Douglas P. Jutte MD, MPH

• Associate Adjunct Professor, Community Health and Human Development

https://publichealth.berkeley.edu/people/douglas-jutte/

Case 2 A previously healthy 25-year-old security guard is admitted to the emergency department in status epilepticus spasms back muscles 60mg mestinon for sale. In practice it is more useful to think of four broad categories of head and face pain (see the table below) muscle relaxant non drowsy buy mestinon 60 mg otc, and to become familiar with the common disorders in each category yellow round muscle relaxant pill purchase 60mg mestinon amex. By far the most common are the longstanding headaches which affect the patient most of the time muscle relaxant starting with b generic mestinon 60 mg otc, namely tension headaches and analgesic-dependent headaches, and the longstanding but intermittent headaches of migraine. Contrary to public belief, it is extremely rare for brain tumours to present with chronic headache without additional symptoms. It is frequently described as a tight band around the head, often radiating into the neck. Most of us have experienced headaches of this kind from time to time, when tired or stressed. Patients who seek medical advice about tension headaches tend to get them most of the time and with considerable severity. The source of the pain is believed to be chronic contraction of the neck and facial muscles. There is usually a background of stress and worry, sometimes with clinically significant anxiety or depression. The patient is often concerned about the possibility of a brain tumour, creating a vicious circle where headaches cause anxiety and anxiety causes more headaches. Treatment therefore starts with trying to help the patient to understand the nature of the headache, with reassurance (based upon a careful neurological examination) that there is no serious physical cause. Some patients cannot be reassured without a brain scan but this is not a good use of resources from a medical point of view. It characteristically causes episodes of headache, lasting between a few hours and a few days; the patient feels normal between these attacks. Attacks may be precipitated by a wide range of triggers, and commonly by a combination of these. Some then have an aura, which characteristically evolves over a period of about 20 minutes. The commonest is visual, with an area of blurred vision or an arc of scintillating zigzags slowly spreading across the visual field. Less commonly there may be tingling, for example in one hand spreading slowly to the ipsilateral tongue, or dysphasia, or unilateral weakness, or a succession of all three. It used to be thought that these aura symptoms reflected cerebral ischaemia, but recent research has shown that the phenomena have a neuronal rather than a vascular basis. The next phase of the attack is the headache itself, although older patients may find they gradually stop experiencing this. It is often accompanied by pallor, nausea or vomiting, and an intense desire to lie still in a quiet darkened room. It is not always possible to persuade the patient to pursue the life of sustained tranquillity and regularity that seems to suit migraine best. Individual attacks may respond to simple analgesia taken promptly, if necessary together with a dopamine antagonist. Failing that, serotonin agonists such as ergotamine and the triptan family of drugs can be of great benefit. If vomiting is pronounced, such agents can be given sublingually, by nasal spray, by suppository or by injection. This is a particular problem with ergotamine but can also occur with the triptans and can lead to overuse of medication and a chronic headache (see overleaf). Preventive treatment should be considered if migraine attacks are frequent or when there are rebound attacks. Regular administration of beta-adrenergic blockers such as atenolol, the tricyclic amitriptyline and the anticonvulsant sodium valproate all have significant benefits. Current research suggests that some of the newer anticonvulsants may be even more effective, supporting the view that migraine may be a disorder of ion channels. During the cluster, the attacks themselves are brief, lasting between 30 and 120 minutes. They often occur at the same time in each 24-hour cycle, with a predilection for the early hours of the morning. The pain can sometimes be controlled by inhaling high-flow oxygen or injecting sumatriptan. Prophylactic treatment can be enormously helpful, starting with steroids and verapamil and moving on to methysergide or anticonvulsants (such as topiramate) if necessary. Reassurance is usually all that is required but regular administration of non-steroidal anti-inflammatory drugs can suppress them. They develop a daily headache, often with a throbbing quality, that is transiently relieved by the offending drug. Treatment consists of explanation, gradual introduction of headache prophylaxis (such as amitriptyline) and planned, abrupt discontinuation of the analgesic. The daily headaches usually settle after a short but unpleasant period of withdrawal headache. The diagnosis of raised intracranial pressure therefore largely relies upon the detection of the focal symptoms and signs of the causative intracranial space-occupying lesion (tumour, haematoma, abscess, etc. Such features tend to arise in the context of a subacute and clearly deteriorating illness, and require prompt investigation with brain scanning. Lumbar puncture should not be performed unless a focal cause has been confidently excluded. The headaches of raised intracranial pressure tend to be worse when the patient is lying flat, and may therefore wake the patient from sleep or be present on waking. As a general rule, raised-pressure headaches are more likely to be occipital and mild. They can also occur spontaneously, because of a leak arising in a thoracic nerve root sheath following coughing or air travel. The first attack may be difficult to distinguish from subarachnoid haemorrhage (which can, of course, occur at times of exertion). It is very reassuring if one discovers a history of previous attacks under similar circumstances. Happily, and unlike subarachnoid haemorrhage, benign sex headaches are not associated with loss of consciousness or vomiting. The attacks tend to disappear spontaneously but beta-adrenergic blockers can be a very effective preventive treatment. The danger lies in the fact that the lumen of these arteries may become obliterated because of the thickening of their walls and associated thrombosis. Patients with giant cell arteritis generally feel unwell, short of energy and apathetic. The condition overlaps with polymyalgia rheumatica, in which similar symptoms are associated with marked stiffness of muscles. The arteritis causes headache and tenderness of the scalp (when resting the head on the pillow, and when brushing the hair), because of the inflamed arteries. The condition is sometimes known as temporal arteritis because of the very frequent involvement of the superficial temporal arteries, but the facial arteries are often involved, as are other arteries in the scalp. The arterial occlusive aspects of the disease chiefly concern the small branches of the ophthalmic artery in the orbit. Sudden and irreversible blindness due to infarction of the distal part of the optic nerve is the main danger. In all but the most clear-cut cases, the diagnosis should be rapidly confirmed with a temporal artery biopsy. Most patients will continue to need steroids in much diminished doses for a couple of years, and sometimes for much longer. Occasional cases present with a subacute headache and raised intracranial pressure. Forward flexion of the neck moves the inflamed meninges, and is involuntarily resisted by the patient. The headache and neck stiffness are severe and sudden in onset when the meningeal irritation is due to blood in the subarachnoid space (subarachnoid haemorrhage) (see pp.

Continuing insulin dosage-The total daily insulin dosage may need to be increased gradually to 1 U/kg (especially if ketones are present at onset) spasms after eating safe mestinon 60 mg. When gluconeogenesis and glycolysis are suppressed by insulin muscle relaxant jaw clenching purchase 60 mg mestinon otc, a honeymoon or grace period is a common phenomenon spasms coronary artery discount mestinon 60 mg with mastercard. Examples of thinking scales are included in Understanding Diabetes (see references) zyprexa spasms order 60 mg mestinon. However, small decreases may be made for heavy activity (eg, afternoon sports or overnight events). As noted earlier, when one of the more physiologic (closer to human insulin output) basal insulins, Lantus or Levemir, is used, it must be given alone in the syringe or pen. The dose of Lantus or Levemir is then increased or decreased 1 or 2 units every few days based on the fasting morning blood glucose levels. Continuous subcutaneous insulin (insulin pump) therapy is being used more often in children, particularly for emotionally mature teens who are willing to do frequent blood glucose monitoring and to count carbohydrates. Insulin pump therapy is discussed in depth in Chapter 26 of Understanding Diabetes (see references). The following regimen constitutes intensive diabetes management: (1) three or more insulin injections per day, or insulin pump therapy; (2) four or more blood glucose determinations per day; (3) careful attention to dietary intake; and (4) frequent contact with the health care provider. All teenagers with suboptimal glucose control who are willing to comply should be considered for intensive diabetes management. Treatment of type 2 diabetes-The treatment of type 2 diabetes in children varies with the severity of the disease. If the glycosylated hemoglobin (HbA1c) fraction is still normal (or near normal) and ketone levels are not moderately or significantly increased, modification of lifestyle (preferably for the entire family) is the first line of therapy. If needed, and if gastrointestinal adaptation has occurred, the dose can be gradually increased to 1 g twice daily. If the presentation is more severe, with moderately or significantly increased urine ketone levels, or blood -hydroxybutyrate is more than 1. Oral hypoglycemic agents may be tried at a later date, particularly if weight loss has been successful. Exercise Regular aerobic exercise-at least 30 minutes a day-is important for children with diabetes. Exercise fosters a sense of well-being; helps increase insulin sensitivity; and helps maintain proper weight, blood pressure, and blood fat levels. Children using insulin pumps should reduce preexercise bolus insulin dosages as well as the basal dosages during (and sometimes after) the exercise. In general, the longer and more vigorous the activity, the greater the reduction in insulin dose. Stress Management Management of stress is important on a short-term basis because stress hormones increase blood glucose levels. Chronic emotional upsets may lead to missed injections or other compliance problems. When this happens, counseling for the family and child becomes an important part of diabetes management. Diet the mainstays of dietary treatment are discussed in detail in Understanding Diabetes (see references). Some families and children (particularly those with weight problems) find exchange diets helpful initially while they are learning food categories. Most centers now just use exchanges of carbohydrates, referred to below as carbohydrate-counting or "carb-counting. Two other nutritional factors include adjusting insulin levels for meals and maintaining a consistent schedule of nighttime snacks. Home Blood Glucose Measurements All families must be able to monitor blood glucose levels three or four times daily-and more frequently in small infants and patients who have glucose control problems or intercurrent illnesses. Blood glucose levels can be monitored using any of the available meters, which generally have an accuracy of 90% or better. If more than 50% of the values are above the desired range for age or more than 14% below the desired range, the insulin dosage usually needs to be adjusted. Some families are able to make these changes independently (particularly after the first year), whereas others need help from the health care provider. The values should also be below the upper limits for age when tested 2 h after a meal. As with insulin pump therapy, additional education, usually at a specialty diabetes center, is required. Laboratory Evaluations In addition to home measurements of blood glucose and blood or urine ketone levels, the HbA1c level should be measured every 3 months. This test reflects the frequency of elevated blood glucose levels over the previous 3 months. Higher levels are allowed in younger children to reduce the risk of hypoglycemia because their brains are still developing and they may not relate symptoms of hypoglycemia to a need for treatment. Low HbA1c values are generally associated with a greater risk for hypoglycemia (see the following section). Using either method, longitudinal averages more than 33% above the upper limit of normal are associated with a higher risk for later renal and retinal complications. Since atherosclerosis is the major cause of death in older patients with diabetes it is important to measure serum cholesterol, low-density lipoprotein cholesterol, and highdensity lipoprotein cholesterol levels once yearly. Cholesterol levels should be below 200 mg/dL and low-density lipoprotein cholesterol levels below 100 mg/dL in postpubertal patients with diabetes. When puberty is reached and the individual has had diabetes for 3 years or longer, the urinary excretion of albumin should be measured (as microalbumin) in two separate urine samples once yearly (see discussion of chronic compli- cations, later). This can be done using timed overnight urine collections or first-morning voids (expressed per milligram of creatinine). Normal values differ with the methodology of the laboratory but are generally below 20 mcg/min (or 30 mcg/ mg creatinine). People with type 2 diabetes should have this test done soon after diagnosis and then annually. If the thyroid is enlarged (about 20% of patients with type 1 diabetes), the thyroid-stimulating hormone level should be measured yearly. This is usually the first test to become abnormal in the autoimmune thyroiditis commonly associated with type 1 diabetes. In recent years antiendomysial and transglutaminase antibodies, reliable predictors of celiac disease, have been shown to be more common in children with diabetes as well as in their siblings. The celiac antibodies should be checked in diabetic children with poor growth (especially when not related to poor glucose control) or those who present with gastrointestinal symptoms. The 21hydroxylase autoantibody, a marker of increased risk of Addison disease, is present in approximately 1. Type 2 diabetes is not an autoimmune disease, and the islet antibody tests are negative. An elevated insulin or Cpeptide level is also helpful, indicating that insulin production is normal or elevated. Hypoglycemia Hypoglycemia (or insulin reaction) is defined as a blood glucose level below 60 mg/dL (or 3.

Radioisotope experiments by Baxter and Pruitt et al have demonstrated that plasma expansion during the first 24h was independent of the type of fluid given muscle relaxant non-prescription generic mestinon 60mg with mastercard, whether crystalloid or colloid muscle spasms zinc 60mg mestinon overnight delivery. A marked proportion of fire related deaths are not attributable to burn injury spasms prednisone generic 60 mg mestinon with mastercard, but to the toxic effects of airborne combustion byproducts spasms colon symptoms discount 60mg mestinon free shipping. Clinical signs of inhalation injury vary, but inhalation injury can be suspected when the patient has been exposed to smoke in an enclosed area and has physical findings of burns on the face, singed nasal vibrissae, bronchorrhoea, sooty sputum, and wheezing or rales. Once inhalation injury is diagnosed, treatment of the injury should start immediately. Patients with inhalation injury should not be prophylactically intubated, nor should they receive prophylactic antibiotics. Standard care protocols for inhalation injury include bronchodilators (salbutamol), nebulised heparin, nebulised acetylcysteine, and for extreme mucosal oedema, racemic adrenaline. It is important to identify pediatric patients who may require definitive airway management early, as securing the airway becomes increasingly challenging with the development of oedema. Within the first 24 h after burn injury, succinylcholine is safe to use without the risk of lethal hyperkalemia. Previously, the standard practice in pediatric patients was to place uncuffed endotracheal tubes to prevent mucosal damage. However, recent evidence suggests that low pressure high volume cuffed endotracheal tubes should be used since patients may have decreased compliance and may require high ventilatory pressures that can cause leaks around uncuffed tubes. In the acute phase, patients may have facial and airway edema that distorts the normal anatomy as well as limited neck mobility and mouth opening. All patients with face, neck, or upper chest injuries should be approached as potential difficult airways. Anesthetic considerations for acute burn procedures the management of pediatric burn patients provides challenges for the anesthesiologist. Preoperative assessment and management the preoperative assessment of a burn patient begins with an evaluation of the type and severity of burn injury and any associated injuries. Significant co-existing medical illness may merit more aggressive treatment and resuscitation even with minor burns. The physical exam should include a thorough airway evaluation as many of these patients have distorted anatomy and are potential difficult intubations. These patients have high metabolic demands; therefore, perioperative nutrition should be continued as long as possible. While some evidence shows that preoperative fasting of nasogastric feeds for <2 h may not increase aspiration risk, there is limited data on the safety and efficacy of this practice. Naso-jejunal enteral feeds are an alternative to nasogastric feeds to minimize the risk of aspiration. Continuing naso-jejunal feeds perioperatively does not appear to increase the risk of aspiration. While parenteral nutrition can be continued perioperatively in lieu of enteral nutrition; this practice is not without risk since parenteral nutrition is associated with in-creased mortality and altered gut physiology. During the preoperative assessment, attention should be paid to any fear, anxiety, and pain that the child may have. Appropriate premedication should be given as indicated prior to transport to the operating room. Peripheral pulse oximetry may be unreliable with extensive burn injury, hypoperfusion, or hypothermia. Alternative sites of probe placement include the ear lobe, buccal mucosa, tongue, and esophagus. Invasive blood pressure monitoring is advantageous if the extremities are injured or if large fluid shifts or blood loss are expected. During the initial burn shock phase, decreased circulatory blood volume, cardiac output and tissue perfusion lead to reductions in renal and hepatic blood flow, which prolongs the rate of drug distribution and onset of clinical effects. Lower doses of agents are typically required because of prolonged duration of action and slower rates of renal clearance. During the subsequent hypermetabolic phase, high blood flow to the liver and kidneys, decreased plasma albumin, and an increased level of -1-acid glycoprotein result in altered protein binding and increased renal clearance. Anesthetic requirements are generally increased including minimal alveolar concentration for volatile anesthetics, and the duration of action is decreased requiring frequent redosing of agents. Propofol and thiopental have been used successfully for induction, though they should be carefully titrated to minimize dose dependent cardiac and respiratory depression. Etomidate is an effective induction agent because of its stable hemodynamic profile and is considered a good choice for burned patients who may not tolerate changes in heart or cardiac output. However, the use of etomidate in septic patients is controversial because of adrenocortical suppression following a single bolus dose and likewise may not be the best choice of induction agent for immunocompromised burn patients. Ketamine offers many advantages for induction and maintenance of anesthesia for burn-injured patients and is routinely used for burnrelated procedures. Ketamine may be particularly useful for the induction of hypovolemic patients due to sympathomimetic effects that cause dose-dependant increases in arterial blood pressure and heart rate. Increased systemic vascular resistance may be advantageous during burn surgery, as it reduces heat and blood loss from burned skin compared with vasodilatation caused by virtually all other anesthetic agents. Ketamine offers additional benefits of airway reflex preservation, dissiciative anesthesia, and potent analgesia. Minimal increases in heart rate observed after ketamine is administered to hypermetabolic patients may result from preexisting elevated levels of cateholamines that result in a decrease in the number of receptors and a down-regulation of receptor affinity. Patients that are in the acute phase of their injury may be too hemodynamically unstable to tolerate the potent inhalational agents; therefore, a nitrous-narcotic technique with or without ketamine supplementation might be preferred. Burn patients are shown to have higher requirements for thiopental up to a year postinjury. Burn patients also have an increased requirement for opioids due to both pharmacokinetic changes and to development of tolerance. Because of the pharmacologic changes with burn injury, all drugs should be titrated to clinical effect. There is limited data to approximate the amount of blood loss during excision and grafting procedures. Expected blood loss increases each day postinjury as the wound becomes more hyperemic. Blood loss is greater for tangential excisions as compared with fascial excisions and is approximated as 4 ml/cm2 and 1. Frequent hematocrit and hemoglobin measurements are necessary to best determine blood loss for each individual patient. Intraoperative fluid losses can be replaced with crystalloid or colloid solutions. Temperature regulation Pediatric burn patients are at great risk for intraoperative heat loss due to the lack of an intact skin layer and due to their high surface area to volume ratio. Hypothermia increases metabolic heat production, which diverts metabolic energy from other areas such as wound healing. Therefore, one must take care to prevent intraoperative heat loss in these patients. At this time, volume losses are ongoing from the blood and serum oozing from the operative sites. Feeding and drinking should be re-introduced as soon as possible, and nausea and vomiting aggressively managed. Background pain, which is proportional to the size of the thermal injury, must be adequately controlled before procedural pain and postoperative pain can be addressed. These patients do develop tolerance to opioids; therefore, the doses should be reassessed frequently and should be titrated to patient comfort. In order to minimize the escalation of opioid doses patents other agents, such as acetaminophen, ketamine, or alpha-2 agonist, such as clonidine, can be used as analgesic adjuncts. Nonsteroidal antiinflammatory drugs are also useful analgesic adjuncts; however, they carry the risk of renal tubular dysfunction. Burn pain can have a depressive effect and /or associated anxiety, which can be treated with anti-depressants and benzodiazepines, respectively. Background pain should be adequately controlled in order to have effective control of procedural pain. Procedure related pain is controlled with additional boluses of opioids, benzodiazepines, and /or ketamine. Regional anesthesia Regional anesthesia techniques, epidural and peripheral nerve blocks, can provide postoperative pain control. There is limited data on the efficacy of epidural block in pediatric burn patients.

It is also present in an alarming frequency among young muscle relaxant before massage purchase mestinon 60 mg visa, eating-disordered muscle relaxant 16 proven mestinon 60 mg, amenorrheic female athletes spasms upper back discount 60 mg mestinon overnight delivery. Although the cause of osteoporosis remains unknown muscle relaxant name brands purchase mestinon 60 mg with mastercard, the condition can often be improved through hormone therapy, avoidance of negative lifestyle factors, and a regular exercise program. Explain why the bones of the human body are stronger in resisting compression than in resisting tension and shear. In the human femur, bone tissue is strongest in resisting compressive force, approximately half as strong in resisting tensile force, and only about one-fifth as strong in resisting shear force. If a tensile force of 8000 N is sufficient to produce a fracture, how much compressive force will produce a fracture? Rank the following activities according to their effect on increasing bone density: running, backpacking, swimming, cycling, weight lifting, polo, tennis. What kinds of fractures are produced by compression, tension, and shear, respectively? How much stress is present on the 22 cm2 surface area of that vertebra in an erect 756 N man? In Problem 8, how much total stress is present on the fifth lumbar vertebra if the individual holds a 222 N weight bar balanced across his shoulders? Hypothesize about the way or ways in which each of the following bones is loaded when a person stands in anatomical position. Outline a six-week exercise program that might be used with a group of osteoporotic elderly persons who are ambulatory. Speculate about what exercises or other strategies may be employed in outer space to prevent the loss of bone mineral density in humans. Hypothesize as to the ability of bone to resist compression, tension, and shear, compared to the same properties in wood, steel, and plastic. When an impact force is absorbed by the foot, the soft tissues at the joints act to lessen the amount of force transmitted upward through the skeletal system. If a ground reaction force of 1875 N is reduced 15% by the tissues of the ankle joint and 45% by the tissues of the knee joint, how much force is transmitted to the femur? What do the bone shapes indicate about the probable locations of muscle tendon attachments and the directions in which the muscles exert force? Write a paragraph summarizing how the structure of each bone type contributes to its function. Summary for compact bone: Summary for spongy bone: 4. Using a paper soda straw as a model of a long bone, progressively apply compression to the straw by loading it with weights until it buckles. Using a system of clamps and a pulley, repeat the experiment, progressively loading straws in tension and shear to failure. Record the weight at which each straw failed, and write a paragraph discussing your results and relating them to long bones. Ding M: Age variations in the properties of human tibial trabecular bone and cartilage, Acta Orthop Scand Suppl 292:1, 2000. Hawkey A: Physiological and biomechanical considerations for a human Mars mission, J Br Interplanet Soc 58:117, 2005. Heinonen A, Sievanen H, Kannus P, Oja P, Pasanen M, Vuori I: High-impact exercise and bones of growing girls: a 9-month controlled trial, Osteoporosis Int 11:1010, 2000. Hreljac A: Impact and overuse injuries in runners, Med Sci Sports Exer 36:845, 2004. Humphries B, Fenning A, Dugan E, Guinane J, and MacRae K: Whole-body vibration effects on bone mineral density in women with or without resistance training, Aviat Space Environ Med 80:1025, 2009. Kontulainen S, Kannus P, Haapasalo H, Sievanen H, Pasanen M, Heinonen A, Oja P, and Vuori I: Good maintenance of exercise-induced bone gain with decreased training of female tennis and squash players: a prospective 5-year follow-up study of young and old starters and controls, J Bone Miner Res 16:202, 2001. Krolner B and Pors Nielsen S: Bone mineral content of the lumbar spine in normal and osteoporotic women: cross-sectional and longitudinal studies, Clin Sci 62:329, 1982. Lips P: Epidemiology and predictors of fractures associated with osteoporosis, Am J Med 103:3S, 1997. Merriman H and Jackson K: the effects of whole-body vibration training in aging adults: a systematic review, J Geriatr Phys Ther 32:134, 2009. Mosekilde L: Age-related changes in bone mass, structure, and strength- effects of loading, Z Rheumatol 59 (Suppl 1):1, 2000. Naganathan V, and Sambrook P: Gender differences in volumetric bone density: a study of opposite-sex twins, Osteoporos Int 14:564, 2003. Pettersson U, Nordstrom P, and Lorentzon R: A comparison of bone mineral density and muscle strength in young male adults with different exercise level, Calcif Tissue Int 64:490, 1999. Sowers M: Epidemiology of calcium and vitamin D in bone loss, J Nutr 123 (2 Suppl):413, 1993. Uusi-Rasi K, Sievanen H, Pasanen M, Oja P, and Vuori I: Maintenance of body weight, physical activity and calcium intake helps preserve bone mass in elderly women, Osteoporosis Int 12:373, 2001. Wang Q and Seeman E: Skeletal growth and peak bone strength, Best Pract Res Clin Endocrinol Metab 22:687, 2008. Yamazaki S, Ichimura S, Iwamoto J, Takeda T, and Toyama Y: Effect of walking exercise on bone metabolism in postmenopausal women with osteopenia/ osteoporosis, J Bone Miner Metab 22:500, 2004. Summarizes current understanding of the mechanical properties of bone, as well as clinically related issues, such as bone prostheses, implants, and imaging of bone structure. Review of bone structure and mechanics, with numerous insights on form following function. Pronouncement of the American College of Sports Medicine updating scientific knowledge on the female athlete triad. Reviews knowledge related to requirements for rehabilitation of the musculoskeletal system following space flight. National Institutes of Health Osteoporosis and Related Bone Diseases-National Resource Center. Explain advantages and disadvantages of different approaches to increasing or maintaining joint flexibility. Describe the biomechanical contributions to common joint injuries and pathologies. The anatomical structure of a given joint, such as the uninjured knee, varies little from person to person; as do the directions in which the attached body segments, such as the thigh and lower leg, are permitted to move at the joint. However, differences in the relative tightness or laxity of the surrounding soft tissues result in differences in joint ranges of movement. This chapter discusses the biomechanical aspects of joint function, including the concepts of joint stability and joint flexibility, and related implications for injury potential. Since this book focuses on human movement, a joint classification system based on motion capabilities is presented. The mid-radioulnar joint is an example of a syndesmosis, where fibrous tissue binds the bones together. Synarthroses (immovable) (syn 5 together; arthron 5 joint): these fibrous joints can attenuate force (absorb shock) but permit little or no movement of the articulating bones. Sutures: In these joints, the irregularly grooved articulating bone sheets mate closely and are tightly connected by fibers that are continuous with the periosteum. The fibers begin to ossify in early adulthood and are eventually replaced completely by bone. Syndesmoses (syndesmosis 5 held by bands): In these joints, dense fibrous tissue binds the bones together, permitting extremely limited movement. Examples include the coracoacromial, mid-radioulnar, mid-tibiofibular, and inferior tibiofibular joints. Amphiarthroses (slightly movable) (amphi 5 on both sides): these cartilaginous joints attenuate applied forces and permit more motion of the adjacent bones than synarthrodial joints. Synchondroses (synchondrosis 5 held by cartilage): In these joints, the articulating bones are held together by a thin layer of hyaline cartilage. Examples include the sternocostal joints and the epiphyseal plates (before ossification).

In young athletes muscle relaxant gas effective 60 mg mestinon, it is infrequently associated with swelling and crepitus of the knee joint spasms and pain under right rib cage mestinon 60 mg with amex. The Q-angle is measured by drawing a line from the anterosuperior iliac spine down to the center of the patella and then through the tibial tubercle knee spasms at night mestinon 60mg mastercard. Q-angles greater than 20 degrees tend to cause the patella to track laterally muscle relaxant during pregnancy safe mestinon 60mg, changing the knee biomechanics. Use of braces providing proprioceptive feedback during competition is controversial. Femoral Neck Fractures Femoral neck fractures (stress fractures) are generally the result of repetitive microtrauma. Athletes with this type of injury present with persistent pain in the groin and pain with internal and external rotation. The meniscus of the knee cushions forces in the knee joint, increases nutrient supply to the cartilage, and stabilizes the knee. Medial meniscus injuries have a history of tibial rotation in a weight-bearing position. Lateral meniscus injuries occur with tibial rotation with a flexed knee, as in exercises such as squatting or certain wrestling maneuvers. Osgood-Schlatter Disease (Tibial Tubercle Apophysitis) this condition is caused by the recurrent traction on the muscle-tendon unit that occurs in jumping and running sports. Fragmentation and microfractures of the tibial tubercle occur during its time of rapid growth. Pain usually is present at the tibial tubercle, and is aggravated by activities using eccentric quadriceps muscle movement. Radiographs typically demonstrate fragmentation or irregular ossification of the tibial tubercle. Clinical Findings the athlete with such an injury has a history of knee pain, swelling, snapping, or locking or may report a feeling of the knee giving way. Physical examination often reveals swelling, joint line tenderness, and a positive McMurray hyperflexionrotation test. Sinding-Larsen-Johansson Disease (Apophysitis of the Inferior Pole of the Patella) this condition involves a process similar to that in OsgoodSchlatter disease, but occurring in younger athletes, usually between ages 9 and 12 years. Traction from the patellar tendon results in fragmentation of the inferior patella that is often obvious on a lateral knee radiograph. Treatment Treatment may be symptomatic for minor, isolated injuries of the meniscus that do not involve a mechanical block. Persistent loss of motion and other signs of meniscal damage suggest meniscal impingement and require more urgent referral for surgical management. If surgery is needed, weight bearing may not be allowed, depending on the amount of meniscal damage and the type of repair required. Alignment problems and mechanics across the anterior knee can be improved with an effective rehabilitation program that includes flexibility and strengthening. Quadriceps, pelvic, and core strengthening are all important components of this program. Orthotics, in theory, can have an impact on mechanics across the knee joint if they correct excessive pronation or supination. Knee bracing is controversial, and the major benefits are proprioceptive feedback and patellar tracking. Posterior Knee Pain Posterior knee pain usually results from an injury to the gastrocnemius-soleus complex caused by overuse. It can also include a Baker cyst, tibial stress fracture, or tendonitis of the hamstring. Medial injuries occur either with a blow to the lateral aspect of the knee, as seen in a football tackle, or with a noncontact rotational stress. Radiographs are useful, especially in the skeletally immature athlete, to evaluate for distal femoral or proximal tibial bone injury. All other structures of the knee need to be examined to rule out concomitant injuries. Structured physical therapy can be instituted early to assist in regaining range of motion and strength. Conservative treatment includes bracing, strengthening, and restricting physical activity. Conservative management can be complicated by continued instability and damage to meniscal cartilage. Surgical repair is typically indicated for young athletes in cutting sports and is also required for persistent instability. Partial weight bearing is allowed in a brace that is set in full extension as the quadriceps strengthen. The goals of the subsequent program are continued strength, muscle reeducation, endurance, agility, and coordination. A protective brace needs to be worn, and full knee motion in the brace can be permitted within a few days. The athlete should use the brace until the pain and range of motion have improved. The use of a functional brace is often required when a player returns to competition. Bracing is temporary, until the ligament heals properly and the athlete has no subjective feelings of instability. The mechanism of injury involves force applied to the knee during hyperextension, with excessive valgus stress and forced external rotation of the femur on a fixed tibia. Clinical Findings the athlete often reports hearing or feeling a "pop," followed by swelling that occurs within hours of the injury. Grade 1 injury is a stretch without instability, grade 2 is a partial tear with some instability, and grade 3 is a total disruption of the ligament with instability of the joint. The ankle has three lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and a medial deltoid ligament. Inversion of the foot generally damages the anterior talofibular ligament, whereas eversion injures the deltoid ligament. Lateral ankle sprains are far more common than medial ankle sprains because the deltoid ligament is stronger, mechanically, than the lateral ligaments. Clinical Findings the athlete presents with swelling and pain in the posterior and lateral knee. Confirmatory testing includes the posterior drawer test, performed with the patient supine, the knee flexed to 90 degrees, and the foot stabilized. Treatment Treatment can be determined as soon as the exact injury has been isolated. Treatment is controversial with respect to surgical versus nonsurgical management, although nonsurgical management is gaining popularity as outcomes tend to be similar for both groups. Braces and a progressive rehabilitation program have been used successfully in athletes with grade 1 and 2 injuries. Kyist J: Rehabilitation following anterior cruciate ligament injury: Current recommendations for sports participation. Clinical Findings Physical examination often reveals swelling, bruising, and pain. Obtaining radiographs is especially important when evaluating skeletally immature athletes who are more prone to growth plate injury. Tenderness over the malleoli, tenderness beyond ligament attachments, and excessive swelling are reasons to obtain radiographs. Differential Diagnosis Other injuries to consider include injuries to the fifth metatarsal, which can occur with an inversion mechanism. In this injury, the athlete presents with localized swelling and tenderness over the base of the fifth metatarsal.

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