Common Extensor Research Articles

¿Es transferible la terapia de locomoción refleja a una plataforma de teleneurorrehabilitación en el tratamiento del paciente adulto?

IntroductionTele-rehabilitation refers to the providing of physiotherapy services based on the new information and communication technologies. The potential of Vojta therapy is studied in order to be partially used in adults in this setting. Material and methodA randomized, double blind clinical trial was performed with 45 healthy adult subjects (20 men and 25 women; aged: 23 to 41 years; SD: 2.73). Chance selection. Two types of chest area stimulation are studied in the Reflex Rolling pattern: manual compared to a mechanical mechanism that reproduces the same stimulation. Primary endpoint: microvolts of muscle contractions with a surface EMG, over the common fingers extensor. Finally, the subject's capacity of control of the reflex activation caused with the mechanism is studied. The session are supervised by distance with a webcam. ResultsThere are significant contradictions in both types of intervention regarding resting levels P=.00. However, significant differences are not found in the main result between manual intervention or that produced by the mechanical mechanism P=.29. It was not possible to demonstrate significant differences, P=.64 in the activation stage with webcam. ConclusionsThe mechanical mechanism produces a contraction in the muscle similar to the manual intervention. Furthermore, the remote activation with the mechanism shows that the trained subject is capable of self-management under the supervision of the webcam specialist. Therefore, Vojta therapy in the Reflex Rolling pattern has the potential to be transferred to a tele-rehabilitation platform for adults.

Psychosocial and personality factors and physical measures in lateral epicondylalgia reveal two groups of “tennis elbow” patients, requiring different management

Background and purposeNirschl's lateral epicondylalgia (LE) classification appears prognostic but is based upon an outdated model of tendinopathy. Psychosocial factors which may negatively influence treatment outcomes, central nervous system mediated hypersensitivity and motor impairment all occur in epicondylalgia. This study examines psychosocial/personality factors and physical measures in LE correlating them with Nirschl's sub-groups. MethodsFifty-four subjects with LE and 43 healthy controls, recruited from primary care in Norway were assessed. Measures included: pressure pain threshold (PPT), isometric maximal load pain tolerance (MLT) and isometric low load (sustained hold of 0.5kg weight) pain tolerance (LLT) of the wrist extensors, all of which were undertaken bilaterally; the Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), and the Swedish Scales of Personality. ResultsPatients had significantly lower pain thresholds than controls especially at the common extensor origin, but thresholds did not differentiate Nirschl's groups. MLT did not differentiate between controls and patients or between pain groups. LLT differentiated pain patients from controls but not between different pain groups. The ÖMPSQ score was significantly different between three out of four of Nirschl's pain groups and both pain thresholds and MLT in both the painful and non-/less painful arms were significantly but negatively correlated with the ÖMPSQ score. Somatic anxiety was significantly different between healthy controls and Nirschl's most symptomatic pain group; and also correlated with the ÖMPSQ score. ConclusionsThe ÖMPSQ differentiated Nirschl's sub-groups more effectively than the PPT, MLT or LLT, but the control group did not complete the ÖMPSQ, so a comparison of the subjects with LE to symptom-free subjects was not possible. Elevated somatic anxiety in the most symptomatic patients may indicate possible alexithymia or an inability to understand or cope with somatic symptoms of distress. The subjects in this study with epicondylalgia exhibited widespread, likely central nervous system mediated hypersensitivity, motor impairment and psychosocial factors in keeping with a modern model of LE. This hypersensitivity suggests epicondylalgia should not be considered a localised pathology and management should be tailored towards underlying multidimensional biopsychosocial pain mechanisms. Possible pain mechanisms driving this hypersensitivity are postulated. LLT, a novel impairment test, is significantly reduced in LE and should be examined in this patient group, and possibly rehabilitated specifically. Based upon physical and psychological data from this study, Nirschl's sub-grouping seems too detailed and our results suggest that the four groups should be reduced to two. Thus, for diagnostic purposes the Nirschl's groups I and II could be collapsed to one group, and groups III and IV to a second group. ImplicationsPsychosocial and personality factors should be measured in subjects with epicondylalgia as they correlate with physical signs. Management should therefore be tailored to patient presentations, particularly where significant psychosocial factors or specific motor impairments exist.

FRI0510 Elbow pathology in patients with inflammatory arthropathies: a clinical, sonographic and radiographic study

BackgroundUltrasonography is widely used in Rheumatology practice to detect articular and periarticular lesions. To date, elbow clinical findings have not been compared with ultrasonography (US) and conventional radiography (RX) in...

AB1440-HPR The immediate effect of lateral epicondylitis bandage and kinesiotape in patients with lateral epicondylitis: A pilot study

BackgroundLateral Epicondylitis or tennis elbow is a frequently encountered clinical entity characterized by pain in the region of the lateral epicondyle of the humerus which is aggravated during resisted dorsiflexion...

Die transossäre Refixation der Extensoren bei chronischer radialer Epikondylopathie mit und ohne Rekonstruktion des LUCL-Komplexes - eine retrospektive Analyse von 101 Patienten

The chronic lateral epicondylitis (EHR) as a common pathology of the elbow is often associated with posterolateral rotatory instability of the elbow (PLRI). After evaluation of intra-articular pathology by prior diagnostic arthroscopy, we aimed to build patient groups regarding the stability of the elbow joint. In patients with a stable elbow joint, open surgery with a debridement to the origin of the common extensor tendon and transosseous refixation was performed. Patients with relevant posterolateral rotatory instability, however, underwent an additional LUCL complex stabilisation using triceps tendon graft besides debridement as mentioned above. The purpose of this study was to evaluate and compare the clinical functional outcome between these groups. 101 patients were included in our study. Arthroscopies were first performed on all patients to identify intra-articular pathological changes. In 26 patients with stable elbows, open surgery with debridement to the origin of the common extensor tendon and transosseous refixation was performed. For the other 75 patients who were found presenting a relevant posterolateral rotatory instability, a stabilisation of the LUCL in addition to the open procedure mentioned above was performed. Examinations and questionnaires were used for retrospective evaluation at follow-up. Both groups of patients revealed significant improvement in pain relief and elbow function. We observed no significant difference between the two methods concerning clinical and functional outcome. We recommend diagnostic arthroscopy with assessment of stability prior to the open performance to offer a more reliable evidence for surgical technique selection and therefore to achieve a better clinical outcome.

Helical sub-structures in energy-storing tendons provide a possible mechanism for efficient energy storage and return

The predominant function of tendons is to position the limb during locomotion. Specific tendons also act as energy stores. Energy-storing (ES) tendons are prone to injury, the incidence of which increases with age. This is likely related to their function; ES tendons are exposed to higher strains and require a greater ability to recoil than positional tendons. The specialized properties of ES tendons are thought to be achieved through structural and compositional differences. However, little is known about structure–function relationships in tendons. This study uses fascicles from the equine superficial digital flexor (SDFT) and common digital extensor (CDET) as examples of ES and positional tendons. We hypothesized that extension and recoil behaviour at the micro-level would differ between tendon types, and would alter with age in the injury-prone SDFT. Supporting this, the results show that extension in the CDET is dominated by fibre sliding. By contrast, greater rotation was observed in the SDFT, suggesting a helical component to fascicles in this tendon. This was accompanied by greater recovery and less hysteresis loss in SDFT samples. In samples from aged SDFTs, the amount of rotation and the ability to recover decreased, while hysteresis loss increased. These findings indicate that fascicles in the ES SDFT may have a helical structure, enabling the more efficient recoil observed. Further, the helix structure appears to alter with ageing; this coincides with a reduction in the ability of SDFT fascicles to recoil. This may affect tendon fatigue resistance and predispose aged tendons to injury.

Treatment Outcome of Tennis Elbow by Percutaneous Needle Tenotomy

Introduction: Tennis elbow (TE), or lateral epicondylitis of the humerus, is a painful condition seen commonly in the daily practice of Orthopaedic surgeons. One of the myriad of treatment methods for TE is percutaneous needle tenotomy of the common extensor origin. It is a simple operation with minimal morbidity and good-to-excellent results in most of the patients. The aim of this study was to evaluate the outcome in patients with chronic TE. Methods: this was a prospective study in 33 consecutive patients of both sexes with TE who were above 30 years of age. An 18 Gauge hypodermic needle was used under local anaesthesia to percutaneously tenotomise the extensor origin at the point of maximum tenderness. Visual analogue score (VAS) was used to assess the pain prior to intervention and in subsequent follow-ups at first, third, sixth and 12th weeks. Persistence of pain and return to activities of the patients was used to evaluate outcome as excellent, good, fair or poor. Results: At the end of 12 weeks, eleven out of 30 elbows (36.7%) had an excellent outcome, 13 (43.3%) had good, 5 (16.7%) had fair and 1 patient (3.3%) had poor outcome. At first week follow-up, the mean pain at rest was 4.60, the same at night was 2.73 and activity pain was a mean of 7.70 (max-9, min-5). By 12 week follow-up, the mean VAS scores at rest, night and activites were 0.87, 0.63 and 1.53 respectively, showing significant decrease in pain. Conclusions:Percutaneous tenotomy is a simple, safe, patient friendly, effective and easily reproducible method of treating tennis elbow.Medical Journal of Shree Birendra Hospital; July-December 2012/vol.11/Issue2/32-35 DOI: http://dx.doi.org/10.3126/mjsbh.v11i2.7907

Proximal Disinsertion of the Common Extensor Tendon for Lateral Elbow Tendinopathy

To evaluate surgical outcomes of disinsertion of the common extensor tendon for lateral elbow tendinopathy. Records of 277 men and 128 women who underwent surgery for lateral elbow tendinopathy were reviewed. The indication for surgery was insufficient improvement of pain and inability to return to work after 3 weeks of physiotherapy (stretching, ultrasound) and local corticosteroid injections. According to the Tavernier technique, the origin of the tendons of the extensor carpi radialis brevis and extensor digitorum communis was located, and proximal disinsertion of the common extensor tendon was performed. Outcome was excellent in 344 (85%) of the patients, good in 46 (11.5%), regular in 9 (2%), and poor in 2 (0.5%). The mean time to return to work was 29 (range, 5-93) days. Immediate complications included infection (n=1), seroma (n=1), cicatricial fibrosis (n=10), radial neuritis (sensory) [n=4], and reactive dermatitis (n=2). Late complications included Frohse's arcade syndrome (n=1) and carpal tunnel syndrome (n=2). Disinsertion of the proximal common tendon is a good option for treating lateral elbow tendinopathy.

Sonographic examination of the common extensor tendon of the forearm at three different locations in the normal asymptomatic population

The aim is to examine the common extensor tendon (CET) thicknesses at three locations in the normal population with ultrasound (US), to determine changes related to dominancy, age, gender, body mass index and to evaluate structural changes in normal tendons. The study included 100 normal volunteers (200 elbows). CET was examined at three landmark locations bilaterally (humeral, articular and radial) and if present, other structural abnormalities such as tendinosis (focal or diffuse tendon echogenicity changes), tears, bone changes (enthesophytes, spurs, irregularities), tendon calcification, effusion and neovascularization were noted. Common extensor tendon was thicker on the dominant side at all three locations (humeral 4.60 versus 4.22 mm, articular 3.55 versus 3.23 mm, radial 3.17 versus 2.88 mm, p < 0.001) and gradually tapered from proximal to distal, moderate relation with age and BMI was present, most pronounced at the humeral location. Bone changes (spurs, irregularities) correlated positively with age and CET thickened in the dominant arm after 42.5 years of age which was also a cut-off age for bone changes (p < 0.05). Asymptomatic tendinosis (12%) within the normal population was significantly related to the dominancy (p = 0.032) but was not influenced by age, gender, BMI, bone degeneration or tendon thickening. When interpreting CET thickness, caution should be placed on tendon measurement points in addition to variables such as age, gender, BMI, dominancy and bone changes. Structural tendon changes (tendinosis) may be encountered in the symptom free (healthy), normal population and, not tendon thickening but dominancy is a feature of this asymptomatic tendinosis.

Capacity for sliding between tendon fascicles decreases with ageing in injury prone equine tendons: a possible mechanism for age-related tendinopathy?

Age-related tendinopathy is common in both humans and horses; the initiation and progression of which is similar between species. The majority of tendon injuries occur to high-strain energy storing tendons, such as the human Achilles tendon and equine superficial digital flexor (SDFT). By contrast, the low-strain positional human anterior tibialis tendon and equine common digital extensor (CDET) are rarely injured. It has previously been established that greater extension occurs at the fascicular interface in the SDFT than in the CDET; this may facilitate the large strains experienced during locomotion in the SDFT without damage occurring to the fascicles. This study investigated the alterations in whole tendon, fascicle and interfascicular mechanical properties in the SDFT and CDET with increasing age. It was hypothesised that the amount of sliding at the fascicular interface in the SDFT would decrease with increasing horse age, whereas the properties of the interface in the CDET would remain unchanged with ageing. Data support the hypothesis; there were no alterations in the mechanical properties of the whole SDFT or its constituent fascicles with increasing age. However, there was significantly less sliding at the fascicular interface at physiological loads in samples from aged tendons. There was no relationship between fascicle sliding and age in the CDET. The increase in stiffness of the interfascicular matrix in aged SDFT may result in the fascicles being loaded at an earlier point in the stress strain curve, increasing the risk of damage. This may predispose aged tendons to tendinopathy.

Cross-sectional area and mean echogenicity of shoulder and elbow tendons in adult German Shepherd dogs

The aim of this study was to describe the cross-sectional area and mean echogenicity of the main tendons of the shoulder and elbow joints in adult German Shepherd dogs and to determine the effects of sex, weight, and age on these parameters. No previous publications in the veterinary literature have reported information regarding quantitative ultrasonographic tendon measurements in dogs. Thirty German Shepherd dogs were examined: 13 males and 17 females. The cross-sectional area was significantly higher in males than in females (p <0.05) for the distal tendon of the triceps brachii muscle and the tendons of the flexor carpi ulnaris and common digital extensor muscles. The influence of sex on mean echogenicity was not significant. According to age, mean echogenicity was higher in older dogs, while the cross-sectional areas were similar in the two groups. Cross-sectional area and mean echogenicity of the tendons showed a direct increase with an increase in body weight. The data gained from this study can help support the clinician to discriminate between normal and pathological conditions.

Knee ligament injuries: biomechanics comparative study of two suturetechnique in tendon – analysis “in vitro” tendon of bovine

ObjectiveTo evaluate and compare the biomechanical behavior of two different suture configurations:“X”and“Loop”in the preparation of tendons for knee ligament reconstruction. MethodsWe used common digital extensor tendons of bovine that can replace the human flexor tendons in experimental studies of traction. In the first group, point “X” suture with Ethibond ® No. 5 began in the distal graft points transfixing, with spacing of 7.5mm points to reach 03cm distal to the beginning of the suture, returning suture in the same manner, transfixing the tendon in open spaces across the suture configuration “X”. The second group, the point “Loop” was prepared with the same type Ethibond ® No. 5 of the needle wire was removed for use only of the wire was mounted in a twofold manner in a single piece forming a needle loop. Started the suture 3cm from the end of the graft through loops and transfixing points throughout the tendon substance, with spacing between dots of 7.5mm. ResultThe Maximum Force of Rupture suture in “Loop” was 444.45N and the suture in “X” was 407.59N with statistical significance (p = 0.030). The average Tension obtained at the suture in “Loop” was 27.67MPa and at the suture in “X” was 25.73MPa with a statistically significant difference (p = 0.036). The stiffness showed no statistical differences (p = 0.350) at 11.804N / mm at the point where “Loop” and 11.570N / mm at the suture “X”. ConclusionThe suture in “Loop” had a higher biomechanical behavior to the suture “X”, considering the Maximum Force and Tension.

Lesões ligamentares do joelho: Estudo biomecânico comparativo de duas técnicas de sutura em tendões: análise in vitro em tendões de bovinos

ObjectiveTo evaluate and compare the biomechanical behavior of two different suture configurations:“X”and“Loop”in the preparation of tendons for knee ligament reconstruction. MethodsWe used common digital extensor tendons of bovine that can replace the human flexor tendons in experimental studies of traction. In the first group, point “X” suture with Ethibond ® No. 5 began in the distal graft points transfixing, with spacing of 7.5mm points to reach 03cm distal to the beginning of the suture, returning suture in the same manner, transfixing the tendon in open spaces across the suture configuration “X”. The second group, the point “Loop” was prepared with the same type Ethibond ® No. 5 of the needle wire was removed for use only of the wire was mounted in a twofold manner in a single piece forming a needle loop. Started the suture 3cm from the end of the graft through loops and transfixing points throughout the tendon substance, with spacing between dots of 7.5mm. ResultThe Maximum Force of Rupture suture in “Loop” was 444.45N and the suture in “X” was 407.59N with statistical significance (p = 0.030). The average Tension obtained at the suture in “Loop” was 27.67MPa and at the suture in “X” was 25.73MPa with a statistically significant difference (p = 0.036). The stiffness showed no statistical differences (p = 0.350) at 11.804N / mm at the point where “Loop” and 11.570N / mm at the suture “X”. ConclusionThe suture in “Loop” had a higher biomechanical behavior to the suture “X”, considering the Maximum Force and Tension.

The Anatomy of the Forearm Extensor Muscles and the Fascia in the Lateral Aspect of the Elbow Joint Complex

Aim: This study aimed to address the lack of detailed information on the fascia, and the potentially diverse attachments of the Extensor Carpi Radialis Brevis and Extensor Digitroum Communis on the lateral epicondyle. Methodology: Twenty cadavers were dissected by layers consisting of the skin, subcutaneous fat, superficial fascia, deep fascia, and muscles. Results/Conclusion: The separable attachment of the Extensor Capri Radialis Brevis and Extensor Digitorum Communis on the lateral epicondyle is best described as the Common Extensor Origin. This Common Extensor Origin is formed by the Extensor Digitorum Communis at its superficial portion (approximately 65-75% of the Common Extensor Origin thickness) and by the Extensor Carpi Radialis Brevis at its deepest quarter (approximately 25-35% of the Common Extensor Origin thickness). Distal to the radiocapitellar joint, the proximal bellies of the Extensor Carpi Radialis Brevis and Extensor Digitorum Communis appear tightly attached to the deep fascia. The attachments of lateral intermuscular septum and superficial fascia in the lateral elbow appear to be tight. Clinical relevance: Cadaveric findings on the location of the Extensor Carpi Radialis Brevis and Extensor Digitorum Communis at the lateral elbow may potentially guide the sonologists during diagnostic scan and surgeons during operation in localizing pathological changes within the Common Extensor Origin in the elbow.

Soft Tissue Constraint Injuries in Complex Elbow Instability: Surgical Techniques and Clinical Outcomes

The surgical procedures for and outcomes of soft tissue constraint reconstruction in complex elbow instability have been rarely investigated. The purpose of this study was to analyze the clinical outcomes in a series of patients with complex elbow instability in whom the associated soft tissue constraint injures were identified and treated based on the pathoanatomic changes found intraoperatively. Forty-five patients (23 men and 22 women; mean age, 54 years) with complex elbow instability were followed prospectively. Surgical treatment included the anatomic reduction and internal fixation of any fracture and radial head replacement in Mason type III injuries. Soft tissue constraint lesions were then repaired based on the type of lesion (eg, proximal or distal ligament avulsion, middle-zone lesion, or presence of detached bony fragments). Posterolateral capsular lesions and common extensor and flexor origin injuries were also repaired. Patients were followed clinically and radiographically after a mean of 25 months. Functional range of motion was achieved in 39 (86%) patients. Average Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; and American Shoulder and Elbow Surgeons shoulder score were 94, 5.6, and 89, respectively. At last follow-up, 42 (93%) patients showed no evidence of elbow instability, 2 (4%) patients had mild varus instability, and 1 (2%) patient had moderate posterolateral instability. The accurate identification of pathoanatomic changes of elbow soft tissue constraint lesions associated with complex elbow instability is an essential prerequisite to planning proper surgical treatment. The results of this study show that, in patients with complex elbow instability, once the fracture has been treated and each type of soft tissue constraint lesion adequately repaired, a high percentage of satisfactory functional outcomes may be achieved.

Soft Tissue Constraint Injuries in Complex Elbow Instability: Prevalence, Pathoanatomy, and Classification

The types and prevalence of soft tissue constraint injuries associated with complex elbow instability have been rarely investigated. The purpose of this study was to analyze the intraoperative findings of soft tissue constraint injuries in complex elbow instability and provide a comprehensive classification of these lesions. Forty-seven patients undergoing surgery for complex elbow instability were prospectively analyzed. Ligament injuries were classified as simple or complex lesions, depending on whether the ligament was damaged at a single zone or 2 to 3 zones, including its proximal, middle, and distal portions. Posterolateral capsule injuries were classified as small or large in the presence of capsular avulsions smaller than or larger than 1 cm, respectively. The presence of lesions of the common extensor and flexor-pronator muscles were also recorded. Ligament injuries were found in 96% of patients. The lateral collateral ligament showed a simple lesion, including a proximal and distal avulsion, in 19% and 2% of patients, respectively, and a middle-zone tear in 13%. Complex lesions, including the association of a middle-zone tear with a proximal or distal avulsion, were found in 47% and 6% of patients, respectively, and a combination of proximal, distal, and middle-zone injuries in 4%. Small and large posterolateral capsule lesions were found in 49% and 17% of patients, respectively. A medial collateral ligament injury was present in 45% of patients. A high prevalence of soft tissue constraint lesions was found to be associated with complex elbow instability. Soft tissue constraint status should be carefully evaluated pre- and intraoperatively in patients with complex elbow instability. The classification reported herein may be helpful in planning the proper treatment of these complex injuries.

Upper limb entheseal change with the transition to agriculture in the southeastern United States: A view from Moundville and the central Tombigbee River valley

We analyzed entheseal change in 159 skeletons from Moundville and surrounding settlements using primary fibrocartilaginous attachments of the upper limbs. Risk of entheseal change did not differ bilaterally, suggesting a wide variety of activities were used to exploit a diverse ecosystem. Consistent with predictions, Mississippian (1000–1500CE) agriculturalists experienced greater risk of entheseal change than did Late Woodland (500–900CE) hunter-gatherers. Attachments used in arm flexion were most affected, while rotator cuff entheses remained consistent over time. A temporal increase in muscular changes in males in concert with faunal evidence for resurgence of larger game (e.g., deer) is consistent with continued reliance on hunting alongside domestication of maize. Among Mississippians, younger males appear to have been carrying out the most strenuous tasks, contrary to earlier studies that suggested a decline in male activities with domestication. Mound centers consistently experienced the greatest upper body changes, in spite of faunal and botanical data supporting provisioning of elites by outlying sites. Center males, respectively, experienced more than 26 and 12 times greater changes at elbow extensors and brachialis than those from outlying settlements, with a significant decline from young to middle age among adults. Center females experienced increased risk at biceps insertions and common extensors of the humeri – trends that disappeared with age. Overall findings suggest increased upper body demands and shifting sex and age-dependent divisions of labor with maize intensification, but trends across settlements point to significant status-related body size selection in center males, with fewer differences among females.

Platelet-rich plasma for the treatment of lateral epicondylitis: sonographic assessment of tendon morphology and vascularity (pilot study)

To investigate the efficacy of using contrast-enhanced ultrasound to assess the relationship of altered vascularity and tendon morphology following injection of platelet-rich plasma (PRP) for lateral epicondylitis. This study prospectively evaluated six patients who had a baseline ultrasound confirming tendinosis of the common extensor tendon. Patients received a single 3-ml PRP injection under ultrasound guidance. Grayscale images of the injected elbow were obtained at baseline and were repeated at 1 and 6months after injection. DEFINITY® contrast was also injected after by 2 sets of wrist-extension exercises in order to obtain contrast-enhanced images of the elbow. Qualitative and quantitative analyses of the level of enhancement to the regions of interest were performed using off-line quantitative analysis software. All patients had either moderate or severe common extensor tendinosis as determined on clinical examination and baseline imaging. Five patients demonstrated improved tendon morphology using ultrasound imaging 6months after PRP injection (one patient was lost to follow-up). At baseline, there was evidence of increased vascularity at the myotendinous junction (MT) of the common extensor tendon when compared to its footprint (FP). There was a trend towards no change in FP vascularity between baseline and 6months (p = 0.062) and between 1 and 6months (p = 0.288). There was a trend for increased vascularity to the MT region from baseline to 6months (p = 0.433) and from 1 to 6months (p = 0.783). Contrast-enhanced ultrasound provides a sensitive method the display alterations in vascularity in the common extensor tendon of the elbow. PRP therapy for lateral epicondylitis can improve extensor tendon morphology. Corresponding increased extensor tendon FP vascularity, however, was not seen. There is a trend for increased vascularity at the MT up to 6months following PRP injection, based on limited pilot data.

Bilateral Extensor Digitorum Brevis Manus

Dorsal wrist pain and swelling is commonly attributed to a dorsal wrist ganglion. However, based on the authors' experience, a cautious surgeon should keep the uncommonly symptomatic diagnosis of an extensor digitorum brevis manus in their differential despite classic ganglion presentation and suggestive advanced imaging. This article describes a case of a young patient who presented with bilateral symptomatic extensor digitorum brevis manus anomalies that required surgical intervention. An extensor digitorum brevis manus is present in 3% of the population in a classic anatomy study from Japan and is most commonly symptomatic with heavy activity and extremes of wrist extension. Anatomically, the extensor digitorum brevis manus is located in the fourth wrist compartment and most commonly inserts on the index finger extensor mechanism. Examination often reveals a spindle-shaped mass that is palpable distal to the extensor mechanism and moves with extensor tendon motion. Magnetic resonance imaging shows a typical dorsal mass distal to the common extensors with a similar signal as muscle with all image sequencing. Treatment includes activity alterations to relieve symptoms or surgical excision of the muscle belly for refractory cases with care taken to preserve the index extensor mechanism.

Low-Dose Sublingual Ketamine Does Not Modulate Experimentally Induced Mechanical Hyperalgesia in Healthy Subjects

Musculoskeletal pain has been associated with N-methyl-d-aspartate (NMDA) receptor-mediated mechanisms. This randomized controlled trial (RCT) investigated the effect of the NMDA receptor antagonist ketamine (25 mg sublingually) on modulating experimental muscle pain. Two groups (N = 11/group) of age- and sex-matched healthy subjects performed eccentric exercise using the nondominant arm wrist extensors (time 0) to induce muscle soreness 24 hours later (time 1). Immediately prior to exercise, subjects were administered either a 25 mg ketamine lozenge or a placebo. At time 1, experimental muscle pain was augmented by injection of hypertonic saline into the extensor carpi radialis brevis (ECRB) muscle of the exercised arm. Pressure pain thresholds (PPTs), muscle soreness, muscle pain intensity (electronic visual analog scale [VAS]), and maximal wrist extension force were assessed at time 0 (pre- and postexercise) and at time 1 (pre-, during, and post saline-induced pain). Regardless of group, PPT was reduced at ECRB (P < 0.021) and at the common extensor origin (P < 0.034) at time 1 preinjection compared with time 0 pre-exercise. At time 1, elevated levels of muscle soreness and force attenuation were similar between groups compared with time 0 pre-exercise (P < 0.0001), and similar hypertonic saline-induced pain areas and pain intensity profiles were evident. In comparison with placebo, a single low-dose sublingual pharmacological intervention targeting the processes of sensitization via antagonism of NMDA receptors did not modulate the effects of acute experimentally induced mechanical hyperalgesia, suggesting a higher dose or repeat doses may be required.