Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.

Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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Hamate Fractures

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Fractures of the hamate bone are rare, difficult to diagnose, and routine x-rays may not show the fracture. Hamate fractures are classified as either a hook fracture or as a body fracture.

Hamate hook fractures are usually seen in individuals who participate in sports which involve a racquet, baseball bat, or from swinging a golf club.

Swinging of the golf club may cause a hook fracture of the Hamate bone. Missing the fracture can lead to persistent pain from nonunion.

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Hamate body fractures are associated with axial force trauma, such as a fist striking a hard object, a fall, or from crushing injuries. It may also be accompanied by 4th and 5th metacarpal subluxation. Coronal fractures are the most common type of Hamate body fractures.

There are three types of coronal fractures; Type A (large piece), Type B (moderate piece) and Type C (avulsion). Make sure to watch out for subluxation of the joint due to pull from the Extensor Carpi Ulnaris.

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Hook fractures of the Hamate are best seen by carpal tunnel or supination x-ray views. For hamate fractures, CT scan is the best study. A 30° pronated view is helpful for body fractures.

Clinical Evaluation

Pain will be present, especially with axial loading of the ring and little finger or by grasping an object. The patient will have dismissed grip strength. They may have ulnar and median nerve neuropathy symptoms. The most common findings are pain and tenderness on the ulnar side of the wrist, distal to the wrist joint.

The pull test has been recently described. This is when the palm of the hand is placed into supination, the wrist is in full ulnar deviation, and the fingers of the patient should be flexed. The examiner pulls on the ulnar two digits with the patient resisting the pull. A positive test with pain in the area of the hook indicates a fractures hook of hamate injury. Pain may also be felt due to compression of the ulnar nerve in the Guyon Canal.

Treatment                        

Early immobilization for acute fractures with short arm splint for 6 weeks will be used to avoid a nonunion. For symptomatic nonunion, excision of the fracture fragment will be needed.

Types A and B require open reduction and internal fixation, in addition to stabilization of the joint if needed. Type C requires closed reduction and percutaneous pinning of the fragment for stabilization of the joint. If a closed reduction of the joint is not adequate, open reduction and stabilization of the joint should be done. A displaced fragment with subluxation requires reduction of the joint and stabilization of the joint with K-wires or fixation of the fragment.

When a 4th or 5th carpometacarpal dislocation occurs, one should make special effort to find a coronal fracture of the hamate.

 

 

 

Running Injuries

There are three general causes of running related injuries: anatomic factors, shoes and running surface, and training errors.

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Anatomical Factors

There are many different anatomical factors that may cause running injuries including leg length discrepancies, femoral neck anteversion, asymmetrical muscle inflexibility or weakness, genu valgum, genu varum, genu recurvatum, excessive Q angle, patella alta, tibial torsion, tibial varus, lower leg-heel or heel- forefoot malalignment, pes cavus or planus, structural toe abnormalities and bunions.

Leg length discrepancies are a variation in limb length may be causes by a previous injury to a bone in the leg or arthritis.

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A femoral neck anteversion is a developmental abnormality causing abnormal rotation of the femoral neck. With femoral neck anteversion, the femoral neck tilts forward in respect to the rest of the femur causing the lower extremity to rotate internally. Too much femoral anteversion and the toes will turn in.

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Asymmetrical muscle inflexibility or weakness is a condition that distributes abnormal and uneven forces to the body creating uneven stresses across the muscle groups and joints.

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Genu valgum is also known as “knock knee”. Genu Varum is known as “bow leg”. Genu recurvatum is a deformity in the knee joint where the knee bends backwards at the tibiofemoral joint.

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An excessive Q angle is one that is greater than 15°. The presence of an excessive Q angle causes the knee cap to track out of alignment and degeneration of the cartilage behind the knee cap will occur due to increases stresses resulting in pain around the knee cap.

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Patella Alta occurs when the knee cap is in an “alta” position; it sits above the trochlear groove and is less stable. The patella tendon that connects the knee cap to the tibia is longer than normal.

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Tibial Torsion is the inward twisting of the tibia causing the feet to turn inward. This is commonly referred to as having a “pigeon-toed” appearance. Tibial varus is a curvature of the tibia inwards from the proximal to distal end. It causes problems of the structures around the knee.

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Lower leg – heel or heel – forefoot malalignment causes distortions in the knee that may causes the lower leg bones to be off center on the heel of the foot.

Pes cavus is a high arch that is raised more than normal and distinctly hollowing during weight bearing.

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Pes Planus is a common deformity in adults that is also known as “flat foot”. The entire sole of the foot will come into complete or nearly complete contact with the ground.

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Structural Toe Abnormalities such as Morton’s neuroma. Morton’s neuroma is an enlargement and inflammation of a portion of the plantar digital nerve. It is usually located in the third web space between the metatarsal heads which is felt in the front of the foot, extending to the toes.

Bunions (hallux valgus) can be a big problem with shoe wear.

Shoes and Running Surface

Wearing the proper shoes that are comfortable and provide shock absorbency is important. Old, worn out, uncomfortable shoes may cause running injuries. Attention should be given to the climate surface and terrain to avoid running related injuries.

Training Errors

Consideration should be given to using the appropriate equipment and the progression of workouts in order to avoid injuries. Common training mistakes include wearing the wrong clothing/shoes, not drinking enough fluids, bad body form, and lack of preparation.

The most common running problems are over striding and too much running.