGN. The courses of SMGN, SLGN, RFN, and IMGN are similar to recent anatomical studies. However, discrepancies exist in their relative anatomy to bony and radiographic landmarks. Genicular denervation using classical anatomical landmarks may not be sufficient to treat the anterior knee joint pain. Our findings illustrate more accurate anatomic landmarks for the three-target paradigm and support additional targets for more complete genicular denervation. This cadaveric study provides robust anatomical findings that can provide a foundation for new anatomical landmarks and targets to improve genicular denervation outcomes.