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This pain is perceived to a much greater extent when there Redness is only observed over mechanically exposed is nothing else to distract the patient buy cheap xalatan 2.5 ml online medications 6 rights, i. Cell growth is also more pronounced during the likely to be ganglia or cysts (a typical lesion in children is night than the day, since growth hormone is primarily the popliteal cyst). But this pain pattern is also typical ous tissues that are highly mobile over the underlying of infections. Fairly rough, poorly demarcated areas of hard tissue and protuberances are in-! Unilateral pain that is not clearly load-related dicative of a fibromatosis or desmoid. Painful, moderately should always raise the suspicion of a tumor hard protuberances are highly suspicious of a malignant or inflammation. Nocturnal pain in the legs, particularly in the knee Laboratory investigations area, is very common in small children between the The most important differential diagnosis to be considered ages of three and eight. These are described as »grow- in relation to bone tumors is always an infection (osteomy- ing pains« ( Chapter 3. Infections can also cause nocturnal ticularly difficult to differentiate between these pain pain, swellings, redness and protuberances. Laboratory sensations: growing pains usually occur (alternately) on investigations (differentiated white cell count, erythrocyte both sides, which is never the case with painful tumors sedimentation rate, CRP) can often help in establishing (⊡ Table 4. Pain characteristics of tumors or tumor-like lesions during childhood and adolescence (malignant tumors are shown in red colour) Tumors that produce no pain Tumors that produce Tumors that produce nocturnal pain Tumors that no pain or only produce severe mechanical pain nocturnal pain Bone tumors and tumor-like lesions Non-ossifying bone fibroma Osteochondroma Osteoblastoma Osteoid osteoma, osteosarcoma Enchondroma Chondroblastoma, hemangioma, giant cell tumor Simple bone cyst Aneurysmal bone cyst, Ewing sarcoma, chondrosarcoma Soft tissue tumors and tumor-like lesions Fibroma, lipoma Desmoid, ganglia, cysts Hemangioma and other vascular tumors, sarcomas 587 4 4. A suitable (and inexpensive) flammatory parameters are generally negative in the case primary imaging investigation for soft tissue processes is of malignant bone tumors (except for Ewing sarcomas), a sonogram, since it can differentiate effectively between and any changes tend to occur at a late stage. The serum Conventional x-ray level of alkaline phosphatase is also a good indicator for The conventional x-ray shows very characteristic chang- the response of the tumor to chemotherapy. In any patient with unilateral musculoskeletal pain procedures can only strengthen or weaken a suspicion. Thus, for example, chondroblastomas almost invariably affect the epiphyses, while osteosarcomas are usually located in the metaphyses, and the rare adaman- Conventional x-ray in 2 planes tinomas are predominantly found in the diaphyses. The following tumors are not primarily located in the epiphyses: Ewing sarcoma, osteochondroma , simple bone cyst, non-ossifying bone fibroma, aneurysmal bone cyst. Giant Diagnosis clear, Diagnosis clear, Diagnosis Diagnosis clear Usually no Treatment unclear, rather or unclear, cell tumors, which are frequently located in the epiphysis treatment necessary benign rather malignant or metaphysis, also do not occur at purely epiphyseal level necessary Treatment Treatment if the growth plates are open. Osteo- graphic morphology to the biological behavior and patho- chondroma, osteoma, blastoma, giant sarcoma, non ossifying osteoblastoma cell tumor, Ewing-sarcoma, bone fibroma, aneurysmal chondrosarcoma, fibrous dysplasia, bone cyst metastases ⊡ Table 4. Typical sites of tumors within the long bone infarct bones (malignant tumors are shown in red) Possibly follow- Scintigram, CT scan and/ Scintigram, Site Tumor up, no further CT scan, or MRI thorax-x-ray Epiphysis Chondroblastoma, clear cell chondro- steps possibly MRI or CT-scan of sarcoma the lungs, MRI, poss. CT-scan Metaphysis Osteochondroma, non-ossifying bone of tumor-site fibroma, juvenile bone cyst, osteoblas- toma, giant cell tumor (usually with epiphyseal involvement), aneurysmal Resection Biopsy Biopsy at bone cyst, osteosarcoma, chondrosar- institution, coma where further treatment is Diaphysis Fibrous dysplasia, osteofibrous dyspla- carried out sia, Ewing sarcoma, adamantinoma Secondarily in Osteochondroma, non-ossifying bone ⊡ Fig. Diagnostic-therapeutic algorithm based on the conven- diaphysis fibroma, juvenile bone cyst tional x-ray 588 4. Since their classification already provides the formation of new stabilizing bone (sclerosis, increased valuable information about the aggressive nature to be thickness). In the case of faster growth the bone does not expected, without any knowledge of the histology, it will have time to react with new bone formation, and osteolysis be described briefly below. If bone breakdown predominates, osteolysis results, whereas ex- Periosteal reactions cessive bone formation results in osteosclerosis. The turn- Tumors can produce widely differing periosteal reactions over processes differ depending on whether cancellous or (⊡ Table 4. But these are not visible on the x-ray until they 4 The above statements indicate that the site is very important for the appearance of the tumor on the x-ray. While the degree of loading influences the reaction to tu- mor growth, the appearance on the x-ray is most strongly affected by the rate of tumor growth. Destruction pattern in compact and cancellous bone according to Lodwick and Wilson The classification system involves three basic patterns of bone destruction: ▬ I: geographic (map-like), primarily involving the can- cellous bone, ▬ II: mixed forms (geographic and moth-eaten/perme- ative), ▬ III: moth-eaten lesion, in compact and cancellous bone, or permeative destruction in the compact bone only. Various grades are differentiated according to the reac- tion of the compact bone and the penetration of the cortex in each case (⊡ Table 4.

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Remarkably 2.5 ml xalatan sale medications in carry on luggage, the Ukrainian children reported fewer physical symptoms than the Ameri- can ones of the same age, but their mothers reported nearly three times as many symptoms in their own children than those in Nashville. It is uncer- tain, of course, whether this reflects a generalized difference in awareness of bodily symptoms between American and Ukrainian women, developing at a later stage in life, or whether the Chernobyl incident fostered a more vigilant pattern in the latter group. Overall concern scores ranged from a high of 51 in Portugal to a low of 19 in Sweden, but the nature of the concerns also showed large inter-nation variability. Israeli patients were particularly con- cerned about pain and suffering whereas the Portuguese subjects worried about social stigma. Given the many behavioral consequences of chronic pain (McCracken, Zayfert, & Gross, 1992; Turk, Okifuji, Sinclair, & Starz, 1996), it is imperative to fully explore the sensory, affective, and cognitive reactions of pain patients, irrespective of ethnic background. ETHNOCULTURAL VARIATIONS IN PAIN 167 International studies of pain, particularly ones that focus on supposed ethnic or cultural differences, are influenced by differences in litigation or compensation systems in different countries. Hadjistavropoulos (1999), in a broad review of litigation and compensation, included a number of cross- cultural studies. Carron, DeGood, and Tait (1985), for example, found that back pain patients in the United States used more medication, experienced more disphoric mood states, and were more hampered in social-sexual, rec- reational, and vocational functioning than ones in New Zealand. In- dividuals in both countries who were receiving pretreatment compensation were less likely to report a return to full activity, although the relationship appeared more pronounced among those in the United States. Other studies that demonstrate that certain expensive interventions are more likely to reduce acute pain (e. Many of the published studies of ethnocultural factors and pain have made broad generalizations based upon exceedingly small sample sizes. Thomas and Rose (1991) asked 28 African Caribbean males and females, 28 Anglo-Saxons, and 28 Asians in London, England, who were having an ear pierced with a piercing gun, to complete the McGill Pain Questionnaire. Asian subject scores were nearly twice those of the African Caribbeans, with Anglo-Saxon scores nearly as high, leading them to con- clude, “the present results provide clear evidence that there are ethnic dif- ferences in pain experience in this test situation” (pp. Their subject pool consisted of 10 or 11 chronic low back pain pa- tients from each of the six countries. Likewise, Brena, Sanders, and Moto- yama (1990), evaluating 11 back pain patients from Tokyo and a like number of patients from Atlanta, reported, “Japanese low back pain patients were less psychosocially, vocationally, and avocationally impaired than similar American patients” (p. Sheffield, Kirby, Biles, and Sheps (1999) evaluated 124 Caucasians and 18 African Americans who had taken an exercise treadmill test which showed certain electrocardiographic abnormalities. Because 9 of the latter but only 34 of the former had angina during testing, they concluded, “African Ameri- 168 ROLLMAN cans reported anginal pain at twice the rate of Caucasians” (p. A sub- sequent study of pain perception (Sheffield, Biles, Orom, Maixner, & Sheps, 2000) using a contact thermode to deliver noxious levels of heat to 27 Whites and 24 African Americans, showed that the latter group gave higher ratings than the former to each of 5 temperatures, leading them to indicate that “these data suggest that different pain mechanisms underlie race dif- ferences in pain perception” (p. Edwards and Fillingim (1999), testing 30 Whites and 18 African Ameri- cans, also found that the Whites had a greater thermal pain tolerance and gave lower unpleasantness ratings at the lower two of four temperatures in a scaling study, with no group differences in intensity ratings. There were also no group differences in questionnaire measures of pain reactivity or in pain complaints over the preceding month, although African Americans re- ported greater average pain severity and two pain sites rather than the Whites’ number of 1. The two unpleasantness rating differences led to the proposal that there are racial differences in the affective-motivational di- mension of pain. A significant correlation between pain tolerance and pain symptoms brought the suggestion that ethnic variation in affective-moti- vational judgments may account for the severity and number of pain sites. The authors presented the admittedly speculative suggestion that African Americans may require quantitatively greater degrees of pain treatment than Whites. In a subsequent study of 68 African Americans and 269 Whites attending an interdisciplinary pain clinic, the African Americans reported significantly greater pain severity and pain-related disability than Whites (Edwards, Doleys, Fillingim, & Lowery, 2001), although no differences in the McGill Pain Questionnaire or measures of pain interference or affective distress. As well, the African Americans had shorter ischemic pain tolerance times for a tourniquet test (about 5 minutes vs. The large difference in the latter, compared to a much smaller difference in clini- cal pain, led to the suggestion that coping styles, attitudes toward pain measurement, or differences in central pain modulating systems may distin- guish the two groups. The inclusion of such diverse putative mechanisms underscores the risk of labeling any of the differences reported in this sec- tion as “racial” rather than “cultural. This problem is exacerbated by the fact that members of a particular group may differ in both their culturally deter- mined practices and in the manner in which they are treated by members of other groups in their society.

The mechanical properties of etiological factor in degenerative hip disease J Bone Joint Surg 2 the various structures change during growth generic xalatan 2.5 ml free shipping symptoms 7 days after conception. The critical structure in small children under 10 dylolysis in the female athlete. Clin Orthop 372: years of age is bone tissue, while this role is as- 74–84 sumed by growth cartilage in adolescents. Pouliquen JC, Kassis B, Glorion C, Langlais J (1997) Vertebral adults, the ligaments can ultimately be described growth after thoracic or lumbar fracture of the spine in children. J as the weakest point in the tissue system of the Pediatr Orthop 17: 115–20 14. Segesser B, Morscher E (1978) Die Coxarthrose bei ehemaligen musculoskeletal apparatus. Segesser B, Morscher E, Goesele A (1995) Störungen der Wachs- the lowest loading tolerance. Stokes I, Mente P, Iatridis J, Farnum C, Aronsson D (2002) Enlarge- So what advice should we give to young athletes? When ment of growth plate chondrocytes modulated by sustained should they start performance training? J Bone Joint Surg Am 84-A: 1842–8 cents wait until growth is completed and run the risk of 17. Tanchev P, Dzherov A, Parushev A, Dikov D, Todorov M (2000) no longer being competitive? Spine 25: 1367–72 questions we need to know more about the long-term ef- 18. Williamson A, Chen A, Masuda K, Thonar E, Sah R (2003) Tensile mechanical properties of bovine articular cartilage: variations fects of the aforementioned illnesses. Legitimate doubts exist as to whether a thoracic Orthop Res 21: 872–80 19. Clin Scheuermann disease or spondylolysis actually rep- Sports Med 21: 77–92 resents a major problem in later life. Wren T, Beaupré G, Carter D (1998) A model for loading-depen- apply, however, to a tilt deformity, which leads to dent growth, development, and adaptation of tendons and liga- impingement in the hip and constitutes a distinct ments. J Biomech 31: 107–14 form of pre-arthrosis – and coxarthrosis does actu- ally appear to be more common in former athletes than in the general population. Consequently, ex- cessive loading should be avoided particularly dur- ing early puberty. Beunen GP, Malina RM, Renson R (1992) Physical activity and growth, maturation and performance: A longitudinal study. Dorizas J, Stanitski C (2003) Anterior cruciate ligament injury in the skeletally immature. Herman M, Pizzutillo P, Cavalier R (2003) Spondylolysis and spon- dylolisthesis in the child and adolescent athlete. Hasler C, Dick W (2002) Spondylolyse und Spondylolisthesis im Wachstumsalter. Hatton J, Pooran M, Li C, Luzzio C, Hughes-Fulford M (2003) A short pulse of mechanical force induces gene expression and growth in MC3T3-E1 osteoblasts via an ERK 1/2 pathway. Hefti F, Morscher E (1985) Die Belastbarkeit des wachsenden Be- wegungsapparates. Hefti FL, Kress A, Fasel J, Morscher EW (1991) Healing of the tran- sected anterior cruciate ligament in the rabbit. Mankin K, Zaleske D (1998) Response of physeal cartilage to low- level compression and tension in organ culture. Morscher E (1968) Strength and morphology of growth cartilage under hormonal influence of puberty Reconstr. Karger, Basel New York (Surgery and Traumatology, vol 10) 3 Diseases and injuries by site 3. History To ensure that the patient’s back is at eye-level, the examiner himself should not stand but preferably ▬ Trauma history: Has trauma occurred?

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Can J Appl Physiol 22:307–327 xalatan 2.5 ml amex medicine 44-527, (2) joint lubrication, and (3) stress distribution with 1997. Tanaka H, Monahan KD, Seals DR: Age-predicted maximal heart Articular cartilage injury most commonly occurs in the rate revisited. Cartilage injuries of the knee affect approxi- myosin isoform composition. More recently, Hjelle and colleagues (2002) prospectively American College of Sports Medicine: Guidelines for Exercise evaluated 1000 knee arthroscopies and found chondral Testing and Prescription, 6th ed. The weight-bearing zone of the medial femoral Champaign IL, Human Kinetics, 2003. Campos GE, Luecke TJ, Wendeln HK, et al: Muscular adaptations in response to three different resistance training regimens: COMPOSITION AND ORGANIZATION Specificity of repetition maximum training zones. McArdle WD, Katch FI, Katch VL: Exercise Physiology: Energy, Articular cartilage consists primarily of a large extra- Nutrition, and Human Performance, 5th ed. Baltimore, MD, cellular matrix (ECM) and a sparse population of Lippincott, Williams & Wilkins, 2001. CHAPTER 9 ARTICULAR CARTILAGE INJURY 47 TABLE 9-1 Organization of Articular Cartilage ZONE CHONDROCYTE COLLAGEN PROTEOGLYCAN WATER PROPERTIES Middle Random, oblique Larger diameter, — — Less stiff than superficial less organized zone Superficial Flat, parallel to surface Thin, parallel to surface Lowest conc. Low fluid permeability Resistance to shear forces Deep Spherical, in columns Perpendicular to surface, Highest Lowest Anchors cartilage to extending into calcified zone subchondral bone Tidemark Separates deep zone from calcified zone, number increases with age Calcified Small cells in cartilaginous matrix with apatitic salts 1. Chondrocytes (5% of total wet weight) are derived progressive degenerative condition that increases in from mesenchymal stem cells which differentiate prevalence nonlinearly after the age of 50 years. The chondrocytes respond to a fuse fraying, fibrillation, and thinning of the articular variety of factors, including matrix composition, cartilage. Injuries that do not penetrate the (65–80% of the total wet weight), proteoglycans subchondral bone show little sign of spontaneous (PG) (aggrecan, 4–7% of the total wet weight), and repair, whereas those that extend into the depth of collagens (primarily type II, 10–20% of the total subchondral bone initiate a vascular proliferative wet weight), with other proteins and glycoproteins response that produces a mix of normal hyaline carti- in lesser amounts. The collagens provide form and lage (primarily type II collagen) and a structurally and tensile strength. The proteoglycans bind water and biomechanically inferior “scar cartilage,” or fibrocar- help distribute stresses as water flows through the tilage (primarily type I collagen). Each has a characteristic composition that disruption of the articular surface, (2) chondral imparts unique mechanical properties (Table 9-1). Decreased PG concentration, increased hydra- Mechanical injuries to articular cartilage occur when tion, and possibly disorganization of the collagen abnormal blunt traumatic and shear forces result in network. The decreased PG concentration and high compressive stress throughout the tissue and increased hydration are strongly correlated with a high shear stress at the cartilage–subchondral bone decrease in cartilage stiffness and an increase in junction (Finerman and Noyes, 1992). As a result, greater an isolated cartilage injury known as a focal chondral loads are transmitted to the collagen-PG matrix, defect, which is different from chondromalacia and increasing the vulnerability of the ECM to fur- osteoarthritis. It is not known at what point the accumulated including softening and fissuring to variable degrees microdamage is irreversible. Most often it is asymptomatic and chondrocytes can restore the matrix as long as does not require treatment. Primary osteoarthritis is a the loss of matrix PG does not exceed the rate of 48 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE synthesis, the collagen network remains intact, The most common clinical presentation following an and sufficient chondrocytes remain viable acute full-thickness chondral or osteochondral injury (Martin and Buckwalter, 2000). Chondral injuries subtle but often include localized pain, swelling, and a. May result in chondral fissures, flaps, fractures, mechanical symptoms (locking, catching). Lack of vascular access and migration of mes- toms (traumatic or insidious), mechanism of injury, enchymal cells limits the repair response previous injuries, and symptom-provoking activities. The surround- tial to evaluate for concomitant pathology that would ing chondrocytes respond by proliferating and alter the treatment plan. Antalgic postures or gaits increasing the synthesis of matrix components; may be present due to painful weightbearing in the however, the proliferating cells and newly syn- involved knee, or adaptive gait patterns such as in- thesized matrix do not fill the tissue defect, and toeing or out-toeing or a flexed-knee gait may develop soon after injury the increased proliferative and as the patient shifts weight away from the affected synthetic activity ceases. Range of motion testing is usually normal in cartilage may then be overloaded and also patients with isolated focal chondral defects. Acute injuries may fracture deep into subchon- Most often, the history, physical examination, and dral bone plain radiographs are all that are required to make the b. Ideal plain films include 45° inflammatory response, altering the synovial fluid and joint environment. The fibrin clot extends into the cartilage defect and releases vasoactive mediators and growth factors, TABLE 9-2 Components of a Comprehensive including transforming growth factor beta Musculoskeletal Examination (TGF-b) and platelet derived growth factor Habitus (PDGF).

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