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This article reports the postoperative results of 76 operations addressing otosclerosis. All procedures were performed by the same surgeon and took place within a 4-year period. We compared the postoperative audiometric results of 54 laser-assisted procedures with those of 22 nonlaser operations. Our findings revealed a statistically significant improvement in the air-bone gap closure of the laser-operated patients: the air-bone gap was narrowed to within 10 dB in 72% of laser-operated cases versus 54% in nonlaser cases. Furthermore, laser use does not induce high-frequency sensorineural hearing loss. We believe that a laser entails less risk of inner ear microtrauma and improves the accuracy and reliability of stapedotomy.

Background: The excessive motion of subtalar pronation of the foot, can cause stress and burden in tissues of the region, giving origin to aches and microtrauma. In clinical practice, excessive movement has been limited to the use of techniques of bandages applied to the plantar arch. Objective: Was to analyze the influence of rigid bandage in plantar pressure distribution corridors pronators. Method: This is a randomized clinical trial, blinded, with twenty runners pronators (33±7 y, 71±7 kg, 174±6 cm). Technique was applied bandage (rigid - BR) to support the plantar arch, described as antipronation. Plantar pressure data were collected using the F -scan system in three tests run at 9 km/h being: no bandages, rigid taping. We considered seven areas of pressure for data analysis, performed by means of ANOVA for repeated measures followed by paired t test. Results: BR resulted in significant reductions (p

Pubichairgrooming isbecomingan increasinglycommonpracticeamong women of all societies and demographic groups. In the United States, womenaremore likely togroomfor reasons that are sexuallydrivenand aremore likely to stopgroomingwhen lacking a current sexual partner. Further, pubic hair removal is significantly associated with a greater interest in sex and having a casual sex partner. Waxing is apopularepilation technique forpubichair removal,which involves applying hot wax to an area of skin that is then covered with muslin. The muslin is quickly removed, extracting the wax and unwanted hairs from the pubic area. Although relatively safe, waxing can cause microtrauma to the skin and its underlying structures with reported complications that include folliculitis, local spread of infection, burns, and syringoma development. Waxing-inducedfolliculitisofthepubicarea isacommoncomplication, usually secondary to infectionwithStaphylococcusaureus,Streptococcus pyogenes, orPseudomonasaeruginosa. The sourceof infectionmaybe normalskin flora,autoinoculation,contaminationofwaxingtools,orcolonizationof the individualperformingtheprocedure.Other infectionscan occur, andone reportdescribedawomanwithpoorly controlled insulindependent diabetesmellituswhodevelopedherpes simplex virus reactivationandsubsequentgroupAstreptococcustoxicshocksyndromefollowinga“Brazilian”bikiniwax.Anotherreportdescribedthedevelopment ofsyringomas in thegroin regionofa31-year-oldman,whichwasthought to be an inflammatory, hyperplastic response to repetitivewaxing. Pubichairwaxingcanalsocauseburns,withmostbeingsuperficialorpartialthicknessburns.Severeburnsrequiringdebridementandsplit skingrafting have been described following the use of self–waxing kits. Waxingcausesdeficits in themucocutaneousbarrier thatmaybesufficient for viral entry and transmission, potentially increasing the risk of acquiring sexually transmitted infections (STIs). One study demonstrated a correlation between sexually transmitted molluscum contagiosumand theuseof pubic hair removal practices. Still, there is a paucityofdataregardingtransmissionofotherviralagents, likelycomplicated bytheasymptomaticgenital sheddingofherpessimplexvirusesand long latency periods of human papillomaviruses. Becauseof itspopularity, healthpractitioners shouldbeawareof the potential dermatologic and systemic complications associatedwithpubic hairwaxing.While it has been shown that pubic hairwaxing directly correlates with increased sexual prevalence, more studies are necessary to further elucidate the risk of STI transmission after waxing. Individualswhowax their pubic hair shouldbe informedof this possible risk and perhaps be advised to abstain from sexual activity for a certain period of time after waxing.

Lumbar disc herniation is characterized with low back and leg pain resulting from the degenerated lumbar disc compressing the spinal nerve root. The etiology of degenerative spine is related to age, smoking, microtrauma, obesity, disorders of familial collagen structure, occupational and sports-related physical activity. However, disc herniations induced by congenital lumbar vertebral anomalies are rarely seen. Vertebral fusion defect is one of the causes of congenital anomalies. The pathogenesis of embryological corpus vertebral fusion anomaly is not fully known. In this paper, a 30-year-old patient who had the complaints of low back and right leg pain after falling from a height is presented. She had right L5-S1 disc herniation that had developed on the basis of S1 vertebra corpus fusion anomaly in Lumbar computed tomography. This case has been discussed in the light of literature based on evaluations of Lumbar Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). This case is unique in that it is the first case with development of lumbar disc herniation associated with S1 vertebral corpus fusion anomaly. Congenital malformations with unusual clinical presentation after trauma should be evaluated through advanced radiological imaging techniques.

Dear Sir: I was interested in the distribution of “non-trophic cutaneous ulcers” shown on the knuckles and dorsal foot in the case report of a 44-year-old female with multibacillary Hansen's disease or leprosy.1 The case had glove stocking sensory and motor neuropathy and histopathology characteristics of multibacillary Ridley Jopling borderline lepromatous or lepromatous leprosy. The patient was treated with three effective drugs and reportedly had resolution of her neuritis symptoms and dorsal pressure ulcers of her knuckles and upper feet. Although she may not have had classic neurotrophic plantar ulcers in the soles or weight-bearing surfaces of the foot, her skin ulcers appeared in hyperpigmented areas, where her sandal straps and toe thong might have rubbed the dorsal foot arch and big toe. The dorsal foot ulcers may then have been true neuropathic skin breakdowns from the rubbing of her sandal straps and thong on the hallux of her insensate foot. Likewise, was the upper dorsum foot midline scar a healed ulcer within a hyperpigmented skin strap line encircling the lower ankle and upper foot? As described by the late Paul Brand, skin ulcers or erosions appear on insensate limbs wherever there is repetitive microtrauma. The ulcers may have evolved from the rubbing of her sandal or shoe straps on her anesthetic feet and ankles. Because the patient had lost the gift of pain, she developed skin ulcerations at the rub sites before she removed her footwear. Although these ulcers were not on her soles or weight-bearing surfaces, the erosions developed on repetitively traumatized skin sites, and therefore, they may be considered, indeed, neurotrophic ulcers, albeit in atypical locations, associated with multibacillary leprosy or Hansen's disease. Thanks again for this unique case report.

The medial ulnar collateral ligament (MUCL) of the elbow is primary static constraint of the ulnohumeral joint to valgus force.1,2) The anterior bundle of the MUCL is the major stabilizing structure of the elbow.3,4) Repeated throwing can lead to microtrauma or rupture of the MUCL.5) The injuries to MUCL of the elbow are most common in the overhead athletes, particularly the baseball players.2,4,6,7,8,9,10) The players with partial tears of the MUCL may return to play after proper rehabilitation. However, those with complete tears, which induce considerable valgus laxity or persistent medial elbow pain, need to have the operation in order to return to sports activities. Several studies have reported outcomes regarding returning to the preinjury level after MUCL reconstruction, in the throwing athletes. In 1986, Jobe et al.11) firstly described a MUCL reconstruction, reporting 62.5% of return rate in the overhead athletes. The return rates reported in the recent clinical studies vary from 33% to 92%.4,6,12,13,14,15,16) One of the probable reasons for the inconsistent return rate is the innate drawback of the figure eight technique. The previous article reported that the disadvantage of MUCL reconstruction, using figure of eight technique, was difficult to maintain tension because of the high number of holes in medial epicondyle.17) However, as far as we are aware, no study has evaluated on the integrity of the incorporated grafts, which would validate the success of the surgical treatment. The aim of this study is to report the clinical and image outcomes after MUCL reconstruction, using the figure of eight fashion in high school and elite baseball players. The primary measure for the outcomes was the graft integrity evaluated with ultrasonography, and the secondary measures for the outcomes were postoperative pain, range of motion (ROM), and the Conway scale.

Elastoubroma dorsi is an uncommon benign soft tissue tumor usually located in the infra-scapular region, deep to serratus anterior muscle, and often attached to the periosteum of the ribs, presenting with long history of swelling and occasionally pain and discomfort. It is seen in elderly age group and may be mistaken for a malignant soft tissue tumor due to its size and location. The pathogenesis of the lesion is still unclear, but repetitive microtrauma by friction between the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroelastic tissue. Diagnosis is straight-forward when the lesion is present in characterstic anatomic location and pathognomonic histopathological features are seen. We describe a case of bilateral elastofibroma dorsi detected incidentally on autopsy.

A pinguecula is a small, raised conjunctival nodule at the temporal or nasal limbus classically associated with conjunctival microtrauma from exposure to sunlight and/or to dust. We report two cases occurring during the course of Sjögren's syndrome. To our knowledge this association has never been described.

The purpose of this study was to describe the sonographic appearance of the common extensor origin in cadavers and asymptomatic volunteers, and to relate this appearance to the findings in patients with lateral epicondylitis.Seventy-two elbows in 71 patients with lateral epicondylitis were examined on sonography. Most of the patients (60/71) gave a history of repetitive microtrauma. The injuries were evaluated with respect to location and severity. Focal areas of degeneration, discrete cleavage tears, and involvement of the lateral collateral ligament were identified. Calcification and bony changes were noted. The appearance of the normal common extensor tendon was described, and cadaveric specimens were dissected. Twenty-one patients subsequently underwent surgery.The normal common extensor origin is composed of longitudinal fibrils bound closely with the extensor carpi radialis brevis constituting most of the deep fibers, with the extensor digitorum making up the superficial part. The lateral collateral ligament can be identified as a discrete and separate band. The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon (46/72). These focal areas were identified at surgery and corresponded histologically to collagen degeneration with fibroblastic proliferation. Often discrete cleavage planes traversing the tendon were manifest as partial (18/72) and complete (2/72) tears. The lateral collateral ligament was involved in eight of 72 elbows.Sonography of the common extensor origin can be used to confirm lateral epicondylitis in patients with lateral elbow pain and provide information about the severity of the disease.

The shoulder complex is particularly susceptible to injury, as it maintains a precarious interplay between stability and motion and is repetitively stressed in occupational and sporting activities. Rotator cuff disorders are among the most common causes of pain and impaired performance in athletes, mainly those involved in repetitive overhead throwing activities and contact sports [1]. In athletes, cuff disease represents a possibly coexistent spectrum of pathologies progressing from tendon strain and edema through inflammation and microscopic failure of fibers after repetitive wear, the final stages being gross cuff fraying and tear. According to some authors [2 – 4], rotator cuff lesions maybe classified based on the etiological mechanism of injury proposed by the following scheme: 1. Primary or secondary compressive cuff lesion: external or subacromial impingement syndrome, posterosuperior or internal impingement syndrome 2. Primary or secondary tensile cuff lesion 3. Macrotraumatic cuff failure resulting from a single direct or indirect traumatic accident or from repetitive microtrauma displayed by a single event Athletes involved in contact sports are more likely to sustain traumatic cuff tears because of the arms being forcefully abducted or violently pulled away from the body or by a fall or blow to the outstretched arm in a forced elevated position.

Lateral epicondylitis, or tennis elbow, was first described in 1883, around the time that lawn tennis was invented.1 It is a common source of lateral elbow pain in athletes and nonathletes alike. Numerous theories for the pathophysiology of tennis elbow have been offered.2–6 Most investigators now agree that this entity represents an overuse syndrome resulting in repetitive microtrauma to the common extensor origin around the lateral epicondyle of the elbow.4,7 According to Nirschl and Pettrone,7 overuse produces tendinous microtears and subsequent “nonrepair with immature reparative tissue,” which histologically resembles angiofibroblastic hyperplasia.

Introduction There are emerging trends of designing motor bikes with sporty looks. These bikes are especially popular among youth due to the speed that it can gain. There are bikers who complain of pain after biking for long distances. This is generally a case with heavy, non-cruiser bikes. The purpose of this poster is to depict the biomechanical and ergonomical basis of this pain felt at the superior angle of the scapula along with the diagnosis and treatment. Description: (1) Pain: the pain (dull and aching type) occurs at the superior angle of the scapula. After driving a bike, the pain stops but the soreness remains for 4–5 days. Any activity involving shrugging brought on the pain. (2) Biomechanics and Ergonomics: to streamline the body according to the speed of the bike, the biker pokes his chin, shrugs his shoulder and flexes his elbow. In this position, levator scapulae muscle is been used to shrug the shoulder as well as to maintain the position of the scapula. As this position is dynamic, the position keeps the levator scapulae in a contracted phase for prolonged period which may lead to repetitive stresses and microtrauma at the insertion of levator scapulae and start causing pain. (3) Diagnosis: eight patients were identified and this type of pathology is suspected wherein superior angle of scapula is tender and resisted shoulder shrugging is painful at the same area. However, scapular mobility and arm movements are normal. (4) Treatment: ultrasound therapy is definitely effective in relieving symptoms in two to three sittings after which resisted shrugging is given with mild resistance. However, it was seen that the pain recurs after a week or so if the long distance biking continues. (5) Prevention: To avoid this, bikers must take care of their posture while riding as well as proper selection of bike. It is also advised to use cruiser bikes for long distances. Conclusion In future, the cases with the similar history must be properly assessed and documented so that the further research can be carried out on the causes, permanent treatment and the other ways to prevent it.

Examination of the excised section of the quadriceps tendon showed a fresh rupture of the tissue of the tendon. Furthermore, there was an extensive infiltrate of the tendon in the area of the rupture by a B-cell chronic lymphocytic leukaemia (figure), besides moderate, partially mucoid degenerative alterations. He mobilised well and was transferred to a rehabilitation centre, where he stayed for 4 weeks. He was given oral chemotherapy. Spontaneous rupture of tendons can be due to degenerative changes after recurrent microtrauma, reduced blood supply, or metabolic diseases. 1 Morphologically, the degenerative changes are visible as mucoid degeneration, chondroid metaplasia, fibrosis, scarring, and calcification. 2

Study design A case report and review of the literature. Objective To describe the diagnosis and successful treatment of a synovial cyst arising from the transverse ligament in a patient with os odontoideum and atlantoaxial instability. Summary of background data Synovial cysts arising from the transverse ligament of the atlas are extremely rare. Development of a synovial cyst is thought to be attributable to degenerative changes of the C1-C2 facet joints or to microtrauma. Direct excision of the cyst is the only treatment cited in previous reports. Methods A synovial cyst arising from the transverse ligament of the atlas in a 45-year-old man with os odontoideum and atlantoaxial instability was treated surgically with posterior atlantoaxial fusion alone. The magnetic resonance images, surgical treatment, and related literature are reviewed. Results Preoperative magnetic resonance images of the cervical spine showed a large cystic mass located ventral to the cord arising at the level of the transverse ligament of the atlas: the mass was of low signal intensity on T1-weighted images, was of high signal intensity on T2-weighted images, and was enhanced marginally with gadolinium-DTPA on T1-weighted images. Spontaneous regression of the cyst was identified on the follow-up magnetic resonance images taken 3 months after C1-C2 posterior wiring and fusion. Conclusions A patient with a synovial cyst arising at the C1-C2 junction ventrally at the level of the transverse ligament showed spontaneous regression of the lesion after C1-C2 posterior wiring and fusion.

To report the incidence, site, and nature of injuries in amateur rugby league over three consecutive seasons.Six hundred players registered with an amateur rugby league organisation were studied over three consecutive seasons. All injuries sustained during the amateur rugby league matches were recorded. Information recorded included the date and time of injury, name of injured player, anatomical site and nature of injury, and position of the player.The incidence of injury was 160.6 per 1000 player-position game hours, with forwards having a significantly higher incidence of injury than backs (182.3 per 1000 v 142.0 per 1000, chi2 = 14.60, df = 1, p0.001). Over 25% of the total injuries (40.6 per 1000) sustained during the three year period were to the head and neck, while injuries to the face (21.3 per 1000, 13.3%), abdomen and thorax (21.3 per 1000, 13.3%), and knee (17.8 per 1000, 11.1%) were less common (chi2 = 21.83, df = 8, p0.01). Muscular injuries (haematomas and strains) were the most common type of injury (45.7 per 1000, 28.5%, chi2 = 17.98, df = 7, p0.05). Significantly more injuries occurred in the latter stages of the season (chi2 = 22.94, df = 1, p0.001), with most injuries (70.8%, chi2 = 162.29, df = 1, p0.001) sustained in the second half of matches.The results show that muscular injuries and injuries to the head and neck are the most commonly sustained injuries in amateur rugby league. Furthermore, injuries are more often sustained in the latter stages of the season and during the second half of matches. These findings suggest that fatigue or accumulative microtrauma, or both, may contribute to injuries in amateur rugby league players.

The skin is well adapted to cope with many types of trauma, but excessive friction and microtrauma can result in the formation of various dermatoses (Table 1). Microtraumas include a variety of superficial skin injuries: friction, abrasions, pressure, stretching, compressions, cuts, etc. Mechanical insults to the skin may affect all levels of the skin from the cornified layer through the subcutaneous fat. The time allowed for adaptation determines the reaction of the skin. Slowly increasing pressure or friction induces hyperkeratosis, lichenification and calluses, while sudden friction can induce blisters. The effects of trauma are modified by humidity, sweating, age, gender, nutritional status, infection, genetic and racial factors.

There is increasing concern that too much physical activity may lead to osteoarthritis. The continuous stress that physical activity places on the joints can result in microtrauma and degeneration of the articular cartilage. However, the onset of osteoarthritis appears to depend on the frequency, intensity and duration of physical activity. Research has shown that individuals of all ages can tolerate moderate amounts of exercise without adverse consequences or accelerated development of osteoarthritis. However, excessive participation in high impact sports, particularly over a long period of time and at an elite level, can increase the risk of developing osteoarthritis. Participants may also be at risk if they have abnormal joint anatomy or alignment, joint instability, underlying muscle weakness or imbalance, or if they are overweight and engage in significant amounts of exercise. Individuals who have experienced sports injuries to joints, or macrotrauma, may also be at risk of accelerated development of osteoarthritis. Certain types of surgery for the treatment of severe sports injuries, particularly to the knee, also appear to be associated with an increased risk. If surgery to the knee is required, continuous passive motion is an ideal form of rehabilitative treatment, as it promotes healing of the articular cartilage, ligaments and tendons. Moreover, athletes who have undergone surgery should return slowly to sporting activities to ensure they do not place too much stress on their injured joint(s). Further research into the causes of osteoarthritis is required; in particular, prospective and retrospective cohort studies are needed to confirm the association between exposure to risk factors and the development of osteoarthritis.

Background Isolated rupture of the patellar tendon is a rare injury. Often occurring during a fall in 20- and 30-year olds, patients may have a preexisting medical condition (eg, history of steroid use) or a history of repetitive microtrauma to the knee. A high-riding patella on physical examination and radiographs is pathognomonic. Methods Immediate orthopaedic referral for surgical repair is necessary to reestablish knee extension. Delay in diagnosis can make surgical treatment more difficult. Current methods of postoperative rehabilitation are evolving. Results Evaluative studies based on rating scales show satisfactory clinical and functional results after surgery. However, time lost from work and recreation may be protracted, and quadriceps atrophy is often evident. Conclusions Ruptures of the patellar tendon should be diagnosed acutely and immediately referred to an orthopaedic surgeon. The impact of the injury to the patient may be long-standing even after operative treatment. Contemporary surgical and rehabilitative techniques give the best opportunity for restoration of functional activity.

Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. At radiography, acute injuries (ie, those resulting from extreme, unbalanced, often eccentric muscular contractions) may be associated with avulsed bone fragments, whereas subacute injuries have an aggressive appearance that may include areas of mixed lysis and sclerosis. Chronic injuries (ie, those resulting from repetitive microtrauma or overuse) or old inactive injuries may be associated with a protuberant mass of bone and may bear a striking resemblance to a neoplastic or infectious process. Although not usually required, computed tomography is helpful in the diagnosis if radiographic findings are equivocal or if the injury is not in the acute phase. MR imaging is best suited for the evaluation of injuries to muscles, tendons, and ligaments. Recognition of characteristic imaging features and familiarity with musculotendinous anatomy will aid in accurate diagnosis of avulsion injuries.

Augmented soft tissue mobilization therapy (ASTM), a newly developed massage therapy, has been successfully used in the treatment of chronic tendinitis patients. We theorized that the ASTM technique promotes healing through a controlled application of microtrauma. Purpose The purpose of this study was to determine morphologic changes in the rat Achilles tendon after enzyme-induced injury with collagenase and subsequent pressure variations in ASTM therapy. Methods Thirty male white rats were randomly assigned to one of five groups with six animals per group: tendinitis (A), tendinitis plus light ASTM (B), tendinitis plus medium ASTM (C), tendinitis plus extreme ASTM (D), and control with surgery only (E). ASTM was performed for 3 min, for a total of six treatment sessions. The Achilles tendons of each group were harvested 1 wk after the last ASTM treatment. Fibroblast numbers were assessed by light microscopy. An electron microscope was used to observe enlargement of fibroblasts. Results Statistical analysis of the number of fibroblasts present indicated a significant difference (P Conclusion The morphological evidence indicated that the application of heavy pressure promoted the healing process to a greater degree than light or moderate pressure.

OBJECTIVE—To assess if the bonding interlayer between the implant and bone in aseptic loosening of total hip replacement (THR) is qualitatively deteriorated by excessive accumulation of anti-adhesive glycoprotein, tenascin-C. METHODS—Alkaline phosphatase-anti-alkaline phosphatase (APAAP) method was used for immunohistochemical staining of tenascin-C in interface tissue and control synovial tissue. RESULTS—Tenascin-C was found to be a major component of the extracellular matrix at a hitherto unrecognised site, namely the synovial membrane-like interface tissue between implant and bone in aseptic loosening of THR. The overall tenascin-C staining (median score 4.0) was greatly increased in aseptic loosening compared with synovial membrane (median score 2.0; p

Chronic tendon pain, frequently described as ‘tendinitis’, is common in the supraspinatus, Achilles and patella tendons, although little is known about the underlying pathology since painful tendons are not routinely biopsied and surgery is usually the last resort of treatment. Repeated microtrauma to the fibrillar matrix is thought to be the principal cause of most tendinopathy, although tendons are immensely strong under tension and do not normally rupture unless there has been prior degeneration of the matrix. Tendon cells (tenocytes) maintain the tendon matrix, and have been shown to have some capacity for remodelling the tendon in response to altered mechanical loads and injury. Tenocytes are not a homogenous cell population however, and there is evidence that, after injury, cells from the epitenon surrounding the fibre bundles are more active in the repair response than the mature tenocytes from within the fibre bundles (Gelberman et al. 1984). In chronic tendinitis, we and colleagues have shown an increase in cell number and activity associated with the lesion, although these cells have not yet been characterized. Having recently obtained access to tendon specimens from patients with mid-stage Achilles and patella tendinitis, the aim of this study was to characterize the cells proliferating within the lesion using a number of cell-specific immunocytochemical markers.

Overuse injuries are the result of repetitive microtrauma to the musculotendinous unit. Treatment protocols are based on the stage of the inflammatory process that is active at the time of diagnosis. Control of the inflammatory response with rest, elevation, and ice is the treatment objective during the inflammatory stage. Prevention of further injury is the primary treatment goal throughout the proliferative phase. Once the inflammatory process has reached the maturation stage, rehabilitation can begin with flexibility exercises, isometric contractions, and a slow return to strength training. Surgical decompression is frequently necessary if chronic inflammation causes fibrosis of the fibro-osseous tendon sheaths. Anomalous muscle bellies and tendinous interconnections can be contributing factors to overuse syndromes. Properly structured training programs and rehabilitation regimens can prevent tendinitis and overuse syndromes.

The aim of this intra-individual study was to examine human buccal mucosa clinically, histologically and immunohistochemically after 9 months' exposure to orthodontic magnets. In each of eight subjects (17.8-42.4 years), a magnet and a demagnetized equivalent of parylene coated neodymium-iron-boron was bonded alternately on the left and right side, to the buccal surface of maxillary premolars. The buccal mucosa was clinically examined and photographed, and three punch biopsies (6 mm diameter) of the buccal mucosa were taken from each subject at the site of contact with the magnet (test), in contact with the demagnetized magnet (control), and also at a site on the control side without contact with the demagnetized magnet (normal). The biopsies were snap-frozen for histological and immunohistochemical investigation, using antibodies to PD7 (lymphocyte 'naive T'), UCHL 1 ('memory T'), HLADR, ELAM-1 and ICAM-1. Clinically, the buccal mucosa showed normal features before and after the experimental period. In four of the eight subjects, the epithelium was 1.4-2.3 times thicker in the control and test tissues than in normal tissues. The difference between controls and tests was negligible, and there were no signs of increased keratinization or other surface abnormalities. Compared with normal sites, all control and test sites showed slightly increased ELAM-1/ ICAM-1 vascular staining, accompanied in three subjects by small infiltrates of PD7/UCHL 1-positive lymphocytic cells and in all subjects by focal keratinocyte HLADR-staining. The minor tissue reactions found in test and control tissues were interpreted to be a result of microtrauma (contact irritation) and not caused by the static magnetic field per se, since there was no difference between test and control tissues.

The glenohumeral articulation maintains a fine balance between mobility and stability. In the throwing athlete, this balance is stressed from the repetitive microtrauma incurred to achieve peak performances. The presentation of shoulder pain in the throwing athlete can be confusing, and a thorough understanding of anatomy and biomechanics, in addition to the history and physical examination, are necessary to delineate the correct diagnosis. Specifically, differentiating between instability and impingement is critical to initiate appropriate nonoperative and operative interventions. This paper discusses the anatomy and biomechanics in the shoulder and provides a comprehensive approach to evaluate anterior shoulder pain in throwing athletes. In addition, treatment options will be discussed with specific emphasis or nonoperative interventions.

Summary Injury to the core of the mid-metacarpal region of the superficial digital flexor tendon in Thoroughbred racehorses is a very frequent but poorly understood condition. It has been suggested that subclinical changes induced by galloping exercise weaken the collagen in this region of the tendon, predisposing it to rupture. The longitudinally arranged collagen fibrils in tendon follow a planar waveform, termed the crimp. Fibril bundles with a smaller crimp angle fail at a lower level of strain than those with a larger crimp angle. This study tested the hypothesis that a specific 18 month exercise programme would result in significant reduction of collagen fibril crimp angle and period length in the core region of the superficial digital flexor tendon of young Thoroughbreds (21 ± 1 months), compared to the normal change in these parameters with age. Central region crimp angle and length were significantly lower in exercised horses than in control horses (P

Tennis elbow or lateral humeral epicondylitis is considered to be an overload injury, which occurs after minor and often unrecognised trauma (microtrauma) to the proximal insertion of the extensor muscles of the forearm. The pathological changes often occur in the tendon of the extensor carpi radialis brevis muscle. The annual incidence of tennis elbow in general practice is four to seven cases per 1000 patients, with a peak in patients 35-54 years of age. Lateral epicondylitis is a self limiting condition. The average duration of a typical episode is about six months to two years, but most patients (89%) recover within one year.1 Various conservative interventions exist for the treatment of this condition including pain relieving drugs, corticosteroid injections, physiotherapy, elbow supports, acupuncture, surgery, and shockwave therapy. However, available evidence for the effectiveness of these interventions is limited.2

COLLATERAL ligament sprains of the canine carpus usually involve the medial collateral complex (Guilliard 1998, Guilliard and Mayo 2000). Injuries involving the lateral collateral ligament complex (LCLC) have been reported (Roe and Dee 1986) but are rare. Chronic ligament sprains may represent late presentation of injuries that were initially acute, or may be due to repetitive microtrauma which exceeds a ligament’s ability to adapt to stresses placed on it (Perry 1992). Healing of ligaments can lead to enthesiophyte formation that can be seen radiographically (Guilliard 1998, Guilliard and Mayo 2000). This short communication describes the chronic disruption of the LCLC of the carpus in two dogs. Chronic sprain injuries of the LCLC of the carpus were diagnosed in two middle-aged female border collies. Both were pet dogs that had previously enjoyed high levels of activity. Each dog had suffered a mild, unilateral forelimb lameness with an insidious onset. Non-steroidal antiinflammatory medication had resulted in only marginal improvement. Each dog had suffered a loss of lateral support to the carpus of the lame limb before presentation, resulting in a more severe lameness and a marked varus deformity of the metacarpus and paw. In both cases, bilateral thickening of the carpi and reduced flexion were noted; thickening was most evident laterally. Forced flexion of the carpi was resented, although severe pain was not a feature. Lateral instability of the carpus of the lame limb in each dog was also noted (Fig 1), although no other ligament instability was apparent. A slight varus conformation of the metacarpus and paw of the contralateral limb of each dog was noted as well. Bilateral radiographic changes in each dog included soft tissue swelling and enthesiophyte formation on the lateral aspect of the carpus and proximal fifth metacarpal bone. New bone formation was evident at all joint levels on the dorsal aspect of the carpus (Fig 2a). Stressed radiographs of the unstable carpus of each dog demonstrated lateral instability (Fig 2b). Synovial fluid analysis was unremarkable. Surgery was undertaken in case 1. Lateral support was reestablished using an ulnaris lateralis autograft (Roe and Dee 1986) augmented with monofilament nylon. To relieve stress on the repair, a 15° laterally based distal radial closing wedge osteotomy was performed and stabilised with a dorsally placed seven-hole 3·5 mm T-plate. Despite suffering a surgical wound infection, the dog used the limb that had been operated on well by eight weeks after surgery. Twelve months postoperatively the dog developed palmar ligament instability of the middle carpal joint; a pancarpal arthrodesis led to a satisfactory outcome. Case 2 was treated conservatively. A lateral splint was applied to the unstable carpus for one month. Following

We present a case of a ballet dancer who was referred for skeletal scintigraphy because of bilateral leg pain. In addition to diffuse stress changes in the legs and feet, skeletal scintigraphy showed bilateral focal uptake in posterolateral lower ribs. The patient had not experienced rib pain. These scintigraphic abnormalities can be attributed to frequent dancing routines in which the patient was held by the sides of the thorax and lifted, causing microtrauma to the ribs.

Posttraumatic pain of the ankle and foot can result from either acute trauma or disorders related to chronic microtrauma. The latter are common causes of referral in everyday rheumatologic clinical practice. Rheumatologists must be familiar with the clinical and imaging appearance of these conditions since they can mimic other joint or periarticular disorders and need specific treatment. Musculoskeletal ultrasound (US) is nowadays considered, together with standard radiographs, the first line imaging techniques in ankle and foot disorders. US is non-invasive, dynamic, cheap and patient-friendly. When performed by an experienced sonologist, using an up-to-date equipment, it allows an accurate assessment of joints, tendons, nerves and bone surfaces. The aim of this lecture is to provide a pictorial review of the most common disorders of the ankle and foot related to chronic microtrauma. We will present the MSUS technique of examination followed by paradigmatic sonograms and clips of micro traumatic diseases affecting tendons (Tibialis posterior and anterior), synovial bursae (Bursitis), ligaments (Plantar plate tears, Spring ligament), nerves (Morton neuroma), bones (Stress fractures), veins (Plantar vein thrombosis). For each condition we will discuss the role of US in the diagnostic work-up and in guiding therapeutic and/or diagnostic procedures. US coupled to clinical evaluation and standard radiographs allows detection and careful assessment of most disorders of the ankle and foot related to chronic microtrauma. In selected patient US allows a real-time, accurate guidance of local procedures. Disclosure of Interest None Declared

Charcot spine is a progressive and destructive process that affects the vertebral bodies, intervertebral discs, and posterior facets. It is the result from repetitive microtrauma in patients who have decreased joint protective mechanisms due to loss of deep pain and proprioceptive sensation, typically because of spinal cord injury. The objective of the study is to report an unusual case of Charcot spine, as a late complication of traumatic spinal cord injury, treated by a circumferential arthrodesis performed with a single staged posterolateral costotransversectomy approach.

Pyogenic granuloma is a benign, localized mass of exuberant granulation tissue produced in response to various stimuli. It is inflammatory hyperplasia of oral cavity commonly seen on gingival and rarely on other parts of oral cavity such as lips, tongue, palate, and buccal mucosa. It is seen predominantly in second to third decade of life in young females. Clinically manifesting as a small red erythematous exophytic lesion must be biopsied to rule out other serious conditions. This article aims to present a case of extragingival pyogenic granuloma on buccal mucosa in a 40-year-old female patient which is comparatively a rare location.

Synovial cyst on prevertebral space of C1-2 joint is rare but may be associated hemorrhagic event. We describe a case of a 72-year-old woman who presented with sudden severe headache in her left occipital area with dyspnea. She had rheumatoid arthritis for 14-years. Large hemorrhagic cystic mass was seen around prevertebral space of the atlantoaxial joint on the left side on cervical MRI (magnetic resonance image) and it obstructed the nasopharyngeal cavity. Aspiration of the cystic lesion was performed via transoral approach, followed by posterior occipito-cervical fusion. The specimen was xanthochromic, suggesting old hemorrhage. The patient was tolerable on her postoperative course and showed good respiration and relieved headache. We suggest that repeated microtrauma due to atalantoaxial subluxation associated with rheumatoid arthritis as a main cause of hemorrhagic event on the cyst.

Rupture of the patellar tendon is a relatively infrequent, yet disabling, injury, which is most commonly seen in patients less than 40 years of age. It tends to occur during athletic activities when a violent contraction of the quadriceps muscle group is resisted by the flexed knee. Rupture usually represents the final stage of a degenerative tendinopathy resulting from repetitive microtrauma to the patellar tendon. This injury may also occur during less strenuous activity in patients whose tendons are weakened by systemic illness or the administration of local or systemic corticosteroid medications. The diagnosis is made on the basis of the presence of a painful, palpable defect in the substance of the tendon; an inability to completely extend the knee against gravity; and the existence of patella alta confirmed by lateral radiographs. Ultrasonography and magnetic resonance imaging are useful in identifying a neglected rupture, as well as when the diagnosis is in question or an intra-articular injury is suspected. The prognosis after a patellar tendon rupture depends in large part on the interval between injury and repair. Surgery soon after the injury is recommended for optimal results. This is best accomplished by accurate reapproximation of the ruptured tendon ends, repair of the torn extensor retinacula, and placement of a reinforcing cerclage suture. An aggressive rehabilitation program, emphasizing early range-of-motion exercises, protected weight bearing, and quadriceps strengthening, will enhance the results of surgery. Patients who undergo delayed repair are at risk for a compromised result secondary to loss of full knee flexion and decreased quadriceps strength, although a functional extensor mechanism is likely to be reestablished.

Most injuries and complaints encountered in swimming athletes are repetitive microtrauma or overuse, and successful management does not usually require surgical intervention. Rest and other measures to reduce inflammation are often required. Many injuries originate from faulty techniques or mechanisms, and an assessment must be made of the swimming biomechanics of any injured athlete to identify faults that may contribute to injury. It is also important to look at the total training programme of the athlete to identify other factors, such as weight training or dry land programmes, that may be contributing to injury. It is important to understand that, while rest or reduced training may be necessary, every effort to keep the swimmer "in the water' should be made, as cessation of training may lead to a rapid detraining effect.

Tennis elbow occurs as a result of repetitive microtrauma to the musculotendinous unit causing inflammatory and degenerative tissue damage. A good understanding of the aetiology and pathoanatomy will aid the clinician in preventing and recognising this condition. Early recognition with a quality rehabilitative programme, and the judicious use of surgical intervention usually results in full recovery and excellent functional outcomes.

There is considerable controversy about whether cystic arthrosis is a primary or secondary phenomenon in the development of degenerative joint disease of the hip1,2,4,5,8,10,13,15,18. Proponents of the bone-contusion theory have suggested that a localized area of subchondral necrosis of bone resulting from repetitive microtrauma leads to cystic degeneration, leaving the articular cartilage intact1,2,4,8,13,18. Proponents of the synovial intrusion theory believe that traumatic defects in the articular cartilage allow intrusion of synovial fluid through subchondral microfractures, resulting in cystic degeneration5,10,15. Both groups of proponents agree that, in the later stages of degenerative osteoarthrosis of the hip, subchondral fractures, cystic collapse of the acetabulum, and diffuse degenerative changes predominate on both sides of the joint. Both groups also agree that it should be possible to slow the progression of the disease by timely and appropriate operative intervention. Often, by the time patients who have pain in the hip secondary to degenerative joint disease are seen, there are characteristic roentgenographic changes, such as decreased joint space, increased subchondral sclerosis, subchondral cysts, and osteophytosis; thus, it is impossible to determine whether the cystic changes were the precursor of the late changes. This report illustrates the evolution of degenerative joint disease of the hip. The sequence of changes supports the theory that cystic arthrosis is a primary phenomenon that may precede and hasten the onset of osteoarthrosis in some patients. A thirty-three-year-old man was involved in a motor-vehicle accident in July 1988; his automobile was struck from behind by a vehicle traveling at approximately sixty-four kilometers (forty miles) per hour. The patient had pain in the lumbosacral region and …

Diffuse idiopathic skeletal hyperostosis (DISH) is a skeletal disease characterized by ligamentous ossification of the anterolateral side of the spine. The radiographs of the spine of 69 patients (22 males, 47 females, mean age 64.97 +/- 8.83 years) affected by DISH according to Resnick's criteria were selected. A lower rate of lumbar spine involvement (71%) and a different distribution between sexes were demonstrated, as compared to the data from the literature. Data on relationships among extent of hyperostosis, occupation and metabolic disorders suggest that an important role might be played by the exposure to microtrauma, while, in subjects affected by a metabolic disorder, this condition would represent a prevalent pathogenetic factor. These data underline some peculiarities in the clinical picture of DISH in the population from Campania, that could depend on genetic factors.

Shoulder impingement syndrome, a common disorder directly related to the unique anatomy, mobility, and biomechanics of the shoulder girdle complex, is a condition that results from repetitive microtrauma to the structures within the subacromial space, primarily the supraspinatus, the long head of the biceps, and the subacromial bursa. Several factors contribute to shoulder impingement syndrome, including rotator cuff weakness, capsular tightness, poor scapulohumeral rhythm, and muscle imbalance of the scapular upward rotation force couple. This article briefly reviews the biomechanics of the shoulder girdle complex and the pathology of shoulder impingement syndrome. The author introduces an adjunctive assessment procedure that assists the clinician in isolating the primary tissue and the structures involved with shoulder impingement syndrome. Conservative treatment management can then be directed to the involved contractile and/or noncontractile tissue involved with shoulder impingement syndrome.

The current criterion used by the automotive industry for injury to the lower extremity is based on visible bone fracture. Studies suggest, however, that chronic joint degeneration may occur after subfracture impact loads on the knee. We hypothesized that subfracture loading of the patellofemoral joint could result in previously undocumented microtrauma in areas of high contact pressure. In the current study, seven patellofemoral joints from human cadavers were subjected to impact with successively greater energy until visible fracture was noted. Transverse and comminuted fractures of the patella were noted at 6.7 kN of load. Approximately 45% of the impact energy then was delivered to the contralateral joint. Subfracture loads of 5.2 kN resulted in no gross bone fracture in five of seven specimens. Histological examination of the patellae horizontal split fracture in the subchondral bone, at the tidemark, or at the interface of calcified cartilage and subchondral bone. The trauma appeared predominantly on the lateral facet, adjacent to or directly beneath preexisting fibrillation of the articular surface. Surface fibrillation was noted in histological sections of control patellae (not subjected to impact loading), but occult damages were not observed. Although the mechanism of this occult trauma is unknown, similar damage has been shown to occur from direct shear loading. As these microcracks can potentiate a disease process in the joint, this study may suggest that the current criterion for injury, based on bone fracture alone, is not sufficiently conservative.

Twelve women were seen with multiple transverse bands on the nail plates of the great toes. The bands were separated by normal nail, and had the same contour as the distal edge of the lunula. This disorder, which is usually bilateral, results from pressure on the free edge of the nail plate when it is not trimmed short.

We investigated 185 adolescents under the age of 19 years with spondylolysis. All but five were active in sport. The pars defect was classified into early, progressive and terminal stages. Of the 346 pars defects in 185 patients, 39.6% were early, 29.5% progressive and 30.9% in the terminal stages. Conservative management produced healing in 73.0% of the early, 38.5% of the progressive and none of the terminal defects. These results suggest that spondylolysis is caused by repetitive microtrauma during growth and can be successfully treated conservatively if treatment is started in the early stage. There was elongation of the pars interarticularis as the pars defect progressed, and this is likely to be a consequence of the defect rather than a contributing cause.

A case of simultaneous bilateral avulsion of the patellar apexes is reported. Plain radiography showed bilateral patella alta, but MR imaging was diagnostic. Weakness of the tendo-osseous junction due to secondary hyperparathyroidism and additional chronic inflammatory changes due to repeated microtrauma were considered to be the cause of the rupture.

Lower extremity overuse injuries due to repeated microtrauma are often asymmetrical in nature. The purpose of this study was to determine if the amount of tibiofibular varum was asymmetrical in individuals with unilateral overuse injuries. The subjects were 20 patients who developed unilateral overuse symptoms of the leg and foot due to compensatory subtalar joint pronation. The distal one-third of the leg was bisected with the subjects standing in their normal base of support. The angle of this bisection to vertical was measured with a fluid inclinometer to determine the amount of tibiofibular varum. This measurement was performed in relaxed calcaneal stance and subtalar joint neutral stance. A single examiner performed all of the measurements and was blinded to the side of the subject's symptoms. A two-way analysis of variance for repeated measures was performed. There was a significant difference in the amount of tibiofibular varum between the injured and the uninjured extremities. There was also a significant difference between the measurements of tibiofibular varum when comparing the resting calcaneal stance and the subtalar joint neutral stance positions. This difference in tibiofibular varum between the injured and uninjured extremities may be one example of an asymmetry that can cause unilateral overuse symptoms.

Aneurysms of the digital artery are rare. Since 1980, we have treated three traumatic aneurysms of the digital artery. There were two lesions of the common palmar digital artery and one of the ulnar pollicis artery. One case was caused by a traumatic laceration with a kitchen knife, and two cases were caused by repetitive microtrauma. On histologic examination, there were two true aneurysms and one false aneurysm. Two cases were treated by excision only, and one case was treated by excision and reanastomosis. The operating microscope was useful during neurolysis, excision of the aneurysm, and vascular anastomosis.

Lateral epicondylitis is a common work-related musculoskeletal disorder. It affects 5.2% of the population and occurs in middle-aged person 30-50 years. Work-related factors are type of work, physical load and psychosocial aspects at work. Associated with lateral epicondylitis are repetitive movements >2h/day, handling tools >1kg, handling loads >20kg 10 times/day. Psychosocial factors are low job control and low social support. The wrist extensor muscles suffer repeated microtrauma, which end up producing their insertion epicondylar injury, developing pain and functional disability. Occupational disease cost, which has been accepted by the Ministry of Labour and Immigration, are 5000 millions in direct costs and EUR 13,000 million in indirect costs in Spain.

Swimming has become a popular recreational activity as well as a highly competitive sport in the United States. The repetitive nature of swimming can predispose the shoulder to mechanical impingement and microtrauma, which may lead to laxity, rotator cuff fatigue, and subsequent secondary impingement. Improper stroke mechanics can place the swimmer's shoulder at further risk. The purpose of this paper is to describe the pathology of secondary impingement in freestyle swimmers and to discuss the clinical implications for rehabilitation of swimmers with the pathology. A thorough subjective and objective evaluation is necessary to design a successful rehabilitation program. The rehabilitation program for swimmers with secondary impingement includes modification of training, flexibility, range of motion, strengthening, and mobilization as indicated. Functional and proprioceptive training may also be useful techniques in the rehabilitation of swimmer's shoulder. Improper stroke mechanics can also have clinical implications on swimmer's shoulders with secondary impingement. The clinical implication of secondary impingement in freestyle swimmers suggests that the primary goal of rehabilitation is to promote equilibrium of the shoulder complex while accounting for the demands of the sport.

This study was conducted to determine the relationship between intraosseous pressure and vertebral microtrauma in the lumbar spine. Functional spinal units were excised from human cadavers. Radio-opaque dye was injected into the nucleus. Miniature transducers were inserted into the vertebrae to record intraosseous pressures. Compressive loading was applied quasistatically (2 mm/sec) until injury occurred. Movement of the contrast medium was monitored under fluoroscopy. The subchondral endplate was the most vulnerable component for initiation of injury to the lumbar spine segment. In the initial stages of loading, the vertebral endplates gradually bulged outward, with the contrast medium staying within the nucleus. However, at higher physiologic load levels, before reaching the limiting load, the deformations increased, resulting in buckling of one of the endplates. This was followed by the contrast medium impregnating the spongiosa. Microlevel trauma was not observed radiographically after load removal, indicating that one cannot always equate a normal radiograph with normal spinal anatomy. Mean forces, deformations, stiffnesses, energies, and strains were 7.8 kN (+/- 1.4), 5.23 mm (+/- 0.78), 1940 N/mm (+/- 226), 18.7 J (+/- 4.4), and 35.5% (+/- 3.7), respectively. Pressure in the vertebral body containing the injured endplate before the onset of microtrauma was different (P0.05) from the pressure after injury; the pressures in the body containing the intact endplate, however, were not statistically different. Significant differences (P0.05) in the intraosseous pressures occurred between the two spinal levels at low-level physiologic loads before the onset of microtrauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Lecture 18 Introduction The recent progress in molecular biology, could make possible to identify the factors which influence the metabolism of the tenocytes and promote their natural healing process. The role of growth factors in the healing of tendons, for example, is still unclear, although basic fibroblast growth factor can stimulate healing by promoting cell proliferation and synthesis of the matrix. Gene transfer for the targeted delivery of growth factors has been used successfully in animal studies. Excessive repetitive overload of tendons is regarded as the main pathological stimulus which leads to tendinopathy. The aetiology of this pathologic condition remains unclear. Tendinopathies have been linked to overuse, poor vascularity, lack of flexibility, genetic make-up, gender, endocrine or metabolic factors. Excessive loading of the tendon during vigorous physical training is regarded as the main pathological stimulus. The tendon may respond to repetitive overload beyond physiological threshold by either inflammation of its sheath or degeneration of its body, or by a combination of both. Damage to the tendon can occur even if it is stressed within its physiological limits since frequent cumulative microtrauma may not leave enough time for repair. Microtrauma can result from non-uniform stress within tendons producing abnormal concentrations of load within the tendon, frictional forces between the fibrils, and localised damage to fibres. Tendinopathy has been attributed to a variety of intrinsic and extrinsic factors. Vascularity, dysfunction of the gastrocnemius-soleus, age, gender, bodyweight and height, are considered to be common intrinsic factors. Changes in training pattern, poor technique, previous injuries are common extrinsic factors which may predispose the athlete to tendinopathy. The aetiology of pain in tendinopathies is still unclear. Management of tendinopathy can be conservative or surgical, but this is recommended after exhausting periods of conservative management, often lasting for at least 6 months. Conservative management is unsuccessful in 24–45.5% of patients with tendinopathy of Achilles tendon. Failure of conservative management after 6 months is an indication for surgery. Surgery may range from percutaneous longitudinal tenotomy to various open procedures. Long-standing tendinopathy, however is associated with poor results after operation, with a greater rate of reoperation before an acceptable outcome is obtained.