Significance of tibial MRI findings of special forces recruits at the onset of their training

INTRODUCTION

MRI is commonly used to evaluate medial tibial stress syndrome (MTSS), based on grading assessments developed in civilian populations. When MTSS represents stress fracture, rest is required to allow for bone remodelling to occur. False positive evaluations can lead to unnecessary recruit attrition.

METHODS

Thirty randomly selected new recruits to a special forces training unit underwent MRI of their tibias using the T2-Dixon sequence at the onset of training. Evaluation was according to the Fredericson MTSS grading system. Prior to undergoing MRI, anthropomorphic measurements, a survey of sports history and an orthopaedic examination of subject tibias were performed. Orthopaedic follow-up was through 11 weeks of training.

RESULTS

Medial periosteal oedema without the presence of bone marrow oedema, corresponding to a grade 1 stress reaction, was present on MRI in 10 recruits (17 tibias). In only one case did the periosteal oedema include the posterior aspect of the medial cortex where medial tibial stress fractures usually occur. Tibial tenderness was present in seven tibias on examination done just prior to the MRI studies, but none were symptomatic and only one had periosteal oedema present on MRI, but without anatomical correlation between the site of the tenderness and the periosteal oedema. During subsequent training, five tibias in four recruits developed pain and tenderness. Two had periosteal oedema in their prior MRIs, but the location did not coincide anatomically with that of the tibial tenderness. The time from stopping sports before induction and the presence of periosteal oedema was not significant.

CONCLUSION

Periosteal oedema, one of the hallmarks used in MRI grading systems to evaluate MTSS, was found to have a 37.7% false positive rate for anatomically corresponding tibial tenderness at the time of the examination and during subsequent training, indicating the grading systems' low utility for the military.

Bracing in external rotation for traumatic anterior dislocation of the shoulder

We undertook a prospective study in 51 male patients aged between 17 and 27 years to ascertain whether immobilisation after primary traumatic anterior dislocation of the shoulder in external rotation was more effective than immobilisation in internal rotation in preventing recurrent dislocation in a physically active population. Of the 51 patients, 24 were randomised to be treated by a traditional brace in internal rotation and 27 were immobilised in external rotation of 15 degrees to 20 degrees. After immobilisation, the patients undertook a standard regime of physiotherapy and were then assessed clinically for evidence of instability. When reviewed at a mean of 33.4 months (24 to 48) ten from the external rotation group (37%) and ten from the internal rotation group (41.7%) had sustained a further dislocation. There was no statistically significant difference (p = 0.74) between the groups. Our findings show that external rotation bracing may not be as effective as previously reported in preventing recurrent anterior dislocation of the shoulder.

Inhibition of NF-kappa-B cellular function via specific targeting of the I-kappa-B-ubiquitin ligase

Activation of the transcription factor NF-kappa B is a paradigm for signal transduction through the ubiquitin-proteasome pathway: ubiquitin-dependent degradation of the transcriptional inhibitor I kappa B in response to cell stimulation. A major issue in this context is the nature of the recognition signal and the targeting enzyme involved in the proteolytic process. Here we show that following a stimulus-dependent phosphorylation, and while associated with NF-kappa B, I kappa B is targeted by a specific ubiquitin-ligase via direct recognition of the signal-dependent phosphorylation site; phosphopeptides corresponding to this site specifically inhibit ubiquitin conjugation of I kappa B and its subsequent degradation. The ligase recognition signal is functionally conserved between I kappa B alpha and I kappa B beta, and does not involve the nearby ubiquitination site. Microinjection of the inhibitory peptides into stimulated cells abolished NF-kappa B activation in response to TNF alpha and the consequent expression of E-selectin, an NF-kappa B-dependent cell-adhesion molecule. Inhibition of NF-kappa B function by specific blocking of ubiquitin ligase activity provides a novel approach for intervening in cellular processes via regulation of unique proteolytic events.