An unexpected cause of palmar paraesthesia in a soldier : a case report

Athletes presenting with neurological symptoms merit thorough assessments that in most cases will include investigations with one or more imaging modality. Imaging is especially useful in atypical presentations of neurological pathology (both acute and chronic) as was the instance in the presented case report. The case of a 22-year-old male soldier is presented who presented with a two week history of paraesthesia involving his right hand. After being assessed by the military medical officer, a presumptive diagnosis of cervical radiculopathy was made and appropriate treatment was prescribed. Symptoms persisted despite treatment and following an inconclusive cervical X-Ray, a magnetic resonance scan was booked that confirmed the diagnosis of multiple sclerosis. The patient was admitted to hospital and started on intravenous methylprednisolone and beta-interferon therapy with resolution of his symptoms. This case highlights the usefulness of imaging in confirming diagnosis, especially in atypical presentations of pathology afflicting the neurological system. Atypical symptoms, lack of response to standard therapy and inconclusive initial radiological investigations, should prompt the physician to carry out further detailed imaging modalities. The choice of the latter will need to reflect the working differential diagnoses. With reference to the presented case, imaging plays a role not only in diagnosis but also in assessing response to treatment and disease progression.peer-reviewe

Fibular stress fracture in a female cross-country runner : a case report

Stress fractures are probably the most feared class of injuries amongst endurance athletes, especially runners, since they require lengthy rehabilitation periods and temporary but drastic modifications of their training regime. A detailed literature review is presented with the aim of highlighting the importance of athlete education as well as pre-participation screening in female athletes for one or more components of the triad.peer-reviewe

Screening for heart disease in athletes

Physical activity, be it regular exercise or sports at whatever level, should be beneficial and not deleterious. Hence, it is important that the medical profession is aware that cardiovascular related deaths are the leading cause of mortality in athletes during sports. In 2009 the International Olympic Committee issued a consensus statement on the periodic health evaluation of elite athletes. This includes ‘a comprehensive assessment of the athlete’s current health status and risk of future injury or disease and, typically, is the entry point for medical care of the athlete’. Although this consensus statement targeted elite athletes, the periodic health evaluation design is simple enough that it could easily be extrapolated for use for all physically active individuals. The periodic health evaluation’s role is to screen for musculoskeletal or medical conditions that may place an athlete at risk for safe participation. Since this statement was issued, numerous international sport organisations have recommended a screening programme for individuals who partake in regular physical activity. Stress is made on the importance of a thorough health and family history with an emphasis on cardiovascular issues. There is no international consensus on the use of an electrocardiogram (ECG) as part of a screening programme; however most international sports federations and the European Cardiac and Sports Medicine societies strongly recommend it. What there is agreement on is that the doctor that reads an ECG should be knowledgeable of the physiological adaptations of the athletic heart that could lead to errant, yet perfectly safe, ECG traces.peer-reviewe

Patellar dislocation : an algorithm for management within primary care

BACKGROUND: Patellar dislocation is a common condition which may present to primary care. The literature available on this condition discusses evaluation, assessment of risk factors for recurrence, and non-surgical versus surgical management. Literature detailing its management specifically within primary care is lacking.OBJECTIVES: The purpose of this review paper is to review and discuss the steps in evaluation and management of this condition and formulate an algorithm summary particular to a primary care setting.METHOD: A database search was carried out using specific keywords and terms. The authors’ initial selection of 12 articles were subsequently reduced to 8 after review of their relevance to a primary care setting, and these were subjected to in-depth analysis. The information gathered was detailed and discussed, and a subsequent algorithm was formulated.RESULTS: Patellar dislocation is a common injury, which may have long-lasting consequences to knee stability if not initially managed appropriately. There is inconclusive evidence to favour a surgical versus non-surgical approach. Evaluation of an individual’s risk factors and whether referral to secondary care is required are crucial steps in management of this condition.CONCLUSION: Primary care physicians may play a key role in appropriate management of an individual’s first presentation of patellar dislocation, as well as assessment on the need for secondary care referral. The algorithm proposed by the authors may assist primary care physicians in improving management of patellar dislocation within a primary care context.peer-reviewe

Medico-legal and obstetric challenges of recent demographic increases in Malta

The southern Mediterranean island of Malta, strategically located between North Africa and Europe and a full member of the European Union, offers an excellent European standard obstetric service. Yet, this obstetric service, like all other medical disciplines, is undergoing a severe evolutionary challenge imposed by rapid demographic shifts. It also finds itself without significant and relevant medico-legal legislation which is likely to lead to serious acute needs at the interface between the rapidly changing nature and number of foreigners residing in Malta and their medical needs, especially in the obstetric sector.The article looks at several factors, which argue for the immediate need of implementation of such legislation. One aspect of crucial importance is the demographic fact of rapidly changing profile of the patients making use of the Maltese Obstetric Service (MOS). This is the result of an influx of both EU nationals as well as irregular migrants, mostly of sub-Saharan origin. Both provide their own form of challenges to the MOS. In both, albeit more likely in the case of EU nationals, these challenges may easily find expression and resolution in eventual medico-legal action.

Supersonic shear wave elastography of human tendons is associated with in vivo tendon stiffness over small strains

Supersonic shear wave (SW) elastography has emerged as a useful imaging modality offering researchers and clinicians a fast, non-invasive, quantitative assessment of tendon biomechanics. However, the exact relationship between SW speed and in vivo tendon stiffness is not intuitively obvious and needs to be verified. This study aimed to explore the validity of supersonic SW elastography against a gold standard method to measure the Achilles tendon’s in vivo tensile stiffness by combining conventional ultrasound imaging with dynamometry. Twelve healthy participants performed maximal voluntary isometric plantarflexion contractions (MVC) on a dynamometer with simultaneous ultrasonographic recording of the medial gastrocnemius musculotendinous junction for dynamometry-based measurement of stiffness. The tendon’s force-elongation relationship and stress-strain behaviour were assessed. Tendon stiffness at different levels of tension was calculated as the slope of the stress-strain graph. SW speed was measured at the midportion of the free tendon and tendon Young’s modulus was estimated. A correlation analysis between the two techniques revealed a statistically significant correlation for small strains (r(10)=0.604, p=.038). SW-based assessments of in vivo tendon stiffness were not correlated to the gold standard method for strains in the tendon greater than 10% of the maximum strain during MVC. The absolute values of SW-based Young’s modulus estimations were approximately three orders of magnitude lower than dynamometry-based measurements. Supersonic SW elastography should be only used to assess SW speed for the detection and study of differences between tissue regions, differences between people or groups of people or changes over time in tendon initial stiffness (i.e., stiffness for small strains)

Elastography in the assessment of the Achilles tendon: a systematic review of measurement properties

Abstract Background Managing and rehabilitating Achilles tendinopathy can be difficult, and the results are often unsatisfactory. Currently, clinicians use ultrasonography to diagnose the condition and predict symptom development. However, relying on subjective qualitative findings using ultrasound images alone, which are heavily influenced by the operator, may make it difficult to identify changes within the tendon. New technologies, such as elastography, offer opportunities to quantitatively investigate the mechanical and material properties of the tendon. This review aims to evaluate and synthesise the current literature on the measurement properties of elastography, which can be used to assess tendon pathologies. Methods A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, PubMed, Cochrane, Scopus, MEDLINE Complete, and Academic Search Ultimate were searched. Studies assessing the measurement properties concerning reliability, measurement error, validity, and responsiveness of the instruments identified in healthy and patients with Achilles tendinopathy were included. Two independent reviewers assessed the methodological quality using the Consensus-based Standards for the Selection of Health Measurement Instruments methodology. Results Out of the 1644 articles identified, 21 were included for the qualitative analysis investigating four different modalities of elastography: axial strain elastography, shear wave elastography, continuous shear wave elastography, and 3D elastography. Axial strain elastography obtained a moderate level of evidence for both validity and reliability. Although shear wave velocity was graded as moderate to high for validity, reliability obtained a very low to moderate grading. Continuous shear wave elastography was graded as having a low level of evidence for reliability and very low for validity. Insufficient data is available to grade three-dimensional shear wave elastography. Evidence on measurement error was indeterminate so evidence could not be graded. Conclusions A limited number of studies explored quantitative elastography on Achilles tendinopathy as most evidence was conducted on a healthy population. Based on the identified evidence on the measurement properties of elastography, none of the different types showed superiority for its use in clinical practice. Further high-quality studies with longitudinal design are needed to investigate responsiveness