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Kim AR, Covey CJ. Distal Clavicular Osteolysis Treated With Platelet-Rich Plasma: A Case Report. Clin J Sport Med 2024; 34:310-311. [PMID: 37921686 DOI: 10.1097/jsm.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/03/2023] [Indexed: 11/04/2023]
Abstract
ABSTRACT Atraumatic distal clavicular osteolysis (DCO) is a cause of shoulder pain in younger athletes, often resulting from weightlifting and activities with repetitive pressing and overhead lifting. Athletes will present with shoulder pain localized to the acromioclavicular (AC) joint, with tenderness to palpation over the joint exacerbated by provocative testing on examination. Conservative management often includes activity modification, oral analgesics, physical therapy, and corticosteroid injection. Distal clavicular osteolysis can be refractory to conservative management and these athletes are often referred for surgical consultation. Platelet-rich plasma (PRP) injections have been used to treat a wide variety of musculoskeletal injuries, but there have been no published studies assessing the efficacy of PRP injections specifically for distal clavicle osteolysis. We present a case of refractory DCO successfully treated with an ultrasound-guided PRP injection of the AC joint.
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Affiliation(s)
- Alexander R Kim
- David Grant Medial Center, Travis Air Force Base, California
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Covey CJ, Knobloch AC, Kim AR. Hip Pain in an Athlete. Curr Sports Med Rep 2023; 22:313-319. [PMID: 37678350 DOI: 10.1249/jsr.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
ABSTRACT Hip pain is a common complaint in sports, and narrowing the differential diagnosis can be difficult. Many etiologies are secondary to overuse and respond well to nonsurgical treatment. The increased use of point-of-care ultrasound has helped provide timely and accurate diagnoses and some guided treatments. The hip is in close proximity to the abdomen and pelvis, and clinicians should be familiar with nonmusculoskeletal pain generators. This article is a comprehensive review of hip pain etiologies in athletes.
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Affiliation(s)
- Carlton J Covey
- Uniformed Services University, Family and Sports Medicine, Travis AFB, CA
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Covey CJ, Cagle SD. Lung cancer screening: New evidence, updated guidance. J Fam Pract 2022; 71:398-415. [PMID: 36538778 DOI: 10.12788/jfp.0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Emerging evidence supports lower thresholds for age and smoking history when screening for lung cancer. Here's how the USPSTF and others have updated their guidelines in response.
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Affiliation(s)
- Carlton J Covey
- Uniformed Services University of the Health Sciences, Bethesda, MD
- David Grant Medical Center, Travis Air Force Base, Fairfield, CA
| | - Stephen D Cagle
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Ehrling Burquist Clinic, Offutt Air Force Base, Bellevue, NE
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Nye NS, Kasper K, Madsen CM, Szczepanik M, Covey CJ, Oh R, Kane S, Beutler AI, Leggit JC, Deuster PA, O'Connor FG. Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective. Curr Sports Med Rep 2021; 20:169-178. [PMID: 33655999 DOI: 10.1249/jsr.0000000000000822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
ABSTRACT Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.
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Affiliation(s)
| | - Korey Kasper
- 559th Trainee Health Squadron, JBSA-Lackland, TX
| | | | | | | | - Robert Oh
- Madigan Army Medical Center, Tacoma, WA
| | - Shawn Kane
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anthony I Beutler
- Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Jeffrey C Leggit
- Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Patricia A Deuster
- Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Francis G O'Connor
- Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, Bethesda, MD
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Webber BJ, Nye NS, Covey CJ, Harmon KG, Ruiz SA, O'Connor FG. Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009-December 2018. MSMR 2021; 28:15-19. [PMID: 33523681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Sickle cell trait (SCT) is associated with incident exertional rhabdomyolysis, but its effect on disease progression and severity is poorly understood. Of 377 exertional rhabdomyolysis cases diagnosed between 2009 and 2018 in the active component of the U.S. Air Force, 200 had records available for chart review, and 185 of these had known SCT status. Pre- and post-event data were stratified by SCT status, and serum chemistry changes among SCT-positive (n=11) and SCT-negative (n=174) airmen were compared using Wilcoxon-Mann-Whitney tests. Of the 200 cases with records available for chart review, 110 (55.0%) were hospitalized; 98 (56.3%) of the 174 who were SCT-negative were hospitalized. Also hospitalized were 4 (36.4%) of the 11 who were SCT-positive, and 8 (53.3%) of the 15 with unknown SCT status. Of the 7 airmen who were admitted to intensive care, 4 required hemodialysis, and 1 underwent a fasciotomy; all 7 were SCT-negative. Alterations in creatine kinase, potassium, creatinine, troponin I, and hemoglobin were statistically equivalent between those with and without SCT. Providers should maintain a high index of suspicion for exertional rhabdomyolysis, especially in warm climates and in the context of high-intensity activities, but should not presume that the presence of SCT portends a higher risk of complications or worse clinical outcomes.
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Nye NS, Covey CJ, Pawlak M, Olsen C, Boden BP, Beutler AI. Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries. Sports Health 2020; 12:449-455. [PMID: 32762527 DOI: 10.1177/1941738120943540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. HYPOTHESIS A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. RESULTS Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. CONCLUSION The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. CLINICAL RELEVANCE For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.
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Affiliation(s)
| | - Carlton J Covey
- Travis Family Medicine Residency, Travis Air Force Base, California
| | - Mary Pawlak
- 559th Trainee Health Squadron, JBSA-Lackland, Texas
| | - Cara Olsen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barry P Boden
- The Orthopaedic Center, a Division of CAO, Rockville, Maryland
| | - Anthony I Beutler
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Covey CJ, Church LT. Could that back pain be caused by ankylosing spondylitis? J Fam Pract 2019; 68:E1-E6. [PMID: 31226181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
It can often take years for patients with this condition to learn the true cause of their pain. But this guide to the work-up can help speed the diagnostic process.
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Affiliation(s)
- Carlton J Covey
- Uniformed Services University of the Health Sciences; Nellis Family Medicine Residency, Las Vegas, Nevada, USA.
| | - Lee T Church
- Nellis Family Medicine Residency, Las Vegas, Nevada, USA
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Abstract
Context: Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio–Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management. Evidence Acquisition: To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014. Study Design: Clinical review. Level of Evidence: Level 4. Results: In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture. Conclusion: Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.
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Affiliation(s)
- Nathaniel S Nye
- 559th Trainee Health Squadron, Joint Base San Antonio-Lackland, Texas
| | - Carlton J Covey
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lucas Sheldon
- 59th Radiology Squadron, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, Texas
| | - Bryant Webber
- 559th Trainee Health Squadron, Joint Base San Antonio-Lackland, Texas
| | - Mary Pawlak
- 559th Trainee Health Squadron, Joint Base San Antonio-Lackland, Texas
| | | | - Anthony Beutler
- Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Covey CJ, Sineath MH, Penta JF, Leggit JC. Prolotherapy: Can it help your patient? J Fam Pract 2015; 64:763-768. [PMID: 26844994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlton J Covey
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Marvin H Sineath
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, USA
| | | | - Jeffrey C Leggit
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Jones BQ, Covey CJ, Sineath MH. Nonsurgical Management of Knee Pain in Adults. Am Fam Physician 2015; 92:875-883. [PMID: 26554281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The role of the family physician in managing knee pain is expanding as recent literature supports nonsurgical management for many patients. Effective treatment depends on the etiology of knee pain. Oral analgesics-most commonly nonsteroidal anti-inflammatory drugs and acetaminophen-are used initially in combination with physical therapy to manage the most typical causes of chronic knee pain. The American Academy of Orthopaedic Surgeons recommends against glucosamine/chondroitin supplementation for osteoarthritis. In patients who are not candidates for surgery, opioid analgesics should be used only if conservative pharmacotherapy is ineffective. Exercise-based therapy is the foundation for treating knee osteoarthritis and patellofemoral pain syndrome. Weight loss should be encouraged for all patients with osteoarthritis and a body mass index greater than 25 kg per m2. Aside from stabilizing traumatic knee ligament and tendon tears, the effectiveness of knee braces for chronic knee pain is uncertain, and the use of braces should not replace physical therapy. Foot orthoses can be helpful for anterior knee pain. Corticosteroid injections are effective for short-term pain relief in patients with osteoarthritis. The benefit of hyaluronic acid injections is controversial, and recommendations vary; recent systematic reviews do not support a clinically significant benefit. Small studies suggest that regenerative injections can improve pain and function in patients with chronic knee tendinopathies and osteoarthritis.
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Affiliation(s)
- Brandon Q Jones
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, USA
| | - Carlton J Covey
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, USA
| | - Marvin H Sineath
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, USA
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Covey CJ, Hawks MK. Nontraumatic knee pain: a diagnostic & treatment guide. J Fam Pract 2014; 63:720-728. [PMID: 25486314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Carlton J Covey
- Nellis Family Medicine Residency Program, Nellis Air Force Base, NV; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Covey CJ, Dy DA. Diffuse, pruritic, papular rash. Am Fam Physician 2013; 88:605-606. [PMID: 24364637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Carlton J Covey
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David A Dy
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, USA
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Covey CJ. Lessons learned in the death and birth of GME programs. Fam Med 2013; 45:652-653. [PMID: 24136697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Carlton J Covey
- Nellis Family Medicine Residency, Nellis Air Force Base, NV, and the Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Covey CJ, Mulder MD. Plantar fasciitis: How best to treat? J Fam Pract 2013; 62:466-471. [PMID: 24080555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In addition to stretching exercises and orthotics, consider steroid injections as part of your first-line treatment options. For recalcitrant pain, a newer injectable reparative treatment is showing promise.
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Affiliation(s)
- Carlton J Covey
- The Nellis Family Medicine Residency, Nellis Air Force Base, NV; Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Crownover BK, Covey CJ. Hereditary hemochromatosis. Am Fam Physician 2013; 87:183-190. [PMID: 23418762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Hereditary hemochromatosis is an autosomal recessive disorder that disrupts the body's regulation of iron. It is the most common genetic disease in whites. Men have a 24-fold increased rate of iron-overload disease compared with women. Persons who are homozygous for the HFE gene mutation C282Y comprise 85 to 90 percent of phenotypically affected persons. End-organ damage or clinical manifestations of hereditary hemochromatosis occur in approximately 10 percent of persons homozygous for C282Y. Symptoms of hereditary hemochromatosis are nonspecific and typically absent in the early stages. If present, symptoms may include weakness, lethargy, arthralgias, and impotence. Later manifestations include arthralgias, osteoporosis, cirrhosis, hepatocellular cancer, cardiomyopathy, dysrhythmia, diabetes mellitus, and hypogonadism. Diagnosis requires confirmation of increased serum ferritin levels and transferrin saturation, with or without symptoms. Subtyping is based on genotypic expression. Serum ferritin measurement is the most useful prognostic indicator of disease severity. Liver biopsy is performed to stage the degree of fibrosis with severe ferritin elevation or transaminitis, or to diagnose nonclassical hereditary hemochromatosis in patients with other genetic defects. Treatment of hereditary hemochromatosis requires phlebotomy, and the frequency is guided by serial measurements of serum ferritin levels and transferrin saturation. Iron avidity can result from overtreatment. If iron avidity is not suspected, it may mimic undertreatment with persistently elevated transferrin saturation. Dietary modification is generally unnecessary. Universal screening for hereditary hemochromatosis is not recommended, but testing should be performed in first-degree relatives of patients with classical HFE-related hemochromatosis, those with evidence of active liver disease, and patients with abnormal iron study results. Screening for hepatocellular carcinoma is reserved for those with hereditary hemochromatosis and cirrhosis.
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Miszko TA, Cress ME, Slade JM, Covey CJ, Agrawal SK, Doerr CE. Effect of strength and power training on physical function in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2003; 58:171-5. [PMID: 12586856 DOI: 10.1093/gerona/58.2.m171] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The performance of daily tasks, such as stair climbing or lifting an object, requires both muscle strength and power. Age-associated reductions in strength and power can affect an older adult's ability to complete daily tasks such as stair climbing and lifting a child. METHODS The purposes of this study were to determine whether power training was more efficacious than strength training for improving whole-body physical function in older adults and to examine the relationship between changes in anaerobic power and muscle strength and changes in physical function. Thirty-nine men and women (mean age +/- SD = 72.5 +/- 6.3 years) with below-average leg extensor power were randomly assigned to control (C, n = 15), strength-training (ST, n = 13) or power-training (PT, n = 11) groups. The ST and PT groups met 3 days per week for 16 weeks; the C group maintained usual activity and attended three lectures during the course of the study. Primary outcome measures included the Continuous Scale Physical Functional Performance test, maximal strength, and anaerobic power. RESULTS After baseline was controlled for, the Continuous Scale Physical Functional Performance test total score was significantly greater for the PT group than for the ST (p =.033) and C (p =.016) groups. Maximal strength was significantly greater for the ST group than for the C group (p =.015) after the intervention. There was no significant difference between groups for peak anaerobic power. CONCLUSIONS Power training was more effective than strength training for improving physical function in community-dwelling older adults.
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Affiliation(s)
- Tanya A Miszko
- Veterans Affairs Medical Center, Decatur, Georgia 30033, USA.
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