Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report

Background Plantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location. Case presentation This article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4–6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting. Conclusions The plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.

Loneliness, social isolation, and pain following the COVID-19 outbreak: data from a nationwide internet survey in Japan

The aim of cross-sectional study was to investigate the association between pain and loneliness and increased social isolation during the COVID-19 pandemic. A total of 25,482 participants, aged 15–79 years, were assessed using an internet survey; the University of California, Los Angeles Loneliness Scale (Version 3), Short Form 3-item (UCLA-LS3-SF3) was used to assess loneliness, and a modified item of the UCLA-LS3-SF3 was used to measure the perception of increased social isolation during the pandemic. The outcome measures included the prevalence/incidence of pain (i.e., headache, neck or shoulder pain, upper limb pain, low back pain, and leg pain), pain intensity, and chronic pain history/prevalence. Pain intensity was measured by the pain/discomfort item of the 5-level version of the EuroQol 5 Dimension scale. Odds ratios of pain prevalence/incidence and chronic pain history/prevalence according to the UCLA-LS3-SF3 scoring groups (tertiles) and the frequency of the perceived increase in social isolation (categories 1–5) were calculated using multinomial logistic regression analysis. The mean pain intensity values among different loneliness and social isolation levels were tested using an analysis of covariance. Increased loneliness and the severity of the perceived social isolation were positively associated with pain prevalence/incidence, intensity, and the history/prevalence of chronic pain.

Appendicular endometriosis: a case report

Endometriosis is an estrogen-dependent inflammatory disease that affects 8 to 10% of women at reproductive age, characterized by the presence of endometrial glands and stroma outside the uterine cavity. In our case we are presenting a case report of a reproductive age group woman with appendicular endometriosis, because of the presence of pelvic endometriosis combined with an enlarged appendix, the choice was appendectomy, with complete suppression of abdominal symptoms after the surgery, a fact also reported by other authors. We concluded that endometriosis of the appendix is rare and almost never diagnosed before the surgery, with the definitive diagnosis obtained through microscopic examination. However, it should always be taken into account for the diagnosis of chronic pelvic pain, especially in young women complaining of recurrent pain, history of infertility and pelvic endometriosis.

The painful chest pain history: improving risk stratification with coronary calcium score

One of the commonest presentations to the Cardiology outpatient clinic is chest pain. Conventional risk scores for predicting coronary artery disease (CAD) depend greatly on chest pain histories which can be subjective and disadvantage individuals who present with less typical symptoms. The coronary calcium score (CACS) has a quick turnabout time and is an objective marker of atherosclerosis which can provide actionable information on presence of coronary artery disease. This study aims to explore a) if CACS can be a surrogate for chest pain history to better manage patients with atypical presentations, and b) determine the feasibility of utilising CACS in a new risk model as a form of triage for chest pain in the outpatient specialist setting. Two cohorts of patients who underwent CT Coronary angiogram (CTCA) were used: Asymptomatic patients with no obstructive coronary artery disease (CAD) and patients with symptomatic chest pain. The readouts of the CTCA include presence or absence of obstructive CAD (epicardial artery stenosis ≥50% on CTCA) and the CACS. In the asymptomatic cohort, we derived the formula for the median predicted CACS using latent class analysis and quantile regression with age and gender. The symptomatic cohort was divided into derivation and validation groups. Multivariate logistic regression was used to select significant risk factors for CAD and develop the prediction model. The presence of a ≥10-point difference between the patient's actual CACS and predicted median CACS was established as a predictive parameter. Performance of the model was assessed and compared with the CAD I consortium score using area under the curve (AUC), net classification index and integrated discriminative index in the validation group. In the asymptomatic cohort of 1911 persons, gender and age were significant factors used to calculate median predicted CACS. In the derivation cohort of 2345 patients, a CACS of 10-point difference between patient's CACS and predicted medium calcium score had a negative predictive value of 96.8%. Performance AUC (Figure 1) of the various models were: new model with chest pain history 0.887 (95% CI 0.858–0.916); without chest pain history 0.884 (95% CI 0.854–0.913); CAD I Consortium score 0.746 (95% CI 0.707–0.784). Both models performed significantly better than calcium score alone, p-value = 0.011. Coronary calcium score is an objective measure of coronary atherosclerosis and appears to be a reliable surrogate for chest pain history. A new risk marker of positive 10-points difference between patient's calcium score and predicted median calcium score can potentially better risk stratify patients presenting with chest pain in the outpatient setting. Funding Acknowledgement Type of funding source: None

Musculoskeletal Pain Survey Outcomes in Cleft Surgeons and Orthodontists

Objective: Determine prevalence and characteristics of musculoskeletal pain and pathology in cleft providers. Design: An IRB-exempt survey based on previously validated surveys was administered. Data collected included demographics, practice description, musculoskeletal pain history, formal diagnoses, and interventions. Setting: Survey was sent to all cleft centers approved by the American Cleft Palate-Craniofacial Association worldwide. Patients, Participants: All cleft surgeons and orthodontists at these centers met entry criteria. Eighty-three providers responded. Cleft center coordinators were unable to confirm the number of survey recipients. Main Outcome Measures: The hypothesis formulated prior to data collection was that prevalence would be comparable to general plastic surgeons and other at-risk health care providers. Results: Average age of respondents was 49.8 ± 11.3 years; 33.9% of respondents were female. Average body mass index was 24.8 ± 3.5 kg/m2. Headaches were observed in 62.7% of surveyed respondents while musculoskeletal symptoms were reported in 89.8%. Of the 12 body parts addressed, most commonly affected were the neck (71.2%), shoulders (52.5%), and lower back (67.8%). Pain interfered with hobbies and home life in the majority of respondents (62.7%). Those who reported a formal diagnosis were more likely to undergo treatment including surgery ( P < .01), medication ( P = .03), and physical therapies ( P < .01). Conclusions: Cleft surgeons and orthodontists experience a higher frequency of headaches compared to the general population, and musculoskeletal disorders are more prevalent than reported by general plastic surgeons. Pain interferes with hobbies and home life. Formal diagnosis leads to treatment. Preventative exercises and interventions are presented.

Ulcerated Keloid Secondary to a Coexisting Complicated Epidermal Inclusion Cyst: A Sonographic Diagnosis

Keloid is a benign fibroblastic tumor that is most often secondary to tissue injury. The clinical presentation is a hard red or purple tumor, mostly itchy or painful. The clinical objectives are to report an ulcerated keloid secondary to a central or inner complicated epidermal inclusion cyst histologically proven and to describe the sonographic findings that permitted the diagnosis. A 29-year-old man with multiple large keloids on the chest wall presented with a two-day pain history, increased volume, and ulceration on one side. Physical examination showed a keloid with edema, peripheral erythema, and a 1-cm central ulcer with purulent discharge. On the sonogram, multiple solid dermal hypodermal pseudotumors were visualized. The lesions were well-defined hypoechogenic heterogeneous solid masses that were hypovascular with color Doppler, concordant with keloids. Within the ulcerated enlarged mass, a complicated epidermal inclusion cyst was discovered with inflammatory changes. The significance of this case lies in the very low frequency of ulceration of a keloid and the high diagnostic value of sonography to demonstrate the presence of a coexisting epidermal inclusion cyst. In the differential diagnosis of an ulcerated keloid, sonography can assist in achieving a better presurgical approach.

Taking a headache history

The first tip is to take a full medical history. The trick is to interpret it. Around 400 bc Hippocrates described exertional and sex headaches with no aid other than a reed pen and papyrus or parchment. The second tip is to let patients tell the story in their own words as much as possible. The trick is to extract the salient features of the headache syndrome from what is often a cascade of irrelevancies while still trying to let the patient do most of the talking. This is a form of guided democracy. The final tip is to regard the headache as a pain problem to be analysed and hopefully solved by including a traditional pain history as taught in medical school. The trick is not to take shortcuts unless the patient is in extremis on being brought to the Emergency Department, when leaping straight to testing for neck rigidity and looking for signs of infection, a dilating pupil, and other warning signs is preferable.