[SUPRASCAPULAR NEUROPATHY]

Supra-scapular nerve (SSN) damage is a rare, but classical diagnosis that can often be overlooked since the nonspecific clinical history and examination commonly lead to the misdiagnosis of another shoulder disorder. This article details the etiopathology, the patients at risk, the reasons for consultation and the clinical aspects of suprascapular neuropathy; it also outlines its diagnostic and therapeutic approaches.

Trunk muscle profile in elite tennis players with and without low back pain

AIM

The aim of this study was to compare tennis players with and without low back pain (LBP) and healthy sedentary participants regarding the trunk muscle strength and flexibility.

METHODS

Thirty-eight male elite tennis players and 22 healthy sedentary male students (24.8±4.0 years) participated in this investigation. Tennis players were divided into two groups: 11 players (27.8±5.5 years) with current LBP and 27 players (24.3±5.9 years) without LBP. Maximal isometric strength of trunk extensor, rotator, flexor and lateralflexor muscles was assessed by means of specific trunk dynamometers. Pelvic and lumbar flexion mobility were measured by means of inclinometer technique.

RESULTS

Comparison of tennis players with and without LBP revealed no significant difference regarding trunk muscle strength and ratio or lumbar spine flexibility (all P>0.05). In comparison with sedentary participants, the tennis players showed a sport-specific profile determined by a non-dominant trunk lateralflexors (P=0.02, F=4.05) and rotators (P=0.03, F=3.62) strength significantly higher than the dominant side.

CONCLUSION

In the current study, comparison of tennis players with and without LBP showed no significant difference regarding trunk strength and spine flexibility. Trunk profile of tennis players showed selective unilateral strength increase of the non-dominant trunk lateralflexors and rotators. This finding could result from the forehand and the service action which involves simultaneously left trunk rotators and lateralflexors, in right-handed players, to generate power. In order to confirm that trunk muscle imbalance has no influence on LBP, further studies should study the effectiveness of a programme aiming to normalize strength ratios in tennis players with LBP.

[New conservative treatments of chronic tendinopathies]

The pathophysiological mechanisms of tendinopathies integrate various intrinsic and extrinsic factors. Classic "passive" therapeutics have a limited action. Because of a better pathophysiological understanding of tendinopathies, more recent treatments (injections of various compounds, infiltrations of platelet-rich plasma, stem cells) would lead to a long-term healing. In case of failure of conservative managements and depending on the anatomical site, a surgical approach may be considered.

One injection of platelet-rich plasma associated to a submaximal eccentric protocol to treat chronic jumper's knee

AIM

Jumper's knee is a frequent chronic overuse syndrome of the proximal part of the patellar tendon. Platelets contain lots of growth factors which could enhance the healing process of tendons. The aim of this study was to clarify the possible efficacy of one injection of Platelet-rich plasma (PRP) in cases of rebel jumper's knees.

METHODS

Twenty patients with chronic proximal patellar tendinopathy were enrolled. Assessments were made before infiltration of PRP, and 6 weeks and 3 months after the infiltration, using a 10-point visual analogic scale of pain, clinical examinations with a pressure algometer, algofunctional scores (IKDC and VISA-P), functional assessments (isokinetic and optojump evaluations) and imagery (ultrasounds and MRI). The PRP was obtained with an apheresis system (COMTEC®, Fresenius-Kabi, Bad Homburg, Germany). Six millilitres of PRP were injected without local anesthetic. One week after infiltration, patients started a standardized sub-maximal eccentric reeducation.

RESULTS

During daily activities pain significantly decreased with time. At functional evaluation, it decreased as well, but without significant functional improvement. No improvements in the imagery measurements were observed. Younger patients seemed to be more susceptible to have an improvement of pain by the PRP infiltration.

CONCLUSION

This study demonstrates that a local infiltration of PRP associated with a submaximal eccentric protocol can improve symptoms of chronic jumper's knee in patients non-responsive to classical conservative treatments.

[Critical analysis of classical conservative treatments of tendinopathies]

Classic "passive" therapeutics (anti-inflammatory drugs, infiltrations of corticosteroids...) of tendinopathies, which are used relatively empirically, reduce pain and inflammation, without fundamentally changing the tendon structure. The eccentric rehabilitation has been applied to chronic tendinopathies, not only due to the failure of conventional therapies but also due to a better pathophysiological understanding of tendinopathies. Various studies underscore the effectiveness of eccentric rehabilitation which, after 20-30 sessions, leads to healing and especially prevents the risk of chronicity. Shockwave therapy, amending the tendinous structure, would lead to a long term healing.

[The anterior tarsal tunnel syndrome: a case report]

The anterior tarsal tunnel syndrome is a rare entrapment neuropathy of the deep peroneal nerve beneath the inferior extensor retinaculum of the ankle. It is frequently unrecognized and may lead to misdiagnosis and delayed treatment. We report the case of a 77 year old patient complaining of symptoms of an anterior tarsal tunnel syndrome with neuropathic pain located at the dorsal part of the foot, without any sensorimotor loss. The ENMG was in favour of a motor impairment of the deep peroneal nerve. MRI exploration of the ankle showed a millimetric bony overgrowth of the upper pole of the navicular bone, irritative to the deep peroneal nerve. Infiltration at overgrowth of the navicular provided a partial and temporary decrease in pain symptoms. Surgical nerve decompression was then considered.

Evaluation of the impact of 6-month training by whole body vibration on the risk of falls among nursing home residents, observed over a 12-month period: a single blind, randomized controlled trial

BACKGROUND

We have previously shown that short sessions of whole body vibration (WBV) were not able to significantly improve fall risk among nursing home residents but some trends towards an improvement of motor capacity were observed.

OBJECTIVE

The objective of the present study was to evaluate the impact of 6-month training by WBV on functional and motor abilities among nursing home residents observed over a 12-month period.

METHODS

Patients were randomized into two groups: the WBV group which received three training sessions every week composed of five series of 15 s of vibration at 30 Hz intensity for a period of 6 months and a control group with normal daily life. The impact of this training on the risk of falls was assessed blindly after 6 and 12 months by the Tinetti Test, the "Timed Up and Go" test and a quantitative evaluation of a 10-s walk performed with a tri-axial accelerometer. The occurrence of falls was also observed.

RESULTS

62 elderly healthy volunteers, (47 women and 15 men, mean age 83.2 ± 7.9 years) were included in this study. There was no significant difference between the two groups regarding the Tinetti test (p = 0.75), the "Timed Up and Go" test (p = 0.19) and the Locométrix(®) test, except for the step length, measured by dual task (p < 0.01). No significant inter-group difference in the frequency of falls was observed during the 12 months of research. A total of 42 falls were recorded during the first 6 months of experimentation: 24 falls in the treated group and 18 in the control group (p = 0.60). During the next 6 months, 19 falls occurred: 8 falls in the treated group and 11 in the control group (p = 0.52).

CONCLUSION

This study failed to establish the effectiveness of low doses of WBV, under the conditions used in our study, on functional and motor abilities of institutionalized elderly patients. However, given the positive results of other studies, further investigations, with modified therapeutic protocols, seem necessary to clarify the effects of WBV in the elderly.

Teriparatide therapy for denosumab-induced osteonecrosis of the jaw in a male osteoporotic patient

We report the first case of teriparatide adjuvant role in the management of a denosumab-induced osteonecrosis of the jaw in a male subject with idiopathic osteoporosis. Clinical benefits and CT healing were obtained within 2 months of teriparatide initiation and denosumab withdrawal. Increase in bone turnover previously described, when denosumab treatment is removed, might have a synergistic effect to the stimulating effect of teriparatide on bone remodeling to promptly heal osteonecrosis of the jaw.

[Is this cerebral cavernoma the cause of a Parkinsonian syndrome?]

We report the case of a patient presenting with an akineto-rigid syndrome of the left hemibody whose etiological exploration by magnetic resonance imaging showed the presence of a cavernoma located in the right lenticular region. The interest of this situation is to establish if there is a pathophysiological link between such symptoms and the lesion revealed by the MRI.

[Pigmented villonodular synovitis of the knee]

This case report is concerned with a 30 year old patient diagnosed with pigmented villonodular synovitis (PVNS) in the knee. The patient underwent an orthopedic surgical operation to remove the lesions. PVNS is a rare proliferative disorder, mostly benign and affecting the knee; its aetiology remains unclear. It represents a medical challenge because of non-specific symptoms that delay the diagnosis with a very high rate of recurrence. MRI imaging is necessary to explore the lesions, but the final diagnosis can only be made after anatomopathologic analysis of the excised lesions. When multiple lesions are present, the treatment consists of their excision by arthrotomy, or by arthroscopy if the disease is localized.

[Single cervical metastasis of breast cancer]

We report a rare case of single cervical metastasis of breast cancer. Bone metastases are the most frequent in breast cancer. Early diagnosis combined with the new therapeutic advances have considerably improved the quality of life and increased the survival. Imaging plays a great role in the diagnosis, particularly scintigraphy and radiography, but sometimes also CT and MRI. The treatment is currently not standardized and it combines hormone therapy, chemotherapy, radiotherapy, and/or surgery.

Shoulder function after latissimus dorsi transfer in breast reconstruction

BACKGROUND/AIMS

Latissimus dorsi (LD) transfer in the case of breast reconstruction remains frequently used because this muscle provides a good size source of tissue in reconstructive surgery. Given that, the consequences of the LD removal on shoulder function and the actual loss of maximal strength developed must be investigated.

METHODS

Twenty women (50 ± 7.5 years old) were evaluated before surgery, 3 and 6 months after an unilateral transfer of a pedicle flap of LD muscle used for breast reconstruction. Women performed a bilateral shoulder isokinetic assessment [for the internal rotators (IRs) and external rotators and for the abductor and adductor (ADD) muscles] allowing the establishment of bilateral muscular deficit status and the study of agonist/antagonist muscle ratios. The algofunctional and clinical status of the shoulders was analysed by the means of Constant score and specific shoulder clinical tests. The women did not perform any specific strengthening of muscle shoulder after surgery.

RESULTS

The isokinetic assessment showed a muscle weakness 3 and 6 months after LD transfer, mainly on the ADDs (33 ± 9% at 6 months) and on the IRs (16 ± 11% at 6 months). The Constant score significantly decreased after surgery on the operated shoulder. Women with a Constant score impairment showed pain during specific shoulder clinical tests. We also found a correlation between Constant score impairment and internal rotators weakness or rotator muscle imbalance.

CONCLUSION

Given those results, we could advocate a specific shoulder strengthening after LD transfer, focused mainly on the IRs and ADDs.

Isokinetic assessment of the shoulder rotators: a study of optimal test position

BACKGROUND

  Isokinetic assessment of the shoulder rotator cuff is a common component of shoulder muscles assessment. Nevertheless, the extensive mobility of the shoulder poses great difficulty in finding a consensus protocol for evaluation.

OBJECTIVE

  To select an optimal protocol, among three, based on the best reproducibility and reliability of strength scores derived from internal and external rotator tests.

METHOD

  The dominant side external and internal rotator muscles of twelve healthy male subjects were evaluated based on a concentric protocol (60° s(-1) and 240° s(-1) ) in three different test positions: two in lying supine with the arm in either 90° or 45° abduction and one in the seated position with the arm moving in the scapular plane on the dominant shoulder. Subjects were tested twice over 10 days.

RESULTS

  The two lying installations were associated with the lowest coefficient of variation (7.1-11.8%) and smallest detectable difference (7-15.9 N.m) for peak moment and strength ratios. Consequently, the lying positions were chosen for rotators assessment with 90° of abduction associated with a higher reproducibility for the agonist/antagonist ratios or 45° if some pain was provoked. In any case, the coefficient of variation did not exceed 12%.

CONCLUSION

  Based on a reproducibility and reliability analysis, we recommend the testing of isokinetic strength of the shoulder rotators to be conducted in supine lying, with the arm at 90° or 45° abduction in the frontal plane.

[Myxoid liposarcoma]

Soft-tissue sarcoma is a rare pathology. Due to restricted symptomatology, the diagnosis is often late. Any soft tissues swelling requires at first an ultrasound exam and a radiography, though MRI remains the most appropriate investigation. Treatment will be selected according to the tumor type and its histological grading, these parameters being determined after a surgical or a needle biopsy. The surgical care is often complemented by radiotherapy and sometimes chemotherapy.

[Osteogenesis imperfecta]

We report the case of a young boy who had had multiple bone fractures (more than 10) since the age of 19 months. The father had the same clinical history. The clinical examination was normal for his age except blue sclera. The bone densitometry showed a severe osteoporosis for his age. Biological exam swere correct. The genetic exploration revealed mutation of COL1A2 gene. With this clinical history, the diagnosis of Osteogenesis imperfecta (OI) was retained. OI is a hereditary dystrophy with abnormal synthesis or metabolism of collagen with, often, mutation of COL1A1 or COL1A2 genes. There are 7 different forms. We consider the possible differential diagnoses. The goal of any treatment is to promote bone remineralisation and to decrease the fracture frequency. The treatment includes calcium and vitamin D, and in the presence of some precise criteria, biphosphonate therapy.